Page 10 - 2023 Mersen Benefit Guide

Highmark BCBS Summary of Medical Plans – Key Plan

Benefit In Network Out of Network
General Provisions
Benefit Period (1) Calendar Year
HSA (Individual/Family) Mersen funds to your HSA $750/ $1,250

Deductible (per benefit period)
Individual $2,500 $4,000
Family $5,000 $8,000
Plan Pays – payment based on the plan allowance 80% after deductible 60% after deductible

Total Maximum Out-of-Pocket (OOP) (Includes deductible,
coinsurance, copays, prescription drug cost sharing 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 $5,000 $8,000
Family $10,000 $16,000
Office/Clinic/Urgent Care Visits
Retail Clinic Visits & Virtual Visits 80% after deductible 60% after deductible
Primary Care Provider Office Visits & Virtual Visits 80% after deductible 60% after deductible
Specialist Office Visits & Virtual Visits 80% after deductible 60% after deductible
Virtual Visit Provider Originating Site Fee 80% after deductible 60% after deductible
Urgent Care Center Visits 80% after deductible 60% after deductible
Teladoc Services (3) 80% after deductible Not Covered
(Approx. $55 charge)
Preventive Care (4)
Routine Adult 100% (deductible does not apply) 60% after deductible
Physical Exams
Adult Immunizations 100% (deductible does not apply) 60% after deductible
Routine Gynecological Exams, including a Pap Test 100% (deductible does not apply) 60% (deductible does not apply)
Mammograms, Annual Routine, and Medically Necessary Routine: 100% (deductible does not 60% after deductible
apply)
Medically Necessary: 100% after
deductible
Diagnostic Services and Procedures 100% (deductible does not apply) 60% after deductible
Routine Pediatric 100% (deductible does not apply) 60% after deductible
Physical Exams
Pediatric Immunizations 100% (deductible does not apply) 60% (deductible does not apply)
Diagnostic Services and Procedures 100% (deductible does not apply) 60% after deductible
Emergency Services
Emergency Room Services 80% after in-network deductible
Ambulance - Emergency 80% after deductible 60% after deductible
Ambulance - Non-Emergency 80% after deductible 60% after deductible
Hospital and Medical / Surgical Expenses (including maternity)
Hospital Inpatient 80% after deductible 60% after deductible
Hospital Outpatient 80% after deductible 60% after deductible
Maternity (non-preventive facility & professional services) 80% after deductible 60% after deductible
including dependent daughter
Medical Care (including inpatient visits and 80% after deductible 60% after deductible
consultations)/Surgical Expenses
Therapy and Rehabilitation Services
Physical Medicine 80% after deductible 60% after deductible
Limit: 40 visits/benefit period
Respiratory Therapy 80% after deductible 60% after deductible

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PLEASE NOTE: Employees covered by a collective bargaining agreement should refer to their union agreement to determine if they are eligible for these plans.