WESTERN PENNSYLVANIA REGION BENEFIT PORTFOLIO · Highmark Blue Cross Blue Shield understands the importance of reliable, affordable health coverage for Small Groups (with 50 or fewer

WESTERN PENNSYLVANIA REGION

HIGHMARKBCBS.COM

Effective January 1, 2017

For Small Groups

BENEFIT PORTFOLIO

1

INTRODUCTION

Highmark Blue Cross Blue Shield understands the importance of reliable, affordable health coverage for Small Groups (with 50 or fewer full-time, part-time and seasonal employees). To meet the unique needs of this market, our 2017 Product Portfolio reinforces our commitment to offer a wide range of benefit designs that provide your clients with a variety of options to best meet their needs, as well as the needs of their employees. Highmark also is committed to providing superior customer service, as well as clear and complete benefit information to help you service your clients and their employees. To provide you with the information and tools you need, and to make it easier for you to present the Highmark benefit options to your clients, we created this design for easier viewing of all of the health plan options. It puts the most important facts and figures front and center - including network information, and more.

Using the Product Portfolio

In addition to the 2017 health plan options, detailed information on the Pediatric Dental and Vision benefits integrated into the Highmark ACA plans is also included in the portfolio.

The 2017 Product Portfolio can easily be printed from any printer, on 8 ½ x 11 inch paper that you already have on hand, so you can print a copy anytime you need it. You can print the entire product portfolio, or only the sections that you want to use for your client meeting – without disrupting the look of the document or the layout of the information.

Plus, it’s simple and fast to access benefit details using the interactive links from the 2017 product portfolio. If you are viewing the portfolio (a PDF version) on a computer connected to the Internet, you can view a copy of the detailed Summary of Benefits for that health plan just by clicking on the plan name at the top of a column. This live link to the most current version of the Summary of Benefits means that you can now view, save, or print the summary for a client meeting without having to search for the information in different locations!

Don’t miss our newest health plan, Connect Blue.SM It gives employees patient-centered care with the opportunity for significant cost savings — all with top-quality doctors and hospitals that are close to where they live and work.

Pages 30-37

Pages 24-28

PEDIATRIC DENTAL & VISION BENEFIT INFO

TABLE OF CONTENTS

INTRODUCTION Page 1

PPO BLUE Pages 6-13

COMMUNITY BLUE FLEX Pages 14-23

CONNECT BLUE

Components of Group Plan DesignEssential Health Benefits CategoriesActuarial Value and Metal Levels2017 Provider Network Information

Product Description, Service Area Map & Provider Network

Benefit Grids — Service Areas: Zone C – All 29 counties of western PA: Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Centre, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington and Westmoreland Counties


Benefit Grids — Service Areas:Zone A: Allegheny, Armstrong, Beaver, Butler, Crawford, Erie, Fayette, Greene, Indiana, Lawrence, McKean, Mercer, Warren, Washington and Westmoreland Counties

Zone B: Bedford, Blair, Cambria, Cameron, Centre, Clarion, Clearfield, Elk, Forest, Huntingdon, Jefferson, Potter, Somerset and Venango Counties

Zone G: Armstrong, Blair, Cameron, Clarion, Crawford, Forest, Huntingdon, Indiana, Jefferson, Lawrence, McKean, Potter and Somerset Counties

Zone H: Clearfield, Centre, Elk and Jefferson Counties


Benefit Grids — Service Areas:Zone J: Allegheny, Beaver, Butler, Erie, Washington and Westmoreland Counties

Pediatric Dental: benefits apply to Qualified High Deductible Health Plans (QHDHP)Pediatric Dental: benefits apply to Non-QHDHPsPediatric Vision: benefits apply to Qualified High Deductible Health Plans (QHDHP)Pediatric Vision: benefits apply to Non-QHDHPs

Pages 7-8

Pages 9-13

Pages 15-16

Pages 17-20

Page 21

Page 22

Page 23

Page 3Page 3Page 3Page 4

Pages 31-32

Pages 33-34Page 35

Page 36

Pages 25-26

Pages 27-28

All Affordable Care Act (ACA) compliant plans must cover the following Essential Health Benefits categories to a benchmark level of coverage established by the state:

• Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance use disorder services • Prescription drugs • Rehabilitative and habilitative services and devices • Laboratory services • Preventive and wellness services and chronic disease • Pediatric services including oral and vision management

Pediatric Dental and Vision services are offered to children under the age of 19; services include dental and vision checkups, as well as one pair of glasses per year. These services are integrated into all plans in the Small Group market.

Prescription Drugs are offered with cost sharing within all plans.

ESSENTIAL HEALTH BENEFITS CATEGORIES

COMPONENTS OF GROUP PLAN DESIGN

Under health care reform, insurance companies must define the level of health care costs a particular plan will pay (on average) for covered benefits. To make it easier to understand, the government established metal levels and requires that plans meet the actuarial value in a given metal level.

ACTUARIAL VALUE AND METAL LEVELS

Out-of-Pocket Costs Average Coverage Level (Actuarial Value)

Platinum Plans Lowest 90%

Gold Plans Low 80%

Silver Plans Moderate 70%

Bronze Plans High 60%

PRESCRIPTION COVERAGE

MEDICALCOVERAGE

EMPLOYER CONTRIBUTION

TO AN HSA(if applicable)

+ +

Access to quality care• A network of high-performing, patient-focused care

providers and specialists. There are more than 7,200 primary care physicians and specialists in western Pennsylvania alone.

• Allegheny Health Network hospitals and physicians anchor Highmark’s provider network. Many of these hospitals have been recognized by U.S. News & World Report, Thomson Reuters, Health Grades and other agencies for care innovations and superb clinical outcomes. Additionally, Highmark offers access to the new Allegheny Health Network Health + Wellness Pavilions in Wexford, Peters Township and Bethel Park. You’ll enjoy one-stop shopping close to home for most patient care.

• Access to nearly 720,000 providers in the BluelCross BlueiShield network across the country

• Health and wellness discounts on products, services, classes and fitness facilities

Plus…• Reliable health care coverage and member service and

support from a health insurer with 75 years’ experience

For your convenience, Highmark connects you to every kind of care through a quality network of more than 50 hospitals in western Pennsylvania...

2017 provider network informationKnow Your Options for CareWith Highmark, members will have access to the region’s leading health care providers, including those that are a part of Allegheny Health Network, as well as other community hospitals. They’ll also have access to all UPMC facilities outside of the five-county Pittsburgh region. Members who have been diagnosed with cancer have in-network access to all UPMC services, facilities, doctors and joint ventures for oncology covered services through June 2019. This includes illnesses and complications resulting from cancer treatment, such as endocrinology, orthopedics and cardiology. (The member’s physician must determine that the member should be treated by a UPMC provider who renders oncology services.)1

ER AccessMembers who seek care at any UPMC emergency room will be covered at in-network rates, including any inpatient admission and follow-up care for the emergency condition.2

“Continuation of Care” for Members in Treatment NowMembers who were in a continuing course of treatment for a chronic or persistent condition in 2013, 2014 or 2015 with a UPMC provider or an independent provider, and received care for that condition at UPMC, can receive care from those providers at the in-network level of benefits through June 2019 if the care is related to, or in conjunction with, a chronic or persistent condition. This includes routine, preventive and acute care that is received during treatment for a chronic or persistent condition. Otherwise, routine and preventive care will not be covered on an in-network basis.1

Members cannot be referred to or treated by a new UPMC doctor on an in-network basis for care related to a chronic or persistent condition or other conditions they might have or develop. A “new” UPMC doctor means a doctor they have not seen in the past.

Members who were treated at UPMC or by a UPMC physician for a confirmed pregnancy in 2015 may continue to access UPMC on an in-network basis for maternity care, delivery and post-partum care related to that pregnancy. This includes delivery at Magee-Womens Hospital.

