What Is Tier a and Tier Blue Shiels

October 2019

Understanding Tiered Products: Are you an in-network PPO provider?

Tiered products – such as Blue Options PPO^SM and Blue Choice Options PPO^SM – are designed to give the employer and the member the opportunity to help them self-manage their health care spending. With a tiered product, the member's benefit level of cost-sharing is determined by the network of the independently contracted provider that renders the service. Keep in mind that an employer can customize the benefit levels for each tier.

Here is the basic benefit structure of a tiered product:

• Tier 1 is the highest benefit level and most cost-effective level for the member, as it is tied to a narrow network of designated providers.
• Tier 2 benefits offer members the option to select a provider from the broader network of contracted PPO providers, but at a higher out-of-pocket expense.
• Tier 3 benefits, if offered, typically address the use of out-of-network providers as the highest cost option for covered services.

Using the example of the Blue Choice Options PPO tiered product, which currently is offered by the City of Chicago (group numbers 195500, 195501, 195502 and three-character prefix CTY) and Rivers Casino (group number 154061) and any group number with three-character prefix XOX, the tier 1 contracted network is Blue Choice OPT PPO^SM (BCO). This network is identified on our Provider Finder^® as follows: Blue Options^SM/Blue Choice Options^SM (BCO). The tier 2 contracted provider network for Blue Choice Options members includes participating providers in the broader PPO network. Tier 3 benefits, when available, give these members the option to use out-of-network providers, but with the largest responsibility for the cost of care.

All PPO participating providers and Blue Choice PPO^SM participating providers are considered to be in-network for Blue Choice Options members.

From the Blue Choice Options member perspective, here's how it works:
In-network	Tier 1 (BCO)	If the member wants to select a Tier 1 contracted provider and pay the least out-of-pocket costs: The member will select the network code of BCO when conducting a search on our Provider Finder. The search will return a list of participating providers in the BCO network. "Blue Choice OPT" will appear under participating providers' names.
	Tier 2 (PPO)	If the member wants to select a Tier 2 contracted provider, knowing they will incur higher out-of-pocket costs: The member will select the network code of PPO when conducting a search on our Provider Finder. The search will return a list of participating providers in the PPO network. When the member clicks on the provider's name, applicable networks will be displayed.
Out-of- network	Tier 3 (when available)	The member may select a non-participating provider knowing this option will result in incurring the highest out-of-pocket costs for covered services.

How to Identify Blue Choice Options Members
Here are some tips to assist your staff when scheduling appointments for these members:

• Ask for the name of the product. The product name, Blue Choice Options, appears on the front of the member's ID card in the lower left corner. This will help you identify that this is a tiered benefit product. As indicated in the chart above, you are considered an in-network provider for this patient if you are either a contracted Blue Choice PPO or a PPO provider.
• Ask for the three-letter network code. This code appears in the lower left on the front of the member's ID card. The network code for Blue Choice Options is BCO – another indicator that this is a tiered benefit product.
• Ask for the statement on the back of the ID card. For Blue Choice Options members this statement will read: This plan is part of the Blue Choice OPT (BCO) network with tiered benefits.

Our growing portfolio of product offerings is part of our initiative to increase access and affordability of health care products for our members and the community we serve. Making it easier for you and your staff to conduct business with us is equally important.

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Source: https://www.bcbsilcommunications.com/newsletters/br/2019/october/understanding_tiered_products.html

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