SECTION 8.0 - PPO Blue (Preferred Provider Organization)
In order to provide you with a brief description of your medical and hospital benefits, a schedule of benefits provided by the PPO Blue Program is shown below. It is not intended to be a complete description of the benefits available to eligible participants. A detailed description of your PPO Blue Program will be provided by Highmark Blue Cross Blue Shield and will govern any discrepancies between the information provided below and that provided by Highmark Blue Cross Blue Shield.
Several definitions that may aid you in understanding the PPO Blue Program are shown below.
Coinsurance
- For Hospital or Facility Other Providers, the percentage of the Provider’s Reasonable Charge for Covered Services which must be paid by the participant and which will be deducted from the Provider’s Reasonable Charge.
- For Professional Providers or Professional Other Providers, the percentage of the Provider’s Reasonable Charge for Covered Services which must be paid by the Subscriber and which will be subtracted from the Provider’s Reasonable Charge.
Copayment
- The fixed, up-front dollar amount you pay for certain covered expenses. Copayment amounts do not apply toward your deductible or coinsurance, and they do not accumulate toward the out-of-pocket maximum.
- For Hospital or Facility Other Providers, a specified dollar amount of the Provider’s Reasonable Charge which must be paid by the participant and which will be deducted from the Provider’s Reasonable Charge before determination of the benefits payable under the Preferred Blue PPO Contract.
- For Professional Providers or Professional Other Providers, a specified dollar amount of the Provider’s Reasonable Charge which must be paid by the participant and which will be subtracted from the Provider’s Reasonable Charge before determination of the benefits payable under this Contract.
Covered Care
You can receive care from the health care provider of your choice. The PPO program does not require that you select a primary care physician to receive covered care. Instead, the program gives you access to a vast network of physicians, hospitals, and other providers throughout the country. Simply call 1-800-810-BLUE (2583) for information on the nearest PPO providers
Benefits are paid at the higher level of reimbursement. You are responsible to pay the co-payment amounts.
Covered Service
A service or supply specified by the Preferred Blue PPO Contract for which benefits will be provided when rendered by a Provider or Supplier.
Deductible
Initial amount a participant must pay each year for covered services before the plan begins to provide benefits.
Network (In- or Out-of-Network) Provider or Supplier
Participating providers have entered into an agreement with Highmark pertaining to payment of benefits for covered services. If you receive services from a health care provider within the PPO Network you will receive a higher level of benefits for covered care from network providers.
Out-of-Network Providers or Suppliers have not entered into an agreement with Highmark. These non-participating providers may not accept the Highmark allowed charges plus any deductible, coinsurance amounts, or copayments as payment-in-full. You will be responsible for payment of any remaining charges. Please consult the material provided by the Preferred Blue PPO Program for complete details regarding In- and Out-of-Network Providers.
Self-Referred Care
You can receive covered care from any health care provider, including specialists, at any time, and there is no need for a referral. You do not have to choose a PCP.
Authorization
The official agreement between the provider and Healthcare Management Services (HMS) that care meets the definition of “medically necessary and appropriate.” Please note that care authorization does not necessarily indicate benefits coverage.
