State System Employee Benefits
Health Care Changes Newsletter for January 2016
Nonrepresented, Nurses (OPEIU), Security/Police (SPFPA)
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Upcoming Health Care Plan Changes
Like most employers, the State System has been challenged by the rapidly increasing trends in health care costs. Medical
inflation, increased utilization, and health care reform have all been contributing factors. We believe it is important to provide a
health plan that ensures our members have broad network access to the best providers, facilities, and centers of medical
excellence–here in Pennsylvania, across the country, and when travelling internationally. The Highmark PPO Blue Plan provides
such access. To ensure that a high quality health plan remains affordable for both the State System and our enrolled
employees, changes will be implemented on January 1, 2016 with regard to how costs are shared between the plan and the
members. Depending upon the types of medical services that you and your covered family members utilize, you may either
experience little change in your out-of-pocket costs, or you may experience a more significant increase if you or your family use
a higher volume of more costly medical services. Regardless of where you currently are in that range of medical spending, there
are ways you and your family can reduce your out-of-pocket costs. You will find information about cost-savings strategies
throughout this newsletter, and you will continue to receive ongoing communications in 2016 about this important topic.
Changes at a Glance
• Elimination of the HMO Plan Options (p. 3) >
• PPO Plan Medical Service Cost-Sharing Changes (p. 3) >
• $250 individual in-network deductible on certain medical services ($500 family deductible)
• 10% member coinsurance on certain medical services, to an annual maximum of $1,000/individual
($2,000/family annual maximum)
• Full-Time Employee Premium Contribution Changes (p. 4) >
• Healthy U participants – 18% of premiums
• Healthy U nonparticipants – 28% of premiums
• Change in Same-Sex Domestic Partner Health Plan Eligibility (p. 5) >
• Prescription Drug Copay Changes (p. 6) >
Retail (30-day supply)
$10 Generic
$30 Brand, Formulary
$50 Brand, Nonformulary
Mail-Order (90-day supply)
$20 Generic
$60 Brand, Formulary
$100 Brand, Nonformulary
• Prescription Drug Program Administrative Changes (p. 6) >
• New Virtual Health Benefits (p. 9) >
Reminder: If you make any changes to your current
coverage during Open Enrollment, you must retain a
copy of your benefits election email confirmation. In the
event that there is any discrepancy with your enrollment,
you will be required to present the email confirmation to
the human resources office.
Important Dates and Information
Open Enrollment Dates
November 9-20, 2015
Make changes to your existing coverage.
• Elect or drop coverage/add or remove dependents.
• Enroll in a Flexible Spending Account (Healthcare or
Dependent Care) for pre-tax savings.
If you don’t take action
If you are currently enrolled in the HMO plan, you and your
covered dependents will be moved into the PPO plan
effective January 1, 2016. You will receive Highmark member
ID cards in the mail in late December. If you are currently
enrolled in the PPO plan, you will remain in the PPO plan with
the plan changes discussed in this guide. If you are a current
PPO plan member, you will not receive new member ID cards
and you should continue to use the cards you currently have.
Elections should be completed through Employee SelfService (ESS) at https://portal.passhe.edu/irj/portal.
Upon login, click Employee Self-Service, then Benefits,
lastly select Benefits Enrollment.
All changes will be effective January 1, 2016
1
The State System Health Plan—Market Competitive
With the changes to the health plan outlined in this newsletter, the State System’s health care benefit program will remain
extremely competitive within the higher education sector, both in Pennsylvania—comparing very favorably with plans
offered by Penn State, Pitt and Temple—and nationally, and will still exceed the level of benefits provided to most
Pennsylvania residents.
Dollars may not add due to rounding.
Above is a comparison of the total cost of health care premiums for both single and family coverage, and how those
premiums are shared by the employer and employee (via payroll contributions). Data is presented for the State System
PPO plan (after changes for 2016), higher education market averages, and national benchmark data of plans offered by
cross-industry employers (both public and private).
