CommunityBlue High Point-of-Service

*** This plan is only effective until 1/1/2005 ***

CommunityBlue, a point-of-service plan from Highmark Blue Cross Blue Shield, was developed for employers who want to give their employees all the advantages of Blue Cross Blue Shield coverage while meeting the demands of a tight budget. As a point-of-service plan, CommunityBlue gives members a choice every time they receive medical care. They can allow their Primary Care Physician (PCP) or Blues On Call^SM to "coordinate" their care and receive a higher level of benefits coverage…or they can choose to "self-refer" for care and receive benefits at a lower level.

CommunityBlue helps employers save money because it uses a more select network of health care providers. The CommunityBlue network includes advanced teaching hospitals as well as local community medical centers. Blue Cross Blue Shield managed care network physicians who have admitting privileges to these hospitals are part of the CommunityBlue network. Each CommunityBlue member chooses a PCP from the CommunityBlue network.

Currently CommunityBlue is available in the following counties:

The CommunityBlue High Plan allows members to visit their PCP and pay a $10 Co-Payment. Generic prescription drugs purchased at a Premier Pharmacy Network cost the member a $10 Co-Payment. The Co-Payment for brand name drugs is $20. If a generic drug is available and the member or physician requests a brand name drug, the member is responsible for the $20 Co-Payment plus the difference in cost between the brand and generic drugs.

CommunityBlue also includes these important features for maximum member convenience:

• Female members can receive gynecological or maternity care - at the higher level of benefits - from the CommunityBlue network Ob/Gyn or nurse midwife of their choice, at any time, without a PCP referral.
• 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.
• 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, specialty referrals for coverage at the maximum level of benefits, and help making informed health care decisions.
• Prescription drugs are covered when received at any pharmacy in the Premier Gold III Pharmacy Network or through the convenient mail order service.

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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Care is considered coordinated (in-network) when it is performed or referred by your PCP, or referred through the Blues On Call^SM Health Information and Support Line. Exceptions apply for emergency room, Ob/Gyn, and mental health and substance abuse services. If you choose to obtain medical care through another provider, in most cases, this care will be considered self-referred care. Following a referral from your PCP or through Blues On Call^SM, network specialists may continue to provide follow-up care and refer for diagnostic services for a 60-day time period. Below are specific benefit levels.

Wish to have a printable version of this benefit grid? A simple click will open a pdf version...CommunityBlue High 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	Coordinated Care "In-Network" Care	Self-Referred 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 Mandatory Generic + Formulary4 31 day supply Maintenance Drugs through Mail order $20 Co-Pay Generic $40 Co-Pay Brand Mandatory Generic + Formulary4 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 tests1	100% after $10 Co-Payment	Self-referred to in-network provider: 100% after $10 Co-Pay Self-referred to out-of-network provider: 80%; deductible/policy max. does not apply
Mammograms, as required	100%	80% after deductible
Pediatric
Pediatric immunizations	100%	80% (deductible/policy max does not apply)
Routine physical exams	100% after $10 Co-Pay	Not Covered
Emergency Room Services
	100% after $35 Co-Pay (waived if admitted)
	Emergency care is paid at the coordinated benefits level	Self-referred benefits (80% after deductible) apply for non-emergency care
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
Medical/Surgical Expenses
(except office visits)	100%	80% after deductible
Maternity 1
	100%	Self-referred to in-network provider, 100% Self-referred to out-of-network provider, 80% after deductible
Infertility
Infertility Counseling, Testing and Treatment2	100%	80% after deductible
Assisted Fertilization Procedures
Not Covered
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
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
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 5
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-Payment Limit: 20 visits per calendar year	80% after deductible Limit: 10 visits per calendar year
	Combined Limit: 20 visits per calendar year
Substance Abuse 5
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-Community Blue network hospital 3
Claim Forms Required
	No	Yes

¹A female member may self-refer to a Community Blue network OB/GYN of her choice for any gynecological or maternity care. These services do not require authorization or a referral from your PCP.

²Treatment 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.

³If 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.

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 drug and the generic drug in addition to the brand drug Co-Pay or coinsurance amounts which may apply.

⁵To obtain mental health and substance abuse services at maximum benefits level, you must contact Highmark's Mental Health and Substance Abuse unit before seeking treatment.

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.

• CommunityBlue

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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.