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HIGHMARKBCBS.COM(27606)
Effective January 1, 2018
For Small Groups
BENEFIT PORTFOLIOWESTERN PENNSYLVANIA REGION
this page was left blankintentionally
TABLE OF CONTENTSINTRODUCTION PAGE 12018 Highmark Portfolio Overview by CountyEssential Health Benefits CategoriesMetal LevelsFinding a ProviderAccess to Quality Care & 2018 Provider NetworkBlue Cross Blue Shield Difference
PPO BLUE PAGE 6Product Description, Service Area Map & Provider NetworkBenefit Grids — Service Areas:Zone C – All 29 Counties of Western PA: Allegheny, Armstrong, Beaver, Butler, Fayette, Greene, Indiana, Lawrence, Washington, Westmoreland, Crawford, Erie, McKean, Mercer, Warren, Bedford, Blair, Cambria, Centre,Clearfield, Huntingdon, Jefferson, Somerset, Cameron, Clarion, Elk, Forest, Potter, and Venango
COMMUNITY BLUE FLEX PAGE 16Product Description, Service Area Map & Provider NetworkBenefit Grids — Service Areas:Zone A: Allegheny, Armstrong, Beaver, Butler, Crawford, Erie, Fayette, Greene, Indiana, Lawrence, McKean, Mercer, Warren, Washington and Westmoreland Zone B: Bedford, Blair, Cambria, Cameron, Centre, Clarion, Clearfield, Elk, Forest, Huntingdon, Jefferson, Potter, Somerset, and Venango Zone G: PA Mountains Healthcare Region available in Armstrong, Blair, Cameron, Clarion, Crawford, Forest, Huntingdon, Jefferson, Indiana, Lawrence, McKean, Potter, and Somerset Zone H: Penn Highlands Region available in Centre, Clearfield, Elk, and Jefferson
CONNECT BLUE & CONEMAUGH REGION CONNECT BLUE PAGE 26Product Description, Service Area Map & Provider Network
Benefit Grids — Service Areas:
Zone J: Allegheny, Beaver, Butler, Erie, Washington, and Westmoreland
Zone Y: Blair, Cambria and Somerset
PEDIATRIC DENTAL & VISION BENEFIT INFO PAGE 34Pediatric Dental: benefits apply to Qualified High Deductible Health Plans (QHDHP)Pediatric Dental: benefits apply to Non-QHDHPsPediatric Vision: benefits apply to Qualified High Deductible Health Plans (QHDHP)
Pediatric Vision: benefits apply to Non-QHDHPs
1
ALLEGHENY
ARMSTRONG
ELK
BEAVER
BEDFORD
CAMBRIA
CLEARFIELD
HUNTINGDON
BLAIR
BUTLER
CAMERON
CENTRE
CLARION
CRAWFORD
ERIE
FAYETTE
FOREST
GREENE
INDIANA
JEFFERSON
LAWRENCE
MCKEAN
MERCER
POTTER
SOMERSET
VENANGO
WARREN
WASHINGTON
WESTMORELAND
INTRODUCTION
At Highmark we believe one size never fits all. That’s why we offer a range of flexible, high-performing network solutions built specifically to meet the unique needs of Small Groups (with 50 or fewer full-time, part-time, and seasonal employees).
Choosing health coverage is one of the most important decisions to make each year and Highmark understands the importance of providing reliable, affordable health coverage that provides peace of mind. The result of our broad network of providers and superior customer service is a health plan that has been trusted for more than 85 years by generations of satisfied members.
To provide you with the information and tools you need, and to make it easier for you to present the Highmark benefit options to your clients, we created this 2018 Product Portfolio. It was designed for easier viewing of all of the health plan options by putting the most important facts and figures front and center (including network information and more).
Premier Balance PPO $0 Platinum APremier Balance PPO $250 Platinum APremier Balance PPO $0 Gold A Premier Balance PPO $250 Gold APremier Balance PPO $500 APremier Balance PPO $750 A Premier Balance PPO $1000 A Balance PPO $1000 A Premier Balance PPO $1250 A Premier Balance PPO $1400 APremier Balance PPO $1500 AHealth Savings PPO $1500 Balance PPO $1750 APremier Balance PPO $2000 A Balance PPO $2000 APremier Balance PPO $2500 AHealth Savings PPO Embedded $2600 Premier Balance PPO $3500 AHealth Savings PPO Embedded $4000 High Deductible PPO Embedded $4750 Qualified A Health Savings PPO Embedded $5500 High Deductible PPO Embedded $6300 Qualified A
Connect Blue EPO $100 a Community Blue PlanConnect Blue EPO $250 a Community Blue PlanConnect Blue EPO $500 a Community Blue PlanConnect Blue EPO $750 a Community Blue PlanConnect Blue EPO $900 a Community Blue Plan Connect Blue EPO $1100 a Community Blue Plan Connect Blue EPO $2500 a Community Blue PlanConnect Blue EPO $3200 a Community Blue Plan
Conemaugh Region Connect Blue EPO $0 Conemaugh Region Connect Blue EPO $1000 Conemaugh Region Connect Blue EPO $3800 Conemaugh Region Connect Blue EPO Embedded $5000
2018 Highmark Portfolio Overview by County
CAMBRIABLAIR
SOMERSET
ALLEGHENY
ARMSTRONG
ELK
BEAVER
BEDFORD
CAMBRIA
CLEARFIELD
HUNTINGDON
BLAIR
BUTLER
CAMERON
CENTRE
CLARION
CRAWFORD
ERIE
FAYETTE
FOREST
GREENE
INDIANA
JEFFERSON
LAWRENCE
MCKEAN
MERCER
POTTER
SOMERSET
VENANGO
WARREN
WASHINGTON
WESTMORELAND
ALLEGHENY
BEAVER
BUTLER
WASHINGTON
WESTMORELAND
ERIE
Flex PPO $500/$1500 Penn Highlands Region a Community Blue PlanFlex PPO PA Mountains Healthcare Region $500/$1500 a Community Blue Plan
Premier Balance PPO $0 Platinum A a Community Blue Flex Plan Premier Balance PPO $250 Platinum A a Community Blue Flex Plan Premier Balance PPO $0 Gold A a Community Blue Flex Plan Premier Balance PPO $250 Gold A a Community Blue Flex Plan Premier Balance PPO $500 A a Community Blue Flex Plan Premier Balance PPO $750 A a Community Blue Flex Plan Premier Balance PPO $1000 A a Community Blue Flex Plan Balance PPO $1000 a Community Blue Flex PlanPremier Balance PPO $1250 A a Community Blue Flex PlanPremier Balance PPO $1400 A a Community Blue Flex Plan Premier Balance PPO $1500 A a Community Blue Flex Plan Health Savings PPO $1500 a Community Blue Flex PlanBalance PPO $1750 A a Community Blue Flex Plan Premier Balance PPO $2000 A a Community Blue Flex Plan Balance PPO $2000 A a Community Blue Flex PlanBalance PPO $600 a Community Blue Flex PlanBalance PPO $2600 a Community Blue Flex PlanHealth Savings PPO Embedded $2600 a Community Blue Flex PlanHealth Savings PPO Embedded $3000 a Community Blue Flex PlanBalance PPO $5000 1x a Community Blue Flex PlanHealth Savings PPO Embedded $5500 a Community Blue Flex PlanHealth Savings PPO Embedded $6000 a Community Blue Flex Plan
Premier Balance PPO $250 IP A a Community Blue Flex PlanPremier Balance PPO $750 IP A a Community Blue Flex Plan Premier Balance PPO $1500 IP A a Community Blue Flex Plan Health Savings PPO Embedded $5500 a Community Blue Flex Plan
FINDING A PROVIDER IS EASY
All Affordable Care Act (ACA) compliant plans must cover the following Essential Health Benefits categories to a benchmark level of coverage established by the state:
• Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance use disorder services • Prescription drugs • Rehabilitative and habilitative services and devices • Laboratory services • Preventive and wellness services and chronic disease • Pediatric services including oral and vision management
Pediatric Dental and Vision services are offered to children under the age of 19; services include dental and vision checkups, as well as one pair of glasses per year. These services are integrated into all plans in the Small Group market.
Prescription Drugs are offered with cost sharing within all plans.
ESSENTIAL HEALTH BENEFITS CATEGORIES
Under health care reform, insurance companies must define the level of health care costs a particular plan will pay (on average) for covered benefits. To make it easier to understand, the government established metal levels.
METAL LEVELS
Out-of-Pocket Costs Estimated Plan Cost
Platinum Plans Lowest $$$$
Gold Plans Low $$$
Silver Plans Moderate $$
Bronze Plans High $
There Are Several Ways to Find Providers
Search Find a Doctor on highmarkbcbs.com (no login required). Members can use this search, no matter where they are to find all Blue Network providers.
Call My Care Navigator at 1-888-BLUE-428. Representatives can help members find a new doctor and transfer their health records.
Call the Member Service number on the back of the Highmark ID card.
Zone G PA Mountains Healthcare Region
Zone H Penn Highlands Region
Zone A
Zone B
Zone CZone J
Zone Y
Access to quality care• Reliable health care coverage and member service and
support from a health insurer with 75 years’ experience.
• A network of high-performing, patient-focused care providers and specialists.
• Allegheny Health Network (AHN) hospitals and physicians anchor Highmark’s western Pennsylvania provider network. As an integrated health system, AHN’s physicians, nurses, and staff are dedicated to providing exceptional care across seven hospitals, 4 Health+Wellness Pavilions, and hundreds of care facil-ities. AHN has received numerous national, regional, and local accolades for superior outcomes, quality care, and positive impacts on the community. As one of the largest health care systems serving western PA, many hospitals are ranked #1 in the market for delivering the highest quality of care in several clinical categories according to the Quantros’ CareChex® 2017 Hospital Quality Ratings.
• Access to nearly 720,000 providers in the BluelCross BlueiShield network across the country.
• Health and wellness discounts on products, services, classes, and fitness facilities.
2018 provider network informationKnow Your Options for CareWith Highmark, members will have access to the region’s leading health care providers, including those that are a part of Allegheny Health Network, as well as other community hospitals. They’ll also have access to all UPMC facilities outside of the five-county Pittsburgh region. Members who have been diagnosed with cancer have in-network access to all UPMC services, facilities, doctors, and joint ventures for oncology covered services through June 2019. This includes illnesses and complications resulting from cancer treatment, such as endocrinology, orthopedics, and cardiology. (The member’s physician must determine that the member should be treated by a UPMC provider who renders oncology services.)1
ER AccessMembers who seek care at any UPMC emergency room will be covered at in-network rates, including any inpatient admission and follow-up care for the emergency condition.2
“Continuation of Care” for Members in Treatment NowMembers who were in a continuing course of treatment for a chronic or persistent condition in 2013, 2014, or 2015 with a UPMC provider or an independent provider and received care for that condition at UPMC can receive care from those providers at the in-network level of benefits through June 2019 if the care is related to, or in conjunction with, a chronic or persistent condition. This includes routine, preventive, and acute care that is received during treatment for a chronic or persistent condition. Otherwise, routine and preventive care will not be covered on an in-network basis.1
Members cannot be referred to or treated by a new UPMC doctor on an in-network basis for care related to a chronic or persistent condition or other conditions they might have or develop. A “new” UPMC doctor means a doctor they have not seen in the past.