State System Employee Benefits–A Comprehensive Package
Your health care benefits are only one component of a comprehensive package of benefits provided to you and your
eligible dependents, which include*:

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Generous retirement benefits (Alternative Retirement Plan (ARP), State Employees’ Retirement System
(SERS), Public School Employees’ Retirement System (PSERS).)
Retiree Health Plan.
Tuition benefits for employees and dependents.
Paid time off (holidays, annual leave, sick leave, personal leave).
Employer-paid dental and vision benefits.
Employer-paid life insurance.
*Specific benefits may vary based upon university, employee group and/or collective bargaining unit.
2
January 1, 2016 Health Care Plan Changes
HMO Elimination
The four regional HMO plan options (Geisinger Health Plan HMO,
Keystone Health Plan Central HMO, Keystone Health Plan East
HMO, and the UPMC Health Plan HMO) will be eliminated. The
health plan offered will be the Highmark PPO Blue Plan. Employees
who are currently enrolled in an HMO plan will be automatically
enrolled in the PPO plan at the appropriate tier. If desired, during
open enrollment, affected employees may also elect to add or
remove dependents, or waive coverage entirely.
Addition of Deductibles and Coinsurance to PPO Plan
The PPO plan will now include deductibles and coinsurance for
certain types* of medical services, per the chart below.
PPO Plan Feature
Do you live in western Pennsylvania?
Please see the UPMC/Highmark website for
resources and information about in-network
medical providers, as well as additional
information about the various consent decree
provisions that may allow you to continue
using UPMC providers on an in-network
basis.
What you will pay…
In-network
Out-of-network
Deductible
$250 per person, up to a maximum of
$500 per family
$500 per person, up to a maximum of
$1,000 per family
Coinsurance
10%
30%
Out-of-Pocket Maximum
(Applicable to coinsurance only; does
not include deductible and copays)
$1,000 per person, up to a maximum
of $2,000 per family
$2,000 per person, up to a maximum
of $4,000 per family
* Deductibles and coinsurance do not apply to in-network preventive care or to services for which a copay applies.
Definition of Plan Terms
Deductible–The amount you will pay for the applicable health care services before the health plan begins to pay.
Coinsurance–Your share of the cost of the applicable health care services, after the deductible is met.
Out-of-Pocket Maximum–The maximum amount you will be required to pay in a calendar year in coinsurance payments.
After this amount has been satisfied, the health plan will pay 100% of the applicable covered health care costs for the
remainder of the calendar year. (Members will continue to be responsible for copays for office visits and prescription
drugs.)
Copay–A fixed, upfront dollar amount that you pay each time you receive certain health care services (such as an office
visit or a prescription). The deductible/coinsurance do not apply to services subject to a copay.
Important–The deductible and coinsurance only apply to certain types of health care expenses.
Here are some areas where the deductible and
coinsurance do not apply.
Here are some common medical services where the
deductible and coinsurance will apply.
• In-Network Preventive Care–Preventive services (such
as annual physicals, well-baby visits, immunizations
and mammograms) will continue to be covered at
100% by the health plan; there will be no member cost
associated with these services.
• Diagnostic/Imaging Services (e.g., x-ray, MRI,
nonpreventive lab/pathology).
• Inpatient and outpatient surgery.
• Hospitalization.
• Durable medical equipment.
• Services to which a copay applies–If a copay applies to
the service you are obtaining, then that service is not
subject to the deductible or coinsurance. This includes
primary care and specialist office visits, emergency
room visits, and prescription drugs. For these services,
your cost is the associated member copay amount.
• Chemotherapy, dialysis and infusion therapy.
• Home health care, skilled nursing facility care and
hospice care.
Not a comprehensive list of services, click here for more details.
3
Employee Premium Contributions
The current full-time employee premium contributions rates are 15% of plan costs for Healthy U participants, and 25% for
Healthy U nonparticipants. Effective with the January 22, 2016 pay, the full-time employee premium contribution rates will
be 18% of plan costs for Healthy U participants, and 28% for Healthy U nonparticipants. However, because the plan’s
total overall costs will decrease as a result of the plan changes being implemented January 1, 2016, the biweekly increase
in premium will be lessened.
