2003 DirectBlue Open Access

DirectBlue, an open access program from Highmark Blue Cross Blue Shield, makes managed care more convenient…by permitting members to go directly to the specialist of their choice without a referral from their primary care physician (PCP). Because DirectBlue 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.

DirectBlue also includes these important features for maximum member convenience:

• Prescription drugs are covered when received at any pharmacy in the Premier Pharmacy Network.
• The Blues on Call^SM 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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Wish to have a printable version of this benefit grid? A simple click will open a pdf version...DirectBlue Option

¹ The Premier formulary is an extensive list of Food & Drug Administration (FDA) approved prescription drugs selected for their quality, safety and effectiveness. It includes products in every major therapeutic category. The formulary was developed by the Highmark Pharmacy and Therapeutics Committee made up of Clinical pharmacists and physicians. Your program includes coverage for both formulary and non-formulary drugs at the specific copayment or coinsurance amounts listed above.

² The member is responsible for the payment differential when a generic drug is authorized by the doctor and the patient elects to purchase a brand name drug. The member's payment is the price difference between the brand and generic in addition to the copayment or coinsurance amounts which may apply.

³ 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 benefits.

⁴ The Maternity Home Health Care Visit on In-Network Care is not subject to the program copayment, coinsurance or deductible amounts, if applicable.

⁵ If Blue Cross Blue Shield is not contacted prior to an 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 along with a $300 precertification penalty.

⁶ To obtain mental health and substance abuse services at the maximum benefits level, you must contact Highmark's Mental Health and Substance Abuse Unit before seeking treatment.

⁷ 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.

⁸ First instance or course of treatment reimbursed at 80% after deductible for Out-of-Network care.

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

• DirectBlue

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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 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 Call^SM 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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