“Balance Bill” ProtectionOut-of-network UPMC providers can only bill Highmark members up to the difference between the Plan’s payment and 60% of the UPMC provider’s billed charges for covered services.
To view the most up-to-date information on the Consent Decree and in-network access to UPMC, visit DiscoverHighmark.com.
Allegheny Health Network hospitals
Potter
Allegheny
ArmstrongBeaver
Bedford
Cambria
Cleareld
Huntingdon
Blair
Butler
Cameron
Centre
Clarion
Crawford
Elk
Erie
Fayette
Forest
Greene
Indiana
Je�ersonLawrence
McKean
Mercer
Somerset
Venango
Warren
WashingtonWestmoreland
1When members enrolled in Community Blue Flex and Connect Blue products access UPMC facilities in network for oncology/cancer services and continuation of care. The specific terms of coverage will be according to the member’s benefit plan. Covered claims from UPMC may be processed at the lower level of benefits.
2 Emergency room and any related inpatient care is covered at the Enhanced Value Level of Benefits for Community Blue Flex products and at the Preferred Value Level of Benefits for Connect Blue. The specific terms of coverage will be according to the member’s benefit plan.
THE BLUE CROSS BLUE SHIELD® DIFFERENCE:LOCAL FOCUS, NATIONAL SCALE
Blue Cross Blue Shield One of the Most Recognized Brands in Health InsuranceBlue Cross Blue Shield’s unmatched scale, both domestically and globally, makes Highmark uniquely positioned to provide the best health insurance for our members and your families, no matter where you work, live, or travel.
Nationwide 96 percent of hospitals and 93 percent of physicians in every zip code in the 50 states, as well as the District of Columbia and Puerto Rico, participate in BlueCard program.
Globally, through the BlueCard and Blue Cross Blue Shield Global Core programs, members have access to the largest network of physicians and hospitals across more than 170 countries.
Investing in Local CommunitiesFor decades, the Highmark has been investing in their communities to lead local change and improve the health of residents.
Blue Cross Blue Shield Global Core®Blue Cross Blue Shield Global Core® is a national program that links participating health care providers and the independent Blue plans across the country and around the world.
Members are covered anywhere within the network, just as they are through their “home” plan. Plans interact through an electronic network for claims processing and reimbursement.
Blue networks are powered by Blue Cross Blue Shield Global Core® and provide:
• Seamless, nationwide access to provider networks and discounts • Consistency in health care benefits wherever employees live or travel • Timely settlements, centralized decision-making, and robust reporting
Blue Cross Blue Shield Global Core® provides access to physicians and hospitals in more than 200 countries, along with value-added medical assistance and claims support services
From other locations call 1-804-673-1177.BCBSGlobalCore.com
When you need medical help, call this number from the United States, Puerto Rico or Panama:
1-800-810-BLUE
BLUE CROSS BLUE SHIELD GLOBAL CORE®
Blue Cross Blue Sield Association (BCBSA), Blue Facts (June 2017). Retrieved from https://www.bcbs.com/sites/default/files/file-attachments/page/BCBS.Facts__0.pdf 9/5/17
5 6
Effective January 1, 2018
For Small Groups
PPO BLUE
WESTERN PENNSYLVANIA REGION
this page was left blankintentionally
7 8
PROVIDER NETWORK
Highmark offers multiple plan designs within Preferred Provider Organization (PPO) plans at all metal levels.
In this type of health plan, members pay less if they use providers in the plan’s network. They can also use providers outside of the plan’s network, but will generally have higher out-of-pocket costs.
Outside western Pennsylvania, providers that participate in their local Blue Cross and/or Blue Shield PPO network, or Blue Card® program are covered in network.
PPO BLUE
SERVICE AREA
ALLEGHENY
ARMSTRONG
ELK
BEAVER
BEDFORD
CAMBRIA
CLEARFIELD
HUNTINGDON
BLAIR
BUTLER
CAMERON
CENTRE
CLARION
CRAWFORD
ERIE
FAYETTE
FOREST
GREENE
INDIANA
JEFFERSON
LAWRENCE
MCKEAN
MERCER
POTTER
SOMERSET
VENANGO
WARREN
WASHINGTON
WESTMORELAND Zone C
The BlueCard® Program - With the Blue Cross and Blue Shield BlueCard® network, your coverage travels with you. When you enroll in a Highmark plan, you have access to thousands of providers and hospitals nationwide. Getting access to care is as easy as presenting your Highmark identification (ID) card. Providers who participate with the local Blue Cross and Blue Shield plan, wherever you are, will
recognize and honor your card. So no matter where you go, your benefits go with you.
PPO BLUE FACILITY LISTING
ALLEGHENY• Allegheny General Hospital• Allegheny Valley Hospital• Children’s Hospital of Pittsburgh
of UPMC• Forbes Hospital• Heritage Valley Sewickley• Jefferson Hospital• Ohio Valley Hospital• St. Clair Hospital• West Penn Hospital• Western Psychiatric Institute
and ClinicARMSTRONG• Armstrong County Memorial
HospitalBEAVER• Heritage Valley BeaverBEDFORD• UPMC Bedford MemorialBLAIR• Nason Hospital• Tyrone Hospital• UPMC AltoonaBUTLER• Butler Memorial HospitalCAMBRIA• Conemaugh Memorial
Medical Center• Conemaugh Miners
Medical Center
CLARION• Clarion HospitalCLEARFIELD• Penn Highlands Clearfield• Penn Highlands DuBoisCRAWFORD• Meadville Medical Center• Titusville Area HospitalELK• Penn Highlands ElkERIE• Corry Memorial Hospital• Millcreek Community Hospital• Saint Vincent Hospital• UPMC HamotFAYETTE• Highlands Hospital• Uniontown HospitalGREENE• Washington Health
System GreeneHUNTINGDON• J. C. Blair Memorial HospitalINDIANA• Indiana Regional Medical CenterJEFFERSON• Penn Highlands Brookville• Punxsutawney Area HospitalLAWRENCE• Ellwood City Hospital• UPMC Jameson
MCKEAN• Bradford Regional
Medical Center• Kane Community HospitalMERCER• Edgewood Surgical Hospital• Grove City Medical Center• Sharon Regional Health System• UPMC HorizonPOTTER• Cole MemorialSOMERSET• Conemaugh Meyersdale
Medical Center• Somerset Hospital• Chan Soon-Shiong Medical
Center at WindberVENANGO• UPMC NorthwestWARREN• Warren General HospitalWASHINGTON• Advanced Surgical Hospital• Canonsburg Hospital• Monongahela Valley Hospital• Washington HospitalWESTMORELAND• Excela Frick Hospital• Excela Latrobe Hospital• Excela Westmoreland Hospital
*Provider list as of September 2017. Please refer to the online Find a Doctor tool at highmarkbcbs.com for a listing of network hospitals.
9 10
For Health Plans with Effective Dates Beginning January 1, 2018
Medical DeductiblePlan Payment Level
(Coinsurance)After Deductible
Out-of-PocketMaximum1
Primary Care
ProviderSpecialist2 Urgent
Care Telemedicine Inpatient Hospital
Emergency Room
Basic Diagnostic Services(standard imaging,diagnostic medical,lab/pathology, etc.)
Advanced Imaging(MRI, CAT, PET scan,
etc.)
Rx Formulary(Comprehensive)3
In-Network(2 x Family)
Out-of-Network
(2 x Family)
In-Network(2 x Family)
Out-of-Network
(2 x Family)
In-Network(2 x Family)
Out-of-Network
(2 x Family)In-Network In-Network In-Network In-Network In-Network In-Network In-Network In-Network
Low Cost Generic/Standard Generic/Brand Formulary/
Non-Formulary/ Specialty Formulary/
Specialty Non-Formulary
Member Pays Plan Pays Member Pays
PLAT
INU
M Premier Balance PPO $0 Platinum A
$0 $500 100% 80% $2,000 $4,000 $20 $35 $40 $15 $0 $150 $35 $75$3/$10/$50/
$85/20%/30%*
Premier Balance PPO$250 Platinum A
$250 $500 100% 80% $2,250 $4,500 $20 $35 $40 $15$0
after ded$150 $35 $75
$3/$10/$50/$85/20%/30%*
GO
LD
Premier Balance PPO $0 Gold A
$0 $500 100% 80% $7,350 $14,700 $30 $75 $85 $15 $0 $300 $75 $300$3/$15/$55/
$90/20%/30%*
Premier Balance PPO $250 Gold A
$250 $500 100% 80% $7,350 $14,700 $30 $60 $75 $15$0
after ded$300 $60 $300
$3/$15/$55/$90/20%/30%*
Premier Balance PPO $500 A
$500 $1,000 100% 80% $7,350 $14,700 $30 $60 $75 $15$0
after ded$300 $60 $300
$3/$15/$55/$90/20%/30%*
Premier Balance PPO $750 A
$750 $1,500 100% 80% $7,350 $14,700 $30 $60 $75 $15$0
after ded$300 $60 $300
$3/$15/$55/$90/20%/30%*
Premier Balance PPO $1000 A
$1,000 $2,000 100% 80% $7,100 $14,200 $30 $60 $75 $15$0
after ded$300 $60 $300
$3/$15/$55/$90/20%/30%*
Premier Balance PPO $1250 A
$1,250 $2,500 100% 80% $6,850 $13,700 $30 $60 $75 $15$0
after ded$300 $60 $300
$3/$15/$55/$90/20%/30%*
Premier Balance PPO $1400 A
$1,400 $2,800 100% 80% $7,350 $14,700 $45 $75 $85 $15$0
after ded$250
$75after ded
$325after ded
$3/$15/$55/$90/20%/30%*
*Member pays (at retail) a maximum of $350 for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx
Continued on next page...