Below are the employee premium contributions effective with the January 22, 2016 pay.
Tier of Coverage
Single
Full Time Biweekly Rates
Healthy U
Healthy U
Participant Nonparticipant
$51.22
$79.67
Part Time Biweekly Rates
Healthy U
Healthy U
Participant
Nonparticipant
$163.61
$177.84
Two-Party
$113.55
$176.64
$362.74
$394.28
Multi-Party
$139.16
$216.47
$444.55
$483.20
Medical Services–Member Costs (In-Network)
The chart below summarizes the types of medical services you may receive and identifies the services that are provided at
no member cost, those that are subject to a copay, and those that are subject to the annual deductible and coinsurance.
No Member
Copay
Annual Deductible, Then Coinsurance (up
Types of Services
Cost
Only
to out-of-pocket maximum)
Routine physical exams, well-baby visits,
annual gynecological exams
Adult and pediatric immunizations,
preventive diagnostic services
Preventive screenings (e.g.,
mammograms, routine PSA screening,
colorectal cancer screening)
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Primary care provider office visits for
nonpreventive care of sickness and injury
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Specialist office visits
Urgent care visits
Emergency room visits
Speech, occupational and physical
therapy, chiropractic
Outpatient mental health visits
Inpatient hospitalization (e.g., acute care,
maternity, rehabilitation)
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Surgery–inpatient and outpatient
Nonpreventive laboratory and diagnostic
services (e.g., X-ray, MRI, lab/pathology)
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Chemotherapy, radiation therapy, dialysis,
and infusion therapy
Durable Medical Equipment
Hospice, skilled nursing, home health
care
These are examples only and not a comprehensive list of covered services – for more information see exhibit 1, PPO Benefit Summary.
4
How the PPO member cost-sharing will work at in-network providers
Single Coverage
Two-Party Coverage
If you incur medical services that are subject to the
deductible, you will pay the first $250 of those costs, and
then 10% of the subsequent costs, up to an annual
maximum of $1,000 in coinsurance payments. In total,
your expenses for these types of services are capped at
$1,250 for the year ($250 in deductible + $1,000 in
coinsurance). All remaining costs for these applicable
services for the calendar year will be paid 100% by the
plan.*
Your maximum annual deductible would be $500 ($250
for each person) and then 10% of the subsequent costs
up to your annual maximum coinsurance payments of
$2,000 ($1,000 maximum for each person). Then, all
remaining costs for these types of services for the
calendar year would be paid 100% by the plan.*
Multi-Party Coverage
Your maximum deductible for your family is $500 for the year. This maximum deductible may be satisfied in a number
of different ways:
- Two members of the family could each meet the $250 maximum for a total of $500.
- Or together as a family, they could meet the $500 maximum deductible on an aggregate basis.
For example, in a four-person family, each person could incur $125 of applicable medical services in a year, and satisfy
the $500 family deductible in that manner ($125 times four people). In that example, any applicable medical services
incurred by any member of the family after that point would be subject to the 10% coinsurance payments (with the
remaining 90% of costs paid by the plan).
The 10% coinsurance annual out-of-pocket family maximum of $2,000 works in the same manner–it could be satisfied
individually by two members of the family, or on an aggregate basis by three or more family members. No one person
in the family will ever pay more than $250 in deductible, or more than $1,000 in coinsurance payments.
Examples assume all medical services are incurred in-network.
*Members may incur other medical costs in the form of office visit and prescription drug copays.
Preventive Care
There are no member costs for preventive care at in-network providers–the plan continues to pay 100% of the costs for
qualifying preventive services. By following the recommendations in the preventive schedule, you may be able to either
prevent certain medical conditions, or detect them before they become more serious.
Take a moment to review the preventive schedule and, if needed, contact your medical provider to obtain any
recommended services.
