Provider: Highmark
Plan: PPO Blue – Gettysburg College QHDHP 2000
Groups: 104250-22, -23, 104753-68
This program is a qualified high deductible plan as defined by the Internal Revenue Service. It is designed for use with a Health Savings Account (HSA). On the chart below, you’ll see what your plan pays for specific services. You may be responsible for a facility fee, clinic charge or similar fee or charge (in addition to any professional fees) if your office visit or service is provided at a location that qualifies as a hospital department or a satellite building of a hospital.
On this page:
General provisions
| Benefit | In Network | Out of Network |
|---|---|---|
| Effective Date | January 1, 2023 | January 1, 2023 |
| Benefit Period | Contract Year | Contract Year |
| Deductible: Individual | $2,000 | $4,000 |
| Deductible: Family | $4,000 | $8,000 |
| Plan Pays – payment based on the plan allowance | 90% after deductible | 70% after deductible |
| Out-of-Pocket Limit (Includes coinsurance. Once met, plan pays 100% coinsurance for the rest of the benefit period): Individual | $2,000 | $5,000 |
| Out-of-Pocket Limit (Includes coinsurance. Once met, plan pays 100% coinsurance for the rest of the benefit period): Family | $4,000 | $10,000 |
| Total Maximum Out-of-Pocket (Includes deductible, coinsurance, copays, prescription drug cost sharing and other qualified medical expenses, Network only) (2) Once met, the plan pays 100% of covered services for the rest of the benefit period: Individual | $7,050 | $14,100 |
| Total Maximum Out-of-Pocket (Includes deductible, coinsurance, copays, prescription drug cost sharing and other qualified medical expenses, Network only) (2) Once met, the plan pays 100% of covered services for the rest of the benefit period: Family | $13,800 | Not Applicable |
Office/clinic/urgent care visits
| Benefit | In Network | Out of Network |
|---|---|---|
| Retail Clinic Visits & Virtual Visits | $20 copay after deductible, 100% thereafter | 70% after deductible |
| Primary Care Provider Office Visits & Virtual Visits | $20 copay after deductible, 100% thereafter | 70% after deductible |
| Specialist Office Visits & Virtual Visits | $40 copay after deductible, 100% thereafter | 70% after deductible |
| Virtual Visit Provider Originating Site Fee | 90% after deductible | 70% after deductible |
| Urgent Care Center Visits | $40 copay after deductible, 100% thereafter | 70% after deductible |
| Telemedicine Services (3) | $15 copay after deductible, 100% thereafter | not covered |
Preventive care
| Benefit | In Network | Out of Network |
|---|---|---|
| Routine Adult: Physical Exams | 100% (deductible does not apply) | 70% after deductible |
| Routine Adult: Adult Immunizations | 100% (deductible does not apply) | 70% after deductible |
| Routine Adult: Routine Gynecological Exams, including a Pap Test | 100% (deductible does not apply) | 70% (deductible does not apply) |
| Routine Adult: Mammograms, Annual Routine | 100% (deductible does not apply) | 70% after deductible |
| Routine Adult: Mammograms, Medically Necessary | 100% (deductible does not apply) | 70% after deductible |
| Routine Adult: Diagnostic Services and Procedures | 100% (deductible does not apply) | 70% after deductible |
| Routine Pediatric: Physical Exams | 100% (deductible does not apply) | 70% after deductible |
| Routine Pediatric: Pediatric Immunizations | 100% (deductible does not apply) | 70% (deductible does not apply) |
| Routine Pediatric: Diagnostic Services and Procedures | 100% (deductible does not apply) | 70% after deductible |
Emergency services
| Benefit | In Network | Out of Network |
|---|---|---|
| Emergency Room Services | $100 copay (waived if admitted) after in-network deductible, 100% thereafter | $100 copay (waived if admitted) after in-network deductible, 100% thereafter |
| Ambulance - Emergency | 90% after in-network deductible | 90% after in-network deductible |
| Ambulance - Non-Emergency | 90% after deductible | 70% after program deductible |
Hospital and medical/surgical expenses (including maternity)
| Benefit | In Network | Out of Network |
|---|---|---|
| Hospital Inpatient | 90% after deductible | 70% after deductible |
| Hospital Outpatient | 90% after deductible | 70% after deductible |