2018 PPO BLUEFor Small Groups with 50 or fewer employees
HIGHMARKBCBS.COM
ALLEGHENY
ARMSTRONG
ELK
BEAVER
BEDFORD
CAMBRIA
CLEARFIELD
HUNTINGDON
BLAIR
BUTLER
CAMERON
CENTRE
CLARION
CRAWFORD
ERIE
FAYETTE
FOREST
GREENE
INDIANA
JEFFERSON
LAWRENCE
MCKEAN
MERCER
POTTER
SOMERSET
VENANGO
WARREN
WASHINGTON
WESTMORELAND
Zone C – PPO Blue
11 12
For Health Plans with Effective Dates Beginning January 1, 2018
Medical DeductiblePlan Payment Level
(Coinsurance)After Deductible
Out-of-PocketMaximum1
Primary Care
ProviderSpecialist2 Urgent
Care Telemedicine Inpatient Hospital
Emergency Room
Basic Diagnostic Services(standard imaging,diagnostic medical,lab/pathology, etc.)
Advanced Imaging(MRI, CAT, PET scan,
etc.)
Rx Formulary(Comprehensive)3
In-Network(2 x Family)
Out-of-Network
(2 x Family)
In-Network(2 x Family)
Out-of-Network
(2 x Family)
In-Network(2 x Family)
Out-of-Network
(2 x Family)In-Network In-Network In-Network In-Network In-Network In-Network In-Network In-Network
Low Cost Generic/Standard Generic/Brand Formulary/
Non-Formulary/ Specialty Formulary/
Specialty Non-Formulary
Member Pays Plan Pays Member Pays
GO
LD
Premier Balance PPO $1500 A
$1,500 $3,000 100% 80% $6,600 $13,200 $30 $60 $75 $15$0
after ded$300 $60 $300
$3/$15/$55/$90/20%/30%*
Premier Balance PPO $2000 A
$2,000 $4,000 100% 80% $6,100 $12,200 $30 $60 $75 $15$0
after ded$300 $60 $300
$3/$15/$55/$90/20%/30%*
Premier Balance PPO $2500 A
$2,500 $5,000 100% 80% $7,350 $14,700 $45 $65 $75 $20$0
after ded$250 $65 $250
$3/$15/$55/$90/20%/30%*
Premier Balance PPO $3500 A
$3,500 $7,000 100% 80% $5,800 $11,600 $45 $65 $75 $20$0
after ded$250 $65 $250
$3/$15/$55/$90/20%/30%*
Balance PPO $1000 A
$1,000 $2,000 80% 60% $5,600 $11,200 $60 $80 $90 $1520%
after ded$350
$80after ded
$350after ded
$3/$15/$55/$90/20%/30%*
Balance PPO $1750 A
$1,750 $3,500 90% 70% $7,350 $14,700 $45 $65 $75 $2010%
after ded$250 $65
$250after ded
$3/$15/$55/$90/20%/30%*
Balance PPO$2000 A
$2,000 $4,000 90% 70% $7,150 $14,300 $45 $65 $75 $2010%
after ded$250 $65 $250
$3/$15/$55/$90/20%/30%*
Health Savings PPO $15004,6 $1,500 $3,000 100% 80% $3,000 $6,000
$20after ded
$40after ded
$55after ded
$0after ded
$0after ded
$200after ded
$40after ded
$200after ded
$3/$10/$50/$85/20%/30% after ded*
*Member pays (at retail) a maximum of $350 for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx
Continued on next page...
2018 PPO BLUEFor Small Groups with 50 or fewer employees
HIGHMARKBCBS.COM
ALLEGHENY
ARMSTRONG
ELK
BEAVER
BEDFORD
CAMBRIA
CLEARFIELD
HUNTINGDON
BLAIR
BUTLER
CAMERON
CENTRE
CLARION
CRAWFORD
ERIE
FAYETTE
FOREST
GREENE
INDIANA
JEFFERSON
LAWRENCE
MCKEAN
MERCER
POTTER
SOMERSET
VENANGO
WARREN
WASHINGTON
WESTMORELAND
Zone C – PPO Blue
13 14
For Health Plans with Effective Dates Beginning January 1, 2018
Medical DeductiblePlan Payment Level
(Coinsurance)After Deductible
Out-of-PocketMaximum1
Primary Care Provider Specialist2 Urgent
Care Telemedicine Inpatient Hospital
Emergency Room
Basic Diagnostic Services(standard imaging,diagnostic medical,lab/pathology, etc.)
Advanced Imaging(MRI, CAT, PET scan,
etc.)
Rx Formulary(Comprehensive)3
In-Network(2 x Family)
Out-of-Network
(2 x Family)
In-Network(2 x Family)
Out-of-Network
(2 x Family)
In-Network(2 x Family)
Out-of-Network
(2 x Family)In-Network In-Network In-Network In-Network In-Network In-Network In-Network In-Network
Low Cost Generic/Standard Generic/Brand Formulary/
Non-Formulary/ Specialty Formulary/
Specialty Non-Formulary
Member Pays Plan Pays Member Pays
SILV
ER
Health Savings PPO Embedded $26004,5,6 $2,600 $5,200 100% 80% $5,300 $10,600
$20after ded
$35after ded
$75after ded
$0after ded
$0after ded
$250after ded
$35after ded
$250after ded
$3/$15/$55/$90/20%/30% after ded*
Health Savings PPO Embedded $40004,5,6 $4,000 $8,000 100% 100% $4,000 $8,000
$0after ded
$0after ded
$0after ded
$0after ded
$0after ded
$0after ded
$0after ded
$0after ded
$0 after ded
BRO
NZE
High Deductible PPO Embedded $4750 Qualified A4,5,6 $4,750 $9,500 60% 50% $6,550 $13,100
40%after ded
40%after ded
40%after ded
40%after ded
40%after ded
40%after ded
40%after ded
40%after ded
40% after ded
Health Savings PPO Embedded $55004,5,6 $5,500 $11,000 80% 60% $6,550 $13,100
20%after ded
20%after ded
20%after ded
20%after ded
20%after ded
20%after ded
20%after ded
20%after ded
20% after ded
High Deductible PPO Embedded $6300 Qualified A4,5,6 $6,300 $12,600 90% 70% $6,550 $13,100
10%after ded
10%after ded
10%after ded
10%after ded
10%after ded
10%after ded
10%after ded
10%after ded
10% after ded
*Member pays (at retail) a maximum of $350 for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx
2018 PPO BLUEFor Small Groups with 50 or fewer employees
HIGHMARKBCBS.COM
ALLEGHENY
ARMSTRONG
ELK
BEAVER
BEDFORD
CAMBRIA
CLEARFIELD
HUNTINGDON
BLAIR
BUTLER
CAMERON
CENTRE
CLARION
CRAWFORD
ERIE
FAYETTE
FOREST
GREENE
INDIANA
JEFFERSON
LAWRENCE
MCKEAN
MERCER
POTTER
SOMERSET
VENANGO
WARREN
WASHINGTON
WESTMORELAND
Zone C – PPO Blue
15 16
COMMUNITY BLUE FLEX,PA MOUNTAINS HEALTHCARE,& PENN HIGHLANDS
WESTERN PENNSYLVANIA REGION
Effective January 1, 2018
For Small Groups
this page was left blankintentionally
17 18
The Community Blue Flex PPO plans have two value levels of benefits: Enhanced and Standard. Your employees may choose from many doctors or hospitals that participate in the network.
When they choose a doctor at the Enhanced level, they may spend less out of pocket than if they use a doctor at the Standard level. They can choose in-network doctors, labs, hospitals, and other facilities based on convenience, past experience, recommendations and accreditations, as well as cost.
Highmark has developed a collaborative relationship with PA Mountains and Penn Highlands Healthcare that is focused on the overall health of the community and improving patients’ care, while managing the cost of care and improving the value of employers’ health care dollars.
Outside of the counties where the Community Blue Flex plans are offered, services received from providers participating in a local Blue plan, or BlueCard® program, are covered at the Enhanced value level of benefits.
SERVICE AREA
Level of Benefits Your Cost
In-N
etwo
rk Enhanced
Access to all of the covered services you need. Your
out-of-pocket are the lowest with this level.
Enhanced Value– Members spend less with lower deductible
and out-of-pocket costs for care from Enhanced Value providers
StandardProvides additional choice, but out-of-pocket costs are often
higher than Enhanced.
Standard Value– Higher costs for care from other
in-network providers
Out-of-NetworkIf you use out-of-network
providers, you will have the highest out-of-pockets costs.
COMMUNITY BLUE FLEX PROVIDER NETWORK
SERVICE AREA
ALLEGHENY
ARMSTRONG
ELK
BEAVER
BEDFORD
CAMBRIA
CLEARFIELD
HUNTINGDON
BLAIR
BUTLER
CAMERON
CENTRE
CLARION
CRAWFORD
ERIE
FAYETTE
FOREST
GREENE
INDIANA
JEFFERSON
LAWRENCE
MCKEAN
MERCER
POTTER
SOMERSET
VENANGO
WARREN
WASHINGTON
WESTMORELAND
Zone G — PA Mountains Healthcare Region
Zone H — Penn Highlands Region
*Provider list as of September 2017. Please refer to the online Find a Doctor tool at highmarkbcbs.com for a listing of network hospitals.
The Community Blue Flex Plans Offer Two Tiers of in-Network Benefits
Zone A
Zone B
Region CountyIn-Network
Enhanced Value Standard Value
WPA Allegheny • Allegheny General Hospital• Allegheny Valley Hospital• Children’s Hospital of Pittsburgh
of UPMC• Forbes Hospital• Heritage Valley Sewickley
Armstrong • Armstrong County Memorial Hospital
Beaver • Heritage Valley Beaver
Bedford • UPMC Bedford Memorial
Blair • Nason Hospital• Tyrone Hospital
Butler • Butler Memorial Hospital
Cambria • Conemaugh Memorial Medical Center• Conemaugh Miners Medical Center
Clarion • Clarion Hospital• Clarion Psychiatric Center
Clearfield • Penn Highlands Clearfield• Penn Highlands DuBois
Crawford • Meadville Medical Center• Titusville Area Hospital
Elk • Penn Highlands Elk
Erie • Corry Memorial Hospital• Millcreek Community Hospital
• UPMC Hamot
Fayette • Highlands Hospital• Uniontown Hospital
Greene • Washington Health System Greene
Huntingdon • J. C. Blair Memorial Hospital
Indiana • Indiana Regional Medical Center
Jefferson • Penn Highlands Brookville• Punxsutawney Area Hospital
Lawrence • Ellwood City Hospital • UPMC Jameson
McKean • Bradford Regional Medical Center• Kane Community Hospital
Mercer • Edgewood Surgical Hospital• Grove City Medical Center
• UPMC Horizon
Potter • Cole Memorial Hospital
Somerset • Conemaugh Meyersdale Medical Center
• Somerset Hospital
Venango • UPMC Northwest
Warren • Warren General Hospital
Washington • Advanced Surgical Hospital• Canonsburg Hospital
Westmoreland • Excela Frick Hospital• Excela Latrobe Hospital
COMMUNITY BLUE FLEX FACILITY LISTING
• Jefferson Hospital• Ohio Valley General Hospital• St. Clair Hospital• West Penn Hospital• Western Psychiatric Institute and Clinic
• Monongahela Valley Hospital• Washington Hospital
• UPMC Altoona
• Saint Vincent Hospital
• Sharon Regional Health System
• Excela Westmoreland Hospital
• Chan Soon-Shiong Medical Center at Windber
The BlueCard® Program - With the Blue Cross and Blue Shield BlueCard® network, your coverage travels with you. When you enroll in a Highmark plan, you have access to thousands of providers and hospitals nationwide at the Enhanced Value Benefit Level. Getting access
to care is as easy as presenting your Highmark identification (ID) card. Providers who participate with the local Blue Cross and Blue Shield plan, wherever you are, will recognize and honor your card. So no matter where you go, your benefits go with you.
