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August 28, 2008
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2003 DirectBlue Value

Overview

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 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, and help making informed health care decisions.

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Benefits at a Glance

Wish to have a printable version of this benefit grid? A simple click will open a pdf version...DirectBlue Value

Benefits "In-Network" Care "Out-of-Network"
Deductible
Individual $250 $500
Family $500 $1,000
Out-of-Pocket Maximums
(Excludes deductible, copayments, Prescription Drug Expenses, Mental Health and Substance Abuse Expenses, and amounts over UCR) $2,500 Individual
$5,000 Family		 $5,000 Individual
$10,000 Family
Coinsurance
  80% after deductible 50% after deductible
Policy Maximum
  Unlimited $1,000,000
Prescription Drugs
  $100 Individual/$200 Family deductibles apply to retail and mail-order prescription drugs combined Drug deductible is separate deductible and not part of overall program deductible Retail drugs: 20% coinsurance with $10 min/$50 max co-pay per prescription. Mandatory generic + formulary; 31 days supply Mail-Order Maintenance drugs: 20% coinsurance with $20 min/$100 max co-pay per prescription; mandatory generic, 90 days supply1
Covered only at Premier Pharmacy Network
Physician Office Visits
  100% after $20 copayment
(deductible does not apply)		 50% after deductible
Specialist Office Visits
  100% after $20 copayment
(deductible does not apply)		 50% after deductible
Preventive Care
Adult
Routine physical exams 100% after $20 copayment
(deductible does not apply)		 Not Covered
Routine gynecological exams, including PAP tests 100% after $20 copayment
(deductible does not apply)		 50%
(deductible does not apply)
Mammograms, as required 80%
(deductible does not apply)		 50% after deductible
Pediatric
Pediatric immunizations 80%
(deductible does not apply)		 50%
(deductible does not apply)
Routine physical exams 100% after $20 copayment
(deductible does not apply)		 Not Covered
Emergency Room Services
Accidental/Medical 80% after deductible
Hospital Expenses
Inpatient 80% after deductible 50% after deductible
Outpatient 80% after deductible 50% after deductible
Infertility counseling, testing, and treatment2 80% after deductible 50% after deductible
Medical/Surgical Expenses
  80% after deductible 50% after deductible
Physical Therapy
  100% after $20 copayment
(deductible does not apply)
Limit: 20 visits/year per therapy		 Not Covered
Spinal Manipulations
  100% after $20 copayment
(deductible does not apply)
Limit: 20 visits/year per therapy		 Not Covered
Skilled Nursing Facility Care
  80% after deductible 50% after deductible
Limit: 100 day limit per calendar year
Home Health Care3
  80% after deductible 50% after deductible
Hospice
  80% after deductible 50% after deductible
Diagnostic Services
Lab, X-Ray and other tests 80% after deductible 50% after deductible
Other Covered Services
Durable Medical Equipment 80% after deductible 50% after deductible
Ambulance services 80% (deductible does not apply) 50% after deductible
Speech and Occupational Therapy
  100% after $20 copayment
(deductible does not apply)		 50% after deductible
  Limit: 20 visits/year per therapy
Mental Health4,5
Inpatient
  80% after deductible
Limit: 30 days per calendar year		 50% after deductible
Limit: 10 days per calendar year
  Combined Maximum: 30 days per calendar year
Outpatient
  100% after $20 copayment
(deductible does not apply)
Limit: 20 visits per calendar year		 50% after deductible
Limit: 10 visits per calendar year
  Combined Maximum: 20 visits per calendar year
Substance Abuse
Inpatient
Detoxification 80% after deductible 50% after deductible
  Combined Maximum: Limit: 7 days/admission; 4 admissions/lifetime
Rehabilitation 80% after deductible 50% after deductible
  Combined Maximum: Limit: 30 days/year; 90 days/lifetime
Outpatient
  100%
after $20 copayment
(deductible does not apply)6		 50% after deductible
  Combined Maximum: 60 visits per calendar year
120 visits per lifetime
Precertification Requirements
  Performed by Network Medical Management Performed by Member7
Failure to precertify will result in a $300 penalty.
Claim Form Required
  No Yes

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 or coinsurance amounts, which may apply.

2Treatment 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.

3The Maternity Home Health Care Visit on In-Network Care is not subject to the program copayment, coinsurance or deductible amounts, if applicable.

4To 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.

5 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.

6First instance or course of treatment reimbursed at 80% after $20 copayment for In-Network care.

7If Blue Cross Blue Shield is not contacted prior to a non-emergency inpatient admission, the patient will be responsible for a $300 precertification penalty. If 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.