Routine care includes elective services and any other services that are for conditions that are not for emergency care or urgent care. Examples include office visits for consultations or for basic health services (such as treatment for chronic high blood pressure or routine gynecological care), any follow-up care necessary after receiving services for a medical emergency or urgent care situation, and ongoing conditions such as allergy shots or treatment of arthritis.

Will I need a primary care physician's referral for my annual check-up and pap test with an OB/GYN physician?
Female members may receive up to two office visits each year to any participating OB/GYN physician or gynecologist under the in-plan benefits without first receiving a referral from the member's primary care physician. If more than two visits are needed to the OB/GYN physician's office or if services are needed outside of the OB/GYN physician's office or if a referral is needed to another specialist physician, then a referral will be needed from the primary care physician for such services. The number of visits wihout a referral may vary by benefit plan.

How are referrals to a physical therapist or chiropractor handled?
All visits to a physical therapist or chiropractor must receive a referral from the primary care physician. Piedmont will work directly with the primary care physician, the physical therapist or chiropractor, and the member when the member needs these services to coordinate health care.

Do I need a referral for hospital inpatient services?
In order to receive in-plan benefits for elective inpatient services, the member must first receive authorization from the primary care physician and Piedmont. Inpatient services received without authorization or from nonparticipating hospitals are considered out-of-plan.

If I am seeing a specialist now, will I need to get a referral from my primary care physician?
Piedmont's point of service system is intended to create a "family doctor" relationship between the member and his/her physician. In order to obtain in-plan benefits, every member must receive a referral from his/her primary care physician prior to receiving services from a specialist physician. In some cases, it may be possible to obtain this referral by telephone from the primary care physician.

Extended referrals are available in situations where an ongoing specialist service is being provided. Members who need such a referral should discuss this need with their primary care physician who will make the referral as necessary. Piedmont will consider each individual's circumstances when a covered employee or covered dependent is receiving ongoing follow-up treatment from a nonparticipating physician. Employees to whom this situation applies are encouraged to contact Piedmont in advance of the group's effective date so that we and the member's physician(s) can discuss the member's needs in advance.

Can your primary care physician be a specialist? If your only doctor is your OB/GYN doctor, do you need to select a primary care physician?
Each member enrolled under the point of service plan must select a participating primary care physician. Primary care physicians include family practitioners, general practitioners, internists and pediatricians. Services to be received from physicians other than the OB/GYN physician require a referral from the primary care physician in order to be covered in-plan.

If I choose a primary care physician, and that physician is in a group, can I see anyone in the group? Can a member have more than one primary care physician?
While each member needs to name one primary care physician, if that physician is not available when services are needed, the member can see any of the other physicians in the group and receive in-plan benefits. Like the member's own primary care physician, this physician can also refer the member to a specialist physician for services. While a member may change primary care physicians at any time by notifying Piedmont, each member can only have one primary care physician at a time.

If a member uses an out-of-plan physician who orders blood work (which is done by a participating provider such as Centra Lab), would that blood work be covered under in-plan benefits or out-of-plan benefits?
If a member decides to receive services out-of-plan, these services and any tests or follow-up services that may be provided are all considered out-of-plan.

What happens if I receive medical care from a network physician without first getting a referral from my primary care physician?
In order to receive in-plan benefits for a visit to a specialist, the member must receive a referral in advance from his/her primary care physician. The only exception to this requirement is that female members may receive at least two office visits annually, depending on the specific benefit plan, from a participating OB/GYN physician without a referral from the primary care physician. Any services received from a network provider when the primary care physician did not first provide a referral will be covered under the out-of-plan benefit.

Will I have to file claim forms?
Participating physicians will file claims for members when they receive in-plan services. Members may need to file their own claim forms for out-of-plan services.

How do I add coverage for a newborn child?
Newborn children of the female employee or male employee's spouse may be enrolled under the employee's coverage. Coverage will be effective as of the date of birth if the newborn is added within 31 days of birth.

If I have children away in college, how do they receive medical care coverage?
Members who are outside of the area served by Piedmont, including college students, may receive in-plan benefits for urgent or emergency services that are needed while the member is outside of the network area. While routine services are not covered outside of the network area, routine services are often available from the college's infirmary. Routine and elective services may also be received under the out-of-plan benefit, which would require the employee to pay a higher coinsurance and deductible for these services.

What if I decide that I want to change my primary care physician?
We recognize that a member may want to change his/her primary care physician. Any member who wants to change can call the customer service telephone number listed on the ID card and indicate the name of the new primary care physician. There is no limit on the number of times a member may change primary care physicians. We do ask for 24 hours notice to make the change.

How are pharmacy benefits administered?
Piedmont has developed a pharmacy network service using the services of a large national company called Caremark. A broad network of local pharmacies and national chain pharmacies participate in the Caremark pharmacy network. The network directory lists all national and local participating pharmacies. To fill prescriptions members will need only to present their ID card and pay the appropriate copayment, deductible or coinsurance amount in order to receive prescription benefits.