There's a plan in here with all over it - For Benefit Period: January 1 to December 31, 2021 - Highmark Insurance ...
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There’s a plan
in here with
your name
all over it.
Your guide to finding just the right
Individual or Family plan for you.
For Benefit Period:
January 1 to December 31, 2021Go ahead. Get picky about your plan. With lots of great coverage options from Highmark, this book will help you find the plan, the product, and the network access that matters most to you. Looking for something in particular? You can easily navigate through the guide by clicking on the headings in the Table of Contents. Why choose Highmark?������������������������������������������������������������������������������������ 1 Affordable Care Act basics������������������������������������������������������������������������������6 Financial help info����������������������������������������������������������������������������������������������8 Enrollment dates���������������������������������������������������������������������������������������������� 10 Enrollment checklist����������������������������������������������������������������������������������������� 11 Product and network highlights���������������������������������������������������������������������12 Plan details by county ������������������������������������������������������������������������������������ 24 Helpful health insurance definitions������������������������������������������������������������ 37 Legal info ���������������������������������������������������������������������������������������������������������� 38
Why choose a
Highmark health plan?
Woah. So many reasons. Here are three big ones right off the top of our heads.
Expert care, close to home.
With Highmark, you’re covered here, there, just about everywhere
with a network that gives you access to in-network facilities
throughout Pennsylvania, as well as select facilities in Maryland,
New Jersey, New York, Ohio, and West Virginia.
Coast-to-coast coverage
with BlueCard®.
All of our plans come with BlueCard coverage, accepted by 96%
of hospitals and 95% of doctors in the U.S.* BlueCard gives you
access to routine, urgent, and emergency care, no matter where
you are. Traveling abroad? You’re also covered in 190 countries.
No red tape.
Lose the timewasting of going to an appointment just to get
another appointment. See whichever in-network doctors you
want to see — no referral. Or call 1-888-Blue-428, and we’ll find a
specialist for you. No hoops, no hoopla.
And that’s just for starters.
Turn the page for even more reasons to choose Highmark.
* According to the Blue Cross and Blue Shield Association.
1How easy do we
make it to find care
and get care?
Almost too easy.
2DENTAL AND VISION COVERAGE
All your care, all in one plan.
Healthy eyes and teeth are important parts of your overall health and
regular check-ups can help you stay ahead of potential problems down
the road. That’s why many of our plans come with adult dental and
vision benefits included. No need to purchase separate plans.
TELEMEDICINE
Face to face with
a doctor, 24/7.
Need to see a doctor but don’t want to leave your couch? Get a
diagnosis, treatment plan, or prescription any time, right from your
phone or computer. Best of all — telemedicine services provided by
American Well are free with many of our plans. Just call the number on
the back of your ID card for details. That’s laid-back-in-a-recliner easy.
BLUE DISTINCTION**
See specialists who
get proven results.
Only doctors who consistently deliver safe, effective treatments
make our Blue Distinction list. When you use our Find a Doctor
tool, a special logo will be by their name, so you can cherry-pick
a top-performing specialist for any care you need
JOHNS HOPKINS MEDICINE COLLABORATION
Expert teamwork
for advanced care.
We collaborate with some of the best minds, like Johns Hopkins
Medicine, for cancer research. That lets us bring the latest innovative
medical breakthroughs right to your neighborhood.
3How simple is it
for you to get
answers and
reach your goals?
Super simple.
4THE HIGHMARK APP AND MEMBER WEBSITE
Your entire plan at your fingertips.
No more searching for old files or waiting on snail mail. Your digital
ID card, Find a Doctor tool, deductible progress, and claims status
are all available via the Highmark Plan app (available on Google Play
or in the Apple App Store) or online at highmarkblueshield.com.
MY CARE NAVIGATOR
Your appointments, booked for you.
It’s as simple as calling 1-888-Blue-428. We’ll help you find the in-
network doctor you need and reserve some space on their calendar
for a checkup. Which means less on-hold music for you.
BLUES ON CALLSM
Answers from a health pro, 24/7.
Medical concerns during off hours? Just call 1-888-Blue-428
to get support from a registered nurse or a health coach any time
and put your worries to bed.
WELLNESS
Personalized support
for health goals.
Looking to lose weight? Quit smoking? Be more active? Get guidance
based on your lifestyle, trackers to measure your progress, resources
like Sharecare, and access to experienced wellness coaches to make
healthy choices and keep you motivated. Once you’re enrolled,
visit mycare.sharecare.com.
BLUE365®
Discounts to help you
stay healthy and active.
From workout gear to gym memberships to healthy meal services,
we’ll take a little off the top while you’re taking a little off your
middle. Member-only deals are at blue365deals.com.
5Before we get
much further,
let’s cover some
Affordable Care Act
(ACA) essentials.
6ACA basics
Metal levels
ACA plans are broken into four categories based on how
you and your plan share the costs of your health care.
Just so you know, metal levels reflect cost-sharing differences
only — which means you get the same quality of care at any level.
CATASTROPHIC BRONZE SILVER GOLD
Premium $ $$ $$$ $$$$
Out-of-Pocket
Costs
$$$$ $$$ $$ $
Never use health care Use health care services
services unless it’s Don’t use a lot of Are eligible for CSR somewhat frequently
Makes sense an emergency. health care services or want to balance and/or want low
if you: Only available and/or want to keep premiums with out-of-pocket costs
if you’re under 30 premium payments low. out-of-pocket costs. for most commonly
or have a hardship. used services.
ACA also includes Platinum level plans; however, Highmark does not offer these types of plans in Pennsylvania.
Ways to save
Good news: There are two ways to Even better news: More than 80% of
save available for Affordable Care our ACA members qualify.* Take a look
Act (ACA) enrollees. to see if you do.
Advanced Premium Tax Credits (APTC), which may be applied — in advance — to lower what
you pay each month for your premium on any level Marketplace plan except Catastrophic.
Cost-Sharing Reductions (CSR) will lower out-of-pocket costs that you may pay at the time of
service for doctor visits, lab tests, drugs, and other covered services. CSR plans also offer lower
deductibles. You can only get these savings if you enroll in an Extra Savings Silver plan.
*Based on on-exchange Highmark enrollment during 2020 OEP.
7See if you qualify
To see if you’re eligible for financial help, locate your qualifying income and household size on the chart
below. Then refer to the Standard or Extra Savings plans for your county to find the plans that will reduce
how much you pay for care.
If you don’t qualify for Cost-Sharing Reductions, you may be eligible for Advanced Premium Tax Credits.
Please refer to the Standard plan options for your county.
What is the income for those covered under this health plan?
Eligible for Eligible for Eligible for
Who Needs Medicaid CSRs and APTCs APTCs
Coverage?
