Pittsburgh Technology Council
August 28, 2008
Home 
   Benefits
  Policies
     Resources
Statements

2003 Out-of-Area Program Low Option

Overview

Under the Out-of-Area Comprehensive Plan, health care benefits are provided under one integrated program. These benefits include coverage for hospital services, physician services and many other covered services. Most benefits are subject to deductible and coinsurance provisions which require you to share a small portion of the medical costs.

Benefits at a Glance

Wish to have a printable version of this benefit grid? A simple click will open a pdf version...Out-of-Area Low Option

Benefits Out-of-Area
Comprehensive
Deductible
Individual $250
Family $750
Out-of-Pocket Maximums
(Excludes deductible, copayments, Prescription Drug Expenses, Mental Health and Substance Abuse Expenses, and amounts over UCR) $750 Individual
$2,250 Family
Coinsurance
  80%
Policy Maximum
  $1,000,000
Prescription Drugs
  Generic: $6 for maintenance drugs
Brand: $12 for maintenance drugs
All other drugs are subject to the deductible and coinsurance
Physician Office Visits
Diagnostic 80% after deductible
Preventive Care
Adult
Routine physical exams 100% deductible does not apply
Routine gynecological exams, including PAP smears 100% deductible does not apply
Mammograms, as required 100% after deductible
Pediatric
Pediatric immunizations 100% deductible does not apply
Routine physical exams 100% deductible does not apply
Emergency Room Services
  80% after deductible
Hospital Expenses
Inpatient 80% after deductible
Outpatient 80% after deductible
Medical/Surgical Expenses
Except office visits 80% after deductible
Physical Therapy
  80% after deductible
Mental Health
Inpatient
  80% after deductible Limit: 30 days per calendar year
Outpatient
  50% after deductible
Substance Abuse
Detoxification 80% after deductible 7 days/admission; 4 admissions/lifetime
Rehabilitation 80% after deductible 30 days/year; 90 days/lifetime
Outpatient
  80% after deductible after Limit: 60 visits per calendar year 120 visits per lifetime
Precertification
Non-compliance penalty $300
Claim Form Required
  Yes

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.

back to top

Provider Network

Members can use the  Provider Network to locate a participating provider in your area.

back to top

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.

back to top

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.

back to top

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: 

Copyright © 2003 Pittsburgh Technology Council.
All Rights Reserved.