“Balance Bill” ProtectionOut-of-network UPMC providers can only bill Highmark members up to the difference between the Plan’s payment and 60% of the UPMC provider’s billed charges for covered services.

To view the most up-to-date information on the Consent Decree and in-network access to UPMC, visit DiscoverHighmark.com.

Allegheny Health Network hospitals

Potter

Allegheny

ArmstrongBeaver

Bedford

Cambria

Cleareld

Huntingdon

Blair

Butler

Cameron

Centre

Clarion

Crawford

Elk

Erie

Fayette

Forest

Greene

Indiana

Je�ersonLawrence

McKean

Mercer

Somerset

Venango

Warren

WashingtonWestmoreland

1 Highmark members in Community Blue Flex products and Connect Blue can access UPMC facilities in network for oncology/cancer services and continuation of care. The specific terms of coverage will be according to the member’s benefit plan. Covered claims from UPMC may be processed at the lower level of benefits.

2 Emergency room and any related inpatient care is covered at the Enhanced Value Level of Benefits for Community Blue Flex products and at the Preferred Value Level of Benefits for Connect Blue.

this page was left blankintentionally

PPO BLUEFOR SMALL GROUPS

EFFECTIVE JANUARY 1, 2017


7

ALLEGHENY

ARMSTRONG

ELK

BEAVER

BEDFORD

CAMBRIA

CLEARFIELD

HUNTINGDON

BLAIR

BUTLER

CAMERON

CENTRE

CLARION

CRAWFORD

ERIE

FAYETTE

FOREST

GREENE

INDIANA

JEFFERSONLAWRENCE

MCKEAN

MERCER

POTTER

SOMERSET

VENANGO

WARREN

WASHINGTON

WESTMORELAND

Zones A and B combine to make up Zone C, which includes all 29 counties of the Highmark Blue Cross Blue Shield western Pennsylvania service area.

Zone A

Zone B

Choice of Plan DesignsHighmark Blue Cross Blue Shield offers multiple plan designs within Preferred Provider Organization (PPO) plans, at all metal levels. This means that clients can choose a plan that meets their health care needs while balancing costs and coverage.

Access to Every Blue Plan Hospital and Physician in the CountryOutside western Pennsylvania, providers participating in a local Blue plan offer quality care and are covered at the Enhanced Value Level of Benefits. More than 96 percent of all U.S. hospitals and more than 93 percent of all U.S. physicians — nearly 720,000 providers across the country — participate in their local Blue Cross and/or Blue Shield PPO network, or Blue Card® program.

PPO BLUE

SERVICE AREA

FINDING A PROVIDER IS EASY

There Are Several Ways to Find Providers

Search Find a Doctor on highmarkbcbs.com (no login required). Members can use this search, no matter where they are, to find all Blue Network providers.

Call My Care Navigator at 1-888-BLUE-428. Representatives can help members find a new doctor and transfer their health records.

Call the Member Service number on the back of the Highmark Blue Cross Blue Shield ID card.

8

PPO BLUE FACILITY LISTING

ALLEGHENY• Allegheny General Hospital• Allegheny Valley Hospital• Children’s Hospital of Pittsburgh

of UPMC• Forbes Hospital• Heritage Valley Sewickley• Jefferson Hospital• Ohio Valley Hospital• St. Clair Hospital• West Penn Hospital• Western Psychiatric Institute

and ClinicARMSTRONG• Armstrong County Memorial

HospitalBEAVER• Heritage Valley BeaverBEDFORD• UPMC Bedford MemorialBLAIR• Nason Hospital• Tyrone Hospital• UPMC AltoonaBUTLER• Butler Memorial HospitalCAMBRIA• Conemaugh Memorial

Medical Center• Conemaugh Miners

Medical Center

CLARION• Clarion HospitalCLEARFIELD• Penn Highlands Clearfield• Penn Highlands DuBoisCRAWFORD• Meadville Medical Center• Titusville Area HospitalELK• Penn Highlands ElkERIE• Corry Memorial Hospital• Millcreek Community Hospital• Saint Vincent Hospital• UPMC HamotFAYETTE• Highlands Hospital• Uniontown HospitalGREENE• Washington Health

System GreeneHUNTINGDON• J. C. Blair Memorial HospitalINDIANA• Indiana Regional Medical CenterJEFFERSON• Penn Highlands Brookville• Punxsutawney Area HospitalLAWRENCE• Ellwood City Hospital• UPMC Jameson

MCKEAN• Bradford Regional

Medical Center• Kane Community HospitalMERCER• Edgewood Surgical Hospital• Grove City Medical Center• Sharon Regional Health System• UPMC HorizonPOTTER• Cole MemorialSOMERSET• Conemaugh Meyersdale

Medical Center• Somerset Hospital• Chan Soon-Shiong Medical

Center at WindberVENANGO• UPMC NorthwestWARREN• Warren General HospitalWASHINGTON• Advanced Surgical Hospital• Canonsburg Hospital• Monongahela Valley Hospital• Washington HospitalWESTMORELAND• Excela Frick Hospital• Excela Latrobe Hospital• Excela Westmoreland Hospital

*Provider list as of August 2016. Please refer to the online Find a Doctor tool at highmarkbcbs.com for a listing of network hospitals.

Blue networks include more than 96 percent of all U.S. hospitals and more than 93 percent of all U.S. physicians – nearly 720,000 providers across the country!

PROVIDER NETWORK

9

2017 PPO BLUEFor Small Groups with 50 or fewer employees

See "Important Plan Details" on page 37 for additional benefit information.

EFFECTIVE JANUARY 2017

PLATINUM GOLD

Premier Balance PPO $0 Platinum A

Premier Balance PPO $250 Platinum A

Premier Balance PPO $0 Gold A

Premier Balance PPO $250 Gold A

Premier Balance PPO $500 A

Medical Deductible

In-Network(2 x Family)

Mem

ber P

ays

$0 $250 $0 $250 $500

Out-of-Network(2 x Family) $500 $500 $500 $500 $1,000

Plan Payment Level (Coinsurance)

After Deductible


Plan

Pay

s 100% 100% 100% 100% 100%

Out-of-Network(2 x Family) 80% 80% 80% 80% 80%

Out-of-PocketMaximum1


Mem

ber P

ays

$1,000 $1,250 $7,150 $7,150 $5,600

Out-of-Network(2 x Family) $2,000 $2,500 $14,300 $14,300 $11,200

Primary Care Provider In-Network $20 $20 $25 $20 $20

Specialist2 In-Network $35 $35 $75 $40 $40

Urgent Care In-Network $40 $40 $75 $65 $65

Telemedicine In-Network $15 $15 $15 $15 $15

Inpatient Hospital In-Network $0 $0 after ded $0 $0 after ded $0 after ded

Emergency Room In-Network $150 $150 $200 $200 $200

Basic Diagnostic Services (standard imaging, diagnostic medical, lab/pathology, etc.)