19 20
For Health Plans with Effective Dates Beginning January 1, 2018
Medical DeductiblePlan Payment Level
(Coinsurance)After Deductible
Out-of-PocketMaximum1
Primary Care Provider/Retail
Clinic(except where
noted)
Specialist2 Urgent Care Telemedicine Inpatient Hospital
Emergency Room
Basic Diagnostic Services(standard imaging,diagnostic medical,lab/pathology, etc.)
Advanced Imaging
(MRI, CAT, PET scan, etc.)
Rx Formulary(Comprehensive)3
In-Network Out-of-Network(2 x Fam)
In-Network Out-of-Network(2 x Fam)
In-Network(2 x Fam)
Out-of-Network(2 x Fam)
In-Network In-Network In-Network In-Network In-NetworkEnhanced/Standard
In-Network In-Network Low Cost Generic/Standard Generic/Brand Formulary/
Non-Formulary/Specialty Formulary/
Specialty Non-FormularyEnhanced(2x Fam)
Standard(2x Fam)
Enhanced(2x Fam)
Standard(2x Fam)
Enhanced Standard Enhanced Standard Enhanced StandardEnhanced/Standard
Enhanced Standard Enhanced Standard Enhanced Standard
Member Pays Plan Pays Member Pays
PLAT
INU
M
Premier Balance PPO $0 Platinum A a Community Blue Flex Plan
$0 $500 $1,500 100% 70% 50% $2,000 $6,000 $10 $40 $20 $60 $40 $70 $5 $030%
after ded$150 $20 $60 $40 $100
$3/$10/$50/$85/20%/30%*
Premier Balance PPO $250 Platinum A a Community Blue Flex Plan
$250 $750 $2,250 100% 70% 50% $1,700 $5,100 $10 $40 $20 $60 $40 $70 $5$0
after ded30%
after ded$150 $20 $60 $40 $100
$3/$10/$50/$85/20%/30%*
GO
LD
Premier Balance PPO $0 Gold A a Community Blue Flex Plan
$0 $5,000 $15,000 100% 60% 50% $7,350 $22,050 $25 $70 $65 $90 $75 $100 $15$500
per admit40%
after ded$275 $65
$90after ded
$275$375
after ded$3/$15/$55/$90/
20%/30%*
Premier Balance PPO $250 Gold A a Community Blue Flex Plan
$250 $750 $2,250 100% 70% 50% $7,350 $22,050 $25 $65 $60 $90 $75 $100 $15$0
after ded30%
after ded$250 $60 $90 $225 $325
$3/$15/$55/$90/20%/30%*
Premier Balance PPO $500 A a Community Blue Flex Plan
$500 $1,500 $4,500 100% 70% 50% $7,350 $22,050 $25 $65 $55 $90 $70 $100 $15$0
after ded30%
after ded$225 $55 $90 $225 $325
$3/$15/$55/$90/20%/30%*
Premier Balance PPO $750 A a Community Blue Flex Plan
$750 $1,500 $4,500 100% 70% 50% $7,350 $22,050 $25 $65 $55 $90 $70 $100 $15$0
after ded30%
after ded$225 $55 $90 $225 $325
$3/$15/$55/$90/20%/30%*
Premier Balance PPO $1000 A a Community Blue Flex Plan
$1,000 $2,000 $6,000 100% 70% 50% $7,350 $22,050 $25 $65 $55 $90 $70 $100 $15$0
after ded30%
after ded$225 $55 $90 $225 $325
$3/$15/$55/$90/20%/30%*
*Member pays (at retail) a maximum of $350 for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx
Zone A: Allegheny, Armstrong, Beaver, Butler, Crawford, Erie, Fayette, Greene, Indiana, Lawrence, McKean, Mercer, Warren, Washington and Westmoreland Counties
2018 COMMUNITY BLUE FLEXFor Small Groups with 50 or fewer employees
HIGHMARKBCBS.COM
ALLEGHENY
ARMSTRONG
ELK
BEAVER
BEDFORD
CAMBRIA
CLEARFIELD
HUNTINGDON
BLAIR
BUTLER
CAMERON
CENTRE
CLARION
CRAWFORD
ERIE
FAYETTE
FOREST
GREENE
INDIANA
JEFFERSONLAWRENCE
MCKEAN
MERCER
POTTER
SOMERSET
VENANGO
WARREN
WASHINGTON
WESTMORELAND
Zone A
Continued on next page...
21 22
For Health Plans with Effective Dates Beginning January 1, 2018
Medical DeductiblePlan Payment Level
(Coinsurance)After Deductible
Out-of-PocketMaximum1
Primary Care Provider/
Retail Clinic(except where
noted)
Specialist2 Urgent Care Telemedicine Inpatient Hospital
Emergency Room
Basic Diagnostic Services(standard imaging,diagnostic medical,lab/pathology, etc.)
Advanced Imaging
(MRI, CAT, PET scan, etc.)
Rx Formulary(Comprehensive)3
In-Network Out-of-Network(2 x Fam)
In-Network Out-of-Network(2 x Fam)
In-Network(2 x Fam)
Out-of-Network(2 x Fam)
In-Network In-Network In-Network In-Network In-NetworkEnhanced/Standard
In-Network In-Network Low Cost Generic/Standard Generic/Brand Formulary/
Non-Formulary/Specialty Formulary/
Specialty Non-FormularyEnhanced(2x Fam)
Standard(2x Fam)
Enhanced(2x Fam)
Standard(2x Fam)
Enhanced Standard Enhanced Standard Enhanced StandardEnhanced/Standard
Enhanced Standard Enhanced Standard Enhanced Standard
Member Pays Plan Pays Member Pays
GO
LD
Premier Balance PPO $1250 A a Community Blue Flex Plan
$1,250 $2,500 $7,500 100% 70% 50% $6,000 $18,000 $25 $65 $55 $90 $70 $100 $15$0
after ded30%
after ded$225 $55 $90 $225 $325
$3/$15/$55/$90/20%/30%*
Premier Balance PPO $1400 A a Community Blue Flex Plan
$1,400 $5,000 $15,000 100% 70% 50% $7,350 $22,050 $40 $75 $70 $90 $85 $125 $15$0
after ded30%
after ded$300 $70
$90after ded
$35030%
after ded$3/$15/$55/$90/
20%/30%*
Premier Balance PPO $1500 A a Community Blue Flex Plan
$1,500 $3,000 $9,000 100% 70% 50% $7,350 $22,050 $25 $65 $55 $90 $70 $100 $15$0
after ded30%
after ded$225 $55 $90 $225 $325
$3/$15/$55/$90/20%/30%*
Premier Balance PPO $2000 A a Community Blue Flex Plan
$2,000 $3,000 $9,000 100% 70% 50% $7,350 $22,050 $25 $65 $55 $90 $70 $100 $15$0
after ded30%
after ded$225 $55 $90 $225 $325
$3/$15/$55/$90/20%/30%*
Balance PPO $1000 a Community Blue Flex Plan
$1,000 $5,000 $12,000 90% 70% 50% $6,400 $19,200 $45$75
after ded$75
after ded$95
after ded$100 $150 $15
10%after ded
30%after ded
$300 $75$95
after ded$350
after ded30%
after ded$3/$15/$55/$90/
20%/30%*
Balance PPO $1750 A a Community Blue Flex Plan
$1,750 $5,250 $15,700 90% 70% 50% $7,150 $21,450 $35 $65 $60 $90 $75 $100 $1510%
after ded30%
after ded$250 $60 $90 $200 $400
$3/$15/$55/$90/20%/30%*
Balance PPO $2000 A a Community Blue Flex Plan
$2,000 $6,000 $18,000 90% 70% 50% $7,150 $21,450 $35 $65 $60 $90 $75 $100 $1510%
after ded30%
after ded$250 $60 $90 $200 $400
$3/$15/$55/$90/20%/30%*
Health Savings PPO $1500 a Community Blue Flex Plan4,6 $1,500 $4,500 100% 70% 50% $3,300 $9,900
$15after ded
$50after ded
$25after ded
$70after ded
$40after ded
$95after ded
$0after ded
$0after ded
30%after ded
$200after ded
$30after ded
$70after ded
$100after ded
$200after ded
$3/$10/$50/$85/20%/30% after ded*
*Member pays (at retail) a maximum of $350 for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx
Zone A: Allegheny, Armstrong, Beaver, Butler, Crawford, Erie, Fayette, Greene, Indiana, Lawrence, McKean, Mercer, Warren, Washington and Westmoreland Counties
2018 COMMUNITY BLUE FLEXFor Small Groups with 50 or fewer employees
HIGHMARKBCBS.COM
Continued on next page...
ALLEGHENY
ARMSTRONG
ELK
BEAVER
BEDFORD
CAMBRIA
CLEARFIELD
HUNTINGDON
BLAIR
BUTLER
CAMERON
CENTRE
CLARION
CRAWFORD
ERIE
FAYETTE
FOREST
GREENE
INDIANA
JEFFERSONLAWRENCE
MCKEAN
MERCER
POTTER
SOMERSET
VENANGO
WARREN
WASHINGTON
WESTMORELAND
Zone A
23 24
For Health Plans with Effective Dates Beginning January 1, 2018
Medical DeductiblePlan Payment Level
(Coinsurance)After Deductible
Out-of-PocketMaximum1
Primary Care Provider/
Retail Clinic(except where
noted)
Specialist2 Urgent Care Telemedicine Inpatient Hospital
Emergency Room
Basic Diagnostic Services(standard imaging,diagnostic medical,lab/pathology, etc.)
Advanced Imaging
(MRI, CAT, PET scan, etc.)