Elimination of Same-Sex Domestic Partner Health Benefits
In light of the recent changes in marriage laws legalizing same-sex marriage at the federal and state level, the State
System will prospectively eliminate same-sex domestic partner health benefits for future benefits enrollment. Effective
January 1, 2016, no new same-sex domestic partners will be enrolled. For employees currently covering their same-sex
domestic partners, there will be no impact to you as a result of this change; your same-sex domestic partner may
remain enrolled in the health plan.
5
January 1, 2016 Prescription Drug Program Changes
The cost of prescription drugs have been rapidly
increasing, particularly in the area of specialty
medications. This plan year, the State System’s
prescription drug cost increase was almost 16% over the
prior year.
Save Money, Save Time
With Mail-Order
Copays for both retail and mail-order prescriptions are
increasing. The new copays are as follows:
Retail
Copay
(30-day
supply)
$10
Mail-Order
Copay
(90-day
supply)
$ 20
Brand Drugs, Formulary
$30
$ 60
Brand Drugs, Nonformulary
$50
$100
Prescription Drug Tier
Generic
If you or a covered family member are(is) taking a
maintenance medication, and you are purchasing
it at a retail pharmacy, you will save money by
switching to mail-order.
Although the mail-order copay is two times the
retail copay, you get three times the amount of
your prescription (a 90-day supply) with the mailorder service.
For example: if you are taking a brand name
formulary drug, you will be spending $360 per
year ($30 copay times12 refills) at the retail
pharmacy. But, if you switch to mail-order, you
will spend $240 per year ($60 copay times 4
refills) saving you $120 per year!
Note–Prescription drugs are not subject to the plan deductible or
coinsurance; the only member cost associated with this plan benefit
are the copays listed above.
Certain prescription drugs may now be subject to prior
authorization requirements, quantity level limits, or other
management programs to ensure that these medications
are being used in a safe and effective manner, and to
help both you and the health plan control costs.
Additionally, mail-order is more convenient–
saving you from making monthly trips to the
pharmacy.
If you are taking a prescription drug in one of these drug
classes, you will receive a letter from Highmark advising
you of any additional requirements with which you or
your medical provider may need to comply.
Call Highmark member services at 1-888-7453212 or logon to
https://www.highmarkblueshield.com, and click
on the Prescription Services link for more
information on the mail-order program.
Specialty Medications
If you or a covered family member need(s) to take a
specialty medication, you will be required to obtain the
prescription from Walgreens Specialty Pharmacy, a mailorder pharmacy provider solely focused on specialty
medications. Walgreens Specialty Pharmacy has
negotiated with Highmark to provide the deepest
discounts on specialty medications, which can average
$5,000 or more in cost per month. Additionally, this
vendor offers a dedicated care coordinator to provide
support to patients. If you are currently taking a specialty
medication provided from a pharmacy other than
Walgreens Specialty Pharmacy, you will be receiving a
letter informing you of the changes and providing
guidance on the transition in drug vendors.
What is a specialty medication?
Specialty medications are used to treat chronic, rare, or
complex conditions (such as rheumatoid arthritis,
multiple sclerosis, or cancer). Additionally, specialty
medications may:
- Be given by infusion, injection, or taken orally.
- Cost more than traditional medications.
- Have special storage and handling requirements.
- Need to be taken on a very strict schedule.
- Have support programs and services available to help
patients receive the most benefit from their medication.
Retail Pharmacy Network–Additional Option
The retail pharmacy network will be expanded to include
Target pharmacies. This network enhancement will add
64 locations in Pennsylvania, and 1,684 locations
nationwide for you to obtain your prescription
medications.
Choose Generics
Ask your doctor to write your prescription for generic
drugs when possible. Generics meet the same FDA
standards as brand-name drugs, but both you and the
health plan will pay less.
View the attached Prescription Benefit Summary (Exhibit 2)
for more information on the prescription drug plan.
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It is important to understand how these changes may affect you. Below are some examples of how costs may work under
the new deductible/coinsurance cost sharing changes.
Example: Having a Baby (Assumes all services received are in-network.)