In-Network $35 $35 $75 $40 $40

Advanced Imaging (MRI, CAT, PET scan, etc.) In-Network $75 $75 $200 $200 $200

Rx Formulary(Comprehensive)3 In-Network

$3/$10/$50/$85/20%/30%

Member pays (at retail) a maximum of $350 for Specialty Formulary Rx /

$500 for Specialty Non-Formulary Rx

$3/$10/$50/$85/20%/30%



$3/$10/$50/$85/20%/30%



$3/$10/$50/$85/20%/30%



$3/$10/$50/$85/ 20%/30%



Add’l Gold Plans on Next Page

https://secure.highmark.com/mccepfWeb/showGrids.do?method=processReport&format=P&_ProdId=175964977&_lob=PPOBlue&_region=W&_market=A












10


GOLD

Premier Balance PPO $750 A

Premier Balance PPO $1,000 A



Health Savings PPO $1,5004,6

Medical Deductible


Mem

ber P

ays

$750 $1,000 $1,250 $1,500 $1,500



After Deductible


Plan

Pay

s 100% 100% 100% 100% 100%




Mem

ber P

ays

$5,100 $4,600 $4,200 $3,700 $3,100


Primary Care Provider In-Network $20 $20 $20 $20 $20 after ded

Specialist2 In-Network $40 $40 $40 $40 $40 after ded

Urgent Care In-Network $65 $65 $65 $65 $65 after ded

Telemedicine In-Network $15 $15 $15 $15 $0 after ded

Inpatient Hospital In-Network $0 after ded $0 after ded $0 after ded $0 after ded $0 after ded

Emergency Room In-Network $200 $200 $200 $200 $200 after ded


In-Network $40 $40 $40 $40 $40 after ded

Advanced Imaging (MRI, CAT, PET scan, etc.) In-Network $200 $200 $200 $200 $200 after ded


$3/$10/$50/$85/ 20%/30%



$3/$10/$50/$85/ 20%/30%



$3/$10/$50/$85/ 20%/30%



$3/$10/$50/$85/ 20%/30%



$3/$10/$50/$85/20%/

30% after dedMember pays (at retail) a maximum of $350 for Specialty Formulary Rx /



Add’l Gold Plan on Next Page












11


GOLD SILVER


Balance PPO $1,000 A




Medical Deductible


Mem

ber P

ays

$2,000 $1,000 $1,400 $1,750 $2,000



After Deductible


Plan

Pay

s 100% 80% 100% 90% 90%




Mem

ber P

ays

$3,400 $7,150 $7,150 $7,150 $7,150


Primary Care Provider In-Network $20 $60 $45 $45 $45

Specialist2 In-Network $40 $80 $75 $65 $65

Urgent Care In-Network $65 $80 $75 $75 $75

Telemedicine In-Network $15 $15 $15 $20 $20

Inpatient Hospital In-Network $0 after ded 20% after ded $0 after ded 10% after ded 10% after ded

Emergency Room In-Network $200 $350 $250 $250 $250


In-Network $40 $80 after ded $75 after ded $65 $65

Advanced Imaging (MRI, CAT, PET scan, etc.) In-Network $200 $350 after ded $325 after ded $250 after ded $250


$3/$10/$50/$85/20%/30%



$3/$15/$55/$90/20%/30%



$3/$15/$55/$90/20%/30%



$3/$15/$55/$90/20%/30%



$3/$15/$55/$90/20%/30%




Add’l Silver Plans on Next Page












12



SILVER


Health Savings PPO Embedded $2,6004,5,6



Medical Deductible


Mem

ber P

ays

$2,500 $2,600 $3,500 $4,000

Out-of-Network(2 x Family) $5,000 $5,200 $7,000 $8,000


After Deductible


Plan

Pay

s 100% 100% 100% 100%

Out-of-Network(2 x Family) 80% 80% 80% 100%



Mem

ber P

ays

$7,150 $5,300 $6,550 $4,000

Out-of-Network(2 x Family) $14,300 $10,600 $13,100 $8,000

Primary Care Provider In-Network $45 $20 after ded $45 $0 after ded

Specialist2 In-Network $65 $35 after ded $65 $0 after ded

Urgent Care In-Network $75 $75 after ded $75 $0 after ded

Telemedicine In-Network $20 $0 after ded $20 $0 after ded

Inpatient Hospital In-Network $0 after ded $0 after ded $0 after ded $0 after ded

Emergency Room In-Network $250 $250 after ded $250 $0 after ded


In-Network $65 $35 after ded $65 $0 after ded

Advanced Imaging (MRI, CAT, PET scan, etc.) In-Network $250 $250 after ded $250 $0 after ded


$3/$15/$55/$90/20%/30%



$3/$15/$55/$90/20%/

30% after dedMember pays (at retail) a maximum of $350 for Specialty Formulary Rx /


$3/$15/$55/$90/20%/30%



$0 after ded

Bronze Plans on Next Page










13



BRONZE

High Deductible PPO Embedded $4,750 Qualified A4,5,6


High Deductible PPO Embedded $6,300 Qualified A4,5,6

Medical Deductible


Mem

ber P

ays

$4,750 $5,500 $6,300

Out-of-Network(2 x Family) $9,500 $11,000 $12,600


After Deductible


Plan

Pay

s 60% 80% 90%

Out-of-Network(2 x Family) 50% 60% 70%



Mem

ber P

ays

$6,550 $6,550 $6,550

Out-of-Network(2 x Family) $13,100 $13,100 $13,100

Primary Care Provider In-Network 40% after ded 20% after ded 10% after ded

Specialist2 In-Network 40% after ded 20% after ded 10% after ded

Urgent Care In-Network 40% after ded 20% after ded 10% after ded

Telemedicine In-Network 40% after ded 20% after ded 10% after ded

Inpatient Hospital In-Network 40% after ded 20% after ded 10% after ded

Emergency Room In-Network 40% after ded 20% after ded 10% after ded


In-Network 40% after ded 20% after ded 10% after ded

Advanced Imaging (MRI, CAT, PET scan, etc.) In-Network 40% after ded 20% after ded 10% after ded

Rx Formulary(Comprehensive)3 In-Network 40% after ded 20% after ded 10% after ded








FOR SMALL GROUPS



COMMUNITY BLUE FLEX, PA MOUNTAINS HEALTHCARE, & PENN HIGHLANDS

15

ALLEGHENY

ARMSTRONG

ELK

BEAVER

BEDFORD

CAMBRIA

CLEARFIELD

HUNTINGDON

BLAIR

BUTLER

CAMERON

CENTRE

CLARION

CRAWFORD

ERIE

FAYETTE

FOREST

GREENE

INDIANA

JEFFERSON

LAWRENCE

MCKEAN

MERCER

POTTER

SOMERSET

VENANGO

WARREN

WASHINGTON

WESTMORELAND

Community Blue Flex is available in Zones A, B, G and H.

Zone A

Zone B

Zone G — PA Mountains Healthcare Region

Zone H — Penn Highlands Region

Coverage That Lets Members Choose and SaveLooking for health care coverage that can actually help control your costs while giving your employees the ultimate in care and cost choice?

Three Tiers, Two Levels of In-Network ChoiceCommunity Blue FlexSM is your answer. This innovative three-tiered benefit design gives both you and your employees a greater opportunity for cost savings by offering two levels of in-network benefits: Enhanced Value Level of Benefits and Standard Value Level of Benefits. At both benefit levels, members receive high-quality care. With the Enhanced Value Level of Benefits, members have lower cost sharing when they receive care from in-network providers, who deliver care more cost-effectively. When they receive care from other in-network providers, members have higher cost sharing (Standard Value Level of Benefits). Community Blue Flex members also can choose out-of-network coverage at the highest level of cost sharing.

COMMUNITY BLUE FLEX

SERVICE AREA



Search Find a Doctor on highmarkbcbs.com (no login required) to see the provider’s benefit level. Members will see “Enhanced” or “Standard” Benefit Level under the provider’s name when they search for Community Blue Flex providers.



