ClassicBlue Traditional

Highmark Blue Cross Blue Shield's "ClassicBlue Traditional" program offers maximum freedom of choice. Members are not required to select a primary care provider or receive a referral for specialty care. They are also not required to use network providers. They can receive medical services from any health care provider, and eligible services will be covered according to the plan's benefits.

Members will find, however, that it's to their advantage to use Participating Blue Cross Blue Shield providers because they accept the Blue Cross Blue Shield payment amount as "payment-in-full" for covered services. Members are only required to pay any deductible, copayments or coinsurance as required by their specific plan. Participating Blue Cross Blue Shield providers also agree to file claims for members for maximum convenience.

The Traditional program includes:

• Hospital coverage for inpatient and outpatient care at hospitals and other health care facilities.
• Medical/Surgical coverage for professional medical and surgical services provided by doctors, independent laboratories and other health care professionals.
• Major Medical coverage for many services not covered or not covered in full by the basic Hospital and Medical/Surgical benefits.
• Prescription drug coverage.
• 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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Under the Traditional benefits program, health care benefits are separated into hospital benefits, medical/surgical benefits and Major Medical benefits. These benefits include coverage for hospital services, physician services, and many other covered services. Most Major Medical benefits are subject to deductible and coinsurance provisions which require you to share a portion of the medical costs. Below are specific benefit levels.

Wish to have a printable version of this benefit grid? A simple click will open a pdf version...Traditional Blue Cross Blue Shield

The following benefits are effective January 1, 2004. Please click on the Site Map to view benefit information for the 2003 plan year.

Benefits	Hospital	Medical/Surgical	Major Medical
Deductible
Individual	None	None	$200
Family	None	None	$400
Coinsurance
	N/A	N/A	80% after deductible until out-of-pocket maximum is met. Then 100%
Out-of-Pocket Maximum
	N/A	N/A	$400
Policy Maximum
	Unlimited	Unlimited	$1,000,000
Physician Office Visits
	N/A	Not Covered	80% after deductible
Preventive Care
Adult
Routine physical exams	Not Covered	Not Covered	Not Covered
Routine gynecological exams, including a PAP Test	100%	100%	80% (deductible/policy maximum does not apply)
Mammograms, as required	100%	100%	80% after deductible
Pediatric
Pediatric immunizations	100%	100%	80% (deductible/policy maximum does not apply)
Routine physical exams (must be performed by PCP)	Not Covered	Not Covered	Not Covered
Emergency Room Services
Accident	100%	100%	80% after deductible
Medical	100% (within 72 hours)	100% (within 72 hours)	80% after deductible
Ambulance
	Not Covered	Not Covered	80% after deductible
Hospital Expenses
Inpatient	100%	N/A	80% after deductible
Outpatient	100%	N/A	80% after deductible
Inpatient Physical Rehabilitation
	100%	100%	80% after deductible
Maternity
	100%	100%	80% after deductible
Infertility counseling, testing and treatment 1
	100%	100%	80% after deductible
Assisted Fertilization Procedures
	Not Covered	Not Covered	Not Covered
Medical/Surgical Expenses
	100%	100%	80% after deductible
Spinal Manipulations
	N/A	Not Covered	80% after deductible Limit: 20 visits/year
Diagnostic Services (Lab, X-ray, other tests)
	100%	100%	80% after deductible
Physical Therapy
	100% Limit: 21 visits/year	N/A	80% after deductible Limit: 20 visits/year
Speech Therapy
	100% Limit: 21 visits/year	N/A	80% after deductible Limit: 20 visits/year
Occupational Therapy
	100% Limit: 21 visits/year	N/A	80% after deductible Limit: 20 visits/year
Durable Medical Equipment, Orthotics and Prosthetics
	Not Covered	Not Covered	80% after deductible
Skilled Nursing Facility Care
	100%	N/A	80% after deductible
Home Health Care
	100% (100 visits/year)	N/A	80% after deductible
Private Duty Nursing
	Not Covered	N/A	80% after deductible
Hospice
	Not Covered	100%	80% after deductible
Mental Health 2
Inpatient	100% (Limit 30 days/calendar year)	100% (Limit 30 days/calendar year)	80% after deductible
Outpatient	Not Covered	Not Covered	80% after deductible
Substance Abuse (PA Mandated Benefits)
Inpatient
Detoxification	100% (Limit: 7 days/admission; 4 admissions/lifetime)	100%	80% after deductible
Rehabilitation	100% (Limit: 30 days/calendar year; 90 days/lifetime)	100% (Limit: 30 days/calendar year)	80% after deductible
Outpatient
	100% (Limit: 60 visits/calendar year; 120 visits/lifetime)	N/A	50% after deductible
Precertification 2
	Performed by Member	Performed by Member	Performed by Member
Prescription Drug (Maintenance drug program defined by Premier Pharmacy Network) 5
	N/A	N/A	80% after deductible

¹Infertility drug therapy may or may not be covered depending on your group's prescription drug program.

²If 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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To locate a participating provider, please click on the link below.

• Classic Blue

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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All Rights Reserved.