2003 KeystoneBlue Health Maintenance Organization (HMO)

Overview

KeystoneBlue, an HMO from Keystone Health Plan West, covers most health care expenses…without any financial surprises later. Most routine and preventive care is covered, and there are no deductibles and no complicated claim forms to worry about. Members pay only a copayment for certain services, so they have lower out-of-pocket expenses, too. Under KeystoneBlue, the majority of care is coordinated by the member's Primary Care Physician (PCP), so each member needs to choose a PCP from the KeystoneBlue provider network. Because KeystoneBlue uses the largest managed care network in western Pennsylvania, it's very likely that the hospitals and physicians your employees use now are part of this network.

KeystoneBlue also includes these important features for maximum member convenience:

• Female members have direct access to the network Ob/Gyn or nurse midwife of their choice, at any time, for gynecological or maternity care, without a PCP referral.
• Mental health/substance abuse care assistance is available without a PCP referral. The member or PCP simply calls the Highmark Behavioral Health Unit for an evaluation to determine the type of care, therapy or counseling needed.
• Prior approval is not required for emergency care services.
• Prescription drugs are covered when received at any pharmacy in the Premier Pharmacy Network or through the convenient mail order service.
• The Blues on Call^SM health decision support line is available to members 24 hours a day, 7 days a week. Members can call this toll-free phone number to speak with a registered nurse for answers to health care questions, specialty referrals for coverage at the maximum level of benefits, and help making informed health care decisions.

back to top

To receive care, services must be performed or referred by your PCP or Blues On Call^SM Health Information and Support Line. Exceptions apply for emergency room, Ob/Gyn, and mental health and substance abuse services. Following a referral from your PCP or through Blues On Call^SM, network specialists may continue to provide follow-up care and refer for diagnostic services for a 60-day time period. All care must be provided by network providers. Below are specific benefit levels.

Wish to have a printable version of this benefit grid? A simple click will open a pdf version...KeystoneBlue

¹ A female member may self-refer to a network ob/gyn of her choice for any gynecological and maternity care. These services do not require authorization or a referral from your PCP or Blues On Call^SM.

² Emergency service is any health care service provided to a member after the sudden onset of a medical condition that manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: 1) placing the health of the member, or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; 2) serious impairment to bodily functions; or 3) serious dysfunction of any bodily organ or part. Emergency services do not require a referral from your PCP or Blues On Call^SM.

³ State mandated benefits (30 inpatient days and 60 outpatient visits annually) may apply for serious diagnosis. Serious diagnosis includes schizophrenia, schizo-affective disorder, major depressive disorder, bipolar disorder, obsessive compulsive disorder, panic disorder, anorexia nervosa, bulimia nervosa and delusional disorder.

⁴ Prescriptions are covered as long as they are listed on the KHPW prescription drug formulary applicable to your plan. Under the mandatory generic provision, the member is responsible for the payment differential when a generic drug is available and the doctor or patient specifies a brand name drug. The member payment is the price difference between the brand drug and the generic drug in addition to the brand drug copayment or coinsurance amounts which may apply.

back to top

To locate a participating provider in your area, please click on the link below.

• KeystoneBlue Provider Network

back to top

To determine premium rates, Highmark Blue Cross Blue Shield uses a demographic rating method based on the following factors: business location, the number of eligible employees enrolling, the average age of all covered employees, and industry classification. Please contact the Council's Employee Benefits Group to determine your specific rates.

If you have any further questions, please contact us; we'll be glad to help you.

back to top

Highmark Blue Cross Blue Shield® is an independent licensee of the Blue Cross and Blue Shield Association serving businesses and residents in western Pennsylvania.

Highmark® is a registered service mark of Highmark Inc.

Blue Cross and Blue Shield® and the cross and shield symbols are registered service marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.

Blues on Call^SM is a service mark of the Blue Cross and Blue Shield Association.

back to top

This information is not intended for use without professional advice. While we have attempted to make this site as accurate as possible, it is only a summary. For more information, see our disclaimer.

Last updated on:  Thursday, November 04, 2004  Page: 

Copyright © 2003 Pittsburgh Technology Council.
All Rights Reserved.