Medical Service
Initial office visit
Initial preventive lab work
(e.g. HIV screening, RH
typing)
Ultrasound
Additional nonpreventive lab
work
Inpatient vaginal delivery–
facility
Inpatient vaginal delivery–
professional
Breast pump – durable
medical equipment
Total
$100
$100
Member
Pays
Deductible
$0
150
150
0
500
250
600
Negotiated
Rate
Plan
Pays
Member
Pays
Coinsurance
$0
Member
Pays Copay
Explanation
$0
Covered under preventive services
0
0
Covered under preventive services
250
0
0
Services subject to $250 deductible
540
0
60
0
Services subject to the 10% coinsurance
6,200
5,580
0
620
0
2,750
2,475
0
275
0
150
150
0
0
0
$10,450
$9,245
$250
$ 955
$0
Services subject to 10% coinsurance
Plan Total: $9,245
Covered under preventive services
Member Total: $1,205
Illustrative purposes only; individual situations may differ.
Example: Knee Replacement (Assumes all services are received in-network.)
Medical Service
Negotiated
Rate
Plan
Pays
Member
Pays
Deductible
Member
Pays
Coinsurance
Member
Pays Copay
Explanation
Initial office visit
$200
$175
$0
$0
$25
MRI
2,000
1,575
250
175
0
Additional pre-surgical office
visits (2 visits)
400
350
0
0
50
Pre-surgical lab work
100
90
0
10
0
10% coinsurance
Inpatient knee replacement
surgery
30,000
29,185
0
815
0
10% coinsurance to meet $1,000
coinsurance maximum for year
Out-patient physical therapy
2,700
2,250
0
0
450
$35,400
$33,625
$250
$1,000
$525
Total
Plan Total: $33,625
Illustrative purposes only; individual situations may differ.
Member Total: $1,775
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Office visit copay – specialist
Services subject to $250 deductible,
followed by 10% coinsurance
$25 copay for each office visit
$25 copay for each office visit (18 visits)
Reducing your health care costs
Health Care Flexible Spending Account (FSA)
Use It or Lose It
You can elect up to $2,500 in a health care FSA for
2016. Plan carefully–at the end of the year, if you have
not spent all of your health care FSA dollars, you can
carryover up to $500 to be used in the following calendar
year. Any health care account balance over $500 will be
forfeited.
Pre-tax payroll contributions–You will reduce your taxes
by participating in an FSA, potentially saving you
hundreds of dollars a year (depending on the amount of
your FSA election and your tax bracket).
Carryover Provision
Up to $500 of your health care FSA dollars can be
carried over into the next plan year.
Enrolling in the health care FSA can help you save
money on your deductible, coinsurance, or other
qualifying medical costs. You contribute money from
your paycheck on a pre-tax basis, and get reimbursed
from your FSA account as you incur eligible expenses.
Financially, this helps you in two ways:
Along with the carryover provision, State System
employees have the opportunity to submit expenses that
occurred in the previous plan year in the first three
months of the following plan year (called a run-out
period).
Budgeting for medical expenses–Your entire health care
FSA election amount is immediately available to you at
the beginning of the year to pay for qualifying expenses.
So if you have a large medical expense early in 2016,
you can submit the claim to your FSA account, and then
take the whole year to pay for it via pre-tax deductions
from your paychecks.
Dependent Care FSA
This type of FSA is for daycare or elder care expenses,
including before/after school care and summer day
camps. You can elect up to $5,000 per calendar year.
Please note: Dependent care is not for health care
expenses for your dependents.
The carryover provision does not apply to dependent
care accounts.
Electing an FSA
From October 19–November 20 you can elect an FSA
for 2016 through Employee Self-Service at
https://portal.passhe.edu/irj/portal.
Upon login, click Employee Self-Service, then Benefits,
then select Benefits Enrollment.
You must retain a copy of your benefits election email
confirmation. In the event there is any discrepancy with
your enrollment, you will be required to present the email
confirmation to the human resources office
Should you enroll?
Enrolling in a health care FSA can save you money if
you or your family members:
Remember: Even if you enrolled in an FSA for 2015,
you must now enroll again to participate in 2016.
• Have copays, deductibles, or coinsurance for
medical expenses.