16

COMMUNITY BLUE FLEX FACILITY LISTING

ALLEGHENY• Allegheny General Hospital• Allegheny Valley Hospital• Children’s Hospital of Pittsburgh

of UPMC• Forbes Hospital• Heritage Valley Sewickley• Jefferson Hospital• Ohio Valley General Hospital• St. Clair Hospital• West Penn Hospital• Western Psychiatric Institute

and ClinicARMSTRONG• Armstrong County Memorial

HospitalBEAVER• Heritage Valley BeaverBEDFORD• UPMC Bedford MemorialBLAIR• Nason Hospital• Tyrone Hospital• UPMC AltoonaBUTLER• Butler Memorial HospitalCAMBRIA• Conemaugh Memorial

Medical Center• Conemaugh Miners

Medical Center

CLARION• Clarion Hospital• Clarion Psychiatric CenterCLEARFIELD• Penn Highlands Clearfield• Penn Highlands DuBoisCRAWFORD• Meadville Medical Center• Titusville Area HospitalELK• Penn Highlands ElkERIE• Corry Memorial Hospital• Millcreek Community Hospital• Saint Vincent Hospital• UPMC HamotFAYETTE• Highlands Hospital• Uniontown HospitalGREENE• Washington Health

System GreeneHUNTINGDON• J. C. Blair Memorial HospitalINDIANA• Indiana Regional Medical CenterJEFFERSON• Penn Highlands Brookville• Punxsutawney Area HospitalLAWRENCE• Ellwood City Hospital• UPMC Jameson

MCKEAN• Bradford Regional

Medical Center• Kane Community HospitalMERCER• Edgewood Surgical Hospital• Grove City Medical Center• Sharon Regional Health System• UPMC HorizonPOTTER• Cole Memorial HospitalSOMERSET• Conemaugh Meyersdale

Medical Center• Somerset Hospital• Chan Soon-Shiong Medical

Center at WindberVENANGO• UPMC NorthwestWARREN• Warren General HospitalWASHINGTON• Advanced Surgical Hospital• Canonsburg Hospital• Monongahela Valley Hospital• Washington HospitalWESTMORELAND• Excela Frick Hospital• Excela Latrobe Hospital• Excela Westmoreland Hospital

*Provider list as of August 2016. Please refer to the online Find a Doctor tool at highmarkbcbs.com for a listing of network hospitals.

Blue networks include more than 96 percent of all U.S. hospitals and more than 93 percent of all U.S. physicians – nearly 720,000 providers across the country!

PROVIDER NETWORK

• Enhanced • Standard

17



PLATINUM GOLD

Premier Balance PPO $0 Platinum A a Community Blue Flex Plan

Premier Balance PPO $250 Platinum A a Community Blue Flex Plan

Premier Balance PPO $0 Gold A a Community Blue Flex Plan

Premier Balance PPO $250 Gold A a Community Blue Flex Plan

Premier Balance PPO $500 A a Community Blue Flex Plan

Zone A: Allegheny, Armstrong, Beaver, Butler, Crawford, Erie, Fayette, Greene, Indiana, Lawrence, McKean, Mercer, Warren, Washington and Westmoreland Counties

Medical Deductible

In-Network

Enhanced(2 x Family)

Mem

ber P

ays $0 $250 $0 $250 $500

Standard(2 x Family) $500 $750 $5,000 $750 $1,500



After Deductible

In-Network


Plan

Pay

s

100% 100% 100% 100% 100%

Standard(2 x Family) 70% 70% 60% 70% 70%




Mem

ber P

ays

$1,600 $1,300 $7,150 $7,150 $5,300


Primary Care Provider/Retail Clinic

(except where noted)In-Network

Enhanced $10 $10 $25 $20 $20

Standard $40 $40 $70 $60 $60

Specialist2 In-NetworkEnhanced $20 $20 $65 $40 $40

Standard $60 $60 $90 $90 $90

Urgent Care In-NetworkEnhanced $40 $40 $75 $65 $65

Standard $70 $70 $100 $100 $100

Telemedicine In-Network Enhanced/Standard $5 $5 $15 $15 $15

Inpatient Hospital In-NetworkEnhanced $0 $0 after ded $500 $0 after ded $0 after ded

Standard 30% after ded 30% after ded 40% after ded 30% after ded 30% after ded

Emergency Room Enhanced/Standard $150 $150 $200 $200 $200


In-NetworkEnhanced $20 $20 $65 $45 $40

Standard $60 $60 $90 after ded $90 $90

Advanced Imaging (MRI, CAT, PET scan, etc.) In-Network

Enhanced $40 $40 $275 $150 $200

Standard $100 $100 $375 after ded $250 $300

Rx Formulary(Comprehensive)3

Low Cost Generic/Standard Generic/Brand Formulary/

Non-Formulary/Specialty Formulary/

Specialty Non-Formulary

$3/$10/$50/$85/20%/30%



$3/$10/$50/$85/20%/30%



$3/$10/$50/$85/20%/30%



$3/$10/$50/$85/20%/30%



$3/$10/$50/$85/20%/30%



2017 COMMUNITY BLUE FLEXFor Small Groups with 50 or fewer employees

ZONE

A


https://secure.highmark.com/mccepfWeb/showGrids.do?method=processReport&format=P&_ProdId=175965009&_lob=Community%20Blue%20Premier%20Flex&_region=W&_market=A






















18



GOLD

Flex PPO $500 Total Health a Community Blue Flex Plan

Premier Balance PPO $750 A a Community Blue Flex Plan

Premier Balance PPO $1,000 A a Community Blue Flex Plan




Medical Deductible

In-Network


Mem

ber P

ays $500 $750 $1,000 $1,250 $1,500

Standard(2 x Family) $1,500 $1,500 $2,000 $2,500 $3,000



After Deductible

In-Network


Plan

Pay

s

100% 100% 100% 100% 100%





Mem

ber P

ays

$5,500 $4,800 $4,800 $4,000 $3,700




Enhanced $10 BDTC$40 Non-BDTC $20 $20 $20 $20

Standard $40(Retail Clinic = $35) $60 $60 $60 $60

Specialist2 In-NetworkEnhanced $45 $40 $40 $40 $40

Standard $75 $90 $90 $90 $90

Urgent Care In-NetworkEnhanced $75 $65 $65 $65 $65

Standard $75 $100 $100 $100 $100

Telemedicine In-Network Enhanced/Standard $15 $15 $15 $15 $15

Inpatient Hospital In-NetworkEnhanced $0 after ded $0 after ded $0 after ded $0 after ded $0 after ded


Emergency Room Enhanced/Standard $200 $200 $200 $200 $200


In-NetworkEnhanced $45 $40 $40 $40 $40

Standard $75 $90 $90 $90 $90


Enhanced $0 after ded $150 $150 $150 $150

Standard 30% after ded $250 $250 $250 $250





$3/$10/$50/$85/20%/30%



$3/$10/$50/$85/20%/30%



$3/$10/$50/$85/20%/30%



$3/$10/$50/$85/20%/30%



$3/$10/$50/$85/20%/30%




ZONE

A






















19


GOLD SILVER

Health Savings PPO $1,500 a Community Blue Flex Plan4,6


Balance PPO $1,000 a Community Blue Flex Plan


Balance PPO $1,750 A a Community Blue Flex Plan


Medical Deductible

In-Network


Mem

ber P

ays

$1,500$2,000 $1,000 $1,400 $1,750

Standard(2 x Family) $3,000 $5,000 $5,000 $5,250



After Deductible

In-Network


Plan

Pay

s

100% 100% 90% 90% 90%





Mem

ber P

ays

$3,500 $3,450 $7,150 $7,150 $7,150




Enhanced $15 after ded $20 $45 $40 $35

Standard $50 after ded $60 $75 after ded $75 $65

Specialist2 In-NetworkEnhanced $30 after ded $40 $75 after ded $70 $60

Standard $70 after ded $90 $95 after ded $90 $90

Urgent Care In-NetworkEnhanced $65 after ded $65 $100 $85 $75

Standard $95 after ded $100 $150 $125 $100

Telemedicine In-Network Enhanced/Standard $0 after ded $15 $15 $15 $15

Inpatient Hospital In-NetworkEnhanced $0 after ded $0 after ded 10% after ded $0 after ded 10% after ded


Emergency Room Enhanced/Standard $200 after ded $200 $300 $300 $250


In-NetworkEnhanced $30 after ded $40 $75 $70 $60

Standard $70 after ded $90 $95 after ded $90 after ded $90


Enhanced $100 after ded $150 $350 after ded $350 $200

Standard $200 after ded $250 30% after ded 30% after ded $400





$3/$10/$50/$85/20%/30% after dedMember pays (at retail) a maximum of $350 for Specialty Formulary Rx /


