DirectBlue Value

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 Value

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	$250	$500
Family	$500	$1,00
Out-of-Pocket Maximums
	$2,500 Individual $5,000 Family	$5,000 Individual $10,000 Family
Coinsurance
	80% after deductible until out-of-pocket maximum is met; then 100%	50% 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)	$100 Individual Deductible/$200 Family Deductible applies to Retail and Mail-Order Prescription Drugs combined Drug deductible is separate deductible and not part of overall program deductibles Retail Drugs: 20% coinsurance with $10 minimum/$50 maximum Co-Pay per prescription Mandatory Generic + Formulary  4 31-day supply Maintenance Drugs through Mail Order: 20% coinsurance with $20 minimum/ $100 maximum Co-Pay per prescription Mandatory Generic + Formulary  4 90-day supply
Physician Office Visits (PCP)
	100% after $20 Co-Pay deductible does not apply	50% after deductible
Specialists Office Visits
	100% after $20 Co-Pay deductible does not apply	50% after deductible
Preventive Care
Adult
Routine physical exams	100% after $20 Co-Pay deductible does not apply	Not Covered
Routine gynecological exams, including PAP smears	100% after $20 Co-Pay deductible does not apply	50% (deductible does not apply)
Mammograms, as required	80% (deductible does not apply)	50% after deductible
Pediatric
Pediatric immunizations	80% (deductible does not apply)	50% after deductible
Routine physical exams	100% after $20 Co-Pay (deductible does not apply)	Not Covered
Emergency Room Services
	80% (deductible does not apply)
	Emergency care is paid at the coordinated benefits level	Self-referred benefits (80% after deductible) apply for non-emergency care
Ambulance
	80% (deductible does not apply)	50% after deductible
Hospital Expenses
Inpatient	80% after deductible	50% after deductible
Outpatient	80% after deductible	50% after deductible
Maternity  1
	80% after deductible	50% after deductible
Infertility
Infertility Counseling, Testing and Treatment 2	80% after deductible	50% after deductible
Assisted Fertilization Procedures
Not Covered
Medical/Surgical Expenses
(except office visits)	80% after deductible	50% after deductible
Spinal Manipulations
	100% after $20 Co-Payment (deductible does not apply) Limit: 20 visits per calendar year	Not Covered
Physical Therapy
	100% after $20 Co-Payment (deductible does not apply) Limit: 20 visits per calendar year	Not Covered
Speech Therapy
	100% after $20 Co-Payment (deductible does not apply) Limit: 20 visits per calendar year	Not Covered
Occupational Therapy
	100% after $20 Co-Payment (deductible does not apply) Limit: 20 visits per calendar year	Not Covered
Durable Medical Equipment
	80% after deductible	50% after deductible
Skilled Nursing Facility
	80% after deductible	50% after deductible Limit: 100 days/calendar year
Home Health Care
	80% after deductible	50% after deductible
Private Duty Nursing
	80% after deductible	50% after deductible
Hospice
	80% after deductible	50% after deductible
Diagnostic Services
(Lab, X-ray or other tests)	80% after deductible	50% after deductible
Mental Health  5
Inpatient
	80% after deductible Limit: 30 days per calendar year	50% after deductible Limit: 10 days per calendar year
	Combined Limit: 30 days per calendar year
Outpatient
	100% after $20 Co-Payment deductible does not apply 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
Inpatient
Detoxification	80% after deductible	50% after deductible
	Combined Limit: 7 days/admission; 4 admissions/lifetime
Rehabilitation	80% after deductible	50% after deductible
	Combined Limit:30 days/year; 90 days/lifetime
Outpatient
	100% after $20 Co-Pay deductible does not apply	50% after deductible
	Combined Limit:60 visits/year; 120 visits/lifetime
Precertification Requirements
	Performed by Network Medical Management	Required for inpatient admission to non-Community Blue network hospital  3
Claim Forms Required
	No	Yes

 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.

 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.

 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 name 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.