• Purchase prescription medications.
• Have out-of-pocket expenses for glasses or
contacts, or plan to have laser eye surgery.
• Receive orthodontia treatments, such as braces.
Visit www.SpendingAccounts.info for more information
about flexible spending accounts, including a list of
eligible expenses and an interactive contribution and
tax-savings calculator. To speak with an FSA
specialist, call 1-888-557-3156.
8
Additional Information
Telemedicine–A New Benefit
Beginning in January, you will be able to access medical care in a different manner via a virtual doctor visit. This service
will be available for two basic types of health care needs – acute care (such as colds, flu and sinus infections) and
behavioral health visits. Accessing care is simple and convenient. Simply register online, choose a doctor (or have one
assigned to you), and consult with the provider on your web-enabled device or via phone. The member copay is only $10
for an acute care visit, and $25 for a behavioral health visit.
Highmark is partnering with two vendors who provide these services-Amwell
(www.amwell.com) and Doctor On Demand (www.doctorondemand.com) who
provide these services. Click here to learn more about this new benefit, log on
to the vendor website, or download their mobile app when you are ready to use
this service.
DermatologistOnCall®
Similar to the telemedicine benefit, there is another virtual health service you
can use today. DermatologistOnCall® (www.dermatologistoncall.com) provides
quality care for many skin problems, such as acne, rosacea or eczema. It
avoids the need for a long wait for an appointment–receive a diagnosis,
treatment plan, and prescription (if needed) within three business days. The
member copay is $25; there are three easy steps–create an online account and
choose a dermatologist, take and upload photos of your condition, and receive
your treatment plan. Click here to learn more, or access the vendor website or
mobile app to start the registration process.
Dental/Vision Benefits
The dental and vision plan benefits are not changing. As a reminder, you and
your eligible dependents are provided with these benefits with no
premium contributions–the State System pays the entire cost of these
plans.
Last year, on average, enrolled employees received almost $900 in dental and vision benefits for themselves and their
families. Both the dental and vision plans operate with a network of providers. By choosing to obtain needed services
within those networks, many employees will experience very little, if any, out-of-pocket expenses for their routine dental
and vision needs.
Obtaining regular preventive dental and vision care services is strongly linked to overall good health, and can aid in the
early detection of some health conditions. Take some time to refamiliarize yourself with the benefits provided under the
dental and vision program, and make sure you and your family members are current with your routine exams.
Questions? Need Additional Information?
For additional information or questions, contact your university benefits office.
9
Exhibit 1 - PPO Blue Benefit Summary – Effective January 1, 2016
Benefit
Network
General Provisions
Out-of-Network
Calendar Year
Benefit Period 
Deductible (per benefit period)
Individual
$250
$500
Family
$500
$1,000
Plan Pays – payment based on the plan allowance
90% after deductible
70% after deductible
Out-of-Pocket Maximums (Once met, plan pays 100% for the
rest of the benefit period)
Individual
$1,000
$2,000
Family
$2,000
$4,000
Total Maximum Out-of-Pocket (Includes deductible,
coinsurance, copays, prescription drug cost sharing and
other qualified medical expenses, Network only  Once
met, the plan pays 100% of covered services for the rest of
the benefit period.
$6,850
None
Individual
$13,700
None
Family
Office/Clinic/Urgent Care Visits
100% after $25 copayment
70% after deductible
Retail Clinic Visits & Virtual Visits 
100%
after
$15
copayment
70% after deductible
Primary Care Provider Office Visits & Virtual Visits 
100%
after
$25
copayment
70% after deductible
Specialist Office & Virtual Visits 
90% after deductible
70% after deductible
Virtual Visit Originating Site Fee 
100% after $25 copayment
70% after deductible
Urgent Care Center Visits
100% after $10 copayment
Not Covered
Telemedicine Service 
Preventive Care with Enhancements 
Routine Adult
Physical exams
100% no deductible
70% after deductible
Adult immunizations
100% no deductible
70% after deductible
Colorectal cancer screening
100% no deductible
70% after deductible
Routine gynecological exams, including a Pap Test
100% no deductible
70% no deductible
Mammograms, annual routine and medically necessary
100% no deductible
70% after deductible
Diagnostic services and procedures
100% no deductible
70% after deductible
Routine PSA Screening
100% no deductible
70% after deductible
Routine Pediatric
Physical exams
100% no dedcutible
70% after deductible
Pediatric immunizations
100% no deductible
70% no deductible
Diagnostic services and procedures
100% no deductible
70% after deductible
Hospital and Medical/Surgical Expenses (including maternity)
Hospital Inpatient/Outpatient
90% after deductible
70% after deductible
Maternity (non-preventive facility & professional services)
90% after deductible
70% after deductible
Excludes Dependent Daughter- except complications.