$3/$10/$50/$85/20%/30%



$3/$15/$55/$90/20%/30%



$3/$15/$55/$90/20%/30%



$3/$15/$55/$90/20%/30%



Add’l Silver Plans on Next Page


ZONE

A






















20


SILVER BRONZE

Balance PPO $2,000 A a Community Blue Flex Plan

Health Savings PPO Embedded $2,600 a Community Blue Flex Plan4,5,6





Medical Deductible

In-Network


Mem

ber P

ays $2,000

$2,600 $3,000 $5,500 $6,000Standard

(2 x Family) $6,000



After Deductible

In-Network


Plan

Pay

s

90% 100% 100% 80% 100%





Mem

ber P

ays

$7,150 $6,550 $6,550 $6,550 $6,550




Enhanced $35 $0 after ded $0 after ded20% after ded

$0 after ded

Standard $65 $30 after ded 30% after ded 30% after ded

Specialist2 In-NetworkEnhanced $60 $30 after ded $25 after ded 20% after ded $0 after ded

Standard $90 $60 after ded 30% after ded 40% after ded 30% after ded

Urgent Care In-NetworkEnhanced $75 $75 after ded $50 after ded 20% after ded $0 after ded

Standard $100 $100 after ded $100 after ded 40% after ded 30% after ded

Telemedicine In-Network Enhanced/Standard $15 $0 after ded $0 after ded 20% after ded $0 after ded

Inpatient Hospital In-NetworkEnhanced 10% after ded $0 after ded $0 after ded 20% after ded $0 after ded


Emergency Room Enhanced/Standard $250 $250 after ded $250 after ded 20% after ded $0 after ded


In-NetworkEnhanced $60 $30 after ded $25 after ded 20% after ded $0 after ded



Enhanced $200 $50 after ded $50 after ded 20% after ded $0 after ded






$3/$15/$55/$90/20%/30%







20% after ded




ZONE

A


























21



GOLD SILVER BRONZE

Premier Balance PPO $250 IP A a Community Blue Flex Plan

Flex PPO $500 Total Health a Community Blue Flex Plan

Premier Balance PPO $750 IP A a Community Blue Flex Plan

Premier Balance PPO $1,500 IP A a Community Blue Flex Plan

Health Savings PPO Embedded $5,500 a Community Blue Flex Plan5,6

Zone B: Bedford, Blair, Cambria, Cameron, Centre, Clarion, Clearfield, Elk, Forest, Huntingdon, Jefferson, Potter, Somerset, and Venango Counties only

Medical Deductible

In-Network


Mem

ber P

ays $250 $500 $750 $1,500

$5,500Standard

(2 x Family) $750 $1,500 $1,500 $4,500



After Deductible

In-Network


Plan

Pay

s

100% 100% 100% 100% 80%





Mem

ber P

ays

$7,150 $5,500 $4,800 $7,150 $6,550




Enhanced $20 $10 BDTC$40 Non-BDTC $30 $45 20% after ded

Standard $60 $40(Retail Clinic = $35) $60 $70 after ded 20% after ded

Specialist In-NetworkEnhanced $50 $45 $50 $70 20% after ded

Standard $80 $75 $90 $90 40% after ded

Urgent Care In-NetworkEnhanced $65 $75 $60 $75 20% after ded

Standard $100 $75 $100 $100 40% after ded

Telemedicine In-Network Enhanced/Standard $15 $15 $15 $15 20% after ded

Inpatient Hospital In-NetworkEnhanced $500 $0 after ded $500 $1,000 20% after ded


Emergency Room Enhanced/Standard $200 $200 $200 $250 20% after ded


In-NetworkEnhanced $50 $45 $50 $70 20% after ded

Standard $80 $75 $90 $95 after ded 40% after ded


Enhanced $100 $0 after ded $150 $350 20% after ded

Standard $200 30% after ded $250 30% after ded 40% after ded





$3/$10/$50/$85/20%/30%



$3/$10/$50/$85/20%/30%



$3/$10/$50/$85/20%/30%



$3/$15/$55/$90/20%/30%



20% after ded

ZONE

B























22



GOLD

Flex PPO PA Mountains Healthcare Region $500/$1,500 a Community Blue Plan

Zone G: PA Mountains Healthcare Region available in Armstrong, Blair, Cameron, Clarion, Crawford, Forest, Huntingdon, Jefferson, Indiana, Lawrence, McKean, Potter, and Somerset Counties only

Medical Deductible

In-Network


Mem

ber P

ays $500

Standard(2 x Family) $1,500

Out-of-Network(2 x Family) $4,500


After Deductible

In-Network


Plan

Pay

s

100%

Standard(2 x Family) 70%

Out-of-Network(2 x Family) 50%


In-Network

Mem

ber P

ays

$5,300




Enhanced $20

Standard $50(Retail Clinic = $30)

Specialist In-NetworkEnhanced $40

Standard $75

Urgent Care In-Network Enhanced/Standard $75

Telemedicine In-Network Enhanced/Standard $15

Inpatient Hospital In-NetworkEnhanced $0 after ded

Standard 30% after ded

Emergency Room Enhanced/Standard $200


In-NetworkEnhanced $40

Standard $75


Enhanced $0 after ded






$3/$10/$50/$85/20%/30%Member pays (at retail) a maximum of $350

for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx

ZONE

G






23



GOLD

Flex PPO $500/$1,500 Penn Highlands Region a Community Blue Plan

Zone H: Penn Highlands Region available in Centre Clearfield, Elk and Jefferson Counties only

Medical Deductible

In-Network


Mem

ber P

ays $500

Standard(2 x Family) $1,500



After Deductible

In-Network


Plan

Pay

s

100%

Standard(2 x Family) 70%

Out-of-Network(2 x Family) 50%


In-Network

Mem

ber P

ays

$5,500




Enhanced $20

Standard $50(Retail Clinic = $30)

Specialist In-NetworkEnhanced $40

Standard $75

Urgent Care In-Network Enhanced/Standard $75

Telemedicine In-Network Enhanced/Standard $15

Inpatient Hospital In-NetworkEnhanced $0 after ded


Emergency Room Enhanced/Standard $200


In-NetworkEnhanced $40

Standard $75


Enhanced $0 after ded






$3/$10/$50/$85/20%/30%Member pays (at retail) a maximum of $350

for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx

ZONE

H





CONNECT BLUEFOR SMALL GROUPS



25

Zone J – Connect BlueALLEGHENY

BEAVER

BUTLER

WASHINGTON

WESTMORELAND

ERIE

Connect Blue Coverage That Lets Members Select and SaveTop-quality care with a health plan that gives members more ways to save on their care!

Connect Blue gives members patient-centered care at a significant cost savings – with doctors and hospitals that are close to where you live and work.

Connect Blue uses the Community Blue network of providers, and lets members save when using a network of health care providers in their community. The most cost savings come when they use hospitals and doctors participating at the Preferred Value Level of Benefits, which includes Allegheny Health Network — providers that you, your employees and your neighbors have relied on for generations.

Allegheny Health Network offers affordable, exceptional care to people in our communities. Their patient-centered approach to care means a greater focus on coordinated health and wellness services. Their physicians and hospitals are accountable and responsive to patients throughout the course of treatment. They are committed to giving patients the right care at the right time and place.

CONNECT BLUE

SERVICE AREA



The Highmark member website offers all kinds of health awareness, health education and health enhancement tools and programs. Members also get 24-hour access to health decision information and wellness services through their Blues On CallSM health coach. Many of the Allegheny Health Network hospitals partner with Highmark to offer healthy eating and weight management programs at no cost to Highmark members.



Search Find a Doctor on highmarkbcbs.com (no login required) to see the provider’s benefit level. Members will see “Preferred,“ “Enhanced” or “Standard” Benefit Level under the provider’s name.

26

Three Levels of In-Network Choice for Added Cost SavingsThree levels of in-network benefits are offered for most health care services: Preferred Value, Enhanced Value and Standard Value. Members can select from hospitals, facilities and physicians participating at any of the three benefit levels.

