EFFECTIVE DATE Blue Distinction Centers Available Benefit Period (used for and Coinsurance limits) (Applies to Network and Non-Network Benefits combined) ($5000 ) December 1, 2017 None Available Centers Available Centers Available January 1 through December 31 (Calendar Year) Centers Available Family (may be met collectively) Note: All Services are subject to the unless otherwise specified. Coinsurance Limit: Family (may be met collectively) Maximum Out of-pocket Family (may be met collectively) $200 $400 $1,000 $2,000 Network & Non-Network Coinsurance dollars cross apply. $6,600 $13,200 Includes:, Network & Non-Network Coinsurance Limits combined Standard Standard Blue Distinction Center Standard Blue Distinction Center $250 $5,000 $500 $10,000 Blue Distinction Center $1,250 $2,500 $6,600 $13,200 Includes:, Network & Non-Network Coinsurance Limits combined Standard $2,500 $5,000 Blue Distinction Center $6,600 $13,200 Includes:, Network & Non-Network Coinsurance Limits combined $1,500 $3,000 $1,500 $3,000 Non-Network Liability Lifetime Maximum Benefit for all Covered Services BENEFIT HIGHLIGHTS Primary Care Medical Office Visit / Office Consultation - Applies to Charges for Visit only. Does not apply to other Services received during Visit. Specialist Care Medical Office Visit / Office Consultation (Includes Specialist Virtual Visits). Applies to Charges for Visit only. Does not apply to other Services received during Visit. NETWORK ONLY $15/Office Visit, $100 thereafter, No Non $15/Office Visit, $100 thereafter, $20/Office Visit, $100 thereafter, No Non $25/Office Visit, $100 thereafter, No $20/Office Visit, $100 thereafter, No Non $25/Office Visit, $100 thereafter, No 100% After 100% After Urgent Care Copay Co-Pay applies to Charges for Visit only. Does not apply to other Services received during Visit. Co-Pays do not apply to or Coinsurance limits. $50 per Office Visit $50 per Office Visit 100% After Virtual Visit Originating Site Telemedicine3 100% $10 per Visit,, 100% After 100% After
Prescription Drug Family PRESCRIPTION DRUGS Prescription Drugs are provided through a Preferred Retail Pharmacy Network If you choose Brand over Generic, you will pay the difference between the Brand and Generic Allowance, in addition to your Coinsurance, unless the physician writes brand necessary (DAW) on the prescription, or if no generic equivalent exists. Maximum 34 day Supply. Note: Prescription s, Copayments and/or Coinsurance amounts apply toward the Total Maximum Out-of-Pocket. ($5000 ) NETWORK ONLY None None Member pays 30% or $5. Maximum out of pocket $75 30% Coinsurance, No Maximum out of pocket $100 None None None None. Maximum out of pocket $75 Specialty Drugs: Member pays 30% Coinsurance, No Maximum out of pocket $100 whichever is greater.. Maximum out of pocket $75 30% Coinsurance, Maximum out of pocket $100 Integrated with medical Integrated with medical 100% After Additional Benefits with Prescription - Guidelines as determined by certain Governmental Agencies. You may access this information at www.healthcare.gov. You may also contact Member Services Mail Order Drugs If you choose Brand over Generic, you will pay the difference between the Brand and Generic Allowance, in addition to your Coinsurance, unless the physician writes brand necessary (DAW) on the prescription, or if no generic equivalent exists. Maximum 90 day supply. Note: Prescription s, Copayments and/or Coinsurance amounts apply toward the Total Maximum Out-of-Pocket Routine Adult Physical Exams Adult Immunizations Colorectal Cancer Screening Routine Gynecological Exam- Including a Pap Test Mammograms, annual routine & medically necessary Mammograms, annual routine & medically necessary Diagnotic services and procedures Routine Pediatric Physical Exams Pediatric