Rx Formulary(Comprehensive)3
In-Network Out-of-Network(2 x Fam)
In-Network Out-of-Network(2 x Fam)
In-Network(2 x Fam)
Out-of-Network(2 x Fam)
In-Network In-Network In-Network In-Network In-NetworkEnhanced/Standard
In-Network In-Network Low Cost Generic/Standard Generic/Brand Formulary/
Non-Formulary/Specialty Formulary/
Specialty Non-FormularyEnhanced(2x Fam)
Standard(2x Fam)
Enhanced(2x Fam)
Standard(2x Fam)
Enhanced Standard Enhanced Standard Enhanced StandardEnhanced/Standard
Enhanced Standard Enhanced Standard Enhanced Standard
Member Pays Plan Pays Member Pays
SILV
ER
Balance PPO $600a Community Blue Flex Plan
$600 $1,800 $5,400 50% 40% 40% $7,350 $22,050 $5560%
after ded$80
60%after ded
$9060%
after ded$15
50%after ded
60%after ded
$500 $8060%
after ded50%
after ded60%
after ded$3/$30/$60/$90/
20%/30%*
Balance PPO $2600a Community Blue Flex Plan
$2,600 $5,200 $15,600 70% 50% 50% $7,350 $22,050 $4050%
after ded$75
50%after ded
$8550%
after ded$15
30%after ded
50%after ded
$500$75
after ded50%
after ded30%
after ded50%
after ded$3/$30/$60/$90/
20%/30%*
Balance PPO $5000 1xa Community Blue Flex Plan
$5,000 1x per family
$6,0001x per family
$18,0001x per family
70% 50% 50%$7,3501x per family
$22,0501x per family
$2550%
after ded$50
50%after ded
$6050%
after ded$15
30%after ded
50%after ded
$500$75
after ded50%
after ded30%
after ded50%
after ded$3/$30/$60/$90/
20%/30%*
Health Savings PPO Embedded $2600 a Community Blue Flex Plan4,5,6
$2,600 $7,800 100% 70% 50% $6,550 $19,650$0
after ded$30
after ded$30
after ded$60
after ded$45
after ded$100
after ded$0
after ded$0
after ded30%
after ded$250
after ded$30
after ded$60
after ded$50
after ded$150
after ded$3/$15/$55/$90/
20%/30% after ded*
Health Savings PPO Embedded $3000 a Community Blue Flex Plan4,5,6
$3,000 $9,000 100% 60% 50% $6,550 $19,650$0
after ded40%
after ded$0
after ded40%
after ded$0
after ded40%
after ded$0
after ded$0
after ded40%
after ded$0
after ded$0
after ded40%
after ded$0
after ded40%
after ded$3/$30/$60/$90/
20%/30% after ded*
BRO
NZE
Health Savings PPO Embedded $5500 a Community Blue Flex Plan4,5,6
$5,500 $11,000 80% 60% 50% $6,550 $19,65020%
after ded40%
after ded20%
after ded40%
after ded20%
after ded40%
after ded20%
after ded20%
after ded40%
after ded20%
after ded20%
after ded40%
after ded20%
after ded40%
after ded20%
after ded
Health Savings PPO Embedded $6000 a Community Blue Flex Plan4,5,6
$6,000 $12,000 100% 70% 50% $6,550 $19,650$0
after ded30%
after ded$0
after ded30%
after ded$0
after ded30%
after ded$0
after ded$0
after ded30%
after ded$0
after ded$0
after ded30%
after ded$0
after ded30%
after ded$3/$15/$55/$90/
20%/30% after ded*
*Member pays (at retail) a maximum of $350 for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx
Zone A: Allegheny, Armstrong, Beaver, Butler, Crawford, Erie, Fayette, Greene, Indiana, Lawrence, McKean, Mercer, Warren, Washington and Westmoreland Counties
2018 COMMUNITY BLUE FLEXFor Small Groups with 50 or fewer employees
HIGHMARKBCBS.COM
ALLEGHENY
ARMSTRONG
ELK
BEAVER
BEDFORD
CAMBRIA
CLEARFIELD
HUNTINGDON
BLAIR
BUTLER
CAMERON
CENTRE
CLARION
CRAWFORD
ERIE
FAYETTE
FOREST
GREENE
INDIANA
JEFFERSONLAWRENCE
MCKEAN
MERCER
POTTER
SOMERSET
VENANGO
WARREN
WASHINGTON
WESTMORELAND
Zone A
25 26
For Health Plans with Effective Dates Beginning January 1, 2018
Medical DeductiblePlan Payment Level
(Coinsurance)After Deductible
Out-of-PocketMaximum1
Primary Care Provider/
Retail Clinic(except where
noted)
Specialist Urgent Care Telemedicine Inpatient Hospital
Emergency Room
Basic Diagnostic Services(standard imaging,diagnostic medical,lab/pathology, etc.)
Advanced Imaging
(MRI, CAT, PET scan, etc.)
Rx Formulary(Comprehensive)3
In-Network Out-of-Network(2 x Fam)
In-Network Out-of-Network(2 x Fam)
In-Network(2 x Fam)
Out-of-Network(2 x Fam)
In-Network In-Network In-Network In-Network In-NetworkEnhanced/Standard
In-Network In-Network Low Cost Generic/Standard Generic/Brand Formulary/
Non-Formulary/Specialty Formulary/
Specialty Non-FormularyEnhanced(2x Fam)
Standard(2x Fam)
Enhanced(2x Fam)
Standard(2x Fam)
Enhanced Standard Enhanced Standard Enhanced StandardEnhanced/Standard
Enhanced Standard Enhanced Standard Enhanced Standard
Member Pays Plan Pays Member Pays
GO
LD
Premier Balance PPO $250 IP A a Community Blue Flex Plan
$250 $750 $2,250 100% 70% 50% $7,350 $22,050 $25 $65 $60 $90 $75 $100 $15$500
per admit30%
after ded$250 $60 $90 $225 $325
$3/$15/$55/$9020%/30%*
Premier Balance PPO $750 IP A a Community Blue Flex Plan
$750 $1,500 $4,500 100% 70% 50% $7,350 $22,050 $35 $65 $55 $90 $70 $100 $15$500
per admit30%
after ded$225 $55 $90 $225 $325
$3/$15/$55/$90/20%/30%*
Premier Balance PPO $1500 IP A a Community Blue Flex Plan
$1,500 $4,500 $13,500 100% 70% 50% $7,150 $21,450 $45$70
after ded$70 $90 $85 $100 $15
$1,000per admit
30%after ded
$250 $70$95
after ded$350
30%after ded
$3/$15/$55/$90/20%/30%*
BRO
NZE Health Savings PPO
Embedded $5500 a Community Blue Flex Plan4,5,6
$5,500 $11,000 80% 60% 50% $6,550 $19,65020%
after ded40%
after ded20%
after ded40%
after ded20%
after ded40%
after ded20%
after ded20%
after ded40%
after ded20%
after ded20%
after ded40%
after ded20%
after ded40%
after ded20%
after ded
*Member pays (at retail) a maximum of $350 for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx
Zone B: Bedford, Blair, Cambria, Cameron, Centre, Clarion, Clearfield, Elk, Forest, Huntingdon, Jefferson, Potter, Somerset, and Venango Counties only
2018 COMMUNITY BLUE FLEXFor Small Groups with 50 or fewer employees
HIGHMARKBCBS.COM
ALLEGHENY
ARMSTRONG
ELK
BEAVER
BEDFORD
CAMBRIA
CLEARFIELD
HUNTINGDON
BLAIR
BUTLER
CAMERON
CENTRE
CLARION
CRAWFORD
ERIE
FAYETTE
FOREST
GREENE
INDIANA
JEFFERSONLAWRENCE
MCKEAN
MERCER
POTTER
SOMERSET
VENANGO
WARREN
WASHINGTON
WESTMORELAND
Zone B
27 28
For Health Plans with Effective Dates Beginning January 1, 2018
Medical DeductiblePlan Payment Level
(Coinsurance)After Deductible
Out-of-PocketMaximum1
Primary Care Provider/
Retail Clinic(except where
noted)
Specialist2 Urgent Care Telemedicine Inpatient
HospitalEmergency
Room
Basic Diagnostic Services(standard imaging,diagnostic medical,lab/pathology, etc.)
Advanced Imaging
(MRI, CAT, PET scan, etc.)
Rx Formulary(Comprehensive)3
In-Network Out-of-Network(2 x Fam)
In-Network Out-of-Network(2 x Fam)
In-NetworkOut-of-
Network(2 x Fam)
In-Network In-Network In-Network In-Network In-NetworkEnhanced/Standard
In-Network In-Network Low Cost Generic/Standard Generic/Brand Formulary/
Non-Formulary/Specialty Formulary/
Specialty Non-FormularyEnhanced(2x Fam)
Standard(2x Fam)
Enhanced(2x Fam)
Standard(2x Fam)
Enhanced Standard Enhanced StandardEnhanced/ Standard
Enhanced/Standard
Enhanced Standard Enhanced Standard Enhanced Standard
Member Pays Plan Pays Member Pays
GO
LD
Flex PPO PA Mountains Healthcare Region $500/$1500a Community Blue Plan
$500 $1,500 $4,500 100% 70% 50% $7,350 $22,050$20
(Retail Clinic $30)
$50(Retail
Clinic $30)$45 $75 $75 $15
$0 after ded
30%after ded
$225 $45 $75$0
after ded30%
after ded$3/$10/$50/$85/
20%/30%*
*Member pays (at retail) a maximum of $350 for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx
Zone G: PA Mountains Healthcare Region available in Armstrong, Blair, Cameron, Clarion, Crawford, Forest, Huntingdon, Jefferson, Indiana, Lawrence, McKean, Potter, and Somerset Counties only
2018 PA Mountains Healthcare RegionFor Small Groups with 50 or fewer employees
HIGHMARKBCBS.COM
ALLEGHENY
ARMSTRONG
ELK
BEAVER
BEDFORD
CAMBRIA
CLEARFIELD
HUNTINGDON
BLAIR
BUTLER
CAMERON
CENTRE
CLARION
CRAWFORD
ERIE
FAYETTE
FOREST
GREENE
INDIANA
JEFFERSONLAWRENCE
MCKEAN
MERCER
POTTER
SOMERSET
VENANGO
WARREN
WASHINGTON
WESTMORELAND
Zone G — PA Mountains Healthcare Region
29 30
For Health Plans with Effective Dates Beginning January 1, 2018
Medical DeductiblePlan Payment Level
(Coinsurance)After Deductible
Out-of-PocketMaximum1
Primary Care Provider/
Retail Clinic(except where
noted)
Specialist2 Urgent Care Telemedicine Inpatient
HospitalEmergency
Room
Basic Diagnostic Services(standard imaging,diagnostic medical,lab/pathology, etc.)