See how the Preferred Value, Enhanced Value and Standard Value Levels of Benefits affect out-of-pocket costs.

Level of Benefits Your Cost

In-N

etwo

rk

Preferred Value If members use providers participating at the Preferred Value Level of Benefits, their out-of-pocket costs are the lowest. $

Enhanced ValueIf members use providers participating at the Enhanced Value Level of Benefits, their out-of-pocket costs are often higher than Preferred. $$

Standard Value If members use providers participating at the Standard Value Level of Benefits, their out-of-pocket costs are the highest. $$$

PREFERRED VALUE LEVEL ENHANCED VALUE LEVEL STANDARD VALUE LEVEL

ALLEGHENY• Allegheny General Hospital• Allegheny Valley Hospital• Children’s Hospital of

Pittsburgh of UPMC• Forbes Hospital• Heritage Valley Sewickley • Jefferson Hospital• St. Clair Hospital• West Penn Hospital• Western Psychiatric Institute

and ClinicBEAVER• Heritage Valley Beaver BUTLER• Butler Memorial HospitalERIE• Saint Vincent HospitalWASHINGTON• Canonsburg Hospital• Washington Hospital

ALLEGHENY• Ohio Valley Hospital

ERIE• Corry Memorial Hospital• Millcreek Community Hospital

WASHINGTON• Advanced Surgical Hospital• Monongahela Valley Hospital

WESTMORELAND• Excela Frick Hospital• Excela Latrobe Hospital• Excela Westmoreland Hospital

ERIE• UPMC Hamot

MEMBERS HAVE ACCESS TO HOSPITALS AND AFFILIATED PHYSICIANS PARTICIPATING AT ANY OF THE THREE LEVELS OF BENEFITS*.

CONNECT BLUE PROVIDER NETWORK

* As of January 1, 2017- subject to change.

27



GOLD

Connect Blue EPO $100 a Community Blue Plan




Zone J: Allegheny, Beaver, Butler, Erie, Washington, and Westmoreland Counties only.

Medical DeductibleIn-Network

Preferred(2 x Family)

Mem

ber P

ays

$100 $250 $500 $750

Enhanced(2 x Family) $1,000 $1,000 $2,000 $3,000


Out-of-Network N/A N/A N/A N/A


After Deductible

In-Network


Plan

Pay

s

100% 100% 100% 100%

Enhanced(2 x Family) 70% 70% 70% 70%

Standard(2 x Family) 50% 50% 50% 50%




Mem

ber P

ays

$7,150 $7,150 $7,150 $6,100




Preferred $25 $10 $10 $0Enhanced $45 $40 $40 $40Standard 50% after ded 50% after ded 50% after ded 50% after ded

Specialist In-NetworkPreferred $45 $35 $30 $20Enhanced $70 $65 $65 $65Standard 50% after ded 50% after ded 50% after ded 50% after ded

Urgent Care In-NetworkPreferred $60 $50 $50 $50Enhanced $60 $50 $50 $50Standard 50% after ded 50% after ded 50% after ded 50% after ded

Telemedicine In-NetworkPreferred/Enhanced/Standard

$15 $15 $15 $15

Inpatient Hospital In-Network

Preferred $250 up to 3 days -then $0 copay

$250 up to 3 days -then $0 copay



Enhanced $1,000 up to 3 days -then $0 copay

$1,000 up to 3 days -then $0 copay



Standard 50% after ded 50% after ded 50% after ded 50% after dedEmergency Room Preferred/Enhanced/Standard $250 $250 $200 $200


In-Network

Preferred $35/$45 (SOS)7 $35/$45 (SOS)7 $20/$40 (SOS)7 $20/$40 (SOS)7

Enhanced $70 $70 $65 $65

Standard 50% after ded 50% after ded 50% after ded 50% after ded



Enhanced $350 $350 $300 $300Standard 50% 50% 50% 50%





$3/$10/$50/$85/20%/30%

Member pays (at retail) a maximum of $350 for Specialty

Formulary Rx / $500 for Specialty Non-Formulary Rx

$3/$10/$50/$85/20%/30%



$3/$10/$50/$85/20%/30%



$3/$10/$50/$85/20%/30%



2017 CONNECT BLUE EPOFor Small Groups with 50 or fewer employees

ZONE

J


https://secure.highmark.com/mccepfWeb/showGrids.do?method=processReport&format=P&_ProdId=175965001&_lob=Connect%20Blue&_region=W&_market=A












28


GOLD SILVER


Connect Blue EPO $1,100 a Community Blue Plan



Zone J: Allegheny, Beaver, Butler, Erie, Washington, and Westmoreland Counties only.

Medical DeductibleIn-Network


Mem

ber P

ays

$900 $1,100 $2,500 $3,200

Enhanced(2 x Family) $3,600 $3,300 $5,000 $4,400




After Deductible

In-Network


Plan

Pay

s

100% 100% 100% 100%

Enhanced(2 x Family) 70% 70% 70% 70%

Standard(2 x Family) 50% 50% 50% 50%




Mem

ber P

ays

$7,150 $6,800 $7,150 $7,150




Preferred $10 $10 $25 $25Enhanced $40 $40 $60 $60Standard 50% after ded 50% after ded 50% after ded 50% after ded

Specialist In-NetworkPreferred $30 $30 $50 $50Enhanced $65 $65 $85 $85Standard 50% after ded 50% after ded 50% after ded 50% after ded

Urgent Care In-NetworkPreferred $65 $65 $65 $65Enhanced $65 $65 $65 $65Standard 50% after ded 50% after ded 50% after ded 50% after ded

Telemedicine In-NetworkPreferred/Enhanced/Standard

$15 $15 $15 $15

Inpatient Hospital In-Network

Preferred $250 up to 3 days -then $0 copay




Enhanced $1,000 up to 3 days -then $0 copay




Standard 50% after ded 50% after ded 50% after ded 50% after dedEmergency Room Preferred/Enhanced/Standard $200 $200 $250 $250


In-Network


Enhanced $65 $65 $85 $85

Standard 50% after ded 50% after ded 50% after ded 50% after ded



Enhanced $300 $300 $400 $400Standard 50% 50% 50% 50%





$3/$10/$50/$85/20%/30%



$3/$10/$50/$85/20%/30%



$3/$10/$50/$85/20%/30%



$3/$10/$50/$85/20%/30%



2017 CONNECT BLUE EPOFor Small Groups with 50 or fewer employees

ZONE

J














this page was left blankintentionally

FOR SMALL GROUPS



PEDIATRIC DENTAL & VISION COVERAGE BENEFIT SUMMARY

31

Pediatric Dental Coverage Benefit SummarySmall Group – 50 or Fewer Employees

For Small Group Health Benefit Plans with Effective Dates Beginning January 2017

These benefits apply to Qualified High Deductible Health Plans (QHDHP).This plan meets the minimum essential health benefit requirements for pediatric oral health as required under the Federal Affordable Care Act.These benefits are only available for children through the end of the contract year that they turn 19.This Policy will pay benefits for Covered Services shown below subject to the Schedule of Exclusions and Limitations and other Policy terms. Payment is based on the Maximum Allowable Charge (MAC) for the specific Covered Service. Participating Dentists accept contracted MACs as payment in full for services.

