Q: What is a copayment?

A: A copayment is a fixed dollar amount that you pay for some services (usually paid at the time the service is provided).

Q: Do I have to pay a copayment for my weekly allergy shot?

A: Your weekly allergy shot is subject to the deductible and co-insurance. You may be required to pay a copayment if your PCP or specialist also charges you for an office visit.

Q: What if I have a medical question in the middle of the night?

A: You can call your PCP or you can call Health Line Blue. This 24-hour, toll-free health information line allows you to have a confidential conversation about your health questions with a registered nurse anytime of the day or night. The Health Line Blue number is 1-877-477-2424.

Q: Does Blue Options cover routine physical exams and immunizations?

A: Yes. Wake Forest University, offering the BCBS of NC Blue Options PPO plan, covers both routine physical exams and immunizations under both the Core and Value Plans.  Check out your Benefit Highlights at www.bcbsnc.com/members/wfu.

Q: If my doctor does not participate in the Blue Options plan, can I still have my routine physical with him or her and just pay the out-of-network costs?

A:Yes.  Any charges will be subject to a deductible and co-insurance.

Q: What services are covered when I receive a routine exam?

A:Routine exams generally cover the following: office visit, mammogram, pap smears, colonoscopy, blood work and prostate screening. For an exclusive list, please refer to your medical plan member guide.

Q: What if I take my child for her immunizations, but she can't receive them because she is sick?

A: Make another appointment for her immunizations. You don't have to pay a copayment for her next visit if all she receives is immunizations.

Q: How can I find a preferred doctor?

A: Use our online Provider Search. New providers will continue to be added to the network and some providers may elect to discontinue their participation. We update our online provider listing weekly. Please check again if your provider is not included in this week's listing. Go to www.bcbsnc.com/members/wfu.

Q: Do you cover emergency care?

A:Yes, your health plan provides benefits for the treatment of an emergency. There will be a $75 copay charge for an emergency room visit if you are not admitted. If you go to an emergency room for treatment of an emergency, your benefits will be the same regardless of whether you use an in-network or out-of-network provider.

If you are admitted to the hospital from the emergency room or held for observation, your initial hospital admission is eligible for in-network benefits and the emergency room copayment will be waived. If you are held for observation, outpatient benefits will apply and your emergency room copayment will be waived. Once you are admitted as a hospital inpatient, your benefits will be paid like any other inpatient facility or professional charges. However, you may need to transfer to a participating hospital once your condition has been stabilized in order to continue receiving in-network benefits.

Q: What happens to my coverage if I move out of the area?

A: Blue Cross and Blue Shield's BlueCard program offers cost-effective, quality health care for covered members living outside of North Carolina. BlueCard is a valuable program that provides you network access and provider discounts across the United States.

Under the BlueCard program, members who live outside of North Carolina can visit a network provider in the state where services are rendered and show their ID card to identify himself or herself as a Blue Cross and Blue Shield member.

After services are rendered, the network provider files the claim for you and routes it to the local Blue Cross and Blue Shield plan. After applying network discounts, the local Blue Cross and Blue Shield plan sends the claim to BCBSNC where the applicable fees are paid.

You will be responsible for all applicable deductibles and coinsurance as well as meeting any precertification requirements.

BlueCard is ideal for members who have children attending out-of-state schools. You can find preferred providers anywhere in the United States by calling toll-free 1-800-810-BLUE. You may also visit www.bcbs.com/members/wfu to obtain detailed information about the program as well as check for Blue Cross and Blue Shield participating providers by specialty and geographic location. With BlueCard, the provider files the claim for you and it is processed as described above.

If you need to fill a prescription, you may continue using your Catalyst prescription drug card at a participating pharmacy. If you don't have access to a participating pharmacy, you can pay for the prescription up front and file a claim later with Catalyst.  You can access a claim form online at www.catalystrx.com.

Q: What do I do if I need care while traveling?

A: Blue Cross and Blue Shield's BlueCard program offers cost-effective, quality health care for covered members traveling outside of North Carolina. You may call toll-free(1-800-810-BLUE) to find participating providers anywhere in the United States. You may also visit www.bcbs.com/members/wfu to obtain detailed information on the program as well as check for BlueCard participating providers by specialty and geographic location. Make sure to show your ID card to identify yourself as a Blue Cross and Blue Shield member. The participating provider will file the claim for you.

In addition, BlueCard Worldwide offers Blue Options members the ability to receive in-network benefits for inpatient health care at participating hospitals in major travel destinations and business centers throughout the world. You can find out which providers participate by calling toll-free 1-800-810-BLUE. You may also visit www.bcbs.com to access the BlueCard Doctor and Hospital Finder. You are responsible for contacting BCBSNC for any care requiring precertification.

If you need to fill a prescription, you may continue using your Catalyst prescription drug card at a participating pharmacy. If you don’t have access to a participating pharmacy, you can pay for the prescription up front and file a claim later with Catalyst.  You can access a claim form online at www.catalystrx.com.

Q: What emergency coverage do I have while I am traveling?

A: Blue Cross and Blue Shield's BlueCard program offers cost-effective, quality health care for covered members traveling outside of North Carolina. BlueCard is a valuable benefit that provides network access and provider discounts to BCBSNC members across the United States. The discounts received through Blue Cross and Blue Shield participating providers in other states reduce the amount of billed charges, which also reduces the amount that you owe.

Under the BlueCard program, you can travel outside of North Carolina and visit a network provider in the state where services are rendered. Make sure to show your ID card to identify yourself as a BlueCard member.

After services are rendered, the network provider files the claim for the member and routes it to the local Blue Cross and Blue Shield plan. After applying network discounts, the local Blue Cross and Blue Shield plan sends the claim to BCBSNC and we make applicable payments.

