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August 28, 2008
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2003 Out-of-Area Comprehensive Program


Overview

Under the Comprehensive program, health care benefits are provided in one integrated program, and, for most covered services, members are responsible for an annual deductible. After the deductible is met, the member and the program share expenses until the member's out-of-pocket expenses reach a certain limit. To protect families, there's a maximum family deductible and out-of-pocket limit, too.

The comprehensive program also includes:

  • Prescription drug coverage.
  • The Blues On CallSM 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.

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Benefits at a glance

Under the Comprehensive benefits program, health care benefits are provided under one integrated program. These benefits include coverage for hospital services, physician services, and many other covered services. Most 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...ClassicBlue Affordable Comprehensive

Benefit Classic Blue Affordable Comprehensive
Deductible
Individual $1,000
Family $3,000
Coinsurance
  80% after deductible until out-of-pocket max is met, then 100%
Out-of-Pocket Maximums
  $5,000 Individual
  $10,000 Family
Lifetime Maximum
  $5,000,000
Physician Office Visits
  80% after deductible
Preventive Care
Adult
  Routine physical exams Not covered
  Routine gynecological exams,
  including a PAP Test		 80% after deductible
  Mammograms, as required 80% (deductible does not apply)
Pediatric
  Routine physical exams Not covered
  Pediatric immunizations 80% (deductible does not apply)
Emergency Room Services
  80% after deductible
Ambulance
  80% after deductible
Hospital Expenses
Inpatient 80% after deductible
Outpatient 80% after deductible
Medical/Surgical Expenses
  80% after deductible
Maternity
  80% after deductible
Physical Therapy
  80% after deductible
Outpatient Speech and Occupational Therapy
  80% after deductible
Inpatient Physical Rehabilitation
  80% after deductible
Skilled Nursing Facility Care
  80% after deductible
Home Health Care
  80% after deductible
Durable Medical Equipment
  80% after deductible
Diagnostic Services
(Lab, X-Ray, other tests) 80% after deductible
Spinal Manipulations
  80% after deductible
Mental Health 1
Inpatient 80% after deductible
Limit: 30 days/calendar year
Outpatient 80% after deductible
Limit: 60 visits/calendar year
Substance Abuse
Inpatient
Detoxification 80% after deductible
7 days/admission; 4 admissions/lifetime
Rehabilitation 80% after deductible
30 days/year; 90 days/lifetime
Outpatient 80% after deductible
Precertification2
  Performed by Member
Prescription Drugs
  80% after deductible

1 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.

2 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.

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.

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Provider Network

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

Rates

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.

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Highmark Disclaimer


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 CallSM is a service mark of the Blue Cross and Blue Shield Association.

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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: 

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All Rights Reserved.