Advanced Imaging
(MRI, CAT, PET scan, etc.)
Rx Formulary(Comprehensive)3
In-Network Out-of-Network(2 x Fam)
In-Network Out-of-Network(2 x Fam)
In-NetworkOut-of-
Network(2 x Fam)
In-Network In-Network In-Network In-Network In-NetworkEnhanced/Standard
In-Network In-Network Low Cost Generic/Standard Generic/Brand Formulary/
Non-Formulary/Specialty Formulary/
Specialty Non-FormularyEnhanced(2x Fam)
Standard(2x Fam)
Enhanced(2x Fam)
Standard(2x Fam)
Enhanced Standard Enhanced StandardEnhanced/ Standard
Enhanced/Standard
Enhanced Standard Enhanced Standard Enhanced Standard
Member Pays Plan Pays Member Pays
GO
LD
Flex PPO $500/$1500 Penn Highlands Regiona Community Blue Plan
$500 $1,500 $4,500 100% 70% 50% $7,350 $22,050$25
(Retail Clinic $35)
$55(Retail Clinic
$35)$45 $75 $75 $15
$0 after ded
30%after ded
$250 $50 $75$0
after ded30%
after ded$3/$10/$50/$85/
20%/30%*
*Member pays (at retail) a maximum of $350 for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx
Zone H: Penn Highlands Region available in Centre, Clearfield, Elk and Jefferson Counties only2018 Penn Highlands RegionFor Small Groups with 50 or fewer employees
HIGHMARKBCBS.COM
ELK
CLEARFIELDCENTRE
JEFFERSON
Zone H — Penn Highlands Region
31 32
Effective January 1, 2018
For Small Groups
CONNECT BLUE & CONEMAUGH REGION CONNECT BLUE
WESTERN PENNSYLVANIA REGION
this page was left blankintentionally
33 34
ALLEGHENY
BEAVER
BUTLER
WASHINGTON
WESTMORELAND
ERIE
Connect Blue and Conemaugh Region Connect Blue are EPO (Exclusive Provider Organization) health plans that provides benefits when care is received from network providers. Out-of-network care is not covered (except in an emergency).
These plans use the Community Blue network of providers that participate at a specific level of benefits. These plans have three value levels of benefits for in-network services: Preferred, Enhanced, and Standard. All levels offer the same high-quality care — no matter which level they use.
With the Conemaugh Region Connect Blue EPO, Highmark and Conemaugh Health System have partnered to provide services at the Preferred Value Benefit Level in Blair, Cambria, and Somerset counties.
Outside of the counties where these plans are offered, services received from providers participating in a local Blue plan, or BlueCard® program, are covered at the Enhanced value level of benefits.
Connect Blue plans offer 3 tiers of in-network benefits & No out-of-network coverage
SERVICE AREA
CONNECT BLUE PROVIDER NETWORK
SERVICE AREA
Level of Benefits Your Cost
In-N
etw
ork Preferred Value If members use providers participating at the Preferred Value
Level of Benefits, their out-of-pocket costs are the lowest. $Enhanced Value
If members use providers participating at the Enhanced Value Level of Benefits, their out-of-pocket costs are often higher than Preferred. $$
Standard Value If members use providers participating at the Standard Value Level of Benefits, their out-of-pocket costs are the highest. $$$
Connect Blue Conemaugh Region
Region CountyIn-Network
Preferred Value Enhanced Value Standard Value
WPA (Plan available for purchase in these counties)
Blair • Nason Hospital • Tyrone Hospital • UPMC Altoona
Cambria • Conemaugh Memorial Medical Center• Conemaugh Miners Medical Center
Somerset • Conemough Meyersdale Medical Center • Somerset Hospital• Chan Soon-Shlong Medical Center
(formerly Windber Medical Center)
WPA (Members may also access facilities in these counties)
AlleghenyErieWashingron
• Allegheny General Hospital• Allegheny Valley Hospital• Canonsburg General Hospital• Forbes Regional Hospital• Jefferson Regional Medical Center• St. Vincent Health System• Western Pennsylvania Hospital• Children’s Hospital of UPMC• Western Psychiatric Institute & Clinic
• All remaining INN providers (with the exception of Standard providers)
• UPMC Hamot• UPMC Consent Decree*
Remaining Counties
• All INN providers • UPMC Bedford• UPMC Horizon• UPMC Jameson• UPMC Kane• UPMC Northwest
CPA/NEPA All 29 Counties • All INN providers
Blue Card Out-of-Area • All INN providers
PREFERRED VALUE LEVEL ENHANCED VALUE LEVEL
ALLEGHENY• Allegheny General Hospital• Allegheny Valley Hospital• Children’s Hospital of Pittsburgh of UPMC• Forbes Hospital• Heritage Valley Sewickley • Jefferson Hospital• St. Clair Hospital• West Penn Hospital• Western Psychiatric Institute and Clinic
ALLEGHENY• Ohio Valley Hospital
ERIE• Corry Memorial Hospital• Millcreek Community Hospital
WASHINGTON• Advanced Surgical Hospital• Monongahela Valley Hospital
STANDARD VALUE LEVEL
ERIE• UPMC Hamot
CONNECT BLUE
CONEMAUGH REGION CONNECT BLUE
Network in WPA = Community Blue; Network in CPA/NEPA = Premier Blue Shield; Out-of-Area = Blue Card*Members enrolled in Connect Blue products access UPMC facilities in network for oncology/cancer services and continuation of care. Covered claims from UPMC may be processed at the lower level of benefits. Emergency room and any related inpatient care is covered at the Preferred Value Level of Benefits for Connect Blue. The specific terms of coverage will be according to the member’s benefit plan.
CAMBRIABLAIR
SOMERSETThe BlueCard® Program - With the Blue Cross and Blue Shield BlueCard® network, your coverage travels with you. When you enroll in a
Highmark plan, you have access to thousands of providers and hospitals nationwide at the Enhanced Value Benefit Level. Getting access to care is as easy as presenting your Highmark identification (ID) card. Providers who participate with the local Blue Cross and Blue Shield
plan, wherever you are, will recognize and honor your card. So no matter where you go, your benefits go with you.
BEAVER• Heritage Valley Beaver BUTLER• Butler Memorial HospitalERIE• Saint Vincent HospitalWASHINGTON• Canonsburg Hospital• Washington Hospital
WESTMORELAND• Excela Frick Hospital• Excela Latrobe Hospital• Excela Westmoreland Hospital
*Provider list as of September 2017. Please refer to the online Find a Doctor tool at highmarkbcbs.com for a listing of network hospitals.
Zone J Zone Y
35 36
For Health Plans with Effective Dates Beginning January 1, 2018
Medical DeductiblePlan Payment Level
(Coinsurance)After Deductible
Out-of-Pocket
Maximum1
Primary Care Provider/
Retail Clinic**Specialist2 Urgent Care Telemedicine Inpatient
HospitalEmergency
Room
Basic Diagnostic Services(standard imaging,diagnostic medical,lab/pathology, etc.)
Advanced Imaging
(MRI, CAT, PET scan, etc.)
Rx Formulary(Comprehensive)3
In-Network
Out-o
f-Net
work In-Network
Out-o
f-Net
work
In-N
etwo
rk(2
x Fa
m)
Out-o
f-Net
work In-Network In-Network In-Network In-Network In-Network
Preferred/Enhanced/Standard
In-Network In-NetworkLow Cost Generic/Standard Generic/Brand Formulary/Non-Formulary/
Specialty Formulary/Specialty
Non-FormularyPrefe
rred
(2x F
am)
Enha
nced
(2x F
am)
Stan
dard
(2x F
am)
Prefe
rred
(2x F
am)
Enha
nced
(2x F
am)
Stan
dard
(2x F
am)
Prefe
rred
Enha
nced
Stan
dard
Prefe
rred
Enha
nced
Stan
dard Preferred/
Enhanced Stan
dard Preferred/
Enhanced/Standard Pr
eferre
d
Enha
nced
Stan
dard
Prefe
rred
Enha
nced
Stan
dard
Prefe
rred
Enha
nced
Stan
dard
Member Pays Plan Pays Member Pays
GO
LD
Connect Blue EPO $100 a Community Blue Plan
$100 $1,000 $3,000 N/A 100% 70% 50% N/A $7,350 N/A $25 $50 50% after ded $40 $70 50%
after ded $60 50% after ded $15
$250up to 3
days-then $0 copay
$1,000up to 3
days-then $0 copay
50% after ded $250 $35/$45
(SOS)7 $70 50% after ded
$125/$150 (SOS)7 $350
50% after ded
$3/$15/$55/$90/20%/30%*
Connect Blue EPO $250 a Community Blue Plan
$250 $1,000 $3,000 N/A 100% 70% 50% N/A $7,350 N/A $15 $40 50% after ded $35 $65 50%
after ded $50 50% after ded $15
$250up to 3
days-then $0 copay
$1,000up to 3
days-then $0 copay
50% after ded $250 $35/$50
(SOS)7 $70 50% after ded
$150/$175 (SOS)7 $350
50% after ded
$3/$15/$55/$90/20%/30%*
Connect Blue EPO $500 a Community Blue Plan
$500 $2,000 $4,000 N/A 100% 70% 50% N/A $7,350 N/A $15 $40 50% after ded $35 $65 50%
after ded $55 50% after ded $15 $500
per admit$1,500
per admit50%
after ded $225 $35/$50 (SOS)7 $70 50%
after ded$150/$175
(SOS)7 $35050% after ded
$3/$15/$55/$90/20%/30%*
Connect Blue EPO $750 a Community Blue Plan
$750 $3,000 $6,000 N/A 100% 70% 50% N/A $7,350 N/A $15 $40 50% after ded $30 $65 50%
after ded $55 50% after ded $15 $500
per admit$1,500
per admit50%
after ded $225 $35/$50 (SOS)7 $70 50%
after ded$150/$175
(SOS)7 $35050% after ded
$3/$15/$55/$90/20%/30%*
Connect Blue EPO $900 a Community Blue Plan
$900 $3,600 $4,600 N/A 100% 70% 50% N/A $7,350 N/A $15 $40 50% after ded $40 $65 50%
after ded $65 50% after ded $15 $500
per admit$1,500
per admit50%
after ded $225 $35/$50 (SOS)7 $70 50%
after ded$150/$175
(SOS)7 $35050% after ded
$3/$15/$55/$90/20%/30%*
Connect Blue EPO $1100 a Community Blue Plan
$1,100 $3,300 $4,300 N/A 100% 70% 50% N/A $7,350 N/A $15 $40 50% after ded $40 $65 50%
after ded $65 50% after ded $15 $500
per admit$1,500
per admit50%
after ded $225 $35/$50 (SOS)7 $70 50%
after ded$150/$175
(SOS)7 $35050% after ded
$3/$15/$55/$90/20%/30%*
Connect Blue EPO $2500 a Community Blue Plan
$2,500 $5,000 $6,000 N/A 100% 70% 50% N/A $7,350 N/A $25 $60 50% after ded $50 $85 50%
after ded $65 50% after ded $15 $500
per admit$1,500
per admit50%
after ded $250 $25/$50 (SOS)7 $85 50%
after ded$150/$200
(SOS)7 $40050% after ded
$3/$10/$50/$85/20%/30%*
Connect Blue EPO $3200 a Community Blue Plan
$3,200 $4,400 $5,400 N/A 100% 70% 50% N/A $7,350 N/A $25 $60 50% after ded $50 $85 50%
after ded $65 50% after ded $15 $500
per admit$1,500
per admit50%
after ded $250 $25/$50 (SOS)7 $85 50%
after ded$150/$200
(SOS)7 $40050% after ded
$3/$10/$50/$85/20%/30%*
*Member pays (at retail) a maximum of $350 for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx**Retail Clinic: Preferred/Enhanced = member pays Preferred benefit level copay. Standard Retail Clinic = member pays Standard benefit level coinsurance.
