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August 28, 2008
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2003 SelectBlue High Option 250 Point-of-Service

Overview

SelectBlue, 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 250 Plan allows members to visit their PCP and pay a $10 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:

  • Female members can receive gynecological or maternity care - at the higher level of benefits - from the network Ob/Gyn or nurse midwife of their choice, at any time, without a PCP referral.
  • Mental health/substance abuse care is available at the higher level of benefits 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.
  • 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, specialty referrals for coverage at the maximum level of benefits, and help making informed health care decisions.

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Benefits at a Glance

Care 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 250

Benefits Coordinated Care
"In-Network" Care		 Self-Referred Care
"In or Out-of-Network"
Deductible
Individual None $250
Family None $750
Out-of-Pocket Maximums
(Excludes deductible, copayments, Prescription Drug Expenses, Mental Health and Substance Abuse Expenses, and amounts over UCR) Not Applicable $750 Individual
$2,250 Family
Coinsurance
  100% 80% after deductible
Policy Maximum
  Unlimited $1,000,000
Prescription Drugs
  Generic: $8 copayment
Brand: $15 copayment
34 day or 100 unit supply whichever is greater
Closed Formulary
Mandatory Generic 1		 Covered only through Premier Pharmacy Network
Primary Care Physician(PCP) Office Visits
  100% after $10 copayment 80% after deductible
Preventive Care
Adult
Routine physical exams(must be performed by PCP) 100% after $10 copayment Not Covered
Routine gynecological exams, including PAP tests2 100% after $10 copayment Self-referred to in-network provider;100% after $10 copayment
Self-referred to out-of-network provider; 80% (deductible does not apply)
Mammograms, as required 100% 80% after deductible
Pediatric
Pediatric immunizations 100% 80% (deductible does not apply)
Routine physical exams 100% after $10 copayment Not Covered
Emergency Room Services3
  100%
$25 copayment/visit
Waived if admitted		 Coordinated benefits apply if authorized by PCP or life-threatening emergency. If not authorized or a life-threatening emergency, self-referred benefits apply (80% after deductible).
Hospital Expenses
Inpatient 100% 80% after deductible
Outpatient 100% 80% after deductible
Maternity Services2 100% Self-referred to in-network provider;100%
Self-referred to out-of-network provider; 80% (deductible does not apply)
Infertility counseling, testing, and treatment4 100% 80% after deductible
Medical/Surgical Expenses
Except office visits 100% 80% after deductible
Physical Therapy
  100% 80% after deductible
Limit: 24 visits/year
Spinal Manipulations
  100%
Limit: 20 visits/year		 80% after deductible
Limit: 20 visits/year
Skilled Nursing Facility Care
  100% 80% after deductible
Limit: 50 days per calendar year
Home Health Care5
  100% 80% after deductible
Limit: 60 visits per calendar year
Other Covered Services
Such as Durable Medical Equipment, Ambulance services, etc. 100% 80% after deductible
Mental Health6
Inpatient
  100%
Maximum: 30 days per calendar year		 80% after deductible
Maximum: 10 days per calendar year
  Combined Maximum: 30 days per calendar year
Outpatient
  100% after $10 copayment
Maximum: 20 visits per calendar year		 80% after deductible
Maximum: 10 visits per calendar year
  Combined Maximum: 20 visits per calendar year
Substance Abuse
Inpatient
Detoxification 100% 80% after deductible
  Combined Maximum: 7 days/admission; 4 admissions/lifetime
Rehabilitation 100% 80% after deductible
  Combined Maximum: 30 days/year; 90 days/lifetime
Outpatient
  100% 80% after deductible
  Combined Maximum: 60 visits/year; 120 visits/lifetime
Precertification Requirements
  Performed by Network Medical Management Required for inpatient admission to non-network hospital7
Claim Form Required
  No Yes

1 Prescriptions 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.

2 A 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.

3 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 CallSM.

4 Treatment 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 program.

5 The Maternity Home Health Care Visit on the Coordinated Care is not subject to the program copayment, coinsurance or deductible amounts, if applicable.

6 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.

7 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.

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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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