Page 55 - Trident 2022 Flipbook

Benefit Network Out-of-Network
Therapy and Rehabilitation Services
Physical Medicine 100% after deductible 80% after deductible
Limit: 70 visits per benefit period combined with Speech
and Occupational Therapy
Occupational Therapy 100% after deductible 80% after deductible
Limit: 70 visits per benefit period combined with Physical Medicine
and Speech Therapy
Speech Therapy 100% after deductible 80% after deductible
Limit: 70 visits per benefit period combined with Physical Medicine
and Occupational Therapy
Respiratory Therapy 100% after In Network deductible
Spinal Manipulations 100% after deductible 80% after deductible
Limit: 20 visits per benefit period
Other Therapy Services (Cardiac Rehab, Infusion 100% after deductible 80% after deductible
Therapy, Chemotherapy, Radiation Therapy and
Dialysis)
Mental Health/Substance Abuse
Inpatient 100% after deductible 80% after deductible
Inpatient Detoxification/Rehabilitation
Outpatient 100% after deductible 80% after deductible
Autism(2) 100% after deductible 80% after deductible
Other Services
Allergy Extracts and injections 100% after deductible 80% after deductible
Assisted Fertilization Procedures Not Covered
Dental Services Related to Accidental Injury 100% after deductible 80% after deductible
Diagnostic Services 100% after deductible 80% after deductible
Advanced Imaging (MRI, CAT, PET scan, etc.)
Basic Diagnostic Services (standard imaging, 100% after deductible 80% after deductible
diagnostic medical, lab/pathology, allergy testing)
Durable Medical Equipment, Orthotics and 100% after deductible 80% after deductible
Prosthetics
Home Health Care/Visiting Nurse(3) 100% after deductible 80% after deductible
Hospice 100% after deductible 80% after deductible
Infertility Counseling, Testing and Treatment(4) 100% after deductible 80% after deductible
Private Duty Nursing 100% after In Network deductible
Skilled Nursing Facility Care 100% after deductible 80% after deductible
Limit: 100 days per benefit period
Transplant Services 100% after deductible 80% after deductible
Precertification Requirements(5) Yes
Prescription Drug
Prescription Drug Deductible
Individual/Family Integrated with medical deductible
Prescription Drug Program(6)(7) Retail Drugs (31-day supply)
Defined by the National Plus Pharmacy Network - Not Plan pays 100% after deductible
Physician Network. Prescriptions filled at a non-network
pharmacy are not covered. Maintenance Drugs through Mail Order (90-day supply)
Plan pays 100% after deductible
Questions? 1-800-701-2324
(1) Your group's benefit period is based on a Calendar Year which runs from January 1 to December 31.
(2) Coverage for eligible members. Services will be paid according to the benefit category, i.e., speech therapy. Treatment for autism spectrum disorders does not reduce visit/day limits.
(3) The maternity home health care visit for network care is not subject to the program copayment, coinsurance or deductible amounts, if applicable. See Maternity Home Health Care Visit in the Covered
Services section.
(4) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered depending on your group’s prescription drug
program.
(5) BCBS Medical Management & Policy (MM&P) must be contacted prior to a planned inpatient 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 not, you are responsible for contacting MM&P. If this does not occur and it is later determined that all or part of the inpatient stay was not medically
necessary or appropriate, you will be responsible for payment of any costs not covered.
(6) Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not included on this formulary, your provider must
complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for clinical review. Under the mandatory generic provision, you are responsible for the payment
differential when a generic drug is available and you or your provider specifies a brand name drug. Your payment is the price difference between the brand name drug and the generic drug in addition to the
brand name drug coinsurance amounts, which may apply.
(7) Certain retail participating pharmacy providers may have agreed to make covered medications available at the same cost-sharing and quantity limits as the mail order coverage. You may contact Highmark at
the toll-free number or the Web site appearing on the back of your ID card for a listing of those pharmacies who have agreed to do so.
(8) 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 benefit.

This is not a contract. This benefits summary presents plan highlights only. Please refer to the policy/plan documents, as limitations and exclusions apply. The policy/ plan documents control in the event of a
conflict with this benefits summary

Page 2 of 3