Pittsburgh Technology Council
August 28, 2008
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2003 CommunityBlue High Point-of-Service

Overview

CommunityBlue, a point-of-service plan from Highmark Blue Cross Blue Shield, was developed for employers who want to give their employees all the advantages of Blue Cross Blue Shield coverage while meeting the demands of a tight budget. As a point-of-service plan, CommunityBlue 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.

CommunityBlue helps employers save money because it uses a more select network of health care providers. The CommunityBlue network includes advanced teaching hospitals as well as local community medical centers. Blue Cross Blue Shield managed care network physicians who have admitting privileges to these hospitals are part of the CommunityBlue network. Each CommunityBlue member chooses a PCP from the CommunityBlue network.

Currently CommunityBlue is available in the following counties:

  • Allegheny
  • Armstrong
  • Beaver
  • Butler
  • Crawford
  • Erie
  • Fayette
  • Greene
  • Indiana
  • Lawrence
  • Mercer
  • Washington
  • Westmoreland

The CommunityBlue High 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.

CommunityBlue 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 CommunityBlue network Ob/Gyn or nurse midwife of their choice, at any time, without a PCP referral.
  • Mental health/substance abuse care assistance is available 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...CommunityBlue High Option

Benefits Coordinated Care
"In-Network" Care		 Self-Referred Care
"Out-of-Network"
Deductible
Individual None $250
Family None $500
Out-of-Pocket Maximums
(Excludes deductible, copayments, Prescription Drug Expenses, Mental Health and Substance Abuse Expenses, and amounts over UCR) Not Applicable $2,000 Individual
$4,000 Family
Coinsurance
  100% 80% after deductible
Policy Maximum
  Unlimited $1,000,000
Prescription Drugs
  Generic: $8 Co-Pay
Brand: $15 Co-Pay
Closed Formulary;
Mandatory Generic1
34 day or 100 unit supply
whichever is greater		 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 100% after $10 copayment Not Covered
Routine gynecological exams, including PAP tests2 100% after $10 copayment 80% (deductible does not apply)
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
Routine physical exams 100% after $10 copayment Not Covered
Pediatric immunizations 100% 80% (deductible does not apply)
Emergency Room Services 3
  100%
$20 copay/visit
(waived if admitted)		 100%
$20 copay/visit
(waived if admitted)
Self-referred benefits, 80% after deductible
apply for non-emergency care
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% after deductible
Infertility
Counseling, Testing and Treatment4 100% 80% after deductible
Physical Therapy
  100% 80% after deductible
    24 visits/calendar year
Medical/Surgical Expenses
(Except office visits) 100% 80% after deductible
Spinal Manipulations
  100% after $10 copayment 80% after deductible
  Combined Maximum: Limit: 20 visits per calendar year
Skilled Nursing Facility
  100% 80% after deductible
    50 days/calendar year
Home Health Care5
  100% 80% after deductible
    50 visits/calendar year
Other Covered Services
(Such as Durable Medical Equipment, Ambulance Services, etc.) 100% 80% after deductible
Mental Health 6
Inpatient
  100%
Limit: 30 days per calendar year		 80% after deductible
Limit: 10 days per calendar year
  Combined Limit: 30 days per calendar year
Outpatient
  100% after $10 copayment
Limit: 20 visits per calendar year		 50% after deductible
Limit: 10 visits per calendar year
  Combined Limit: 20 visits per calendar year
Substance Abuse
Inpatient
Detoxification 100% 80% after deductible
  Combined Limit: 7 days/admission; 4 admissions/lifetime
Rehabilitation 100% 80% after deductible
  Combined Limit:30 days/year; 90 days/lifetime
Outpatient
  100% 80% after deductible
  Combined Limit:60 visits/year; 120 visits/lifetime
Precertification Requirements
  Performed by Network Medical Management Required for inpatient admission to non-network hospital 7
Claim Forms 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 drug and generic drug in addition to the brand drug copayment or coinsurance amounts which may apply.

2 A female member may self-refer to a CommunityBlue 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 care services involve the initial treatment: for bodily injuries resulting from an accident or; following the sudden onset of a medical condition; or following in the case of a chronic condition, a sudden and unexpected medical event 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 one or more of the following: a) 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; or b) serious impairment to bodily functions; or c) serious dysfunction of any bodily organ or part. Emergency care services do not require a referral from your PCP or Blues on Call.

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.

5The Maternity Home Health Care Visit on 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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All Rights Reserved.