Page 9 - 2022 Local 502 Mersen Benefit Guide

Highmark BCBS Summary of Medical Plans – 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
Benefit
Plan Pays – payment based on the plan allowance 90% after deductible 70% after deductible
Out of Network
In Network
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)
services for the rest of the benefit period. Calendar Year
Individual $4,000 $8,000
Deductible (per benefit period)
Family $8,000 $16,000
Individual $150 Office/Clinic/Urgent Care Visits $750
Retail Clinic Visits & Virtual Visits 100% after $25 copay 70% after deductible
$1,500
Family
$300
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
Plan Pays – payment based on the plan allowance
70% after deductible
90% after deductible
Virtual Visit Provider Originating Site Fee 100% after deductible 70% after deductible
Urgent Care Center Visits 100% after $40 copay 70% after deductible
Total Maximum Out-of-Pocket (Includes deductible, coinsurance,
Teladoc Services (3) 100% Not Covered
copays and other qualified medical expenses,
Preventive Care (4)
Network only) (2) Once met, the plan pays 100% of covered
Routine Adult 100% (deductible does not apply) 70% after deductible
services for the rest of the benefit period.
Physical Exams
$6,000
Adult Immunizations 100% (deductible does not apply) 70% after deductible
Individual
$3,000
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
apply) Medically Necessary: 100%
Office/Clinic/Urgent Care Visits
(deductible does not apply)
Diagnostic Services and Procedures 100% (deductible does not apply) 70% after deductible
Retail Clinic Visits & Virtual Visits
70% after deductible
100% after $25 copay
Colorectal Cancer Screening 100% (deductible does not apply) 70% after deductible
Primary Care Provider Office Visits & Virtual Visits
70% after deductible
100% after $25 copay
Routine Pediatric 100% (deductible does not apply) 70% after deductible
Physical Exams
100% after $40 copay
70% after deductible
Specialist Office Visits & Virtual Visits
Pediatric Immunizations 100% (deductible does not apply) 70% (deductible does not apply)
Diagnostic Services and Procedures 100% (deductible does not apply) 70% after deductible
Virtual Visit Provider Originating Site Fee 100% after deductible 70% after deductible
Emergency Services
Urgent Care Center Visits
Emergency Room Services 100% after $40 copay 70% after deductible
90% after $100 copay (waived if admitted)
Ambulance – Emergency 90% after deductible 70% (deductible does not apply)
Teladoc Services (3) 100% no copay Not Covered
Ambulance - Non-Emergency 90% after deductible 70% (deductible does not apply)
Preventive Care (4)
Hospital and Medical / Surgical Expenses (including maternity)
Routine Adult
90% after deductible
70% after deductible
Hospital Inpatient 100% (deductible does not apply) 70% after deductible
Hospital Outpatient 90% after deductible 70% after deductible
Physical Exams
Maternity (non-preventive facility & professional services) 90% after deductible 70% after deductible
Adult Immunizations
including dependent daughter 100% (deductible does not apply) 70% after deductible
Medical Care (including inpatient visits and 90% after deductible 70% after deductible
Routine Gynecological Exams, including a Pap Test
consultations)/Surgical Expenses 100% (deductible does not apply) 70% (deductible does not apply)
Therapy and Rehabilitation Services
Mammograms, Annual Routine and Medically Necessary Visit 1-20: 100% no copay
Routine: 100% (deductible does not apply) Medically
Physical Medicine Necessary: 100% (deductible does not apply) after deductible
70
%
Visit 21-40: 100% after $25 copay
Diagnostic Services and Procedures 100% (deductible does not apply) 70% after deductible
Limit: 40 visits/benefit period
Respiratory Therapy 90% after deductible 70% after deductible
70% after deductible
Colorectal Cancer Screenings
Speech & Occupational Therapy 100% (deductible does not apply) 70% after deductible
90% after deductible
Chiropractic Services 100% after $25 copay 70% after deductible
Routine Pediatric 100% (deductible does not apply) 70% after deductible
Limit: 25 visits/benefit period
Physical Exams
Other Therapy Services (Cardiac Rehab, Infusion Therapy, 90% after deductible 70% after deductible
Chemotherapy, Radiation Therapy and Dialysis)
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
9
Emergency Room Services 100% after $100 copay (waived if admitted)
Ambulance – Emergency 100% (deductible does not apply)