Silver Extra Savings plans Standard
Medicaid
Eligible Range
(100-138% or less FPL) 138-149% 150-199% 200-249%
250%-400%
CSR plans CSR plans CSR plans
Single Less than $17,607 $17,608 - $19,139 $19,140 - $25,519 $25,520 - $31,899 $31,900 - $51,039
Family of 2 Less than $23,790 $23,791 - $25,859 $25,860 - $34,479 $34,480 - $43,099 $43,100 - $68,959
Family of 3 Less than $29,792 $29,973 - $32,579 $32,580 - $43,439 $43,440 - $54,299 $54,300 - $86,879
Family of 4 Less than $36,155 $36,156 - $39,299 $39,300 - $52,399 $52,400 - $65,499 $65,500 - $104,799
Family of 5 Less than $42,337 $42,338 - $46,019 $46,020 - $61,359 $61,360 - $76,699 $76,700 - $122,719
Family of 6 Less than $48,519 $48,520 - $52,739 $52,740 - $70,319 $70,320 - $87,899 $87,900 - $140,639
Family of 7 Less than $54,702 $54,703 - $59,459 $59,460 - $79,279 $79280 - $99,099. $99,100 - $158,559
Family of 8 Less than $60,884 $60,885 - $66,179 $66,180 - $88,239 $88,240 - $110,299 $110,300 - $176,479
*Income between 100% and 400% FPL: If your income is in this range, in all states you qualify for premium tax credits that lower your monthly
premium for a Pennsylvania Insurance Exchange health insurance plan.
*Income below 138% FPL: If your income is below 138% FPL and your state has expanded Medicaid coverage, you qualify for Medicaid based
only on your income.
*American Indians and Alaska Natives who are members of federally recognized tribes are eligible for cost-sharing reductions at alternative dollar
thresholds.
This chart is only applicable for coverage in 2021 and in the 48 contiguous states and the District of Columbia. For families/households with more
than 8 persons, add $4,480 for each additional person. HHS Poverty Guidelines for 2020 (January 31, 2020). Retrieved from
https://aspe.hhs.gov/poverty-guidelines.
Check to see if you qualify for one or both types of help.
Call 855-400-9159.
8ACA plans vs. short-term plans
In addition to the availability of APTC and CSR, all ACA plans provide coverage for preexisting
conditions and the ten essential health benefits (see page 13). Short-term plans — which are
plans that come with a fixed, limited term — do not. Short-term plans can seem like a cheaper
alternative to ACA coverage but often come with hidden costs and exclusions that can make
them more expensive in the long run.
Other types of hidden costs in short-term plans:
SHORT-TERM PLANS ACA PLANS
Capped out-of-pocket spending X ✓
10 Essential Health Benefits X ✓
No limits on covered doctor visits X ✓
No dollar limits on covered benefits X ✓
No limits on prescription drug coverage X ✓
9Next, enrollment dates.
There are two different ways you can be eligible to enroll in or change
your ACA coverage. One is a fixed period that happens every year.
The other is for special cases that can happen any time.
EXTENDED OPEN ENROLLMENT PERIOD
November 1, 2020 – January 15, 2021
If you sign up by December 15, 2020,
your plan takes effect on January 1, 2021.
If you sign up between December 16, 2020
and January 15, 2021, your plan takes effect
on February 1, 2021.
SPECIAL ENROLLMENT PERIODS
Can happen any time throughout the year
Outside the Open Enrollment Period, you can only get or
change coverage if you have a qualifying life event. Examples
include losing your existing coverage, a new addition to the
family, getting married, or moving to a new area where you
can’t keep your current plan. A Special Enrollment Period
only lasts 60 days from the qualifying life event.
If you think you’re eligible for a Special Enrollment Period, you may be asked to submit
documents to prove it. You can go to discoverhighmark.com for more information.
10Finally, your ACA
Enrollment Checklist.
Here’s the info you’ll need for each person
who will be covered on your plan.
Date of birth
Social Security number
(or legal immigrant documents)
Income documentation for all household members,
even if they won’t be covered by the plan
(pay stubs, W-2 forms, or wage and tax statements)
Current health insurance policy numbers (if applicable)
Info on any health insurance you or your family
could get from your job
All set? Great. Let’s dig into the details for 2021 —
and find you the plan with the benefits and features
that matter most to you.
112021 Highmark
product and
network highlights
Now that we’ve gotten the preliminaries out of the way,
let’s take a look at the products and networks available
in your area in 2021.
12Cue the highlight reel.
With Highmark, you get all the essentials — and so much more.
First, you get access to But Highmark goes
the ten essential health above and beyond.
benefits — plus coverage Here are just some of the awesome
for preexisting conditions. benefits you’ll find for the 2021 plan year.*
Go ahead. Start circling the ones you want.
They include:
• Low office visit copay
• Outpatient care
• Free telemedicine through American Well
• Emergency services
• $0 prescription copays for Tier 1 drugs
• Hospitalization (like surgery
and overnight stays) • Free preventive vaccines,** tests,
and screenings***
• Pregnancy, maternity,
and newborn care • Adult dental and vision coverage
• Mental health and substance • Predictable copays that start day 1,
use disorder services no deductible to meet
• Prescription drugs • Prescription drug coverage that
starts day 1, no deductible to meet
• Rehabilitative and habilitative
services and devices • Enhanced resources for managing
chronic conditions
• Laboratory services
• 2 free mental health visits
• Preventive and wellness services
and chronic disease management • 2 free substance abuse disorder visits
• Pediatric services, including dental • Potential tax-free savings with
and vision care a Health Savings Account****
– Money can go in tax-free and lower
your taxable income
– Money comes out tax-free when used
for qualified medical expenses
– Interest and earnings on any unused money
grows tax-free
– Unused money rolls over from year to year
* Not all plans include these benefits. The availability of benefits depends on your selected plan.
** As listed on the Highmark Preventive Schedule when given at a participating pharmacy.
*** As presented on the Highmark Preventive Schedule. To check the preventive schedule for covered care,
visit https://www.highmarkblueshield.com/pdffiles/Highmark_Preventive_Schedule_2020.pdf.
**** Please note: Qualified High Deductible Health Plans may be coupled with a Health Savings Account (HSA). However, certain Cost-Sharing
Reductions (CSR) or plan variations of this plan that are offered through the Health Insurance Marketplace are not intended to be used with an
HSA. If you have questions, please check with your financial advisor.
13my Direct Blue EPO
Enjoy in-network access to top-quality care throughout central
Pennsylvania and the Lehigh Valley, plus full BlueCard access
coast to coast.
With my Direct Blue EPO plans, it’s very simple: providers are either in network or out
of network. You can even see most specialists with no need for referrals. Even better,
the BlueCard program gives you access to the majority of hospitals and doctors
nationwide — so you’ll be covered for routine, urgent, and emergency care wherever
you go.
14To see if your provider is in network,
visit highmarkblueshield.com and click Find a Doctor or Pharmacy.
my Direct Blue EPO plans are available for
residents of the counties highlighted below.
