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2003 SelectBlue High Option 100 Point-of-Service
OverviewSelectBlue, a point-of-service plan from Highmark Blue Cross Blue Shield, gives members a choice every time they receive medical care. They can allow their Primary Care Physician (PCP) or Blues On CallSM to "coordinate" their care and receive a higher level of benefits coverage…or they can choose to "self-refer" for care and receive benefits at a lower level. Each member chooses a PCP from the SelectBlue provider network. Because SelectBlue 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. The Select Blue High Option 100 Plan allows members to visit their PCP and pay a $5 copayment. Generic prescription drugs purchased at a Premier Pharmacy Network cost the member a $8 copayment. The copayment for brand name drugs is $15. If a generic drug is available and the member or physician requests a brand name drug, the member is responsible for the $15 copayment plus the difference in cost between the brand and generic drugs. SelectBlue also includes these important features for maximum member convenience:
Benefits at a GlanceCare is considered coordinated (in-network) when it is performed or referred by your PCP, or referred through the Blues On CallSM Health Information and Support Line. Exceptions apply for emergency room, Ob/Gyn, and mental health and substance abuse services. If you choose to obtain medical care through another provider, in most cases, this care will be considered self-referred care. Following a referral from your PCP or through Blues On CallSM, network specialists may continue to provide follow-up care and refer for diagnostic services for a 60-day time period. Below are specific benefit levels. Wish to have a printable version of this benefit grid? A simple click will open a pdf version...SelectBlue High Option 100
1Prescriptions are covered as long as they are listed on the 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 and generic in addition to the copayment amounts. 2A female member may self-refer to a network Ob/Gyn of her choice for any gynecological or maternity care. These services do not require authorization or a referral from your PCP or Blues On CallSM. 3Emergency 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 CallSM. 4Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered depending on your group's prescription drug benefits. 5The Maternity Home Health Care Visit on the Coordinated Care is not subject to the program copayment, coinsurance or deductible amounts, if applicable. 6State 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. 7If 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 Provider NetworkTo locate a participating provider, please click on the link below. RatesTo 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. Highmark DisclaimerHighmark 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. 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.
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