DirectBlue Open Access

DirectBlue, an open access program from Highmark Blue Cross Blue Shield, makes managed care more convenient…by permitting members to go directly to the specialist of their choice without a referral from their primary care physician (PCP). Because DirectBlue 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.

DirectBlue also includes these important features for maximum member convenience:

• Prescription drugs are covered when received at any pharmacy in the Premier Gold III Pharmacy Network or through the convenient mail order service.
• 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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Wish to have a printable version of this benefit grid? A simple click will open a pdf version...DirectBlue Option

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
	Not Applicable	$2,000 Individual $4,000 Family
Coinsurance
	100%	80% after deductible until out-of-pocket maximum is met; then 100%
Policy Maximum
	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-formulary4 $35 Co-Pay brand-non-formulary Mandatory Generic + Formulary5 31 day supply Maintenance Drugs through Mail order $20 Co-Pay Generic $40 Co-Pay brand-formulary4 $70 Co-Pay brand-non-formulary Mandatory Generic + Formulary5 90 day supply
Physician Office Visits (PCP)
	100% after $10 Co-Pay	80% after deductible
Specialists Office Visits
	100% after $10 Co-Pay	80% after deductible
Preventive Care
Adult
Routine physical exams	100% after $10 Co-Payment	Not Covered
Routine gynecological exams, including PAP tests	100% after $10 Co-Payment	80% (deductible does not apply)
Mammograms, as required	100%	80% after deductible
Pediatric
Pediatric immunizations	100%	80% (deductible does not apply)
Routine physical exams	100% after $10 Co-Pay	Not Covered
Emergency Room Services
	100% after $35 Co-Pay (waived if admitted)
Hospital Expenses
Inpatient	100%	80% after deductible
Outpatient	100%	80% after deductible
Other Covered Services
(such as Durable Medical Equipment. Ambulance Services, etc.)	100%	80% after deductible
Maternity
	100%	80% after deductible
Infertility
Infertility Counseling, Testing and Treatment1	100%	80% after deductible
Assisted Fertilization Procedures
Not Covered
Medical/Surgical Expenses
(except office visits)	100%	80% after deductible
Spinal Manipulations
	100% after $10 Co-Payment	80% after deductible
	Combined Maximum: Limit: 20 visits per calendar year
Diagnostic Services
(Lab, X-ray or other tests)	100%	80% after deductible
Durable Medical Equipment, Orthotics and Prosthetics
	100%	80% after deductible
Physical Therapy
	100% after $10 Co-Pay	80% after deductible
	Combined limit: 20 visits/calendar year
Speech Therapy
	100% after $10 Co-Pay	80% after deductible
	Combined limit: 20 visits/calendar year
Occupational Therapy
	100% after $10 Co-Pay	80% after deductible
	Combined limit: 20 visits/calendar year
Skilled Nursing Facility
	100%	80% after deductible
	Limit: 100 days/calendar year
Home Health Care
	100%	80% after deductible
Private Duty Nursing
	100%	80% after deductible
Hospice
	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 Limit: 30 visits per calendar year	80% after deductible Limit: 10 visits per calendar year
	Combined Limit: 20 visits per calendar year
Substance Abuse 2
Inpatient
Detoxification	100%	80% after deductible
	Combined Limit: 7 days/admission; 4 admissions/lifetime
Rehabilitation	100%	80% after deductible
	Combined Limit:30 days/year; 90 days/lifetime
Outpatient
	100% after $10 Co-Pay	80% after deductible
	Combined Limit:60 visits/year; 120 visits/lifetime
Precertification Requirements
	Performed by Network Medical Management	Required for inpatient admission to non-network hospital 3
Claim Forms Required
	No	Yes

¹Infertility 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.

³If 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.

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 Co-Pay 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 Co-Pay 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.

• DirectBlue

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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.