Page 15 - Mersen Benefit Guide Local 502

Highmark BCBS Summary of Medical Plans – Union Base Plan

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

Deductible (per benefit period)
Individual $150 $750
$1,500
Family
$300
In Network
Out of Network
Benefit 100% after deductible 70% after deductible
Plan Pays – payment based on the plan allowance

Total Maximum Out-of-Pocket (Includes deductible, General Provisions
coinsurance, copays and other qualified medical expenses,
Benefit Period (1) Calendar Year
Network only) (2) Once met, the plan pays 100% of covered
services for the rest of the benefit period.
Deductible (per benefit period) $3,000 $6,000
Individual
Family $6,000 $12,000
Individual $150 Office/Clinic/Urgent Care Visits $750
Retail Clinic Visits & Virtual Visits
$300
$1,500
Family 100% after $25 copay 70% after deductible
Primary Care Provider Office Visits & Virtual Visits 100% after $25 copay 70% after deductible
Plan Pays – payment based on the plan allowance 100% after deductible 70% after deductible
70% after deductible
100% after $40 copay
Specialist Office Visits & Virtual Visits
Virtual Visit Provider Originating Site Fee 100% after deductible 70% after deductible
Total Maximum Out-of-Pocket (Includes deductible, coinsurance, 100% after $40 copay 70% after deductible
Urgent Care Center Visits
copays and other qualified medical expenses, 100% no copay Not Covered
Teladoc Services (3)
Network only) (2) Once met, the plan pays 100% of covered Preventive Care (4)
services for the rest of the benefit period. 100% (deductible does not apply) 70% after deductible
Routine Adult
Physical Exams
$3,000
Individual 100% (deductible does not apply) 70% after deductible
$6,000
Adult Immunizations
$6,000
Family 100% (deductible does not apply) 70% (deductible does not apply)
$12,000
Routine Gynecological Exams, including a Pap Test
Office/Clinic/Urgent Care Visits
Mammograms, Annual Routine and Medically Necessary Routine: 100% (deductible does not 70% after deductible
apply) Medically Necessary: 100%
100% after $25 copay
70% after deductible
Retail Clinic Visits & Virtual Visits (deductible does not apply) 70% after deductible
100% (deductible does not apply)
Diagnostic Services and Procedures
70% after deductible
Colorectal Cancer Screenings
Primary Care Provider Office Visits & Virtual Visits 100% (deductible does not apply) 70% after deductible
100% after $25 copay
Routine Pediatric 100% (deductible does not apply) 70% after deductible
Specialist Office Visits & Virtual Visits 100% after $40 copay 70% after deductible
Physical Exams
Pediatric Immunizations 100% (deductible does not apply) 70% (deductible does not apply)
Virtual Visit Provider Originating Site Fee 100% (deductible does not apply) 70% after deductible
70% after deductible
100% after deductible
Diagnostic Services and Procedures
Urgent Care Center Visits 100% after $40 copay Emergency Services 70% after deductible
Emergency Room Services 100% after $100 copay (waived if admitted)
Teladoc Services (3) 100% no copay Not Covered
Ambulance – Emergency
100% (deductible does not apply)
Ambulance - Non-Emergency 100% after deductible 70% after deductible
Preventive Care (4)
Hospital and Medical / Surgical Expenses (including maternity)
Routine Adult 100% (deductible does not apply) 70% after deductible
100% after $100 inpatient
Hospital Inpatient 70% after deductible
copay/admission
Physical Exams 100% after deductible 70% after deductible
Hospital Outpatient
Adult Immunizations 100% (deductible does not apply) 70% after deductible
70% after deductible
Maternity (non-preventive facility & professional services)
100% after deductible
including dependent daughter
Routine Gynecological Exams, including a Pap Test 100% (deductible does not apply) 70% (deductible does not apply)
Medical Care (including inpatient visits and 100% after deductible 70% after deductible
consultations)/Surgical Expenses
Mammograms, Annual Routine and Medically Necessary Necessary: 100% (deductible does not apply)
Routine: 100% (deductible does not apply) Medically
Therapy and Rehabilitation Services
Visit 1-20: 100% no copay
Physical Medicine
70% after deductible
Diagnostic Services and Procedures 100% (deductible does not apply) 70% after deductible
Visit 21-40: 100% after $25 copay
Limit: 40 visits/benefit period
Colorectal Cancer Screenings 100% (deductible does not apply) 70% after deductible
Respiratory Therapy 100%
Routine Pediatric 100% (deductible does not apply) 70% after deductible
70% after deductible
Speech & Occupational Therapy
100% after deductible
Physical Exams 100% after $25 copay 70% after deductible
Chiropractic Services
Limit: 25 visits/calendar year
Pediatric Immunizations 100% (deductible does not apply) 70% (deductible does not apply)
Other Therapy Services (Cardiac Rehab, Infusion Therapy,
100% after deductible
Chemotherapy, Radiation Therapy and Dialysis)
Diagnostic Services and Procedures 100% (deductible does not apply) 70% after deductible
70% after deductible
Emergency Services 15
Emergency Room Services 100% after $100 copay (waived if admitted)