COLUMBIA
MONTOUR
UNION
CENTRE NORTHAMPTON
NORTHUMBERLAND
SNYDER
MIFFLIN JUNIATA SCHUYLKILL LEHIGH
DAUPHIN
BERKS
PERRY
LEBANON
CUMBERLAND
LANCASTER
FULTON FRANKLIN YORK
ADAMS
15my Direct Blue EPO In-Network Hospitals
ALLEGHENY BLAIR • Penn Medicine – Chester
• AHN Allegheny General • Conemaugh Nason Medical County Hospital
Hospital Center
CLARION
• AHN Allegheny Valley Hospital • Tyrone Hospital
• BHS Clarion Hospital
• AHN Brentwood • UPMC Altoona
Neighborhood Hospital CLINTON
• AHN Forbes Hospital BRADFORD
• Bucktail Medical Center
• AHN Jefferson Hospital • Guthrie Robert Packer Hospital
• UPMC Susquehanna
• AHN McCandless • Guthrie Towanda Memorial
Lock Haven
Neighborhood Hospital Hospital
• AHN West Penn Hospital • Guthrie Troy Community COLUMBIA
Hospital • CHS Berwick Hospital Center
• Heritage Valley Kennedy
• Heritage Valley Sewickley BUCKS CRAWFORD
• St. Clair Hospital • Doylestown Hospital • Meadville Medical Center
• The Children’s Home • Jefferson Health – • Titusville Area Hospital
of Pittsburgh Bucks Hospital
• The Children’s Institute CUMBERLAND
of Pittsburgh BUTLER
• Geisinger Holy Spirit Hospital
• UPMC Children’s Hospital of • BHS Butler Memorial Hospital
• UPMC Carlisle
Pittsburgh
CAMBRIA
• UPMC Western DAUPHIN
Psychiatric Hospital • Conemaugh Memorial
• Penn State Health
Medical Center
Children’s Hospital
ARMSTRONG • Conemaugh Miners
• Penn State Health Milton
• Armstrong County Memorial Medical Center
S. Hershey Medical Center
Hospital • Select Specialty Hospital –
Johnstown DELAWARE
BEAVER
• Crozer-Chester Medical Center
• Heritage Valley Beaver CARBON
• Delaware County
• St. Luke’s Hospital –
BEDFORD Memorial Hospital
Lehighton Campus
• UPMC Bedford • Main Line Health –
CENTRE Riddle Hospital
BERKS • Mount Nittany Medical Center
ERIE
• Penn State Health St. Joseph
Medical Center CHESTER • AHN Saint Vincent Hospital
• Surgical Institute of Reading • Main Line Health – Bryn Mawr • Corry Memorial Hospital
Rehab Hospital • Millcreek Community Hospital
• Main Line Health – • Select Specialty Hospital - Erie
Paoli Hospital
16FAYETTE LUZERNE • Main Line Health –
• Highlands Hospital • CHS Wilkes-Barre Lankenau Medical Center
• Uniontown Hospital General Hospital
NORTHAMPTON
• Geisinger Wyoming Valley
FRANKLIN Medical Center • Lehigh Valley Hospital –
Coordinated Health Bethlehem
• WellSpan Chambersburg • Lehigh Valley Hospital –
Hospital Hazleton PHILADELPHIA
• WellSpan Waynesboro Hospital
LYCOMING • Children’s Hospital
of Philadelphia
GREENE • Geisinger Jersey Shore
• Einstein Medical
• Washington Health System • UPMC Susquehanna Muncy
Center Philadelphia
Greene • UPMC Susquehanna
• Jefferson Health –
Williamsport
LACKAWANNA Frankford Hospital
• UPMC Susquehanna
• CHS Moses Taylor Hospital • Jefferson Health –
Williamsport DP Campus
• CHS Regional Hospital Methodist Hospital
of Scranton MCKEAN • Jefferson Health – Thomas
• Geisinger Community Jefferson University Hospital
• Bradford Regional Medical
Medical Center Center • Jefferson Health –
Torresdale Hospital
• UPMC Kane
LANCASTER • Jefferson Health – WillsEye
• Lancaster General Hospital MERCER Hospital
• Lancaster General Hospital • AHN Grove City Hospital • Penn Medicine – Hospital of
Women & Babies • Edgewood Surgical Hospital the University of Pennsylvania
• Lancaster Surgery Center • Sharon Regional Health System • Penn Medicine – Penn
Presbyterian Medical Center
LAWRENCE • UPMC Horizon – Greenville
• Penn Medicine –
• Lawrence County Surgery • UPMC Horizon – Shenango
Pennsylvania Hospital
Center of Edgewood Surgical Valley
• Temple Health – Fox Chase
Hospital Cancer Center
MONROE
• UPMC Jameson • Temple Health – Temple
• Lehigh Valley Hospital –
Pocono University Hospital
LEBANON
• St. Luke’s Hospital –
• WellSpan Good Samaritan POTTER
Hospital Monroe Campus
• UPMC Cole
LEHIGH MONTGOMERY
SCHUYLKILL
• Lehigh Valley Hospital – • Einstein Medical Center
Elkins Park • Lehigh Valley Hospital –
17th Street Schuylkill E. Norwegian Street
• Lehigh Valley Hospital – • Einstein Medical Center
Montgomery • Lehigh Valley Hospital –
Cedar Crest Schuylkill S. Jackson Street
• Lehigh Valley Hospital – • Holy Redeemer Hospital
Coordinated Health Allentown and Medical Center SOMERSET
• Lehigh Valley Hospital – • Jefferson Health – • Conemaugh Meyersdale
Muhlenberg Abington Hospital Medical Center
• Lehigh Valley Reilly • Jefferson Health – • UPMC Somerset
Children’s Hospital Abington-Landsdale Hospital
• Main Line Health – Bryn
Mawr Hospital
17SUSQUEHANNA
• Barnes-Kasson Hospital IN-NETWORK ACCESS TO THESE
• Endless Mountains Health OUT-OF-STATE HOSPITALS
Systems THROUGH BLUECARD*
MARYLAND
TIOGA
• Meritus Medical Center
• UPMC Susquehanna Wellsboro
• The Johns Hopkins Hospital
UNION • University of Maryland
• Evangelical Community Medical Center
Hospital • UPMC Western Maryland
• WVU Medicine – Garrett
VENANGO Regional Medical Center
• UPMC Northwest
NEW YORK
WARREN • AHN Westfield
Memorial Hospital
• Warren General Hospital
• Guthrie Corning Hospital
WASHINGTON • Olean General Hospital
• Advanced Surgical Hospital • UR Medicine – Jones
• AHN Canonsburg Hospital Memorial Hospital
• Monongahela Valley Hospital • UR Medicine – Strong
• Washington Hospital Memorial Hospital
OHIO
WAYNE
• Cleveland Clinic
• Wayne Memorial Hospital
WEST VIRGINIA
WESTMORELAND • Weirton Medical Center
• AHN Hempfield • WVU Medicine –
Neighborhood Hospital Children’s Hospital
• Excela Health Frick Hospital • WVU Medicine – J.W. Ruby
• Excela Health Latrobe Hospital Memorial Hospital
• Excela Health Westmoreland
Hospital
• Select Specialty Hospital –
Laural Highlands
WYOMING
• CHS Tyler Memorial Hospital
*In addition, my Direct Blue EPO plans provide in-network access to out-of-state providers
that participate with local Blue Plans through the BlueCard program. Please refer to the
provider directory for additional out-of-state hospitals. You can find the provider directory
at highmarkblueshield.com under the Find a Doctor or Pharmacy tab.
18my Blue Access EPO
Your choice for comprehensive in-network access throughout
central Pennsylvania and the Lehigh Valley.
With my Blue Access EPO plans, you have in-network access to high-quality, cost-effective care
from more than 9,800 physicians and 50 community hospitals in western and central Pennsylvania.