Immunizations Diagnostic Services & Procedures Member pays 30% or $5 Maximum out of pocket $100 30% Coinsurance, No Maximum out of pocket $200 PREVENTIVE CARE SERVICES Maximum out of pocket $100 Specialty Drugs: Member pays 30% Coinsurance, No Maximum out of pocket $200 Routine: Medically Necessary: 100%, No deductible Routine: 100%, No Medically Necessary: after deductible whichever is greater. Maximum out of pocket $100 30% Coinsurance, Maximum out of pocket $200 Routine: Medically Necessary: 100% after deductible 100% After Routine: Medically Necessary: 100% after deductible
AUTISM SPECTRUM DISORDER Services for diagnosis and treatment of Autism Spectrum Disorder. (See Section V for additional information.) Covered Services will be paid according to the benefit category (e.g. speech therapy, office visit). ($5000 ) In-Hospital Medical Visit Surgery, Assistant to Surgery, Anesthesia Second Surgical Opinion Consultants (Outpatient) Maternity Care - Dependent daughters are covered. Newborn Care including circumcision. Occupational Therapy ( Habilitative) PHYSICIAN SERVICES Maximum 30 visits per Benefit Period. Limitations are for Physician and Outpatient Facility Services, Physician and Outpatient Facility Services, Network and Non- Network, Physician and Outpatient Facility Services, Network and Non-Network, Rehabilitative and Physical Therapy- ( Habilitative) Maximum 30 visits per Benefit Period. Limitations are for Physician and Outpatient Facility Services, Network and Non-Network, Physician and Outpatient Facility Services, Network and Non-Network, Rehabilitative and Spinal Manipulations- ( Habilitative) Respiratory Therapy Cardiac Rehabilitation Therapy Dialysis Chemotherapy Radiation Therapy Infusion Therapy Speech Therapy ( Habilitative) when necessary due to a medical condition. Temporomandibular Joint Dysfunction / Craniomandibular Disorders Maximum 30 visits per Benefit Period. Limitations are for Network and Non- Network, Maximum 30 visits per Benefit Habilitative, combined.. Habilitative, combined. Diagnostic, X-ray, Lab and Testing Allergy Testing and Treatment
Unlimited Days Semi-Private Room and Board INPATIENT HOSPITAL / FACILITY SERVICES (Bariatric Surgery; Cardiac Care; Complex and Rare Cancer Care; Knee and Hip Replacement; Spine Surgery and Transplants received at approved Blue Distinction Centers will be subject to the Blue Distinction Center deductible and coinsurance limits) ($5000 ) (Bariatric Surgery; Cardiac Care; Complex and Rare Cancer Care; Knee and Hip Replacement; Spine Surgery and Transplants received at approved Blue Distinction Centers will be subject to the Blue Distinction Center deductible and coinsurance limits) Ancillaries, Drugs, Therapy Services, X-ray and Lab General Nursing Care Surgical Services Birthing Center Care / Maternity Services - Dependent daughters are covered. Pre-Admission Testing Diagnostic, X-ray, Lab and Testing Surgery, Operating Room Occupational Therapy ( Habilitative) Maximum 30 visits per Benefit Rehabilitative and OUTPATIENT HOSPITAL / FACILITY SERVICES High Option B Option 2B 80/20, ( Habilitative) Limitations are for Physician and Outpatient Facility Services, Physical Therapy- ( Habilitative) Maximum 30 visits per Benefit Rehabilitative and, ( Habilitative)Limitations are for Physician and Outpatient Facility Services, Respiratory Therapy Cardiac Rehabilitation Therapy Dialysis Chemotherapy Radiation Therapy Infusion Therapy Speech Therapy ( Habilitative) when necessary due to a medical condition. Outpatient Mental Health Services Outpatient Substance Abuse Services Inpatient Mental Health Care Services Inpatient Substance Abuse Care Services BEHAVIORAL HEALTH SERVICES
