Page 13 - Mersen Benefit Guide Local 502

Highmark BCBS Summary of Medical Plans – Mersen Choice Plan

Benefit In Network Out of Network
General Provisions
Benefit Period (1) Calendar Year

Deductible (per benefit period)
Individual $200 $1,000
Family $400 $2,000
Plan Pays – payment based on the plan allowance 80% after deductible 70% after deductible

Total Maximum Out-of-Pocket (Includes deductible, coinsurance,
copays, prescription drug cost share, and other qualified medical
expenses, Network only) (2) Once met, the plan pays 100% of
covered services for the rest of the benefit period.

Individual $4,000 $8,000
Family $8,000 $16,000
Office/Clinic/Urgent Care Visits
Retail Clinic Visits & Virtual Visits 100% after $25 copay 70% after deductible
Primary Care Provider Office Visits & Virtual Visits 100% after $25 copay 70% after deductible
Specialist Office Visits & Virtual Visits 100% after $40 copay 70% after deductible
Virtual Visit Provider Originating Site Fee 80% after deductible 70% after deductible
Urgent Care Center Visits 100% after $40 copay 70% after deductible
Teladoc Services (3) 100% no copay Not Covered
Preventive Care (4)
Routine Adult 100% (deductible does not apply) 70% after deductible
Physical Exams
Adult Immunizations 100% (deductible does not apply) 70% after deductible
Routine Gynecological Exams, including a Pap Test 100% (deductible does not apply) 70% (deductible does not apply)
Mammograms, Annual Routine, and Medically Necessary Routine: 100% (deductible does not 70% after deductible
apply)
Medically Necessary: 100%
(deductible does not apply)
Colorectal Cancer Screening 100% (deductible does not apply) 70% after deductible
Diagnostic Services and Procedures 100% (deductible does not apply) 70% after deductible
Routine Pediatric 100% (deductible does not apply) 70% after deductible
Physical Exams
Pediatric Immunizations 100% (deductible does not apply) 70% (deductible does not apply)
Diagnostic Services and Procedures 100% (deductible does not apply) 70% after deductible
Emergency Services
Emergency Room Services 80% after $100 copay (waived if admitted)
Ambulance - Emergency and 80% after deductible 70% after deductible
Ambulance - Non-Emergency 80% after deductible 70% after deductible
Hospital and Medical / Surgical Expenses (including maternity)
Hospital Inpatient 80% after deductible 70% after deductible
Hospital Outpatient 80% after deductible 70% after deductible
Maternity (non-preventive facility & professional services) 80% after deductible 70% after deductible
including dependent daughter
Medical Care (including inpatient visits and 80% after deductible 70% after deductible
consultations)/Surgical Expenses
Therapy and Rehabilitation Services
Visit 1-20: 100% no copay
Physical Medicine 70% after deductible
Visit 21-40: 100% after $25 copay
Limit: 40 visits/benefit period
Respiratory Therapy 80% after deductible 70% after deductible
Speech & Occupational Therapy 80% after deductible 70% after deductible
Chiropractic Services 100% after $25 copay 70% after deductible

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