You can even see in-network specialists with no need for referrals. Even better, the BlueCard
program gives you access to 96% of hospitals and 95% of doctors nationwide* — so you’ll be
covered for routine, urgent, and emergency care wherever you go.
To see if your provider is in network,
visit highmarkblueshield.com and click Find a Doctor or Pharmacy.*
According to the Blue Cross Blue Shield Association
*
my Blue Access EPO plans are available for
residents of the counties highlighted below.
COLUMBIA
UNION MONTOUR
CENTRE NORTHAMPTON
NORTHUMBERLAND
SNYDER
SCHUYLKILL LEHIGH
JUNIATA
MIFFLIN
DAUPHIN
BERKS
PERRY
LEBANON
CUMBERLAND
LANCASTER
FULTON FRANKLIN YORK
ADAMS
19my Blue Access EPO In-Network Hospitals
ADAMS • UPMC St. Margaret BUTLER
• WellSpan Gettysburg Hospital • UPMC Western Psychiatric • BHS Butler Memorial Hospital
Hospital • UPMC Passavant – Cranberry
ALLEGHENY
• AHN Allegheny General ARMSTRONG CAMBRIA
Hospital • Armstrong County Memorial • Conemaugh Memorial Medical
• AHN Allegheny Valley Hospital Hospital Center
• AHN Brentwood BEAVER • Conemaugh Miners Medical
Neighborhood Hospital • Curahealth Hospital Center
• AHN Forbes Hospital Heritage Valley • Select Specialty Hospital –
• AHN Jefferson Hospital • Heritage Valley Beaver Johnstown
• AHN McCandless
BEDFORD CARBON
Neighborhood Hospital • St. Luke’s – Lehighton Campus
• UPMC Bedford
• AHN West Penn Hospital
BERKS CENTRE
• Curahealth Pittsburgh
• Penn State Health St. Joseph • Mount Nittany Medical Center
• Heritage Valley Kennedy
• Heritage Valley Sewickley Medical Center CHESTER
• LifeCare Behavioral Health • Surgical Institute of Reading • Main Line Health – Bryn
Hospital of Pittsburgh • Tower Health – Mawr Rehab Hospital
• Select Specialty Hospital – Reading Hospital • Main Line Health – Paoli
McKeesport BLAIR Hospital
• Select Specialty Hospital – • Conemaugh Nason • Penn Medicine – Chester
Pittsburgh UPMC Medical Center County Hospital
• St. Clair Hospital • Tyrone Hospital • Tower Health – Brandywine
• The Children’s Home Hospital
• UPMC Altoona
of Pittsburgh • Tower Health – Jennersville
BRADFORD Hospital
• The Children’s Institute
of Pittsburgh • Guthrie Robert Packer Hospital • Tower Health – Phoenixville
• UPMC Children’s Hospital • Guthrie Towanda Memorial Hospital
Hospital
of Pittsburgh CLARION
• UPMC East • Guthrie Troy Community
• BHS Clarion Hospital
Hospital
• UPMC Magee-Womens
CLEARFIELD
Hospital BUCKS
• Penn Highlands Clearfield
• UPMC McKeesport • Doylestown Hospital
• Penn Highlands DuBois
• UPMC Mercy • Jefferson Health –
• UPMC Montefiore Bucks Hospital CLINTON
• UPMC Passavant – • St. Luke’s Hospital – • Bucktail Medical Center
McCandless Quakertown Campus • UPMC Susquehanna Lock
• UPMC Presbyterian • St. Luke’s Hospital – Haven
• UPMC Shadyside Upper Bucks Campus
20COLUMBIA GREENE • St. Luke’s Hospital –
• CHS Berwick Hospital Center • Washington Health System Allentown Campus
• Geisinger Bloomsburg Hospital Greene • St. Luke’s Hospital –
Sacred Heart Campus
CRAWFORD HUNTINGDON
• St. Luke’s University Hospital –
• Meadville Medical Center • Penn Highlands Huntingdon Bethlehem
• Titusville Area Hospital INDIANA LUZERNE
CUMBERLAND • Indiana Regional Medical • CHS Wilkes-Barre
• Geisinger Holy Spirit Hospital Center General Hospital
• Select Specialty Hospital – JEFFERSON • Geisinger Wyoming Valley
Camp Hill • Penn Highlands Brookville Medical Center
• UPMC Carlisle • Punxsutawney Area Hospital • Lehigh Valley Hospital –
• UPMC Pinnacle West Shore Hazleton
LACKAWANNA
DAUPHIN • CHS Moses Taylor Hospital LYCOMING
• Penn State Health Children’s • CHS Regional Hospital • Geisinger Jersey Shore Hospital
Hospital of Scranton • UPMC Susquehanna Muncy
• Penn State Health Milton S. • Geisinger Community • UPMC Susquehanna
Hershey Medical Center Medical Center Williamsport
• UPMC Pinnacle Community • UPMC Susquehanna
LANCASTER
Osteopathic Williamsport Divine
• Lancaster General Hospital Providence Campus
• UPMC Pinnacle Harrisburg
• Lancaster General Hospital
DELAWARE Women & Babies MCKEAN
• Crozer-Chester Medical Center • Lancaster Surgery Center • Bradford Regional Medical
Center
• Delaware County Memorial • UPMC Lititz
Hospital • UPMC Kane
• WellSpan Ephrata Community
• Main Line Health – Hospital MERCER
Riddle Hospital • AHN Grove City Hospital
LAWRENCE
ELK • Lawrence County Surgery • Edgewood Surgical Hospital
• Penn Highlands Elk Center of Edgewood Surgical • Sharon Regional Health System
ERIE Hospital • UPMC Horizon – Greenville
• AHN Saint Vincent Hospital • UPMC Jameson • UPMC Horizon – Shenango
Valley
• Corry Memorial Hospital LEBANON
• Millcreek Community Hospital • WellSpan Good Samaritan MIFFLIN
• Select Specialty Hospital – Erie Hospital • Geisinger Lewistown Hospital
• UPMC Hamot LEHIGH MONROE
FAYETTE • Lehigh Valley Hospital – • Lehigh Valley Hospital – Pocono
17h Street • St. Luke’s Hospital – Monroe
• Highlands Hospital
• Lehigh Valley Hospital – Campus
• Uniontown Hospital
Cedar Crest
MONTGOMERY
FRANKLIN • Lehigh Valley Hospital –
Coordinated Health Allentown • Einstein Medical Center
• WellSpan Chambersburg
Elkins Park
Hospital • Lehigh Valley Hospital –
Muhlenberg • Einstein Medical Center
• WellSpan Waynesboro Hospital
Montgomery
FULTON • Lehigh Valley Reilly
Children’s Hospital • Holy Redeemer Hospital
• Fulton County Medical Center and Medical Center
21• Jefferson Health – PHILADELPHIA POTTER
Abington Hospital • Children’s Hospital • UPMC Cole
• Jefferson Health – of Philadelphia
SCHUYLKILL
Abington-Landsdale Hospital • Einstein Medical
• Geisinger St. Luke’s Hospital
• Main Line Health – Bryn Mawr Center Philadelphia
Hospital • Lehigh Valley Hospital -
• Jefferson Health – Frankford
Schuylkill E. Norwegian Street
• Main Line Health – Lankenau Hospital
Medical Center • Lehigh Valley Hospital -
• Jefferson Health – Methodist
Schuylkill S. Jackson Street
• Tower Health – Pottstown Hospital
Hospital • St. Luke’s Hospital – Miners
• Jefferson Health – Thomas
Campus
MONTOUR Jefferson University Hospital
• Jefferson Health – Torresdale SOMERSET
• Geisinger Jane Weis
Children’s Hospital Hospital • Chan Soon-Shiong Medical
• Jefferson Health – WillsEye Center at Windber
• Geisinger Medical Center
Hospital • Conemaugh Meyersdale
NORTHAMPTON • Penn Medicine – Hospital of Medical Center
• Leigh Valley Hospital – the University of Pennsylvania • UPMC Somerset
Coordinated Health Bethlehem • Penn Medicine – Penn
SUSQUEHANNA
• St. Luke’s Hospital – Anderson Presbyterian Medical Center
Campus • Barnes-Kasson Hospital
• Penn Medicine – Pennsylvania
• St. Luke’s Hospital – Hospital • Endless Mountains Health
Easton Campus Systems
• Temple Health – Fox Chase
NORTHUMBERLAND Cancer Center TIOGA