Medical Care (except office visits)
90% after deductible
70% after deductible
Includes Inpatient Visits and Consultations
Surgical Expenses (except office visits) Includes Assistant
90% after deductible
70% after deductible
Surgery, Anesthesia, Sterilization and Reversal Procedures.
Excludes Neonatal Circumcision
Emergency Services
Emergency Room Services
100% after $100 copayment (waived if admitted)
Ambulance (emergency)
100% no deductible
Ambulance (non-emergency)
90% after deductible
70% after deductible
Mental Health/Substance Abuse
Inpatient Mental Health
90% after deductible
70% after deductible
Inpatient Detoxification/Rehabilitation
90% after deductible
70% after deductible
Outpatient Mental Health includes Virtual Behavioral Health Visits
100% after $25 copayment
70% after deductible
100% after $25 copayment
70% after deductible
Outpatient Substance Abuse includes Virtual Behavioral Health
Visits
10
Physical Medicine
Outpatient
Respiratory Therapy
Spinal Manipulations
Therapy and Rehabilitation Services
100% after $25 copayment
Speech & Occupational Therapy
Outpatient
Other Therapy Services - Cardiac Rehabilitation,
Chemotherapy, Radiation Therapy, Dialysis and Infusion
Therapy
Allergy Extracts and Injections
Applied Behavior Analysis for ASD 
Assisted Fertilization Procedures
Dental Services Related to Accidental Injury
Diabetes Treatment
Diagnostic Services
Advanced Imaging (MRI, CAT, PET scan, etc.)
Basic Diagnostic Services (standard imaging, diagnostic
medical, lab/pathology, allergy testing)
Durable Medical Equipment, Orthotics and Prosthetics
Elective Abortion
Home Health Care (Excludes Respite Care)
Hospice (Includes Respite Care)
Infertility Counseling, Testing and Treatment 
Oral Surgery
Private Duty Nursing
Skilled Nursing Facility Care
Transplant Services
Precertification Requirements 
unlimited
70% after deductible
90% after deductible
70% after deductible
100% after $25 copayment
70% after deductible
30 visits/benefit period
100% after $25 copayment
70% after deductible
30 visits per therapy/benefit period
90% after deductible
70% after deductible
Other Services
90% after deductible
90% after deductible
90% after deductible
90% after deductible
Not Covered
70% after deductible
70% after deductible
70% after deductible
70% after deductible
90% after deductible
90% after deductible
70% after deductible
70% after deductible
90% after deductible
70% after deductible
Not Covered (except in cases of rape, incest, or to avert death of the
mother)
90% after deductible
70% after deductible
60 visits/benefit period
90% after deductible
70% after deductible
180 days/benefit period
90% after deductible
70% after deductible
90% after deductible
70% after deductible
90% after deductible
70% after deductible
240 hours/benefit period
90% after deductible
70% after deductible
100 days/benefit period
90% after deductible
70% after deductible
Yes
Your group's benefit period is based on a Calendar Year.
The Network Total Maximum Out-of-Pocket (TMOOP) is mandated by the federal government, TMOOP must include deductible, coinsurance, copays,
prescription drug cost share and any qualified medical expense. Effective with plan years beginning on or after January 1, 2016, the TMOOP cannot exceed
$6,850 for individual and $13,700 for two or more persons.