Zone J: Allegheny, Beaver, Butler, Erie, Washington, and Westmoreland Counties only2018 CONNECT BLUE EPOFor Small Groups with 50 or fewer employees
HIGHMARKBCBS.COM
Zone J – Connect BlueALLEGHENY
BEAVER
BUTLER
WASHINGTON
WESTMORELAND
ERIE
37 38
*Member pays (at retail) a maximum of $350 for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx**Retail Clinic: Preferred/Enhanced = member pays Preferred benefit level copay. Standard Retail Clinic = member pays Standard benefit level coinsurance.
Zone Y: Blair, Cambria and Somerset2018 CONEMAUGH REGIONAL CONNECT BLUE EPOFor Small Groups with 50 or fewer employees
HIGHMARKBCBS.COM
For Health Plans with Effective Dates Beginning January 1, 2018
Medical DeductiblePlan Payment Level
(Coinsurance)After Deductible
Out-of-Pocket
Maximum1
Primary Care Provider/
Retail Clinic**Specialist2 Urgent Care Telemedicine Inpatient
HospitalEmergency
Room
Basic Diagnostic Services(standard imaging,diagnostic medical,lab/pathology, etc.)
Advanced Imaging
(MRI, CAT, PET scan, etc.)
Rx Formulary(Comprehensive)3
In-Network
Out-o
f-Net
work In-Network
Out-o
f-Net
work
In-N
etwo
rk(2
x Fa
m)
Out-o
f-Net
work In-Network In-Network In-Network In-Network In-Network
Preferred/Enhanced/Standard
In-Network In-NetworkLow Cost Generic/Standard Generic/Brand Formulary/Non-Formulary/
Specialty Formulary/Specialty
Non-FormularyPrefe
rred
(2x F
am)
Enha
nced
(2x F
am)
Stan
dard
(2x F
am)
Prefe
rred
(2x F
am)
Enha
nced
(2x F
am)
Stan
dard
(2x F
am)
Prefe
rred
Enha
nced
Stan
dard
Prefe
rred
Enha
nced
Stan
dard Preferred\
Enhanced Stan
dard Preferred/
Enhanced/Standard Pr
eferre
d
Enha
nced
Stan
dard
Prefe
rred
Enha
nced
Stan
dard
Prefe
rred
Enha
nced
Stan
dard
Member Pays Plan Pays Member Pays
GO
LD
Conemaugh Region Connect Blue EPO $0 $0 $1,500 $3,000 N/A 100% 70% 50% N/A $7,350 N/A $25 $60
50% after ded
$45 $70 50% after ded $55
50%after ded
$15$0
after ded
30% after ded
50% after ded
$250 $45 $7050% after ded
$275 $37550% after ded
$3/$15/$55/$90/ 20%/30%*
Conemaugh RegionConnect Blue EPO $1000 $1,000 $3,000 $4,000 N/A 100% 70% 50% N/A $7,350 N/A $15 $40
50% after ded
$45 $70 50% after ded $55
50% after ded
$15$0
after ded
30% after ded
50% after ded
$250 $45 $7050% after ded
$175 $35050%afterded
$3/$15/$55/$90/ 20%/30%*
SILV
ER Conemaugh Region Connect Blue EPO $3800 $3,800 $5,000 $5,500 N/A 100% 70% 50% N/A $7,350 N/A $50
30% after ded
50% after ded
$7530% after ded
50% after ded $90
50% after ded
$15$0
after ded
30% after ded
50% after ded
$400 $75 30% after ded
50% after ded
$30030% after ded
50%afterded
$3/$20/$60/$90/ 20%/30%*
BRO
NZE Conemaugh Region
Connect Blue EPO Embedded $50004,5,6
$5,000 N/A 100% 70% 50% N/A $6,550 N/A$0
after ded
30% after ded
50% after ded
$35 after ded
30% after ded
50% after ded
$50 after ded
50% after ded
$0after ded
$0after ded
30% after ded
50% afterded
$300 after ded
$35after ded
30% after ded
50% after ded
$0 after ded
30% after ded
50% after ded
$3/$15/$55/$90/ 20%/30%*
after ded
CAMBRIABLAIR
SOMERSETZone Y
39 40
Effective January 1, 2018
For Small Groups
PEDIATRIC DENTAL & VISION COVERAGE BENEFIT SUMMARY
WESTERN PENNSYLVANIA REGION
this page was left blankintentionally
41 42
Pediatric Dental Coverage Benefit SummarySmall Group – 50 or Fewer Employees
For Small Group Health Benefit Plans with Effective Dates Beginning January 2018
These benefits apply to Qualified High Deductible Health Plans (QHDHP).This plan meets the minimum essential health benefit requirements for pediatric oral health as required under the Federal Affordable Care Act.These benefits are only available for children through the end of the contract year that they turn 19.This Policy will pay benefits for Covered Services shown below subject to the Schedule of Exclusions and Limitations and other Policy terms. Payment is based on the Maximum Allowable Charge (MAC) for the specific Covered Service. Participating Dentists accept contracted MACs as payment in full for services.
Contract Year Deductible per Insured Person: Combined with MedicalAnnual Maximum per Insured Person: UnlimitedOut-of-Pocket (OOP) Year Maximum per Insured Person: Combined with Medical
SERVICE CATEGORY WAITINGPERIOD
POLICY PAYS AFTER DEDUCTIBLEParticipating Dentists* Non-Participating
Dentists
Oral Evaluations (Exams) None 100% Not Covered No
Radiographs (All X-rays) None 100% Not Covered No
Prophylaxis (Cleanings) None 100% Not Covered No
Fluoride Treatments None 100% Not Covered No
Palliative Treatment (Emergency) None Coinsurance matches medical coinsurance Not Covered Yes
Sealants None 100% Not Covered No
Space Maintainers None 100% Not Covered No
Basic Restoration Anterior Amalgam None Coinsurance matches medical coinsurance Not Covered Yes
Basic Restoration Anterior Composite None Coinsurance matches medical coinsurance Not Covered Yes
Basic Restoration Posterior Amalgam None Coinsurance matches medical coinsurance Not Covered Yes
Crowns, Inlays, Onlays None Coinsurance matches medical coinsurance Not Covered Yes
Crown Repair None Coinsurance matches medical coinsurance Not Covered Yes
Endodontic Therapy (Root canals, etc.) None Coinsurance matches medical coinsurance Not Covered Yes
Surgical Periodontics None Coinsurance matches medical coinsurance Not Covered Yes
Non-Surgical Periodontics None Coinsurance matches medical coinsurance Not Covered Yes
Periodontal Maintenance None Coinsurance matches medical coinsurance Not Covered Yes
Prosthetics (Complete or Fixed Partial Dentures) None Coinsurance matches medical coinsurance Not Covered Yes
Adjustments and Repairs of Prosthetics None Coinsurance matches medical coinsurance Not Covered Yes
Maxillofacial Prosthetics N/A Not Covered Not Covered N/A
Implant Services None Coinsurance matches medical coinsurance Not Covered Yes
Simple Extractions None Coinsurance matches medical coinsurance Not Covered Yes
Surgical Extractions None Coinsurance matches medical coinsurance Not Covered Yes
Oral Surgery None Coinsurance matches medical coinsurance Not Covered Yes
General Anesthesia, Nitrous Oxide and/or IV Sedation None Coinsurance matches medical coinsurance Not Covered Yes
Consultations None Coinsurance matches medical coinsurance Not Covered Yes
Medically Necessary Orthodontics None Coinsurance matches medical coinsurance Not Covered Yes
* Pediatric Dental benefits utilize the United Concordia Advantage Network. Members must use a United Concordia provider. There is no Out-of-Network coverage for this benefit. United Concordia Companies, Inc., is a separate company that does not provide Blue Cross and/or Blue Shield products or services. United Concordia is solely responsible for the products and services described here.
MEDICALLY NECESSARY ORTHODONTICS COVERAGE
In this section, “Medically Necessary” or “Medical Necessity” shall mean health care services that a physician or Dentist exercising prudent clinical judgment would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms, and that are:
1. in accordance with the generally accepted standards of medical/dental practice;
2. clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury, or disease; and
3. not primarily for the convenience of the patient or physician/Dentist, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury, or disease.
As used in subpart 1, above, “generally accepted standards of medical/dental practice” means:
• standards that are based on credible scientific evidence published in peer-reviewed, medical/dental literature generally recognized by the relevant professional community;
• recognized Medical/Dental and Specialty Society recommendations;
• the views of physicians/Dentists practicing in the relevant clinical area; and
• any other relevant factors.
A Medically Necessary orthodontic service is an orthodontic procedure that occurs as part of an approved orthodontic plan that is intended to treat a severe dentofacial abnormality.
COVERAGE OF MEDICALLY NECESSARY ORTHODONTICS
1. Orthodontic treatment must be Medically Necessary and be the only method capable of:
a) Preventing irreversible damage to the Insured Person’s teeth or their supporting structures and,
b) Restoring the Insured Person’s oral structure to health and function.
2. Insured Persons must have a fully erupted set of permanent teeth to be eligible for comprehensive, Medically Necessary orthodontic services.