• Geisinger Shamokin Area • Temple Health – Temple • UPMC Susquehanna
Community Hospital University Hospital Wellsboro
• Tower Health – Chestnut UNION
Hill Hospital
• Evangelical Community
Hospital
H
22VENANGO
• UPMC Northwest IN-NETWORK ACCESS TO THESE
OUT-OF-STATE HOSPITALS
WARREN THROUGH BLUECARD*
• Warren General Hospital
MARYLAND
WASHINGTON • Meritus Medical Center
• Advanced Surgical Hospital • The Johns Hopkins Hospital
• AHN Canonsburg Hospital • University of Maryland
• Monongahela Valley Hospital Medical Center
• Washington Hospital • UPMC Western Maryland
WAYNE • WVU Medicine – Garrett
Regional Medical Center
• Wayne Memorial Hospital
NEW YORK
WESTMORELAND
• AHN Westfield Memorial
• AHN Hempfield Hospital
Neighborhood Hospital
• Guthrie Corning Hospital
• Excela Health Frick Hospital
• Olean General Hospital
• Excela Health Latrobe
• UR Medicine – Jones Memorial
Hospital
Hospital
• Excela Health Westmoreland
• UR Medicine – Strong
Hospital
Memorial Hospital
• Select Specialty Hospital –
Laurel Highlands OHIO
• Cleveland Clinic
WYOMING
• CHS Tyler Memorial Hospital WEST VIRGINIA
• Weirton Medical Center
YORK
• WVU Medicine –
• OSS Orthopaedic Hospital Children’s Hospital
• UPMC Hanover • WVU Medicine – J.W. Ruby
• UPMC Memorial Memorial Hospital
• WellSpan York Hospital
*
In addition, my Blue Access EPO plans provide in-network access to out-of-state
providers that participate with local Blue Plans through the BlueCard program. You
can find the provider directory at highmarkblueshield.com under the Find a Doctor or
Pharmacy tab.
23Now, let’s dig
into plan details.
24To make it easier, we’ve sorted them
by what’s available where you live.
Just find your county and jump to that section.
Berks, Cumberland, Dauphin, Franklin, Lancaster, Lebanon,
Lehigh, Northampton, Perry, and Schuylkill Counties
Standard plan options ��������������������������������������������������������������������������������������������������26
Extra Savings plan options ������������������������������������������������������������������������������������������28
Adams, Centre*, Columbia, Fulton, Juniata, Mifflin, Montour,
Northumberland, Snyder, Union, and York Counties
Standard plan options ��������������������������������������������������������������������������������������������������30
Extra Savings plan options ������������������������������������������������������������������������������������������ 32
Adult Vision and Dental Benefits ��������������������������������������������������������������������������34
* If you’re a Centre county resident, you must live in one of the following ZIP codes to enroll in one of these plans:
16801, 16802, 16803, 16804, 16805, 16820, 16823, 16826, 16827, 16828, 16832, 16835, 16841, 16844, 16851, 16852,
16853, 16854, 16856, 16864, 16865, 16868, 16870, 16872, 16875, 16877, or 16882
You’ll see plan summaries here. If you want any plan’s
full benefit list, visit Highmark-SBC2021.com or get a
paper copy by calling 1-833-258-0188 (TTY/TDD 711).
25Plan summaries – Berks, Cumberland, Dauphin, Franklin, Lancaster, Lebanon, Lehigh, Northampton, Perry, and Schuylkill Counties
Coverage Level
Catastrophic Bronze Bronze Silver
8550 HSA 6900 3800 HSA 3450
my Direct Blue EPO1 my Direct Blue EPO1 my Direct Blue EPO1 my Direct Blue EPO1
Plan Availability
my Blue Access EPO my Blue Access EPO my Blue Access EPO my Blue Access EPO
Individual: $8,550 Individual: $6,900 Individual: $3,800 Individual: $3,450
In-Network Deductible
Family: $17,100 Family: $13,800 Family: $7,600 Family: $6,900
In-Network, Out-of- Individual: $8,550 Individual: $6,900 Individual: $8,500 Individual: $6,900
Pocket Maximum Family: $17,100 Family: $13,800 Family: $17,000 Family: $13,800
First 3 visits free, then $70 copay after
Primary Care Visit $0 after deductible $60 copay
$0 after deductible deductible
$70 copay after
Specialist Visit $0 after deductible $0 after deductible 50% after deductible
deductible
Outpatient Mental
First 2 visits free, then $70 copay after
Health and Substance $0 after deductible $0 after deductible
50% after deductible deductible
Abuse Visits
Physical &
$70 copay after
Occupational $0 after deductible $0 after deductible 50% after deductible
deductible
Therapy/Chiropractic3
Lab Services $90 copay after
$0 after deductible $0 after deductible 50% after deductible
(Diagnostic / X-ray) deductible
$140 copay after
Urgent Care $0 after deductible $0 after deductible $100 copay
deductible
Emergency $750 copay after
$0 after deductible $0 after deductible 50% after deductible
Services deductible
Hospital Inpatient
(including $0 after deductible $0 after deductible 50% after deductible 10% after deductible
Maternity)
Pharmacy $0/$0/$0/$0 $0/$0/$0/$0 50%/50%/50%/50% $0/$30/$150/50%
Summary4 after deductible after deductible after deductible after deductible
Includes Adult Dental
No No Yes No
and Vision Option5
26Coverage Level
Silver Silver Silver Gold 800 Gold 0
2900 2600 HSA 1850
my Direct Blue EPO1 my Direct EPO1* my Direct Blue EPO1* my Direct Blue EPO1 my Direct Blue EPO1
Plan Availability
my Blue Access EPO my Blue Access EPO* my Blue Access EPO* my Blue Access EPO my Blue Access EPO
Individual: $1,850
In-Network Individual: $2,900 Individual: $2,600 Individual: $800 Individual: $0
Family: $3,700
Deductible Family: $5,800 Family: $5,200 Family: $1,600 Family: $0
[Non-embedded]2
In-Network,
Individual: $7,800 Individual: $8,500 Individual: $6,900 Individual: $6,000 Individual: $7,500
Out-of-Pocket
Family: $15,600 Family: $17,000 Family: $13,800 Family: $12,000 Family: $15,000
Maximum
Primary Care Visit $50 copay $40 copay 30% after deductible $15 copay $20 copay
Specialist Visit $50 copay $40 copay 30% after deductible $15 copay $20 copay
Outpatient
Mental Health and $50 copay $40 copay 30% after deductible $15 copay $20 copay
Substance Abuse Visits
Physical &
Occupational $75 copay $40 copay 30% after deductible $40 copay $45 copay
Therapy/Chiropractic3
Lab Services
$75 copay $65 copay 30% after deductible $30 copay $35 copay
(Diagnostic / X-ray)
Urgent Care $100 copay $80 copay 30% after deductible $30 copay $40 copay
Emergency $750 copay after
30% after deductible 30% after deductible $250 copay $300 copay
Services deductible
Hospital Inpatient
30% after deductible 30% after deductible 30% after deductible 20% after deductible 40% after deductible
(including Maternity)
Pharmacy 30%/30%/30%/30%
$0/$30/$150/50% $0/$30/$150/50% $0/$25/$75/50% $0/$30/$150/50%
Summary4 after deductible
Includes Adult Dental
Yes Yes No Yes No
and Vision Option5
* These plans are available directly from Highmark and are not available on the Pennsylvania Insurance Exchange. They do not qualify for Advanced
Premium Tax Credits or Cost-Sharing Reductions.