Contract Year Deductible per Insured Person: Combined with MedicalAnnual Maximum per Insured Person: UnlimitedOut-of-Pocket (OOP) Year Maximum per Insured Person: Combined with Medical

SERVICE CATEGORY WAITINGPERIOD

POLICY PAYS AFTER DEDUCTIBLEParticipating Dentists* Non-Participating

Dentists

Oral Evaluations (Exams) None 100%, Not subject to deductible Not Covered No

Radiographs (All X-rays) None 100%, Not subject to deductible Not Covered No

Prophylaxis (Cleanings) None 100%, Not subject to deductible Not Covered No

Fluoride Treatments None 100%, Not subject to deductible Not Covered No

Palliative Treatment (Emergency) None Coinsurance matches Medical, subject to deductible Not Covered Yes

Sealants None 100%, Not subject to deductible Not Covered No

Space Maintainers None 100%, Not subject to deductible Not Covered No

Basic Restoration Anterior Amalgam None Coinsurance matches Medical, subject to deductible Not Covered Yes

Basic Restoration Anterior Composite None Coinsurance matches Medical, subject to deductible Not Covered Yes

Basic Restoration Posterior Amalgam None Coinsurance matches Medical, subject to deductible Not Covered Yes

Crowns, Inlays, Onlays None Coinsurance matches Medical, subject to deductible Not Covered Yes

Crown Repair None Coinsurance matches Medical, subject to deductible Not Covered Yes

Endodontic Therapy (Root canals, etc.) None Coinsurance matches Medical, subject to deductible Not Covered Yes

Surgical Periodontics None Coinsurance matches Medical, subject to deductible Not Covered Yes

Non-Surgical Periodontics None Coinsurance matches Medical, subject to deductible Not Covered Yes

Periodontal Maintenance None Coinsurance matches Medical, subject to deductible Not Covered Yes

Prosthetics (Complete or Fixed Partial Dentures) None Coinsurance matches Medical, subject to deductible Not Covered Yes

Adjustments and Repairs of Prosthetics None Coinsurance matches Medical, subject to deductible Not Covered Yes

Maxillofacial Prosthetics N/A Not Covered Not Covered N/A

Implant Services None Coinsurance matches Medical, subject to deductible Not Covered Yes

Simple Extractions None Coinsurance matches Medical, subject to deductible Not Covered Yes

Surgical Extractions None Coinsurance matches Medical, subject to deductible Not Covered Yes

Oral Surgery None Coinsurance matches Medical, subject to deductible Not Covered Yes

General Anesthesia, Nitrous Oxide and/or IV Sedation None Coinsurance matches Medical, subject to deductible Not Covered Yes

Consultations None Coinsurance matches Medical, subject to deductible Not Covered Yes

Medically Necessary Orthodontics 12 Months Coinsurance matches Medical, subject to deductible Not Covered Yes

* Pediatric Dental benefits utilize the United Concordia Advantage Network. Members must use a United Concordia provider. There is no Out-of-Network coverage for this benefit. United Concordia Companies, Inc., is a separate company that does not provide Blue Cross and/or Blue Shield products or services. United Concordia is solely responsible for the products and services described here.

32

MEDICALLY NECESSARY ORTHODONTICS COVERAGE

In this section, “Medically Necessary” or “Medical Necessity” shall mean health care services that a physician or Dentist, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:

1. in accordance with the generally accepted standards of medical/dental practice;

2. clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and

3. not primarily for the convenience of the patient or physician/Dentist, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.

As used in subpart 1, above, “generally accepted standards of medical/dental practice” means:

• standards that are based on credible scientific evidence published in peer-reviewed, medical/dental literature generally recognized by the relevant professional community;

• recognized Medical/Dental and Specialty Society recommendations;

• the views of physicians/Dentists practicing in the relevant clinical area; and

• any other relevant factors.

A Medically Necessary orthodontic service is an orthodontic procedure that occurs as part of an approved orthodontic plan that is intended to treat a severe dentofacial abnormality.

COVERAGE OF MEDICALLY NECESSARY ORTHODONTICS

1. Orthodontic treatment must be Medically Necessary and be the only method capable of:

a) Preventing irreversible damage to the Insured Person’s teeth or their supporting structures and,

b) Restoring the Insured Person’s oral structure to health and function.

2. Insured Persons must have a fully erupted set of permanent teeth to be eligible for comprehensive, Medically Necessary orthodontic services.

3. All Medically Necessary orthodontic services require prior approval and a written plan of care.

33

These benefits apply to Non-Qualified High Deductible Health Plans (Non-QHDHP).This plan meets the minimum essential health benefit requirements for pediatric oral health as required under the Federal Affordable Care Act.These benefits are only available for children through the end of the contract year that they turn 19.This Policy will pay benefits for Covered Services shown below subject to the Schedule of Exclusions and Limitations and other Policy terms. Payment is based on the Maximum Allowable Charge (MAC) for the specific Covered Service. Participating Dentists accept contracted MACs as payment in full for services.

Contract Year Deductible per Insured Person: $0Out-of-Pocket (OOP) Year Maximum per Insured Person: Combined with MedicalAnnual Maximum per Insured Person: Unlimited

Pediatric Dental Coverage Benefit SummarySmall Group – 50 or Fewer Employees

SERVICE CATEGORY WAITINGPERIOD

POLICY PAYS AFTER DEDUCTIBLEParticipating

Dentists*Non-Participating

Dentists

Oral Evaluations (Exams) None 100% Not Covered N/A

Radiographs (All X-rays) None 100% Not Covered N/A

Prophylaxis (Cleanings) None 100% Not Covered N/A

Fluoride Treatments None 100% Not Covered N/A

Palliative Treatment (Emergency) None 100% Not Covered N/A

Sealants None 100% Not Covered N/A

Space Maintainers None 100% Not Covered N/A

Basic Restoration Anterior Amalgam None 50% Not Covered N/A

Basic Restoration Anterior Composite None 50% Not Covered N/A

Basic Restoration Posterior Amalgam None 50% Not Covered N/A

Crowns, Inlays, Onlays None 50% Not Covered N/A

Crown Repair None 50% Not Covered N/A

Endodontic Therapy (Root canals, etc.) None 50% Not Covered N/A

Surgical Periodontics None 50% Not Covered N/A

Non-Surgical Periodontics None 50% Not Covered N/A

Periodontal Maintenance None 50% Not Covered N/A

Prosthetics (Complete or Fixed Partial Dentures) None 50% Not Covered N/A

Adjustments and Repairs of Prosthetics None 50% Not Covered N/A

Maxillofacial Prosthetics N/A Not Covered Not Covered N/A

Implant Services None 50% Not Covered N/A

Simple Extractions None 50% Not Covered N/A

Surgical Extractions None 50% Not Covered N/A

Oral Surgery None 50% Not Covered N/A

General Anesthesia, Nitrous Oxide and/or IV Sedation None 50% Not Covered N/A

Consultations None 100% Not Covered N/A

Medically Necessary Orthodontics 12 Months 50% Not Covered N/A


* Pediatric Dental benefits utilize the United Concordia Advantage Network. Members must use a United Concordia provider. There is no Out-of-Network coverage for this benefit. United Concordia Companies, Inc., is a separate company that does not provide Blue Cross and/or Blue Shield products or services. United Concordia is solely responsible for the products and services described here.

34

MEDICALLY NECESSARY ORTHODONTICS COVERAGE

In this section, “Medically Necessary” or “Medical Necessity” shall mean health care services that a physician or Dentist, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:

1. in accordance with the generally accepted standards of medical/dental practice;

2. clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and

3. not primarily for the convenience of the patient or physician/Dentist, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.

As used in subpart 1, above, “generally accepted standards of medical/dental practice” means:

• standards that are based on credible scientific evidence published in peer-reviewed, medical/dental literature generally recognized by the relevant professional community;

• recognized Medical/Dental and Specialty Society recommendations;

• the views of physicians/Dentists practicing in the relevant clinical area; and

• any other relevant factors.

A Medically Necessary orthodontic service is an orthodontic procedure that occurs as part of an approved orthodontic plan that is intended to treat a severe dentofacial abnormality.

COVERAGE OF MEDICALLY NECESSARY ORTHODONTICS

1. Orthodontic treatment must be Medically Necessary and be the only method capable of:

a) Preventing irreversible damage to the Insured Person’s teeth or their supporting structures and,

b) Restoring the Insured Person’s oral structure to health and function.

2. Insured Persons must have a fully erupted set of permanent teeth to be eligible for comprehensive, Medically Necessary orthodontic services.

