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2003 BlueCard PPO High Option 250
Benefits at a GlanceA PPO, or Preferred Provider Organization, offers two levels of benefits. If you receive services from a provider who is in the PPO network you'll receive the highest level of benefits. If you receive services from a provider who is not in the PPO network you'll receive the lower level of benefits. In either case, you coordinate your own care. There is no requirement to select a Primary Care Physician (PCP) to coordinate your care. Below are specific benefit levels. Wish to have a printable version of this benefit grid? A simple click will open a pdf version...BlueCard PPO High Option 250
1 The member is responsible for the payment differential when a generic drug is authorized by the physician and the patient elects to purchase a brand drug. The member payment is the price difference between the brand drug and generic drug in addition to the brand drug copayment or coinsurance amounts which may apply. 2 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. 3 The Maternity Home Health Care Visit on In-Network Care is not subject to the program copayment, coinsurance or deductible amounts, if applicable. 4 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. 5 You are required to contact Highmark 7-10 days prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related admission to a hospital. If this does not occur and it is later determined that all or part of the inpatient stay was not medically necessary or appropriate, you 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 NetworkMembers can use the 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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