1
Includes my Direct Blue EPO and my Direct Blue Lehigh Valley EPO
2
This plan has a Non-Embedded deductible. See Disclosures page for more info.
3
Limit of 30 combined physical and occupational therapy visits per benefit period.
4
Visit highmarkacaformulary.com to view our Formulary and see if your drug is covered, and at which tier.
5
See page 34 for Adult Dental and Vision benefit details.
27Plan summaries – Berks, Cumberland, Dauphin, Franklin, Lancaster, Lebanon, Lehigh, Northampton, Perry, and Schuylkill Counties Extra Savings Plans
Income Level
138%-149% FPL 150-199% FPL
Coverage Level
Silver 100 Silver 0 Silver 700
my Direct Blue EPO1 my Direct Blue EPO1 my Direct Blue EPO1
Plan Availability
my Blue Access EPO my Blue Access EPO my Blue Access EPO
Individual: $100 Individual: $0 Individual: $700
In-Network Deductible
Family: $200 Family: $0 Family: $1,400
In-Network, Out-of- Individual: $1,400 Individual: $1,200 Individual: $2,850
Pocket Maximum Family: $2,800 Family: $2,400 Family: $5,700
Primary Care Visit $5 copay $1 copay $25 copay
Specialist Visit $5 copay $1 copay $25 copay
Outpatient Mental
Health and Substance $5 copay $1 copay $25 copay
Abuse Visits
Physical & Occupational
$5 copay $5 copay $25 copay
Therapy/Chiropractic2
Lab Services
$15 copay $5 copay $45 copay
(Diagnostic / X-ray)
Urgent Care $10 copay $5 copay $50 copay
Emergency Services $150 after deductible $75 copay $300 after deductible
Hospital Inpatient
10% after deductible 10% after deductible 10% after deductible
(including Maternity)
Pharmacy Summary3 $0/$5/$15/50% $0/$5/$15/50% $0/$10/$50/50%
Includes Adult Dental
Yes No Yes
and Vision Option4
28Income Level
150-199% FPL 200-249% FPL
Coverage Level
Silver 0 Silver 2100 Silver 1050
my Direct Blue EPO1 my Direct Blue EPO1 my Direct Blue EPO1
Plan Availability
my Blue Access EPO my Blue Access EPO my Blue Access EPO
Individual: $0 Individual: $2,100 Individual: $1,050
In-Network Deductible
Family: $0 Family: $4,200 Family: $2,100
In-Network, Out-of- Individual: $2,800 Individual: $6,800 Individual: $5,800
Pocket Maximum Family: $5,600 Family: $13,600 Family: $11,600
Primary Care Visit $15 copay $50 copay $60 after deductible
Specialist Visit $15 copay $50 copay $60 after deductible
Outpatient Mental
Health and Substance $15 copay $50 copay $60 after deductible
Abuse Visits
Physical & Occupational
$30 copay $75 copay $60 after deductible
Therapy/Chiropractic2
Lab Services
$25 copay $75 copay $75 after deductible
(Diagnostic / X-ray)
Urgent Care $30 copay $100 copay $120 after deductible
Emergency Services $275 copay $750 after deductible $750 after deductible
Hospital Inpatient
10% after deductible 30% after deductible 10% after deductible
(including Maternity)
Pharmacy Summary3 $0/$10/$50/50% $0/$30/$150/50% $0/$30/$150/50% after deductible
Includes Adult Dental
No Yes No
and Vision Option4
1
Includes my Direct Blue EPO and my Direct Blue Lehigh Valley EPO
2
Limit of 30 combined physical and occupational therapy visits per benefit period.
3
Visit highmarkacaformulary.com to view our Formulary and see if your drug is covered, and at which tier.
4
See page 34 for Adult Dental and Vision benefit details.
29Plan summaries – Adams, Centre**, Columbia, Fulton, Juniata, Mifflin, Montour, Northumberland, Snyder, Union, and York Counties
Coverage Level
Catastrophic Bronze Bronze Silver
8550 HSA 6900 3800 HSA 3450
Plan Availability my Blue Access EPO my Blue Access EPO my Blue Access EPO my Blue Access EPO
Individual: $8,550 Individual: $6,900 Individual: $3,800 Individual: $3,450
In-Network Deductible
Family: $17,100 Family: $13,800 Family: $7,600 Family: $6,900
In-Network, Out-of- Individual: $8,550 Individual: $6,900 Individual: $8,500 Individual: $6,900
Pocket Maximum Family: $17,100 Family: $13,800 Family: $17,000 Family: $13,800
First 3 visits free,
Primary Care Visit $0 after deductible $60 copay $70 after deductible
then $0 after deductible
Specialist Visit $0 after deductible $0 after deductible 50% after deductible $70 after deductible
Outpatient Mental
First 2 visits free, then
Health and Substance $0 after deductible $0 after deductible $70 after deductible
50% after deductible
Abuse Visits
Physical &
Occupational $0 after deductible $0 after deductible 50% after deductible $70 after deductible
Therapy/Chiropractic2
Lab Services
$0 after deductible $0 after deductible 50% after deductible $90 after deductible
(Diagnostic / X-ray)
Urgent Care $0 after deductible $0 after deductible $100 copay $140 after deductible
Emergency
$0 after deductible $0 after deductible 50% after deductible $750 after deductible
Services
Hospital Inpatient
(including $0 after deductible $0 after deductible 50% after deductible 10% after deductible
Maternity)
Pharmacy $0/$0/$0/$0 $0/$0/$0/$0 50%/50%/50%/50% $0/$30/$150/50%
Summary3 after deductible after deductible after deductible after deductible
Includes Adult Dental
No No Yes No
and Vision Option4
30Coverage Level
Silver 2900 Silver Silver Gold 800 Gold 0
2600 HSA 1850
Plan Availability my Blue Access EPO my Blue Access EPO* my Blue Access EPO* my Blue Access EPO my Blue Access EPO
Individual: $1,850
Individual: $2,900 Individual: $2,600 Individual: $800 Individual: $0
In-Network Deductible Family: $3,700
Family: $5,800 Family: $5,200 Family: $1,600 Family: $0
[Non-embedded] 1
In-Network, Out-of- Individual: $7,800 Individual: $8,500 Individual: $6,900 Individual: $6,000 Individual: $7,500
Pocket Maximum Family: $15,600 Family: $17,000 Family: $13,800 Family: $12,000 Family: $15,000
Primary Care Visit $50 copay $40 copay 30% after deductible $15 copay $20 copay
Specialist Visit $50 copay $40 copay 30% after deductible $15 copay $20 copay
Outpatient Mental
Health and Substance $50 copay $40 copay 30% after deductible $15 copay $20 copay
Abuse Visits
Physical &
Occupational $75 copay $40 copay 30% after deductible $40 copay $45 copay
Therapy/Chiropractic2
Lab Services
$75 copay $65 copay 30% after deductible $30 copay $35 copay
(Diagnostic / X-ray)
Urgent Care $100 copay $80 copay 30% after deductible $30 copay $40 copay
Emergency
$750 after deductible 30% after deductible 30% after deductible $250 copay $300 copay
Services
Hospital Inpatient
(including 30% after deductible 30% after deductible 30% after deductible 20% after deductible 40% copay
Maternity)
Pharmacy 30%/30%/30%/30%
$0/$30/$150/50% $0/$30/$150/50% $0/$25/$75/50% $0/$30/$150/50%
Summary3 after deductible
Includes Adult Dental
Yes Yes No Yes No
and Vision Option4
* Plans are available directly from Highmark and are not available on the Pennsylvania Insurance Exchange. They do not qualify for Advanced
Premium Tax Credits or Cost-Sharing Reductions.
