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2003 CommunityBlue Direct
OverviewCommunityBlue Direct is an open access program that offers two levels of benefits. If you receive services from a provider who is in the CommunityBlue network, you will receive the higher level of benefits for covered services. If you receive services from a provider who is not in the CommunityBlue network, you will receive the lower level of benefits for covered services. There is no requirement to select a Primary Care Physician; however, we request that you choose a Primary Care Physician to assure you get consistent, quality care. Below are specific benefit levels. CommunityBlue helps employers save money because it uses a more select network of healthcare 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. Currently CommunityBlue is available in the following counties:
Benefits at a GlanceCare 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 simply click will open a pdf version...CommunityBlue Direct
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. 2Treatment includes coverage for the correction of a pshysical or medical problem associated with infertility. 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 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. 6 If 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 Provider NetworkTo locate a participating provider, please click on the link below. 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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