Emergency Accident Care and /or Emergency Medical Care provided in the ER- ER copay does not apply to or Coinsurance limits. EMERGENCY CARE SERVICES $100 per visit,, $150 per visit, thereafter, subject to deductible ($5000 ) $150 per visit,, subject to deductible Emergency Ambulance Non-Emergency Medical Care provided in the ER Non-Emergency Ambulance Services NON-EMERGENCY CARE SERVICES $150 per visit, thereafter, subject to deductible $150 per visit,, subject to deductible Private Duty Nursing - Maximum 35 visits per calendar year Note: Maximums are Network and Non-Network combined. OTHER COVERED SERVICES Skilled Nursing Facility: Maximum 200 days per calendar year Day 1-100, 100%, No Day 101-200,, Durable Medical Equipment and Oxygen at home Orthotic Devices and Prosthetic Appliances Home Health Care : Maximum 200 Visits Note: Maximums are Network and Non-Network combined Day 1-100, 100%, No Day 101-200,, Maximum 100 Visits Note: Maximums are Network and Non-Network combined. (Max 100 Visits) (Max 100 Visits) Hospice Care Diabetes Education & Control Subject to, then $20 Co-pay per Office Visit, 100% thereafter
Human Organ Transplant Bone Marrow Procedures Eligible Dependent Age Limitation Includes transportation, meals and lodging. Includes transportation, meals and lodging. HUMAN ORGAN TRANSPLANT / BONE MARROW PROCEDURES Non 100% Non 100% ($5000 ) Coverage stops at the end of the month of the 26th birthday for an adult dependent who is an Eligible Dependent. ALL SERVICES ARE SUBJECT TO A DETERMINATION OF MEDICAL NECESSITY BY HIGHMARK WV. MEDICAL MANAGEMENT & POLICY MUST BE CONTACTED PRIOR TO A PLANNED ADMISSION OR WITHIN 48 HOURS OF AN EMERGENCY OR MATERNITY-RELATED INPATIENT ADMISSION. BE SURE TO VERIFY THAT YOUR PROVIDER IS CONTACTING MM&P FOR PRECERTIFICATION. IF THIS DOES NOT OCCUR AND IT IS LATER DETERMINED THAT ALL OR PART OF THE INPATIENT STAY WAS NOT MEDICALLY NECESSARY OR APPROPIRATE, YOU MAY BE RESPONSIBLE FOR PAYMENT OF ANY COSTS NOT COVERED. PAYMENT IS BASED ON THE PLAN ALLOWANCE. THE PLAN ALLOWANCE WILL GENERALLY BE LESS FOR SERVICES RECEIVED FROM A NON-NETWORK PROVIDER. IN ADDITION, YOU WILL BE RESPONSIBLE FOR THE NON-NETWORK LIABILITY. SERVICES ARE PROVIDED FOR ACUTE CARE FOR MINOR ILLNESSES. SERVICES MUST BE PERFORMED BY A HIGHMARK APPROVED TELEMEDICINE PROVIDER. VIRTUAL BEHAVIORAL HEALTH VISITS PROVIDED BY A HIGHMARK APPROVED TELEMEDICINE PROVIDER ARE ELIGIBLE UNDER THE OUTPATIENT MENTAL HEALTH/SUBSTANCE ABUSE BENEFIT. SERVICES ARE LIMITED TO THOSE LISTED ON THE HIGHMARK PREVENTIVE SCHEDULE (WOMEN'S HEALTH PREVENTIVE SCHEDULE MAY APPLY). AGE AND FREQUENCY LIMITS MAY APPLY. FOR A CURRENT SCHEDULE OF COVERED SERVICES, LOG ONTO YOUR HIGHMARK WV MEMBER WEBSITE, AT WWW.HIGHMARKBCBSWV.COM, OR CALL MEMBER SERVICE AT THE TOLL- FREE NUMBER LISTED ON THE BACK OF YOUR ID CARD. EFFECTIVE WITH PLAN YEARS BEGINNING ON OR AFTER JANUARY 1, 2017, THE NETWORK TOTAL MAXIMUM OUT-OF-POCKET AS MANDATED BY THE FEDERAL GOVERNMENT MUST INCLUDE DEDUCTIBLE, COINSURANCE, COPAYS, AND ANY QUALIFIED MEDICAL AND PRESCRIPTION EXPENSES. THE TOTAL MAXIMUM OUT-OF-POCKET CANNOT BE MORE THAN $7,150 FOR INDIVIDUAL AND $14.300 FOR TWO OR MORE PERSONS. ANTI-CANCER MEDICATIONS ORALLY ADMINISTERED OR SELF-INJECTED. DEDUCTIBLE, COPAYMENT AND COINSURANCE AMOUNTS FOR PATIENT ADMINISTERED ANTI-CANCER MEDICATIONS THAT ARE COVERED BENEFITS ARE APPLIED ON NO LESS FAVORABLE BASIS THAN FOR PROVIDER INJECTED OR INTRAVENOUSLY ADMINISTERED ANTI- CANCER MEDICATIONS. COPAY DIFFERENTIALS APPLY TO HIGHMARK PCP PROVIDERS IN PA, WV & DE. BENEFITS FOR EMERGENCY AMBULANCE SERVICES RENDERED BY A NON-NETWORK PRVIDER WILL BE SUBJECT TO THE SAME COST-SHARING AMOUNT, IF ANY, THAT IS APPLICABLE TO NETWORK SERVICES. THE MEMBER WILL BE RESPONSIBLE FOR ANY AMOUNTS BILLED BY THE NON-NETWORK PROVIDER FOR EMERGENCY AMBULANCE SERVICES THAT ARE IN EXCESS OF THE AMOUNT THAT HIGHMARK WV PAYS.