How to Use Your Outline of Coverage
Your outline of coverage is a handy guide to your health plan benefits. In this article, we discuss why it's important, where you can find it, and how you can put it to use.
Our health plans offer a wide range of benefits — from preventive services like vaccinations and screening tests to coverage for physician office visits and hospital care. How can you quickly find which benefits are included in your health plan and what your costs will be? Checking your outline of coverage is an easy way to learn about your benefits.
Let’s take a closer look at what the outline of coverage is, where to find key information in it, and how it can help you when making decisions about your health care.
What is an Outline of Coverage?
The outline of coverage is a short document that identifies various parts of your health plan’s coverage, such as preventive care, physician office visits, emergency care, and hospital care. It lists your share of the costs for each covered service you receive from a network provider. Restrictions, limitations, and other important information are also provided for each covered service. This is all presented in an easy-to-use grid format (see illustration).
Most of our members receive an outline of coverage by mail when they sign up for their Blue Cross Vermont health plan. You can also access your outline of coverage online through the Member Resource Center (MRC). If you don’t already have an MRC account, all you need is your member ID card to register.
Where to Find Key Information
The first page of the outline of coverage contains several key pieces of information, including:
- The plan’s deductible — the amount you’ll have to pay each year for covered services before your health plan starts to pay.
- Your out-of-pocket limit — the most you’ll have to pay for covered services in a year.
- Primary care provider requirement — whether you’ll need to select a primary care provider.
- Specialist referral requirement — whether your plan requires a referral to see a specialist.
The next several pages of your outline of coverage list all the services or supplies covered by your health plan, along with deductibles, copayments, and coinsurance. You’ll also see when prior approval is needed. This information can be very helpful when planning and budgeting for your healthcare.
- Tip: It’s a good idea to check the outline of coverage before using a healthcare service for the first time, so you’ll know what your share of the costs are. You’ll also see any restrictions or limitations for the service.
Prescription drug coverage, if included in your health plan, is outlined near the end of the document. You’ll see your costs for generic drugs, preferred brands, and non-preferred brand drugs. Information on your prescription drug deductible and out-of-pocket limit is also provided.
Understanding Our Network
When deciding where to go for care, how do you know which doctor or hospital is covered by your health plan? Checking your outline of coverage is an excellent starting point.
The first page of the outline of coverage has information to help you better understand our provider network. “In-network” providers are hospitals, other health care facilities, and clinicians who contract with us to provide care for our members at lower costs. You should use in-network providers whenever possible, as your costs will likely be less than using out-of-network providers. Some of our health plans require use of network providers.
Use your outline of coverage to understand:
- If you must use in-network providers
- When using out-of-network providers is allowed
- If prior approval is required for out-of-network care
- How to find in-network providers, both locally and when travelling
A Handy Guide
With key information about your health plan summarized in only a few pages, the outline of coverage is a handy guide to your health plan benefits. Use it often, so that you’ll get the most out of your health plan!
If you have any questions about your outline of coverage, or need assistance with your health plan, please contact our customer service team. They are available Monday through Friday from 7:00 a.m. to 6:00 p.m. at (800) 247-2583 (TTY: 711) or log in to your Member Resource Center account to send a secure email.