You will be responsible for all applicable deductibles and coinsurance as well as meeting any precertification requirements.

BlueCard is ideal for members who have children attending out-of-state schools or for anyone who travels. You can call toll-free 1-800-810-BLUE to find preferred providers anywhere in the United States. You can also visit www.bcbs.com to obtain detailed information about the program as well as check for participating providers by specialty and geographic location. The provider files the claim for you and it is processed as described above.

In addition, BlueCard Worldwide offers Blue Options members the ability to receive in-network benefits for inpatient health care at participating hospitals in major travel destinations and business centers throughout the world. You can find out which providers participate by calling toll-free 1-800-810-BLUE. You may also visit www.bcbs.com and use the online BlueCard Doctor and Hospital Finder. You are responsible for contacting BCBSNC for any care requiring precertification.

Q: Can I cover a dependent who lives out-of-state or my child away at school?

A: If you currently cover your dependent(s) under a Blue Options plan, your dependent(s) moving out-of-state will continue to be covered until their 19th birthday or until age 26 (in most cases) if a full-time student. Please review your Member Guide for your policy's age limit for full-time students.

Emergency coverage is the same whether your dependent seeks care in-state or out-of-state. In case of an emergency, call 911 or go to the nearest hospital for treatment.

For urgent or follow-up care, your dependent(s) are encouraged to call 1-800-810-BLUE to find a participating provider in the state where they're seeking treatment. This will ensure that they will receive in-network benefits for the services provided.

If you need to fill a prescription, you may continue using your Catalyst prescription drug card at a participating pharmacy. If you don’t have access to a participating pharmacy, you can pay for the prescription up front and file a claim later with Catalyst. You can access a claim form online at www.catalystrx.com.

Q: What if a primary care physician cannot see me right away?

A: As a Blue Options member, you may visit any in-network physician. You can locate in-network providers by visiting our online Provider Search at www.bcbsnc.com/members/wfu or by calling Customer Service at 1-877-258-3334.

Q: What if a network provider isn't available to treat my condition?

A: If you have not found a network provider to be reasonably available, please call BCBSNC Customer Service to assist you. If one is not reasonably available, work with your provider to contact BCBSNC for authorization. You can also submit your claim to be reimbursed based on out-of-network benefits.

Q: Can I go to a non-network provider?

A: In most cases you may visit a non-network provider, but covered services would be paid at the out-of-network benefit level. Please note that BCBSNC will only pay benefits up to the allowed amount. Out-of-network providers may bill you the difference between what BCBSNC pays and the actual charge.

Q: What services require prior approval or a referral?

A: Referrals
You do not need to get a referral from your primary care provider to receive covered services from a participating specialist. However, some participating specialists may require a new patient introduction from your treating doctor. BCBSNC recommends that you take advantage of your primary care provider's expertise in coordinating your care.

Prior Approval
Most inpatient admissions, skilled nursing facility admissions, and all private duty nursing services require prior approval from Blue Cross and Blue Shield of North Carolina (BCBSNC). In addition, BCBSNC requires prior approval for certain other outpatient services received on or after July 1, 2007.

For maternity admissions, your doctor is not required to obtain prior approval from BCBSNC for prescribing a length of stay up to 48 hours for a normal vaginal delivery or up to 96 hours for delivery by cesarean section. You or your doctor must request prior approval for coverage for additional days. Although no prior approval is required for emergency situations, please notify BCBSNC of your inpatient admission as soon as reasonably possible.

Services for mental health and substance abuse must be approved in advance by CBHA. Please call the behavioral health and substance abuse number listed on your ID card.

The list of services, which must be approved in advance, may change from time to time. For the current list of services requiring prior approval, please refer to our prior plan approval list or call the Customer Service number on the back of your BCBSNC ID card.

Additionally, some prescription drugs require prior approval to be covered. Some prescription drugs are also subject to quantity limits under the plan. For these drugs, prior approval is required before excess quantities will be covered. Please contact Catalyst Rx at 888-869-4600.

If your services are out-of-network or you receive services outside of North Carolina, you are responsible for requesting or having your provider request prior approval for those services that require preauthorization from BCBSNC.

Q: How do I get prior approval or a referral?

A: Prior Approval
Participating providers or specialists will coordinate prior approvals or precertification for you. You may want to check with your participating provider to make sure prior approval has been obtained. For services at a nonparticipating provider or out-of-state, you are responsible or having your provider request preauthorization when the services you receive require prior approval from BCBSNC.

Referrals
You do not need to get a referral from your primary care provider to receive covered services from a participating specialist. However, some participating specialists may require a new patient introduction from your treating doctor.

Q: What do I do with a foreign medical bill for care I received outside of the U.S.?

A: If you receive a bill for inpatient, outpatient or professional medical care received outside the United States, please send the bill with an international claim form to our foreign claims center at:

BlueCard Worldwide Service Center
P. O. Box 90320
Richmond, VA 23230

You may view a listing of participating hospitals or obtain an international claim form at http://www.bcbs.com/bluecardworldwide/index.html.

The BlueCard Worldwide Service Center translates foreign claims and calculates the foreign exchange rate. The Service Center then forwards the claim to BCBSNC to be processed.

If you receive a foreign medical bill for outpatient hospital services or other medical services that you received outside of the United States, please file those claims directly to BCBSNC.

Q: Can I get reimbursed for drugs I got from a pharmacy outside of the network?

A: Yes. You may be reimbursed for prescription drugs that you received from an out-of-network pharmacy, but you may have to pay full charges at the pharmacy and file a claim.

You will need to file a claim with Catalyst Rx, by downloading a claim form online at www.catalystrx.com or you can request a form by calling the number provided on your Prescription Drug ID Card.