**If you’re a Centre county resident, you must live in one of the following ZIP codes to enroll in one of these plans: 16801, 16802, 16803, 16804, 16805,
16820, 16823, 16826, 16827, 16828, 16832, 16835, 16841, 16844, 16851, 16852, 16853, 16854, 16856, 16864, 16865, 16868, 16870, 16872, 16875,
16877, or 16882
1 This plan has a Non-Embedded deductible. See Disclosures page for more info.
2 Limit of 30 combined physical and occupational therapy visits per benefit period.
3 Visit highmarkacaformulary.com to view our Formulary and see if your drug is covered, and at which tier.
4 See page 34 for Adult Dental and Vision benefit details.
31Plan summaries – Adams, Centre**, Columbia, Fulton, Juniata, Mifflin, Montour, Northumberland, Snyder, Union, and York Counties Extra Savings Plans
Income Level
138%-149% FPL 150-199% FPL
Coverage Level
Silver 100 Silver 0 Silver 700
Plan Availability my Blue Access EPO my Blue Access EPO my Blue Access EPO
Individual: $100 Individual: $0 Individual: $700
In-Network Deductible
Family: $200 Family: $0 Family: $1,400
In-Network, Out-of- Individual: $1,400 Individual: $1,200 Individual: $2,850
Pocket Maximum Family: $2,800 Family: $2,400 Family: $5,700
Primary Care Visit $5 copay $1 copay $25 copay
Specialist Visit $5 copay $1 copay $25 copay
Outpatient Mental
Health and Substance $5 copay $1 copay $25 copay
Abuse Visits
Physical & Occupational
$5 copay $5 copay $25 copay
Therapy/Chiropractic1
Lab Services
$15 copay $5 copay $45 copay
(Diagnostic / X-ray)
Urgent Care $10 copay $5 copay $50 copay
Emergency Services $150 after deductible $75 copay $300 after deductible
Hospital Inpatient
10% after deductible 10% 10% after deductible
(including Maternity)
Pharmacy Summary2 $0/$5/$15/50% $0/$5/$15/50% $0/$10/$50/50%
Includes Adult Dental
Yes No Yes
and Vision Option3
32Income Level
150-199% FPL 200-249% FPL
Coverage Level
Silver 0 Silver 2100 Silver 1050
Plan Availability my Blue Access EPO my Blue Access EPO my Blue Access EPO
Individual: $0 Individual: $2,100 Individual: $1,050
In-Network Deductible
Family: $0 Family: $4,200 Family: $2,100
In-Network, Out-of- Individual: $2,800 Individual: $6,800 Individual: $5,800
Pocket Maximum Family: $5,600 Family: $13,600 Family: $11,600
Primary Care Visit $15 copay $50 copay $60 after deductible
Specialist Visit $15 copay $50 copay $60 after deductible
Outpatient Mental
Health and Substance $15 copay $50 copay $60 after deductible
Abuse Visits
Physical & Occupational
$30 copay $75 copay $60 after deductible
Therapy/Chiropractic1
Lab Services
$25 copay $75 copay $75 after deductible
(Diagnostic / X-ray)
Urgent Care $30 copay $100 copay $120 after deductible
Emergency Services $275 copay $750 after deductible $750 after deductible
Hospital Inpatient
10% 30% after deductible 10% after deductible
(including Maternity)
Pharmacy Summary2 $0/$10/$50/50% $0/$30/$150/50% $0/$30/$150/50% after deductible
Includes Adult Dental
No Yes No
and Vision Option3
**If you’re a Centre county resident, you must live in one of the following ZIP codes to enroll in one of these plans: 16801, 16802, 16803, 16804, 16805,
16820, 16823, 16826, 16827, 16828, 16832, 16835, 16841, 16844, 16851, 16852, 16853, 16854, 16856, 16864, 16865, 16868, 16870, 16872, 16875,
16877, or 16882
1 Limit of 30 combined physical and occupational therapy visits per benefit period.
2 Visit highmarkacaformulary.com to view our Formulary and see if your drug is covered, and at which tier.
3 See page 34 for Adult Dental and Vision benefit details.
33Adult Vision Benefits
For all plans with Adult Dental and Vision —
these are your vision benefits.
