2003 Traditional Blue Cross Blue Shield, Major Medical Program

Highmark Blue Cross Blue Shield's "traditional" program offers maximum freedom of choice. Members are not required to select a primary care provider or receive a referral for specialty care. They are also not required to use network providers. They can receive medical services from any health care provider, and eligible services will be covered according to the plan's benefits.

Members will find, however, that it's to their advantage to use Participating Blue Cross Blue Shield providers because they accept the Blue Cross Blue Shield payment amount as "payment-in-full" for covered services. Members are only required to pay any deductible, copayments or coinsurance as required by their specific plan. Participating Blue Cross Blue Shield providers also agree to file claims for members for maximum convenience.

The Traditional program includes:

• Hospital coverage for inpatient and outpatient care at hospitals and other health care facilities.
• Medical/Surgical coverage for professional medical and surgical services provided by doctors, independent laboratories and other health care professionals.
• Major Medical coverage for many services not covered or not covered in full by the basic Hospital and Medical/Surgical benefits.
• Prescription drug coverage.
• The Blues On Call^SM health decision support line is available to members 24 hours a day, seven days a week. Members can call this toll-free phone number to speak with a registered nurse for answers to health care questions and help making informed health care decisions.

back to top

Under the Traditional benefits program, health care benefits are separated into hospital benefits, medical/surgical benefits and Major Medical benefits. These benefits include coverage for hospital services, physician services, and many other covered services. Most Major Medical benefits are subject to deductible and coinsurance provisions which require you to share a portion of the medical costs. Below are specific benefit levels.

Wish to have a printable version of this benefit grid? A simple click will open a pdf version...Traditional Blue Cross Blue Shield

¹ Infertility drug therapy may or may not be covered depending on your group's prescription drug program.

² 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, delusional disorder.

³ If Blue Cross Blue Shield is not contacted prior to a non-emergency inpatient admission and it is later determined that all or part of the inpatient stay was not medically necessary or appropriate, the patient will be responsible for payment of any costs not covered.

⁴ Hospice covered by an approved Hospice care program to an essentially home bound subscriber includes: Professional services of an RN or LPN; Medical Care: by Physician affiliated w/Hospice agency. Therapy Services except Dialysis Therapy. Family counseling Services. Medical and surgical supplies and Durable Medical equipment. Respite Care in a facility or at home - up to a maximum of 10 days or 240 hours throughout the treatment period. Benefits provided in accordance with the treatment plan approved by the plan and subject to review by the plan are also subjected to a life time maximum limit of $7,500.00.

⁵ Maintenance drugs covered at Premier Pharmacy Network; Copays $12 for Brand and $6 for Generic with a 60 day supply.

The benefit summary outlines the principal features of the program. It should not be considered the contract of benefits and provisions. Please refer to your member handbook for a complete description of benefits or contact us for a further explanation.

back to top

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

• Classic Blue

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.

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.