Preferred Provider Organization (PPO)

Preferred Provider Organization (PPO) Overview

Helpful Resources

• PPO Member Tip Sheet
• PPO Member Handbook
• Find-A-Doc

Preferred Provider Organization (PPO) Overview

At CDPHP, we know flexibility is key when it comes to selecting a plan that fits the needs of you and your family. So, with our PPO plan, you have a few options. See a doctor within the national network and pay lower copayments or coinsurance. Or, go outside the network and pay a higher coinsurance after meeting the deductible.

The PPO plan features:

• No primary care physician or referrals required
• No charge for well-child care and many other routine preventive health care services, including annual physicals and screenings provided in-network
• Worldwide coverage for emergency care

How it Works

A PPO plan from CDPHP Universal Benefits, Inc. (CDPHP) gives you the freedom to visit CDPHP doctors without a referral and see non-participating doctors if you choose. It all depends on your needs, your wants, and your budget – you make the call.

FAQs

Q. Do I have to choose a primary care physician (PCP) to direct my care?

A. If you have a PPO you do not need to select a PCP. However, we still recommend that you establish yourself with a doctor who will deliver your routine services and coordinate your care with specialists. Please use Find-A-Doc to view the range of doctors available within the CDPHP network.

This summary offers highlights but does not detail all benefits, limitations, or exclusions. It is not a contract and may be subject to change. For more detailed information, a Membership Certificate is available upon request.

Note: The PPO Plan is underwritten by CDPHP Universal Benefits, Inc. (CDPHP UBI). You must comply with CDPHP UBI’s managed benefits program as set forth in the contract to receive the maximum benefits for all services. Failure to do so will result in you being responsible for an additional payment of 50% of the allowed amount up to a maximum of $500 for each service otherwise payable, in addition to the applicable copayment, deductible, and/or coinsurance.

Flexibility & Choice

How it Works

Each time you access care under the PPO plan or the High Deductible PPO (HDPPO) plan, you have a choice. You may elect to get in-network care from a CDPHP participating practitioner or provider, or you may choose to receive services from practitioners and providers not in the CDPHP network.

Our PPO coverage offers flexibility and choice.

Just remember these easy tips:

• Your plan may require you to pay for services until you have met a deductible, after which most services are subject to coinsurance or copayment. So it is important to keep track of these expenses.
• If you are paying toward your deductible or owe a coinsurance, please ask your physician’s office to file a claim on your behalf and bill you for the balance you owe. If you owe a copayment, be prepared to make payment at the time of service.
• Your doctor may contact the CDPHP provider services department with questions about your eligibility or payment obligations.
• Emergency care is covered at the in-network level.

PPO Plan Tools

PPO Plan Tools

Here are some tools that might be helpful to you if you have a PPO plan.

PPO Member Tip Sheet
Find tips to help you understand everything in your plan from receiving care, to what you need to do for prior authorization.

PPO Member Handbook
Download this complete guide to your PPO coverage and all of the services available to you in this flexible plan.

Secure Online Access for Members
Find answers to many of your questions, check your claims, update your address, order new ID cards, and more – all online, 24/7.

Find-A-Doc and Find-A-Doc Mobile
Look up information on in-network and out-of-network providers.

Forms
Find any forms you may need to complete as you use your PPO plan.

Is Your Prescription Covered?
Use a helpful drug search tool to find information on coverage, pricing, and prescription details.

PPO FAQs

PPO FAQs

Get answers to the most common questions about PPO plans.

Q. What should I do if I have an emergency when I’m out of the area?

A. A medical emergency is defined as a sudden illness or injury so severe that the average person would believe that immediate medical attention is needed to avoid serious health damage or bodily harm.

If you have an emergency outside the CDPHP service area, go to the nearest hospital emergency room. CDPHP will cover the hospital emergency room bill in full — minus your copayment or deductible and coinsurance. If the situation is urgent but not an emergency, such as a sore throat, sprain, or infection, contact the CDPHP Resource Coordination Department at 1-800-274-2332 for advice in obtaining the care you need.

Q. How do I access my out-of-network benefits?

A. With your PPO plan you have coverage for care from non-participating providers but you should understand that your costs will be higher than seeking care within the network. Please refer to the benefit materials provided to you at the time of enrollment for specifics on your out-of-pocket costs. These vary according to the plan purchased by your employer group.

Q. Do I have to choose a PCP to direct my care?

If you have PPO coverage you do not need to select a PCP. However, we still recommend that you establish yourself with a doctor who will deliver your routine services and coordinate your care with specialists. Please use Find-A-Doc to view the range of doctors available within the CDPHP network.

Q. How do I submit a claim?

A. If you’ve received a covered service and the provider of medical services requested that you pay the charge at the time of service, send a completely itemized bill to our office so that you receive the maximum available benefits. That bill should include:

• Provider’s name, address, telephone number, and tax ID number
• Date of service
• Name of each procedure/procedure code, including the name of any drugs
• Charge for each procedure
• Diagnosis
• Receipt for any payment made
• Member’s name and ID number

Please send claim to: Capital District Physicians’ Health Plan, Inc., P.O. Box 66602, Albany, NY 12206-6602.

Note: this same process applies to claims for care you received out of the country.

Q. Can I order my prescription drugs by mail?

A. Yes. The CDPHP Mail Order Prescription service is available to members who have a prescription drug rider and who take maintenance medication.