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How the PPO Plan Works

Preferred Provider Organization (PPO) plan is a network-based medical plan that gives you a choice when it comes to getting health care. The PPO Plan is available in all states across the United States and is the plan in which you are automatically enrolled once you become eligible for the Fund's health care benefits. This is how it works. The network organization contracts with physicians, hospitals and other health care providers to provide services at a contracted rateThe fee that is negotiated between the plans and their network providers. Contracted rate applies to network services only.. (See the Summary of Benefits for benefit information.) Neither you nor the Fund is required to pay any amount over the contracted rate.

Each time you need medical care, you have the option of seeing:

The Fund uses a single nationwide hospital and major medical network (Blue Cross/Blue Card) for all PPO and Low Cost Option participants, no matter where you live or travel. (For specific claim submission for services rendered outside of California, see the "Filing A Claim" section for medical claims.)

Whether you see a network provider or a non-network provider, the PPO Plan covers a broad range of medical services and supplies, including wellness benefits, hospital treatment, prescription drug benefits, and mental health and chemical dependency benefits. Keep in mind that you always have the freedom to choose your provider and the services he/she recommends.

Patient Protection Disclosure - If the non-grandfathered group health plan benefit option in which you are enrolled requires the designation of a primary care provider, you have the right to designate any participating primary care provider who is available to accept you or your family members (for children, you may designate a pediatrician as the primary care provider). For The Industry Health Network (TIHN), you can contact TIHN's Customer Service department at (800) 876-8320 or for the Blue Cross/Blue Card network at (800) 810-BLUE (2583) or you can access the network's provider listing through our website, www.wgaplans.org, "Find A Participating Provider". You do not need prior authorization from the Health Plan or from any other person, including your primary care provider, in order to obtain access to obstetrical or gynecological care from a health care professional; however, you may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact TIHN's Customer Service department at (800) 876-8320 or the Blue Cross/Blue Card network, you can call (800) 810-BLUE (2583) or you can access the network's provider listing through our website at www.wgaplans.org, "Find A Participating Provider".

If You Live Outside The PPO Network Area

Participants who live more than 25 miles from a minimum of two providers of any type who participate in the hospital/major medical network, may be considered for out-of-area benefits. The PPO Plan's out-of-area option pays a percentage of the cost of eligible expensesAny reasonable and customary charge for medically necessary services or supplies which is cove red in full or in part by the plan., up to the Reasonable and Customary (R&C) limit, after you meet the calendar-year deductibleThe portion of eligible expenses you're responsible for paying each calendar year before the Fund begins to pay certain benefits. (See the Summary Of Benefits for specific percentages.)

If you're traveling in an area where there are PPO network providers, you can use them. If you live close enough to a PPO provider and you want to travel to that provider for care, you may do so. That way, you can receive the advantage of network negotiated fees and reimbursement of eligible expenses without R&C limits.

If a participant who lives in a network area is being treated for a serious condition there are no network specialists in his or her area, the participant may be considered for out-of-area benefits for services rendered by a non-contracted specialist in his or her network area. A serious condition includes conditions such as cancer and cardiac surgery. It does not include situations of a non-serious nature, such as claims for chiropractic or acupuncture.

The PPO Plan's out-of-area option covers the same medical services and supplies that are otherwise covered under the plan, including prescription drugs and mental health and chemical dependency treatment. You are responsible for contacting the Administrative Office to determine if your provider would qualify for out-of-area benefits.

Sub-Topics:
Getting The Most From Your Plan
Looking At Eligible And Ineligible Expenses
Filing A Claim
Understanding Coordination Of Benefits (COB)