3. All Medically Necessary orthodontic services require prior approval and a written plan of care.
43 44
These benefits apply to Non-Qualified High Deductible Health Plans (Non-QHDHP).This plan meets the minimum essential health benefit requirements for pediatric oral health as required under the Federal Affordable Care Act.These benefits are only available for children through the end of the contract year that they turn 19.This Policy will pay benefits for Covered Services shown below subject to the Schedule of Exclusions and Limitations and other Policy terms. Payment is based on the Maximum Allowable Charge (MAC) for the specific Covered Service. Participating Dentists accept contracted MACs as payment in full for services.
Contract Year Deductible per Insured Person: $0Out-of-Pocket (OOP) Year Maximum per Insured Person: Combined with MedicalAnnual Maximum per Insured Person: Unlimited
Pediatric Dental Coverage Benefit SummarySmall Group – 50 or Fewer Employees
SERVICE CATEGORY WAITINGPERIOD
POLICY PAYS AFTER DEDUCTIBLEParticipating
Dentists*Non-Participating
Dentists
Oral Evaluations (Exams) None 100% Not Covered N/A
Radiographs (All X-rays) None 100% Not Covered N/A
Prophylaxis (Cleanings) None 100% Not Covered N/A
Fluoride Treatments None 100% Not Covered N/A
Palliative Treatment (Emergency) None 100% Not Covered N/A
Sealants None 100% Not Covered N/A
Space Maintainers None 100% Not Covered N/A
Basic Restoration Anterior Amalgam None 50% Not Covered N/A
Basic Restoration Anterior Composite None 50% Not Covered N/A
Basic Restoration Posterior Amalgam None 50% Not Covered N/A
Crowns, Inlays, Onlays None 50% Not Covered N/A
Crown Repair None 50% Not Covered N/A
Endodontic Therapy (Root canals, etc.) None 50% Not Covered N/A
Surgical Periodontics None 50% Not Covered N/A
Non-Surgical Periodontics None 50% Not Covered N/A
Periodontal Maintenance None 50% Not Covered N/A
Prosthetics (Complete or Fixed Partial Dentures) None 50% Not Covered N/A
Adjustments and Repairs of Prosthetics None 50% Not Covered N/A
Maxillofacial Prosthetics N/A Not Covered Not Covered N/A
Implant Services None 50% Not Covered N/A
Simple Extractions None 50% Not Covered N/A
Surgical Extractions None 50% Not Covered N/A
Oral Surgery None 50% Not Covered N/A
General Anesthesia, Nitrous Oxide and/or IV Sedation None 50% Not Covered N/A
Consultations None 100% Not Covered N/A
Medically Necessary Orthodontics None 50% Not Covered N/A
For Small Group Health Benefit Plans with Effective Dates Beginning January 2018
* Pediatric Dental benefits utilize the United Concordia Advantage Network. Members must use a United Concordia provider. There is no Out-of-Network coverage for this benefit. United Concordia Companies, Inc., is a separate company that does not provide Blue Cross and/or Blue Shield products or services. United Concordia is solely responsible for the products and services described here.
MEDICALLY NECESSARY ORTHODONTICS COVERAGE
In this section, “Medically Necessary” or “Medical Necessity” shall mean health care services that a physician or Dentist exercising prudent clinical judgment would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms, and that are:
1. in accordance with the generally accepted standards of medical/dental practice;
2. clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury, or disease; and
3. not primarily for the convenience of the patient or physician/Dentist, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury, or disease.
As used in subpart 1, above, “generally accepted standards of medical/dental practice” means:
• standards that are based on credible scientific evidence published in peer-reviewed, medical/dental literature generally recognized by the relevant professional community;
• recognized Medical/Dental and Specialty Society recommendations;
• the views of physicians/Dentists practicing in the relevant clinical area; and
• any other relevant factors.
A Medically Necessary orthodontic service is an orthodontic procedure that occurs as part of an approved orthodontic plan that is intended to treat a severe dentofacial abnormality.
COVERAGE OF MEDICALLY NECESSARY ORTHODONTICS
1. Orthodontic treatment must be Medically Necessary and be the only method capable of:
a) Preventing irreversible damage to the Insured Person’s teeth or their supporting structures and,
b) Restoring the Insured Person’s oral structure to health and function.
2. Insured Persons must have a fully erupted set of permanent teeth to be eligible for comprehensive, Medically Necessary orthodontic services.
3. All Medically Necessary orthodontic services require prior approval and a written plan of care.
45 46
PEDIATRIC VISION COVERAGE BENEFIT SUMMARYSMALL GROUP - 50 OR FEWER EMPLOYEES
NETWORK BENEFIT (Independents & Visionworks)* FREQUENCY
ELIGIBLE PARTICIPANTS Members under 19 years of age(1)
Eye Examination (including dilation, as professionally indicated) Once every 12 months
Eyeglass Lenses** Once every 12 months
Frames** Once every 12 months
PLAN RESPONSIBILITY
EYE EXAMINATION (including dilation, as professionally indicated) 100%
FRAMES
Pediatric Frame Selection 100% after deductible
EYEGLASS LENSES(2) (Per Pair)
Single vision 100% after deductible
Bifocal 100% after deductible
Trifocal 100% after deductible
Lenticular 100% after deductible
VALUE ADDED BENEFITS Lens Options purchased from a participating provider will be provided to the member at the amounts listed below.
MEMBER RESPONSIBILITY
LENS OPTIONS
Standard progressive lenses (3) $50
Premium progressive lenses (3) $90
Polycarbonate lenses $0
Intermediate vision lenses $30
High-index (thinner and lighter) lenses $55
Polarized lenses $75
Fashion, sun or gradient tinted plastic lenses $11
Ultraviolet coating $12
Scratch-resistant coating $0
Scratch Protection Plan Single Vision $20
Scratch Protection Plan Multifocal $40
Standard ARC (anti-reflective coating) $35
Premium ARC (anti-reflective coating) $48
Ultra ARC (anti-reflective coating) $60
(1) Dependents will be terminated from the contract at the end of the month in which they turn 19. Termination rules for employer groups are determined by the client.(2) Includes glass, plastic or oversized lenses.(3) Progressive multifocals can be worn by most people. Conventional bifocals will be supplied at no additional charge for anyone who is unable to adapt to progressivelenses. However, the member’s payment towards the progressive upgrade will not be refunded.*Vision benefits utilize the Davis Vision Network. Members must use a Davis Vision provider who participates in the Health Care Reform Vision Network. There is noout-of-network coverage. Davis Vision is a separate company that administers Highmark vision benefits. Visionworks, also a separate company, is a providerwithin the Davis Vision Network.**Subject to deductible.
These benefits apply to Qualified High Deductible Health Plans (QHDHP).
For Small Group Health Benefit Plans with Effective Dates Beginning January 2018
PEDIATRIC VISION COVERAGE BENEFIT SUMMARYSMALL GROUP - 50 OR FEWER EMPLOYEES
NETWORK BENEFIT (Independents & Visionworks)* FREQUENCY
ELIGIBLE PARTICIPANTS Members under 19 years of age(1)
Eye Examination (including dilation, as professionally indicated) Once every 12 months
Eyeglass Lenses Once every 12 months
Frames Once every 12 months
PLAN RESPONSIBILITY
EYE EXAMINATION (including dilation, as professionally indicated) 100%
FRAMES
Pediatric Frame Selection 100%
EYEGLASS LENSES(2) (Per Pair)
Single vision 100%
Bifocal 100%
Trifocal 100%
Lenticular 100%
VALUE ADDED BENEFITS Lens Options purchased from a participating provider will be provided to the member at the amounts listed below.
MEMBER RESPONSIBILITY
LENS OPTIONS
Standard progressive lenses (3) $50
Premium progressive lenses (3) $90
Polycarbonate lenses $0
Intermediate vision lenses $30
High-index (thinner and lighter) lenses $55
Polarized lenses $75
Fashion, sun or gradient tinted plastic lenses $11
Ultraviolet coating $12
Scratch-resistant coating $0
Scratch Protection Plan Single Vision $20
Scratch Protection Plan Multifocal $40
Standard ARC (anti-reflective coating) $35
Premium ARC (anti-reflective coating) $48
Ultra ARC (anti-reflective coating) $60
(1) Dependents will be terminated from the contract at the end of the month in which they turn 19. Termination rules for employer groups are determined by the client.(2) Includes glass, plastic or oversized lenses.(3) Progressive multifocals can be worn by most people. Conventional bifocals will be supplied at no additional charge for anyone who is unable to adapt to progressivelenses. However, the member’s payment towards the progressive upgrade will not be refunded.*Vision benefits utilize the Davis Vision Network. Members must use a Davis Vision provider who participates in the Health Care Reform Vision Network. There is noout-of-network coverage. Davis Vision is a separate company that administers Highmark vision benefits. Visionworks, also a separate company, is a providerwithin the Davis Vision Network.
These benefits apply to Non-Qualified High Deductible Health Plans (Non-QHDHP).
For Small Group Health Benefit Plans with Effective Dates Beginning January 2018
47
Important Plan Details:
1 Out-of-pocket maximum calculation includes deductible, copayment and coinsurance.
2 Specialist copay applies to outpatient: mental health, behavior health, substance abuse, chiropractic, physical therapy and speech therapy office visits.
3 Rx information displayed: Retail 31-day supply. NOTE: Member’s maximum coinsurance payment for a retail Specialty Rx is $350 Formulary/$500 Non-Formulary.
4 Integrated Rx plans include all medical and prescription claims accumulating toward one overall deductible.
5 “Embedded” plans: In this approach, an individual family member can be eligible for payment of benefits upon meeting the Individual deductible amount (even if the rest of the family has not met the Family deductible amount). Additionally, an individual family member’s out-of-pocket (OOP) maximum will be the same as that of a member purchasing Individual Coverage for the specified health plan.
6 A Health Savings Account (HSA) is available to employees. Employer contributions in amounts that exceed annual federally mandated maximum(s) may result in actuarial value changes that may impact compliance as a Qualified Health Plan.
7 (SOS): Connect Blue plans have “Site of Service” at the Preferred Level for Labs/Basic Diagnostic Services and Advanced Imaging benefits. Non-Hospital locations have a lower copay and Hospital locations have a higher copay — similar to the Out-Patient Surgery benefit.
Disclosures:
Insurance or benefit administration may be provided by Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Coverage Advantage or Highmark Health Insurance Company, all of which are independent licensees of the Blue Cross and Blue Shield Association.
BlueCard program and Blue Cross Blue Shield Global Core is a registered mark of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
To find more information about Highmark’s benefits and operating procedures, such as accessing the drug formulary or using network providers, please go to DiscoverHighmark.com/QualityAssurance; or for a paper copy, call1-855-873-4106.
HIGHMARKBCBS.COM