KeystoneBlue Health Maintenance Organization (HMO)

Overview

KeystoneBlue, an HMO from Keystone Health Plan West, covers most health care expenses…without any financial surprises later. Most routine and preventive care is covered, and there are no deductibles and no complicated claim forms to worry about. Members pay only a copayment for certain services, so they have lower out-of-pocket expenses, too. Under KeystoneBlue, the majority of care is coordinated by the member's Primary Care Physician (PCP), so each member needs to choose a PCP from the KeystoneBlue provider network. Because KeystoneBlue 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.

KeystoneBlue also includes these important features for maximum member convenience:

• Mental health/substance abuse care assistance is available 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.
• Prescription drugs are covered when received at any pharmacy in the Premier 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, 7 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.

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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To receive care, services must be performed or referred by your PCP or Blues On Call^SM Health Information and Support Line. Exceptions apply for emergency room, Ob/Gyn, and mental health and substance abuse services. Network specialists may continue to provide follow-up care and refer for diagnostic services for a 60-day time period. All care must be provided by network providers. Below are specific benefit levels.

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

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To locate a participating provider in your area, please click on the link below.

• KeystoneBlue Provider Network

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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.

If you have any further questions, please contact us; we'll be glad to help you.

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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:  Wednesday, November 16, 2005  Page: 

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