Virtual, Retail & Behavior Virtual Visits – the purpose of this benefit is to allow a member to have a virtual visit through the use of secure
telecommunications technology. The secure telecommunication technology must provide both audio and video streams. Virtual Visits can be conducted for
initial, follow-up, or maintenance care. The member’s responsibility is the copayment that would normally apply for an in-person primary care, retail or
behavior visit.
Virtual Specialist Office Visit – The purpose of this benefit is to allow a member to have a virtual follow up visit with a specialist that may be located a
significant distance away. The member’s responsibility is the copayment that would normally apply for an in-person specialist visit and a fee from the
“originating site”. The PCP’s office or clinic that provided access to the video conferencing equipment may also charge a fee. The originating fee will be
applied to the deductible and/or coinsurance as determined by the member’s specific benefit design.
 Services are provided for acute care for minor illnesses. Services must be performed by a Highmark approved telemedicine provider. Virtual Behavioral
health visits provided by a Highmark approved telemedicine provider are eligible under the Outpatient Mental Health/Substance Abuse benefit.
Services are limited to those listed on the Highmark Preventive Schedule with Enhancements and Women’s Health Preventive Schedule. Gender, age
and frequency limits may apply.
Coverage for eligible members to age 21. Services will be paid according to the benefit category (e.g. speech therapy). Treatment for autism spectrum
disorders does not reduce visit/day limits.
Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be
covered depending on your group’s prescription drug program.
Highmark Medical Management & Policy (MM&P) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or
maternity-related inpatient admission. Be sure to verify that your provider is contacting MM&P for precertification. If not, you are responsible for contacting
MM&P. If this does not occur and it is later determined that all or part of the inpatient stay was not medically necessary or appropriate, you will be
responsible for payment of any costs not covered.
Customized
11
Exhibit 2 - Prescription Drug Program Summary
PRESCRIPTION DRUG
Deductible
Prescription Drug
Defined by the National Pharmacy
Network - Not Physician Network.
Formulary
Benefit Design
Generic Substitution
Out-of-Pocket Limit
Claim Submission
Non-Network Pharmacy
Contraceptives (oral and injectable)
Fertility Agents
Fluoride Products
Insulin and Diabetic Supplies
Smoking Deterrents (prescription)
Vitamins (prescription)
Weight Loss Drugs
Prescription Hair Growth Products
Exclusive Pharmacy Provider
Quantity Level Limits on selected
prescription drugs
Managed Rx Coverage on selected
prescription drugs
Managed Prior Authorizations
RETAIL PHARMACY
None
MAIL SERVICE PHARMACY
30 day supply
90 day supply
$10 Generic Copay
$20 Generic Copay
$30 Brand Formulary Copay
$60 Brand Formulary Copay
$50 Brand Non-Formulary Copay
$100 Brand Non-Formulary Copay
Comprehensive
Incentive
Soft-When you purchase a brand drug that has a generic equivalent you will be
responsible for the brand drug copayment plus the difference in cost between
the brand and generic drugs, unless your physician requests that the brand
name drug be dispensed
Not Applicable
Pharmacy Files at Point-of-Sale
Member Files Claim
PRESCRIPTION DRUG CATEGORIES
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Not Covered
CARE MANAGEMENT PROGRAMS
Applies - selected high cost prescription drugs are covered only when they are
dispensed through an exclusive pharmacy provider.
Applies – the quantity dispensed under your plan per new or refill prescription
may be limited per recommended guidelines.
Applies – certain drug therapies may be monitored for appropriate usage and
subject to case evaluation if recommended guidelines are exceeded.
Applies on select high cost drugs.
 The formulary is an extensive list of Food and Drug Administration (FDA) approved prescription drugs selected for their quality, safety and
effectiveness. It includes products in every major therapeutic category. The formulary was developed by the Highmark Blue Shield Pharmacy and
Therapeutics Committee made up of clinical pharmacists and physicians. Your program includes coverage for both formulary and non-formulary drugs
at the specific copayment or coinsurance amounts listed above.
Customized
12