PPO Blue Plan
The PPO Blue Plan is a traditional PPO plan. It 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 for the PPO Savings Plan
- Physician network is the same as for the PPO Savings Plan
- Drug formulary is that same as for the PPO Savings Plan
- In-network preventive care is covered at 100% with no deductible or co-insurance or co-payments
- Includes an optional Medical 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
For specific information about PPO Blue Plan coverage and member cost sharing associated with the plan, please see
Co-pays, Deductibles, Coinsurance, and Coinsurance Out-of-Pocket Limits
PPO Blue Plan plan members pay an office visit co-pay each time they visit a provider. Co-pay amounts do not count toward satisfying the deductible or out-of-pocket maximums for the plan.
All medical services, except for prescription drug costs and office visit co-pays, 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 coinsurance.
The subscriber continues to pay 10% of the discounted amount for all medical claims until a coinsurance out-of-pocket maximum is met. After that, any remaining claims for that year are covered at 100%.
Note that the subscriber's deductible and coinsurance amounts are based on Highmark’s discounted price (sometimes called the allowed amount) rather than on the provider's charge.
Coverage Tiers: Individual, Parent/Child(ren), Family
PPO Blue Plan subscribers may select from three coverage tiers: Individual, Parent/Child(ren), and Family.
The Parent/Child(ren) and Family coverage tiers contain different guidelines for satisfying the deductible and out-of-pocket maximums. For example, for the Family plan, the deductible 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% coinsurance to be paid by the subscriber. Once the remaining family members accrue medical expenses totaling $250, the $500 deductible for the entire family has been satisfied, and the plan begins to pay claims at 90%, with 10% coinsurance to be paid by the subscriber.
The Individual deductible applies only when one person is covered on the plan.
Prescription Drug Coverage
Under the PPO Blue Plan, prescription medications follow a separate coinsurance rate schedule which includes pricing for generic and brand name drugs at both retail and mail-order pharmacies.
Under this schedule, any out-of-pocket prescription drug expenses do not count toward satisfying the medical plan deductible and coinsurance out-of-pocket maximums; however, when a plan member reaches $1,000 in out-of-pocket prescription drug expenses in a calendar year, that person's medications are covered at 100% for the remainder of the year.
For specific information about PPO Blue Plan prescription drug coverage and costs, please see Prescription Coverage-PPO Blue.
Paying for Out-of-Pocket Medical Expenses
Office visit co-pays are paid 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.
FSA subscribers are requried to substantiate expenses; therefore, a copy of the receipt of payment for each invoice should be sent to Highmark. 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 the maximum allowable annual contributions to the FSA, and for tips about managing an FSA.
Understanding Medical Costs
Understanding the costs of medical services, procedures, equipment and prescription drugs can greatly assist subscribers in how they select providers and use medical care. PPO Blue members are provided with several ways to view the costs associated with their claims:
- The Highmark website outlines the costs associated with each claim, including the provider's charge, the member discounted rate, the amount paid by the plan and the total out-of-pocket cost to the member. To locate this information, select the Claims tab on the subscriber's Home page of the Highmark website.
- PPO Blue members who are enrolled in a Health Care FSA will receive an Explanation of Benefits (EOB) form each time a medical claim associated with his/her account is submitted. The EOB outlines the provider's charge, the member discounted rate, the amount paid by the plan, and the costs that are the responsibility of the subscriber.
Subscribers who do not wish to receive paper copies may opt to receive them only through the Highmark website.
- PPO Blue members without a Health Care FSA will receive paper EOBs unless they have opted to receive them through the Highmark website, their account has a $0 balance, or their claims are for only an office visit or emergency room copayment. EOBs associated with these types of co-payments may be viewed on the Highmark website.
- Highmark members may view medical services and procedures pricing for providers in their geographic area via the Care Cost Estimator on the member's home page of the Highmark website.
For additional assistance with questions regarding the PPO Blue Plan or Flexible Spending Accounts, please contact Highmark Blue Shield at 800-914-4384
Value-Based Benefit Design
PPO Blue Plan members who have been diagnosed with the following chronic conditions may enroll in Value-Based Benefit Design (VBBD).
- high blood pressure
- high cholesterol
- diabetes (type-1 or type-2)
This program encourages individuals to manage these health conditions by keeping the individual's out-of-pocket expenses low. With VBBD, all office visits, lab work and medical supplies related to these conditions are covered at 100% with no co-pays or coinsurance.
In order to take advantage of this voluntary benefit, plan members must enroll directly with Highmark each year, remain in the PPO Blue Plan, and follow their in-network physician's plan of care.
For more information about VBBD or to enroll, call Highmark at 800-914-4384 beginning January 1 for returning subscribers, or at any time of the year for new subscribers.
(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.
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