The PPO Blue Plan is a traditional PPO plan that has a lower deductible and a higher payroll deduction than the PPO Savings Plan. Following are some features of the PPO Blue Plan:
- Medical coverage is the same as the PPO Savings Plan
- Physician network is the same as the PPO Savings Plan
- Drug formulary is that same as the PPO Savings Plan
- In-network preventive care is covered at 100% with no deductible or co-insurance or co-payments
- Includes access to an optional Flexible Spending Account that allows subscribers to use pre-tax funds to pay for health care expenses incurred during the current plan year
Understanding the Plan
With the PPO Blue Plan, plan members pay an Office Visit Copay each time they visit a provider. The copays are $10.00 for a general office visit, $20.00 for a specialist office visit, and $100 for an emergency room visit (waived if admitted). Co-pay amounts do not count toward satisfying the deductible or out-of-pocket maximums for the plan. In addition, all medical services, except for prescription drug costs, count toward the deductible. Once the deductible has been satisfied for the calendar year, the plan begins to pay claims at 90%, and the subscriber is responsible for paying the remaining 10% of any medical expenses for that year. This 10% cost-sharing component is called co-insurance. The subscriber continues to pay 10% of the discounted amount for all medical claims until a co-insurance out-of-pocket (OOP) maximum is met. After that, any remaining claims for that year are covered at 100%.
It is important to note that the subscriber's deductible and co-insurance amounts are based on Highmark’s discounted price (sometimes called the allowed amount) rather than on the provider's charge.
PPO Blue Plan subscribers may select from one of three coverage tiers: Individual, Parent /Child(ren), and Family. Within the Parent/Child(ren) and Family coverage tiers, there are different guidlines for satisfying the deductible and out-of-pocket maxmiums. For example, the deductible for the Family plan is $250/$500. This means that when the first person in the family has accrued $250 in eligible expenses for the year, any remaining medical claims for that person will be covered at 90%, with 10% co-insurance to be paid by the subscriber. Once the remaining family members accrue medical expenses totalling $250, the $500 deductible for the entire family has been satisfied, and the plan begins to pay claims at 90%, with 10% co-insurance to be paid by the subscriber. The Individual deductible applies only when one person is covered on the plan.
With the PPO Blue plan, the subscriber pays for the office visit co-pay at the time of service. For other services, the subscriber will receive a bill from his/her provider. The subscriber may then choose to pay the bill from a Flexible Spending Account (FSA) or from other personal accounts. If the bill is paid from a FSA, the subscriber may use the Highmark FSA debit card, or may pay the provider directly through the claims portal on the Highmark website. With the FSA, there is a requirement to substantiate expenses; therefore, subscribers are required to send Highmark a copy of the receipt of payment for each invoice. Information about how to submit a medical receipt may be found on the Highmark website under "Spending Accounts".
See Medical Flexible Spending Accounts for more information about emaximum allowable annual contribuitions to the FSA, and for tips about managing an FSA.
For additional assistance with questions regarding the PPO Blue Plan or Flexible Spending Accounts, please contact Highmark Blue Shield directly at 800-914-4384.
For PPO Blue members only without a Health Care FSA:
As Highmark continues to “go green”, effective May 9, they will discontinue printing/mailing paper Explanation of Benefits (EOBs) when there is a $0 balance, or when there is only an office visit or emergency room copayment, due for a medical claim. You will be able to view these EOBs online at www.highmarkblueshield.com or by calling Highmark member services at 800-914-4384.
All other types of claims will continue to generate paper EOB’s, unless you have chosen to receive EOBs through the Highmark website only.
This change does NOT apply to those enrolled in the PPO Blue plan with an FSA or the PPO Savings plan with the HSA. Plan Activity Statements will continue to generate as usual.
It is important you compare each plan to select the plan that best fits your situation. The PPO Blue plan has a deductible and then coinsurance, which is employee cost-sharing, after the deductible is satisfied. Please see the link to to "compare each plan" for details regarding the deductible amounts. If you are covering more than just yourself on the PPO Blue plan, please note that when ONE covered person reaches the $250 individual deductible, that one person's claims begin to pay at 90%; once any combination of other family members reach the remaining $250 FAMILY or $125 PARENT/CHILD deductible, then the plan begins to pay ALL of the family's medical claims at 90%.
Value-Based Benefit Design (VBBD)
If you enroll in the PPO Blue Plan for 2016, you can take advantage of a new way to save on chronic health care conditions: Value-Based Benefit Design (VBBD). You must enroll directly with Highmark EACH YEAR in order to receive the VBBD benefit.
If you are diagnosed by your doctor with high blood pressure, high cholesterol and/or diabetes (type 1 or type 2), you can enroll in VBBD. Office visits, lab work and medical supplies are covered at 100% with no copays or coinsurance for these conditions when you enroll in this voluntary program.
To be eligible for this coverage, you must opt in with Highmark beginning January 1, 2016. You must also remain in the PPO Blue Plan and follow your in-network doctor’s plan of care. For more information on VBBD or to opt-in, call Highmark at 800-914-4384 beginning January 1.
(1.81% of Salary)
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Teamsters Bi-Weekly Premiums
Payroll contributions will be determined based on your annual base salary as of October 31, 2015. Your new payroll contribution amount is effective January 1, 2016 and will remain the same for the entire year.
(2.37% of Salary)
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