PreferredBlue® PPO

The PreferredBlue® PPO (Preferred Provider Organization) plan makes managed care easy! PreferredBlue® is designed for people who want the greatest flexibility and convenience within a network-based program.

PreferredBlue® gives members the freedom to choose any doctor, specialist or hospital. When a member or a covered dependent needs medical care, the member can choose between two levels of service: in-network or out-of-network. If a member uses an "in-network provider", benefits will be received at the highest level of coverage. There are no deductibles or coinsurance, just a $10 Co-Pay for physician office visits. Benefits for eligible "out-of-network" services are subject to the deductible and coinsurance provisions of the plan.

A PPO offers two levels of benefits. If you receive services from a provider who is in the PPO network, you'll receive the highest level of benefits. If you receive services from a provider who is not in the PPO network, you'll receive the lower level of benefits. In either case, you coordinate your own care. There is no requirement to select a Primary Care Physician (PCP) to coordinate your care. Below are specific benefit levels.

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

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

Benefits	"In-Network" Care	"Out-of-Network"
Deductible
Individual	None	$250
Family	None	$500
Out-of-Pocket Maximums
(Excludes deductible, Co-Pays, Prescription Drug Expenses, Mental Health and Substance Abuse Expenses, and amounts over UCR)	Not Applicable	$2,000 Individual $4,000 Family
Coinsurance
	100%	80% after deductible until out-of-pocket maximum is met; then 100%
Lifetime Maximum
Includes Mental Health and Substance Abuse Services	Unlimited	$1,000,000
Premier Prescription Drug Program
(defined by Premier Gold III Pharmacy Network - Not Physician Network)	Retail Drugs $10 Co-Pay Generic $20 Co-Pay brand-formulary 4 $35 Co-Pay brand-non-formulary Mandatory Generic + Formulary 5 31-day supply Maintenance Drugs through Mail Order $20 Co-Pay Generic $40 Co-Pay brand formulary 4 $70 Co-Pay brand-non-formulary Mandatory Generic + Formulary 5 90-day supply
Physician Office Visits
	100% after $10 Co-Pay	80% after deductible
Preventive Care
Adult
Routine physical exams	100% after $10 Co-Pay	Not Covered
Routine gynecological exams, including a PAP Test	100% after $10 Co-Pay	80% (deductible/plan maximums do not apply)
Mammograms, as required	100%	80% after deductible
Pediatric
Pediatric immunizations	100%	80% (deductible/plan maximums do not apply)
Routine physical exams	100% after $10 Co-Pay	Not Covered
Emergency Room Services
	100% after $35 copayment (waived if admitted)
Hospital Expenses
Inpatient	100%	80% after deductible
Outpatient	100%	80% after deductible
Ambulance
	100%
Maternity
	100%	80% after deductible
Infertility counseling, testing, and treatment 1
	100%	80% after deductible
Assisted Fertilization Procedures
	Not Covered
Medical/Surgical Expenses
Except office visits	100%	80% after deductible
Diagnostic Services
(Lab, X-ray and other tests)	100%	80% after deductible
Skilled Nursing Facility Care
	80% after deductible Limit: 100 days per calendar year
Home Health Care3
	100%
Hospice
	100%
Private Duty Nursing
	100%
Spinal Manipulations
	100% after $10 Co-Pay	80% after deductible
	Combined Limit: 20 visits per calendar year
Physical Therapy
	100% after $10 Co-Pay	80% after deductible
	Combined Limit: 20 visits per calendar year
Speech Therapy
	100% after $10 Co-Pay	80% after deductible
	Combined Limit: 20 visits per calendar year
Occupational Therapy
	100% after $10 Co-Pay	80% after deductible
	Combined Limit: 20 visits per calendar year
Durable Medical Equipment, Orthotics and Prosthetics
	100%	80% after deductible
Mental Health 2
Inpatient
	100% Limit: 30 days per calendar year	80% after deductible Limit: 10 days per calendar year
	Combined Limit: 30 days per calendar year
Outpatient
	100% after $10 Co-Pay/visit Limit: 20 visits per calendar year	50% after deductible Limit: 10 visits per calendar year
	Combined Limit: 20 visits per calendar year
Substance Abuse  2
(PA Mandated Benefits Indicated Below) Inpatient Detoxification	100%	80% after deductible
	7 days/admission; 4 admissions/lifetime
Rehabilitation	100%	80% after deductible
	30 days/year; 90 days/lifetime
Outpatient
	100% after $10 copayment	80% after deductible
	60 visits/year; 120 visits/lifetime
Precertification
	Performed by Network Providers	Performed by Member 3
Claim Form Required
	No	Yes

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¹Treatment 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 program.

²To 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.

³Member is required to contact Blue Cross Blue Shield Health Care Management Services prior to a planned impatient admission or within 48 hours of an emergency or maternity-related admission. If this does not occur 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 the payment of any costs not covered.

⁴The formulary is an extensive list of Food & Drug Administration (FDA) approved prescription drugs for their quality, safety and effectiveness. It includes products in every major therapeutic category. The formulary was developed by the Highmark Pharmacy and Therapeutics Committee made up of clinical pharmacists and physicians. Your program includes coverage for both formulary and non-formulary drugs at the specific copayment or coinsurance amounts listed above.

⁵Prescriptions 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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Members can use the  Health Care Directory to locate a participating provider in your area.

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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.