| Benefits | In-Network | Out-of-Network |
|---|---|---|
| Benefit Period | Calendar Year | Calendar Year |
| Deductible | ||
| Individual | $100 | $250.00 |
| Family | $200 | $500.00 |
| Coinsurance | 100% | 80% after deductible |
| Out-of-Pocket Limit | Not Applicable | $1,000 individual; $2,000 per family |
| Lifetime Maximum | $2,000,000 | $300,000 |
| Precertification Requirements for Inpatient Admission |
Performed by Member | |
| Physician Office Visits | 100% after $15 copayment; deductible does not apply |
80% after deductible |
| Hospital Services | 100% after deductible | 80% after deductible |
| (Inpatient and Outpatient) | ||
| Preventive Care | ||
| Adult | ||
| Routine physical exams | 100% after $15 copayment; deductible does not apply |
Not covered |
| Routine GYN exams including PAP tests | 100% after $15 copayment; deductible does not apply |
80%; deductible and maximums do not apply |
| Mammograms as required | 100%; deductible does not apply |
80% after deductible |
| Adult Immunizations | 100% after deductible | 80% after deductible |
| Allergy Extract/Injections | 100% after deductible | 80% after deductible |
| Pediatric Care | ||
| Routine physical exams | 100% after $15 copayment; deductible does not apply |
Not covered |
| Pediatric immunizations | 100%; deductible and maximum do not apply |
80%; deductible and maximums do not apply |
| Benefits | In-Network | Out-of-Network |
|---|---|---|
| Diagnostic Services | 100% after deductible | 80% after deductible |
| (Lab, X-ray and other tests) | ||
| Therapy Services | ||
| Physical Therapy | 100% after $15 copayment; deductible does not apply |
80% after deductible |
| Speech Therapy | 100% after $15 copayment; deductible does not apply |
80% after deductible |
| Occupational Therapy | 100% after $15 copayment; deductible does not apply |
80% after deductible |
| Cardiac Rehabilitation | 100% after deductible | 80% after deductible |
| Chemotherapy | 100% after deductible | 80% after deductible |
| Dialysis Treatment | 100% after deductible | 80% after deductible |
| Infusion Therapy | 100% after deductible | 80% after deductible |
| Radiation Therapy | 100% after deductible | 80% after deductible |
| Maternity Services | 100% after deductible | 80% after deductible |
| Medical Services (except office visits) | 100% after deductible | 80% after deductible |
| Spinal Manipulations | 100% after $15 copayment; deductible does not apply |
80% after deductible |
| Combined Limit: 20 visits per benefit period | ||
| Surgical Services | 100% after deductible | 80% after deductible |
| Emergency Room Services | 100% after $50 copayment (waived if admitted); deductible does not apply | |
| Ambulance Service | 100% after deductible | 100% after deductible |
| Private Duty Nursing | 100% after deductible | Same As Network Services |
| Benefits | Network | Out-of-Network |
|---|---|---|
| Hospice Care | 100% after deductible | 80% after deductible |
| Transplant Services | 100% after deductible | 80% after deductible |
| Skilled Nursing Facility Services | 100% after deductible | 80% after deductible |
| Home Health Care | 100% after deductible | 80% after deductible |
| Durable Medical Equipment | 100% after deductible | 80% after deductible |
| Mental Health Services | ||
| Inpatient Benefits | 100% | 80% after deductible |
| Combined limit: 30 visits per benefit period | ||
| Outpatient Benefits | 100% after $15 copayment; deductible does not apply |
80% after deductible |
| Combined limit: 30 visits per benefit period | ||
| Substance Abuse Services | ||
| Inpatient Benefits | ||
| Detoxification | 100% after deductible | 80% after deductible |
| 7 days per admission; 4 admissions per lifetime | ||
| Residential and Rehabilitation Therapy Services | 100% after deductible | 80% after deductible |
| 30 days per benefit period; 90 days per lifetime | ||
| Outpatient | 100% after $15 copayment; deductible does not apply |
80% after deductible |
| 60 visits per benefit period; 120 visits per lifetime | ||
| Prescription Drug Program | |
|---|---|
| Benefits |
Benefits available through the Premier Pharmacy Network only. Mandatory Generic1 |
| Retail Pharmacy | Up to 34 day supply |
| Copayment |
$10 generic $15 brand/formulary2 $30 brand/non-formulary2 |
| Maitenance Prescription Drugs through Mail Order | Up to 90 day supply |
| Copayment |
$20 generic $30 brand/formulary2 $60 brand/non-formulary2 |
- The member is responsible for the payment differential when a generic drug is authorized by the physician and the patient elects to purchase a brand name drug. The member payment is the price difference between the brand and generic in addition to the copayment or coinsurance amounts, which may apply.
- The Highmark formulary is an extensive list of Food & Drug Administration (FDA) approved prescription drugs selected 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 copayment or coinsurance amounts listed above.