Page 17 - Mersen Benefit Guide Local 502

Highmark BCBS Summary of Medical Plans – Union 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
Out of Network
In Network
Benefit 90% after deductible 70% after deductible
Plan Pays – payment based on the plan allowance
Total Maximum Out-of-Pocket (Includes deductible,
coinsurance, copays and other qualified medical expenses, General Provisions
Network only) (2) Once met, the plan pays 100% of covered
Benefit Period (1) Calendar Year
services for the rest of the benefit period.
Individual $4,000 $8,000
Deductible (per benefit period) $8,000 $16,000
Family
Individual $150 Office/Clinic/Urgent Care Visits $750
Retail Clinic Visits & Virtual Visits 100% after $25 copay 70% after deductible
Family 100% after $25 co 70% after deductibl
$300 pay
Primary Care Provider Office Visits & Virtual Visits
$1,500 e
Specialist Office Visits & Virtual Visits
100% after deductible
Plan Pays – payment based on the plan allowance 100% after $40 copay 70% after deductible
70% after deductible
Virtual Visit Provider Originating Site Fee
90% after deductible
70% after deductible
Urgent Care Center Visits 100% after $40 copay 70% after deductible
Total Maximum Out-of-Pocket (Includes deductible, coinsurance,
copays and other qualified medical expenses, 100% Not Covered
Teladoc Services (3)
Preventive Care (4)
Network only) (2) Once met, the plan pays 100% of covered
Routine Adult
services for the rest of the benefit period. 100% (deductible does not apply) 70% after deductible
Physical Exams
$6,000
Individual 100% (deductible does not apply) 70% after deductible
$3,000
Adult Immunizations
Routine Gynecological Exams, including a Pap Test 100% (deductible does not apply) 70% (deductible does not apply)
Family $6,000 $12,000
Mammograms, Annual Routine and Medically Necessary Routine: 100% (deductible does not 70% after deductible
Office/Clinic/Urgent Care Visits
apply) Medically Necessary: 100%
(deductible does not apply)
Retail Clinic Visits & Virtual Visits 100% (deductible does not apply) 70% after deductible
70% after deductible
100% after $25 copay
Diagnostic Services and Procedures
Colorectal Cancer Screening 100% (deductible does not apply) 70% after deductible
Primary Care Provider Office Visits & Virtual Visits 100% (deductible does not apply) 70% after deductible
70% after deductible
Routine Pediatric
100% after $25 copay
Physical Exams
70% after deductible
100% after $40 copay
Specialist Office Visits & Virtual Visits 100% (deductible does not apply) 70% (deductible does not apply)
Pediatric Immunizations
Virtual Visit Provider Originating Site Fee 100% (deductible does not apply) 70% after deductible
70% after deductible
100% after deductible
Diagnostic Services and Procedures
Emergency Services
Urgent Care Center Visits 100% after $40 copay 70% after deductible
90% after $100 copay (waived if admitted)
Emergency Room Services
100% no copay
Teladoc Services (3) 90% after deductible 70% (deductible does not apply)
Not Covered
Ambulance – Emergency
Ambulance - Non-Emergency 90% after deductible 70% (deductible does not apply)
Preventive Care (4)
Hospital and Medical / Surgical Expenses (including maternity)
Routine Adult 100% (deductible does not apply) 70% after deductible
70% after deductible
Hospital Inpatient
90% after deductible
Hospital Outpatient
Physical Exams 90% after deductible 70% after deductible
Maternity (non-preventive facility & professional 90% after deductible 70% after deductible
Adult Immunizations 100% (deductible does not apply) 70% after deductible
services) 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
90% after deductible
70% after deductible
and consultations)/Surgical Expenses
Therapy and Rehabilitation Services
Mammograms, Annual Routine and Medically Necessary Necessary: 100% (deductible does not apply)
Routine: 100% (deductible does not apply) Medically
Physical Medicine Visit 1-20: 100% no copay 70% after deductible
100% (deductible does not apply)
Diagnostic Services and Procedures Visit 21-40: 100% after $25 copay 70% after deductible
Limit: 40 visits/benefit period
90% after deductible
Respiratory Therapy
Colorectal Cancer Screenings 100% (deductible does not apply) 70% after deductible
70% after deductible
Speech & Occupational Therapy 90% after deductible 70% after deductible
Routine Pediatric 100% (deductible does not apply) 70% after deductible
70% after deductible
Chiropractic Services
100% after $25 copay
Limit: 25 visits/benefit period
Physical Exams
Other Therapy Services (Cardiac Rehab, Infusion Therapy, 90% after deductible 70% after deductible
Pediatric Immunizations 100% (deductible does not apply) 70% (deductible does not apply)
Chemotherapy, Radiation Therapy and Dialysis)

Diagnostic Services and Procedures 100% (deductible does not apply) 70% after deductible

Emergency Services
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Emergency Room Services 100% after $100 copay (waived if admitted)
Ambulance – Emergency 100% (deductible does not apply)