Out-of-Area Comprehensive

Under the Out-of-Area Comprehensive Plan, health care benefits are provided under one integrated program. These benefits include coverage for hospital services, physician services and many other covered services. Most benefits are subject to deductible and coinsurance provisions which require you to share a small portion of the medical costs.

Wish to have a printable version of this benefit grid? A simple click will open a pdf version...Out-of-Area Comprehensive

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

Benefits	Out-of-Area Comprehensive
Deductible
Individual	$3000
Family	$6000
Out-of-Pocket Maximums
Individual	$1,000 per calendar year Once an individual has satisfied the deductible, the next $5,000 of eligible expenses are paid by the individual ($1,000 or 20%) and Blue Cross Blue Shield ($4,000 or 80%). After that, Blue Cross Blue Shield pays 100% of eligible expenses.
Family	$2,000 per calendar year Once the deductible is satisfied and the combined out-of-pocket expenses of family members total $2,000, Blue Cross Blue Shield pays remaining eligible expenses. (No one family member can contribute more than the individual $1,000 out-of-pocket limit.)
Coinsurance
	80% after deductible until out-of-pocket is met; then 100%
Lifetime Maximum
	$1,000,000
Prescription Drugs
(Defined by Premier Gold III Pharmacy Network - Not Physician Network)	Retail Pharmacy: $10 Co-Pay generic $20 Co-Pay brand Mandatory Generic + Formulary 3 31-day supply
Mail Order Prescription Drug Program	Retail Pharmacy: $20 Co-Pay generic $40 Co-Pay brand Mandatory Generic + Formulary 3 90-day supply
Physician Office Visits
	80% after deductible
Preventive Care
Adult
Routine physical exams	100% after $10 Co-Pay
Routine gynecological exams, including PAP smears	100% after $10 Co-Pay
Mammograms, as required	100%
Pediatric
Pediatric immunizations	80% deductible lifetime maximum does not apply
Routine physical exams	100% after $10 Co-Pay
Emergency Room Services
	80% after deductible
Hospital Expenses
Inpatient	80% after deductible
Outpatient	80% after deductible
Maternity
	80% after deductible
Infertility
Infertility Counseling, Testing and Treatment1	80% after deductible
Assisted Fertilization Procedures
	Not Covered
Inpatient Physical Rehabilitation
	80% after deductible
Medical/Surgical Expenses
Except office visits	80% after deductible
Spinal Manipulations
	80% after deductible Limit: 20 visits/calendar year
Diagnostic Services
(Lab, X-ray and other tests)	80% after deductible
Physical Therapy
	80% after deductible Limit: 20 visits/calendar year
Speech Therapy
	80% after deductible Limit: 20 visits/calendar year
Occupational Therapy
	80% after deductible Limit: 20 visits/calendar year
Durable Medical Equipment, Orthotics, and Prosthetics
	80% after deductible
Skilled Nursing Facility Care
	80% after deductible
Home Health Care
	80% after deductible
Private Duty Nursing
	80% after deductible
Hospice
	80% after deductible
Mental Health
Coinsurance
	50% after deductible outpatient
Office Visit
	$80 maximum payment/visit
Substance Abuse
Inpatient Detoxification	80% after deductible 7 days/admission; 4 admissions/lifetime
Rehabilitation	80% after deductible 30 days/year; 90 days/lifetime
Outpatient
	80% after deductible 60 visits per calendar year 120 visits per lifetime
Precertification 2
Non-compliance penalty	Participating employees and family members are required to precertify inpatient admissions by contacting the Healthcare Management Services division of Blue Cross Blue Shield of Western Pennsylvania.
Claim Form Required
	Yes

 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.

 ³Prescriptions 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  Provider Network 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.