3. All Medically Necessary orthodontic services require prior approval and a written plan of care.

35

PEDIATRIC VISION COVERAGE BENEFIT SUMMARYSMALL GROUP - 50 OR FEWER EMPLOYEES

NETWORK BENEFIT (Independents & Visionworks)* FREQUENCY

ELIGIBLE PARTICIPANTS Members under 19 years of age(1)

Eye Examination (including dilation, as professionally indicated) Once every 12 months

Eyeglass Lenses** Once every 12 months

Frames** Once every 12 months

PLAN RESPONSIBILITY

EYE EXAMINATION (including dilation, as professionally indicated) 100%

FRAMES

Pediatric Frame Selection 100% after deductible

EYEGLASS LENSES(2) (Per Pair)

Single vision 100% after deductible

Bifocal 100% after deductible

Trifocal 100% after deductible

Lenticular 100% after deductible

VALUE ADDED BENEFITS Lens Options purchased from a participating provider will be provided to the member at the amounts listed below.

MEMBER RESPONSIBILITY

LENS OPTIONS

Standard progressive lenses (3) $50

Premium progressive lenses (3) $90

Polycarbonate lenses $0

Intermediate vision lenses $30

High-index (thinner and lighter) lenses $55

Polarized lenses $75

Fashion, sun or gradient tinted plastic lenses $11

Ultraviolet coating $12

Scratch-resistant coating $0

Scratch Protection Plan Single Vision $20

Scratch Protection Plan Multifocal $40

Standard ARC (anti-reflective coating) $35

Premium ARC (anti-reflective coating) $48

Ultra ARC (anti-reflective coating) $60

(1) Dependents will be terminated from the contract at the end of the month in which they turn 19. Termination rules for employer groups are determined by the client.(2) Includes glass, plastic or oversized lenses.(3) Progressive multifocals can be worn by most people. Conventional bifocals will be supplied at no additional charge for anyone who is unable to adapt to progressivelenses. However, the member’s payment towards the progressive upgrade will not be refunded.*Vision benefits utilize the Davis Vision Network. Members must use a Davis Vision provider who participates in the Health Care Reform Vision Network. There is noout-of-network coverage. Davis Vision is a separate company that administers Highmark vision benefits. Visionworks, also a separate company, is a providerwithin the Davis Vision Network.**Subject to deductible.

These benefits apply to Qualified High Deductible Health Plans (QHDHP).


36

PEDIATRIC VISION COVERAGE BENEFIT SUMMARYSMALL GROUP - 50 OR FEWER EMPLOYEES

NETWORK BENEFIT (Independents & Visionworks)* FREQUENCY

ELIGIBLE PARTICIPANTS Members under 19 years of age(1)

Eye Examination (including dilation, as professionally indicated) Once every 12 months

Eyeglass Lenses Once every 12 months

Frames Once every 12 months

PLAN RESPONSIBILITY

EYE EXAMINATION (including dilation, as professionally indicated) 100%

FRAMES

Pediatric Frame Selection 100%

EYEGLASS LENSES(2) (Per Pair)

Single vision 100%

Bifocal 100%

Trifocal 100%

Lenticular 100%

VALUE ADDED BENEFITS Lens Options purchased from a participating provider will be provided to the member at the amounts listed below.

MEMBER RESPONSIBILITY

LENS OPTIONS

Standard progressive lenses (3) $50

Premium progressive lenses (3) $90

Polycarbonate lenses $0

Intermediate vision lenses $30

High-index (thinner and lighter) lenses $55

Polarized lenses $75

Fashion, sun or gradient tinted plastic lenses $11

Ultraviolet coating $12

Scratch-resistant coating $0

Scratch Protection Plan Single Vision $20

Scratch Protection Plan Multifocal $40

Standard ARC (anti-reflective coating) $35

Premium ARC (anti-reflective coating) $48

Ultra ARC (anti-reflective coating) $60

(1) Dependents will be terminated from the contract at the end of the month in which they turn 19. Termination rules for employer groups are determined by the client.(2) Includes glass, plastic or oversized lenses.(3) Progressive multifocals can be worn by most people. Conventional bifocals will be supplied at no additional charge for anyone who is unable to adapt to progressivelenses. However, the member’s payment towards the progressive upgrade will not be refunded.*Vision benefits utilize the Davis Vision Network. Members must use a Davis Vision provider who participates in the Health Care Reform Vision Network. There is noout-of-network coverage. Davis Vision is a separate company that administers Highmark vision benefits. Visionworks, also a separate company, is a providerwithin the Davis Vision Network.

These benefits apply to Non-Qualified High Deductible Health Plans (Non-QHDHP).


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Important Plan Details:

1 Out-of-pocket maximum calculation includes deductible, copayment and coinsurance.

2 Specialist copay applies to outpatient: mental health, behavior health, substance abuse, chiropractic, physical therapy and speech therapy office visits.

3 Rx information displayed: Retail 31-day supply. NOTE: Member’s maximum coinsurance payment for a retail Specialty Rx is $350 Formulary/$500 Non-Formulary.

4 Integrated Rx plans include all medical and prescription claims accumulating toward one overall deductible.

5 “Embedded” plans: In this approach, an individual family member can be eligible for payment of benefits upon meeting the Individual deductible amount (even if the rest of the family has not met the Family deductible amount). Additionally, an individual family member’s out-of-pocket (OOP) maximum will be the same as that of a member purchasing Individual Coverage for the specified health plan.

6 A Health Saving Account (HSA) is available to employees. Employer contributions in amounts that exceed the annual federally mandated maximum(s) may result in actuarial value changes that may impact compliance as a Qualified Health Plan.

7 (S0S): Connect Blue plans have “Site of Service” at the Preferred Level for Labs/Basic Diagnostic Services and Advanced Imaging benefits. Non-Hospital locations have a lower copay and Hospital locations have a higher copay — similar to the Out-Patient Surgery benefit.

Disclosures:

Insurance or benefit administration may be provided by Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Coverage Advantage or Highmark Health Insurance Company, all of which are independent licensees of the Blue Cross and Blue Shield Association.

To find more information about Highmark’s benefits and operating procedures, such as accessing the drug formulary or using network providers, please go to DiscoverHighmark.com/QualityAssurance; or for a paper copy, call1-855-873-4106.

Blue Distinction Centers® and Blue Distinction Total Care are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

Designation as a Blue Distinction Total Care Provider means this Provider has met the established national criteria. To find out which services are covered under your policy at any facilities, please call your local Blue Cross and/or Blue Shield Plan; and call your provider before making an appointment, to verify the most current information on its Network participation and Blue Distinction Total Care status. Neither Blue Cross and Blue Shield Association nor any of its Licensees are responsible for any damages, losses, or non-covered charges that may result from using Blue Distinction or receiving care from a Blue Distinction or other provider.

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Discrimination is Against the Law

The Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race,

color, national origin, age, disability, or sex, including sex stereotypes and gender identity. The Plan does

not exclude people or treat them differently because of race, color, national origin, age, disability, or sex

assigned at birth, gender identity or recorded gender. Furthermore, the Plan will not deny or limit coverage

to any health service based on the fact that an individual’s sex assigned at birth, gender identity, or recorded

gender is different from the one to which such health service is ordinarily available. The Plan will not deny

or limit coverage for a specific health service related to gender transition if such denial or limitation results in

discriminating against a transgender individual. The Plan:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

– Qualified sign language interpreters

– Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:

– Qualified interpreters

– Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Plan has failed to provide these services or discriminated in another way on the basis

of race, color, national origin, age, disability, or sex, including sex stereotypes and gender identity, you can

file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295,

TTY: 711, Fax: 412-544-2475, email: [email protected]. You can file a grievance in

person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to

help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services,

Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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Documents

WESTERN PENNSYLVANIA REGION BENEFIT PORTFOLIO · Highmark Blue Cross Blue Shield understands the importance of reliable, affordable health coverage for Small Groups (with 50 or fewer