SelectBlue Low Option 90/70 Point-of-Service

SelectBlue, a point-of-service plan from Highmark Blue Cross Blue Shield, gives members a choice every time they receive medical care. They can allow their Primary Care Physician (PCP) or Blues On Call^SM to "coordinate" their care and receive a higher level of benefits coverage…or they can choose to "self-refer" for care and receive benefits at a lower level. Each member chooses a PCP from the SelectBlue provider network. Because SelectBlue 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.

With the SelectBlue Low Option Plan, premiums are reduced because members share more of the expenses. When care is coordinated by the member's PCP, most services are covered at 90%; self-referred care is covered at 70%. Members can visit their PCP and pay a $20 copayment. Generic prescription drugs pruchased at a Premier Pharmacy Network cost the member a $15 co-payment. The copayment for brand drugs is $30. If a generic drug is available and the member or physician requests a brand name drug, the member is responsible for the $30 copayment plus the difference in cost between the brand and generic drugs.

SelectBlue also includes these important features for maximum member convenience:

• Female members can receive gynecological or maternity care - at the higher level of benefits - from the network Ob/Gyn or nurse midwife of their choice, at any time, without a PCP referral.
• Mental health/substance abuse care is available at the higher level of benefits without a PCP referral. The member or PCP simply calls the Highmark Behavioral Health Unit for an evaluation to determine the type of care, therapy or counseling needed.
• Prior approval is not required for emergency care services.
• 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, specialty referrals for coverage at the maximum level of benefits, and help making informed health care decisions.
• Prescription drugs are covered when received at any pharmacy in the Premier Gold III Pharmacy Network or through the convenient mail order service.

Good News for Highmark POS Members! Effective July 1, 2004 members will no longer need to get a referral from their Primary Care Physicians (PCPs) for their specialty care to be covered at the higher level of benefits. Instead, members can go directly to the network specialist of their choice! If members decide to receive care from an out-of-network provider, they will be covered for eligible services at the lower level of benefits coverage. Members will still need to select a primary care physician to provide certain routine care services, including adult routine physicals, pediatric routine physicals and pediatric immunizations. And in many cases it will still make sense for a PCP to coordinate care with a specialist. But in these cases members will not be required to obtain a referral.

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Care is considered coordinated (in-network) when it is performed or referred by your PCP, or referred through the Blues On Call^SM 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 Call^SM, 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 simple click will open a pdf version...SelectBlue Low Option 90-70

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

Benefits	Coordinated Care "In-Network" Care	Self-Referred Care "In or Out-of-Network"
Deductible
Individual	None	$500
Family	None	$1,000
Out-of-Pocket Maximums
(Excludes deductible, Co-Pays, Prescription Drug Expenses, Mental Health and Substance Abuse Expenses, and amounts over UCR)	$1,500 Individual $3,000 Family	$3,000 Individual $6,000 Family
Coinsurance
	90%	70% after deductible until out of pocket maximum is met; then 100%
Policy Maximum
	Unlimited	$1,000,000
Prescription Drugs
(Defined by Premier Gold III Pharmacy Network - Not Physician Network)	Retail Drugs $15 Co-Pay Generic $30 Co-Pay Brand Mandatory Generic + Formulary 4 31-day supply Maintenance Drugs through Mail Order $30 Co-Pay Generic $60 Co-Pay Brand Mandatory Generic + Formulary 4 90-day Supply
Physician(PCP) Office Visits
	100% after $20 Co-Pay	70% after deductible
Specialist Office Visits
	100% after $20 Co-Pay	70% after deductible
Preventive Care
Adult
Routine physical exams(must be performed by PCP)	100% after $20 Co-Pay	Not Covered
Routine gynecological exams, including PAP tests 1	100% after $20 Co-Pay	Self-referred to in-network provider; 100% after $20 Co-Pay Self-referred to out-of-network provider; 70% (deductible/policy maximum does not apply)
Mammograms, as required	100%	70% after deductible
Pediatric
Pediatric immunizations	100%	70% (deductible/policy maximum does not apply)
Routine physical exams	100% after $20 Co-Pay	Not Covered
Emergency Room Services3
	100% after $50 Co-Pay (Waived if admitted)
	Emergency care is paid at the coordinated benefits level	Self-referred benefits apply for non-emergency care (70% after deductible)
Maternity  1
	90%	Self-referred to in-network provider;100% Self-referred to out-of-network provider; (70% after deductible)
Infertility counseling, testing, and treatment 2
	90%	70% after deductible
Assisted Fertilization Procedures
	Not Covered
Hospital Expenses
Inpatient	90%	70% after deductible
Outpatient	90%	70% after deductible
Medical/Surgical Expenses
Except office visits	90%	70% after deductible
Physical Therapy
	100% after $20 Co-Pay	70% after deductible
	Limit: 20 visits/year
Speech Therapy
	100% after $20 Co-Pay	70% after deductible
	Limit: 20 visits/year
Occupational Therapy
	100% after $20 Co-Pay	70% after deductible
	Limit: 20 visits/year
Spinal Manipulations
	100% after $20 Co-Pay	70% after deductible
	Limit: 20 visits/year
Skilled Nursing Facility Care
	90%	70% after deductible Limit: 100 days per calendar year
Home Health Care5
	90%	70% after deductible
Other Covered Services
Such as Durable Medical Equipment, Ambulance services, etc.	90%	70% after deductible
Mental Health6
Inpatient
	90% Limit: 30 days per calendar year	70% after deductible Limit: 10 days per calendar year
	Compined Maximum: 30 days per calendar year
Outpatient
	100% after $20 Co-Pay Limit: 20 visits per calendar year	50% after deductible Limit: 10 visits per calendar year
	Compined Maximum: 20 visits per calendar year
Substance Abuse
Inpatient
Detoxification	90%	70% after deductible
	7 days/admission; 4 admissions/lifetime
Rehabilitation	90%	70% after deductible
	30 days/year; 90 days/lifetime
Outpatient
	100% after $20 Co-Pay	70% after deductible
	60 visits/year; 120 visits/lifetime
Precertification Requirements
	Performed by Network Medical Management	Required for inpatient admission to non-network hospital 3
Claim Form Required
	No	Yes

¹A female member may self-refer to a network Ob/Gyn of her choice for any gynecological or maternity care. These services do not require authorization or a referral from your PCP.

²Treatment includes coverage for the correction of a physical or medical problem associated with the infertility. Infertility drug therapy may or may not be covered depending on your group's prescription drug program.

³If 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.

⁴Prescriptions 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 the generic drug in addition to the brand drug copayment or coinsurance amounts which may apply.

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.

• SelectBlue

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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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All Rights Reserved.