In-network
Vision Benefits Frequency - Once Every:
Eye Examination (including dilation when professionally indicated) 12 months
Spectacle Lenses 12 months
Frame 12 months
Contact Lenses (in lieu of eyeglass lenses) 12 months
Copayments
Eye Examination $0
Spectacle Lenses $0
Contact Lens Evaluation, Fitting, and Follow-Up Care n/a
Eyeglass Benefit - Frame Average Retail Value
Non-Collection Frame Allowance (Retail): Up to $130 Up to $60
Fashion level Up to $125 Included
Davis Vision Frame Collection 1
Designer level Up to $175 $20 copayment
(in lieu of Allowance):
Premier level Up to $225 $40 copayment
Eyeglass Benefit - Spectacle Lenses Average Retail Value Member Charges
Clear plastic single-vision, lined bifocal, trifocal or lenticular lenses (any Rx) $60-$120 Included
Oversize Lenses $20 Included
Tinting of Plastic Lenses $20 $11
Scratch-Resistant Coating $25-$40 Included
Scratch Protection Plan Single Vision $60-$120 $20
Scratch Protection Plan Multifocal $60-$120 $40
Polycarbonate Lenses2 $60-$75 $0 or $30
Ultraviolet Coating $25-$30 $12
Standard Anti-Reflective (AR) Coating $50-$70 $35
Premium AR Coating $65-$90 $48
Ultra AR Coating $100-$125 $60
Standard Progressive Lenses $150-$195 $50
Premium Progressives (Varilux®, etc.) $195-$225 $90
Ultra Progressive Lenses $225-$300 $140
Intermediate-Vision Lenses $150-$175 $30
High-Index Lenses $90-$150 $55
Polarized Lenses $95-$110 $75
Plastic Photosensitive Lenses $95-$150 $65
34Contact Lens Benefit (in lieu of eyeglasses)
Non-Collection Contact Lenses: Materials Allowance Up to $85
Disposable Covered In Full
Collection Contact Lenses1
Planned Replacement Covered In Full
in lieu of Allowance): Materials
Evaluation, Fitting, and Follow-up Care Included
Medically Necessary Contact
Materials, Evaluation, Fitting, and Follow-Up Care Included
Lenses (with prior approval)
Collection is available at most participating independent provider offices. Collection is subject to change.
1
Collection is inclusive of select torics and multifocals.
2
Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with
prescriptions +/- 6.00 diopters or greater.
One-year eyeglass breakage warranty included.
Adult Vision benefits utilize the Davis Vision Network. There is no out-of-network coverage. Davis Vision
is a separate company that administers Highmark vision benefits.
To find a provider in the Davis Vision Network, visit highmarkblueshield.com and select the Find a Doctor or
Pharmacy tab.
35Adult Dental Benefits
For all plans with Adult Dental and Vision —
these are your dental benefits.
Dental Benefits
Annual Deductible Per Insured Person $50 Per Calendar Year
Annual Deductible Per Insured Family $150 Per Calendar Year
Annual Maximum Per Insured Person $1,250
Policy Pays
Covered Services: Elimination Period
In Network Out of Network
Oral Evaluations (Exams) 100% 0% None
Radiographs (All X-Rays) 100% 0% None
Prophylaxis (Cleanings) 100% 0% None
Palliative Treatment (Emergency) 100% 0% None
Sealants 100% 0% None
Space Maintainers 100% 0% None
Repairs of Crowns, Inlays, Onlays, Fixed Partial
80% 0% 6 Months
Dentures, and Dentures
Basic Restorative (Fillings, etc.) 80% 0% None
Simple Extractions 80% 0% 6 Months
Surgical Extractions 50% 0% 6 Months
Complex Oral Surgery 50% 0% 6 Months
Endodontics (Root canals, etc.) 50% 0% 6 Months
General Anesthesia and/or Nitrous Oxide and/or
80% 0% 6 Months
IV Sedation
Nonsurgical Periodontics 50% 0% 6 Months
Periodontal Maintenance 50% 0% None
Surgical Periodontics 50% 0% 6 Months
Crowns, Inlays, Onlays 50% 0% 6 Months
Prosthetics (Fixed Partial Dentures, Dentures) 50% 0% 6 Months
Adjustments and Repairs of Prosthetics 80% 0% None
Implant Services 0% 0% None
Consultations 100% 0% None
Orthodontics 0% 0% None
The percentage in the Policy Pays column is the percentage of the plan allowance that the Policy will
pay for Covered Services provided by a Participating Dentist. Participating Dentists accept the Maximum Allowable Charge
as payment in full.
Adult 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
administers pediatric dental benefits for Highmark members.
To find a dental provider in the Advantage Network, visit highmarkblueshield.com and select the Find a Doctor or Pharmacy tab.
36Health care lingo, translated.
When you’re choosing plans, you’re bound to see certain terms over and over.
Here’s a cheat sheet for a few of the most important ones.
BlueCARD® HIGH-DEDUCTIBLE HEALTH PREMIUM
A program that connects independent PLAN (HDHP) The monthly amount paid for coverage.
Blue Plans across the country. It A plan that usually comes with
PREVENTIVE CARE SERVICES
gives Blue Plan members access to a lower premium because you pay more
Routine care like screenings and
in-network coverage while outside for health care services up
checkups that help you healthy. Refer to
their plan area. The level of coverage front before the insurance company
the Highmark Preventive Schedule for
depends on your chosen plan. starts to pay. These plans are often
the list of preventive care services.
combined with a health
COINSURANCE
savings account. PRIMARY CARE PROVIDER (PCP)
The percentage of total cost of
The medical professional you see for
care you may owe for certain IN-NETWORK PROVIDER
most of your basic care, like yearly
covered services after reaching your A doctor or hospital that has
preventive visits and screenings.
deductible. For example, if your plan an agreement with the plan and
pays 80%, you pay 20%. will accept plan allowance plus QUALIFIED HEALTH PLAN (QHP)
member copay or coinsurance A plan that has been certified by the
COPAY
as payment in full. Health Insurance Marketplace and
The set amount you pay for certain
meets all ACA requirements. That
covered services, could be $20 for a OUT-OF-NETWORK PROVIDER
includes providing the 10 essential
doctor visit or $30 for a specialist visit. A doctor or hospital that does not
health benefits and staying inside the
If you owe a copay, you must pay it have an agreement with the plan
limits for deductibles, copays, and
when you check in for your visit. and does not have to accept plan
out-of-pocket maximums.
allowance as payment in full.
DEDUCTIBLE
REHABILITATIVE SERVICES
The set amount you pay for covered OUT-OF-POCKET MAXIMUM
Care that helps you keep, get back,
health services or drug costs before The most you’d pay for covered
or improve skills and functioning
your plan starts paying. care in a benefit period or year.
after you were sick, hurt, or disabled.
If you reach this amount, your
EMERGENCY SERVICES
plan pays 100% after that. RETAIL CLINIC
Care for a condition needing
Walk-in centers for less complex health
immediate attention to avoid PLAN ALLOWANCE
needs, generally open in the evenings
severe harm. The set amount an in-network
and on weekends.
provider has agreed to accept for a
FORMULARY
covered health care service. Member TELEMEDICINE
A list of drugs selected by the plan
responsibility for the service can Telemedicine is health care that you get
based on certain clinical factors.
be found in the Outline of Coverage. from a doctor in real time via a smart
The list of medicines is sorted
The plan pays the difference between device, computer, or telephone.
by tier. Lower tiers usually mean
the plan allowance and the member
lower copays.
responsibility. If an out-of-network URGENT CARE CENTER
A walk-in center for when you have a
HABILITATIVE SERVICES provider bills for more than the
plan allowance, you may have to condition that’s serious enough to need
Health care services that help you
pay the difference. If your plan does not care right away, but not serious enough
keep, acquire, or improve skills and
include out-of-network coverage and for a trip to the emergency room.
functioning for daily living following
disease, illness, or injury. you receive care, other than emergency VIRTUAL VISIT
or urgent care, you may be responsible A type of telemedicine that you receive
HEALTH SAVINGS ACCOUNT (HSA) for the entire cost.. from a PCP or specialist via email or
An account to set aside pre-tax money
online videoconferencing.
to pay for qualified medical expenses.
You can only have an HSA if you
have a Qualified High-Deductible
Health Plan.
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