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SECTION 8.0 - PPO Blue (Preferred Provider Organization)

In order to provide you with a brief description of your medical and hospital benefits, a schedule of benefits provided by the PPO Blue Program is shown below. It is not intended to be a complete description of the benefits available to eligible participants. A detailed description of your PPO Blue Program will be provided by Highmark Blue Cross Blue Shield and will govern any discrepancies between the information provided below and that provided by Highmark Blue Cross Blue Shield.


Several definitions that may aid you in understanding the PPO Blue Program are shown below.


Coinsurance

  1. For Hospital or Facility Other Providers, the percentage of the Provider’s Reasonable Charge for Covered Services which must be paid by the participant and which will be deducted from the Provider’s Reasonable Charge.
  2. For Professional Providers or Professional Other Providers, the percentage of the Provider’s Reasonable Charge for Covered Services which must be paid by the Subscriber and which will be subtracted from the Provider’s Reasonable Charge.

Copayment

  1. The fixed, up-front dollar amount you pay for certain covered expenses. Copayment amounts do not apply toward your deductible or coinsurance, and they do not accumulate toward the out-of-pocket maximum.
  2. For Hospital or Facility Other Providers, a specified dollar amount of the Provider’s Reasonable Charge which must be paid by the participant and which will be deducted from the Provider’s Reasonable Charge before determination of the benefits payable under the Preferred Blue PPO Contract.
  3. For Professional Providers or Professional Other Providers, a specified dollar amount of the Provider’s Reasonable Charge which must be paid by the participant and which will be subtracted from the Provider’s Reasonable Charge before determination of the benefits payable under this Contract.

Covered Care

You can receive care from the health care provider of your choice. The PPO program does not require that you select a primary care physician to receive covered care. Instead, the program gives you access to a vast network of physicians, hospitals, and other providers throughout the country. Simply call 1-800-810-BLUE (2583) for information on the nearest PPO providers


Benefits are paid at the higher level of reimbursement. You are responsible to pay the co-payment amounts.


Covered Service

A service or supply specified by the Preferred Blue PPO Contract for which benefits will be provided when rendered by a Provider or Supplier.


Deductible

Initial amount a participant must pay each year for covered services before the plan begins to provide benefits.


Network (In- or Out-of-Network) Provider or Supplier

Participating providers have entered into an agreement with Highmark pertaining to payment of benefits for covered services. If you receive services from a health care provider within the PPO Network you will receive a higher level of benefits for covered care from network providers.


Out-of-Network Providers or Suppliers have not entered into an agreement with Highmark. These non-participating providers may not accept the Highmark allowed charges plus any deductible, coinsurance amounts, or copayments as payment-in-full. You will be responsible for payment of any remaining charges. Please consult the material provided by the Preferred Blue PPO Program for complete details regarding In- and Out-of-Network Providers.


Self-Referred Care

You can receive covered care from any health care provider, including specialists, at any time, and there is no need for a referral. You do not have to choose a PCP.


Authorization

The official agreement between the provider and Healthcare Management Services (HMS) that care meets the definition of “medically necessary and appropriate.” Please note that care authorization does not necessarily indicate benefits coverage.

Benefits In-Network Out-of-Network
Benefit Period Calendar Year Calendar Year
Deductible
Individual $100 $250.00
Family $200 $500.00
Coinsurance 100% 80% after deductible
Out-of-Pocket Limit Not Applicable $1,000 individual;
$2,000 per family
Lifetime Maximum $2,000,000 $300,000
Precertification Requirements
for Inpatient Admission
Performed by Member
Physician Office Visits 100% after $15 copayment;
deductible does not apply
80% after deductible
Hospital Services 100% after deductible 80% after deductible
(Inpatient and Outpatient)
Preventive Care
Adult
Routine physical exams 100% after $15 copayment;
deductible does not apply
Not covered
Routine GYN exams including PAP tests 100% after $15 copayment;
deductible does not apply
80%;
deductible and maximums do not apply
Mammograms as required 100%;
deductible does not apply
80% after deductible
Adult Immunizations 100% after deductible 80% after deductible
Allergy Extract/Injections 100% after deductible 80% after deductible
Pediatric Care
Routine physical exams 100% after $15 copayment;
deductible does not apply
Not covered
Pediatric immunizations 100%;
deductible and maximum do not apply
80%;
deductible and maximums do not apply
Benefits In-Network Out-of-Network
Diagnostic Services 100% after deductible 80% after deductible
(Lab, X-ray and other tests)
Therapy Services
Physical Therapy 100% after $15 copayment;
deductible does not apply
80% after deductible
Speech Therapy 100% after $15 copayment;
deductible does not apply
80% after deductible
Occupational Therapy 100% after $15 copayment;
deductible does not apply
80% after deductible
Cardiac Rehabilitation 100% after deductible 80% after deductible
Chemotherapy 100% after deductible 80% after deductible
Dialysis Treatment 100% after deductible 80% after deductible
Infusion Therapy 100% after deductible 80% after deductible
Radiation Therapy 100% after deductible 80% after deductible
Maternity Services 100% after deductible 80% after deductible
Medical Services (except office visits) 100% after deductible 80% after deductible
Spinal Manipulations 100% after $15 copayment;
deductible does not apply
80% after deductible
Combined Limit: 20 visits per benefit period
Surgical Services 100% after deductible 80% after deductible
Emergency Room Services 100% after $50 copayment (waived if admitted); deductible does not apply
Ambulance Service 100% after deductible 100% after deductible
Private Duty Nursing 100% after deductible Same As Network Services
Benefits Network Out-of-Network
Hospice Care 100% after deductible 80% after deductible
Transplant Services 100% after deductible 80% after deductible
Skilled Nursing Facility Services 100% after deductible 80% after deductible
Home Health Care 100% after deductible 80% after deductible
Durable Medical Equipment 100% after deductible 80% after deductible
Mental Health Services
Inpatient Benefits 100% 80% after deductible
Combined limit: 30 visits per benefit period
Outpatient Benefits 100% after $15 copayment;
deductible does not apply
80% after deductible
Combined limit: 30 visits per benefit period
Substance Abuse Services
Inpatient Benefits
Detoxification 100% after deductible 80% after deductible
7 days per admission; 4 admissions per lifetime
Residential and Rehabilitation Therapy Services 100% after deductible 80% after deductible
30 days per benefit period; 90 days per lifetime
Outpatient 100% after $15 copayment;
deductible does not apply
80% after deductible
60 visits per benefit period; 120 visits per lifetime
Prescription Drug Program
Benefits Benefits available through
the Premier Pharmacy Network only.

Mandatory Generic1
Retail Pharmacy Up to 34 day supply
Copayment $10 generic
$15 brand/formulary2
$30 brand/non-formulary2
Maitenance Prescription Drugs through Mail Order Up to 90 day supply
Copayment $20 generic
$30 brand/formulary2
$60 brand/non-formulary2
  1. The member is responsible for the payment differential when a generic drug is authorized by the physician and the patient elects to purchase a brand name drug. The member payment is the price difference between the brand and generic in addition to the copayment or coinsurance amounts, which may apply.
  2. The Highmark formulary is an extensive list of Food & Drug Administration (FDA) approved prescription drugs selected for their quality, safety and effectiveness. It includes products in every major therapeutic category. The formulary was developed by the Highmark Pharmacy and Therapeutics Committee made up of clinical pharmacists and physicians. Your program includes coverage for both formulary and non-formulary drugs at the specific copayment or coinsurance amounts listed above.