| Maternity (non-preventive facility & professional services) including dependent daughter | 90% after deductible | 70% after deductible |
| Medical Care (including inpatient visits and consultations)/Surgical Expenses | 90% after deductible | 70% after deductible |
| Gender Reassignment Surgery/Transgender Services This benefit covers any treatment leading to or in connection with gender reassignment. This includes any sickness or injury resulting from gender reassignment surgery or treatment. Members must be 18 years of age or older. | 90% after deductible | 70% after deductible |
Therapy and rehabilitation services
| Benefit | In Network | Out of Network |
|---|---|---|
| Physical Medicine | $40 copay after deductible, 100% thereafter | 70% after deductible |
| Respiratory Therapy | 90% after deductible | 70% after deductible |
| Speech Therapy | $40 copay after deductible, 100% thereafter. limit: 12 visits/benefit period. | 70% after deductible. limit: 12 visits/benefit period. |
| Occupational Therapy | $40 copay after deductible, 100% thereafter. limit: 12 visits/benefit period. | 70% after deductible. limit: 12 visits/benefit period. |
| Spinal Manipulations | $40 copay after deductible, 100% thereafter | 70% after deductible |
| Other Therapy Services (Cardiac Rehab, Infusion Therapy, Chemotherapy, Radiation Therapy and Dialysis) | 90% after deductible | 70% after deductible |
| Acupuncture | $40 copay after deductible. Limit: 12 visits per benefit period. | 70% after deductible. Limit: 12 visits per benefit period. |
Mental health/substance abuse
| Benefit | In Network | Out of Network |
|---|---|---|
| Inpatient Mental Health Services | 90% after deductible | 70% after deductible |
| Inpatient Detoxification / Rehabilitation | 90% after deductible | 70% after deductible |
| Outpatient Mental Health Services (includes virtual behavioral health visits) | $40 copay after deductible, 100% thereafter | 70% after deductible |
| Outpatient Substance Abuse Services | $40 copay after deductible, 100% thereafter | 70% after deductible |
Other services
| Benefit | In Network | Out of Network |
|---|---|---|
| Allergy Extracts and Injections | 90% after deductible | 70% after deductible |
| Audiometric Hearing Exam | 100% after $40 copay. 1 routine exam per 24 months. | 70% after deductible. 1 routine exam per 24 months. |
| Applied Behavior Analysis for Autism Spectrum Disorder (6) | 90% after deductible | 70% after deductible |
| Assisted Fertilization Procedures | not covered | not covered |
| Dental Services Related to Accidental Injury | 90% after deductible | 70% after deductible |
| Diagnostic Services: Advanced Imaging (MRI, CAT, PET scan, etc.) | 90% after deductible | 70% after deductible |
| Diagnostic Services: Basic Diagnostic Services (standard imaging, diagnostic medical, lab/pathology, allergy testing) | 90% after deductible | 70% after deductible |
| Diagnostic Services: Durable Medical Equipment, Orthotics and Prosthetics | 90% after deductible | 70% after deductible |
| Diagnostic Services: Hearing Aids | 90% after deductible. $1,000 per 36 months. | 70% after deductible. $1,000 per 36 months. |
| Diagnostic Services: Home Health Care | 90% after deductible. limit: 90 visits/benefit period aggregate with visiting nurse. | 70% after deductible. limit: 90 visits/benefit period aggregate with visiting nurse. |
| Diagnostic Services: Hospice | 90% after deductible. limit: 180 days/benefit period. | 70% after deductible. limit: 180 days/benefit period. |
| Diagnostic Services: Infertility Counseling, Testing and Treatment (7) | 90% after deductible | 70% after deductible |
| Diagnostic Services: Private Duty Nursing | 90% after deductible. limit: 240 hours/benefit period. | 70% after deductible. limit: 240 hours/benefit period. |
| Diagnostic Services: Skilled Nursing Facility Care | 90% after deductible. limit: 100 days/benefit period. | 70% after deductible. limit: 100 days/benefit period. |
| Diagnostic Services: Transplant Services | 90% after deductible | 70% after deductible |
| Diagnostic Services: Precertification Requirements (7) | Yes | Yes |
Prescription drugs
| Benefit | Coverage |
|---|---|
| Prescription Drug Deductible Individual | Integrated with medical deductible |
| Prescription Drug Deductible Family | Integrated with medical deductible |
| Prescription Drug Program (9). Defined by the National Pharmacy Network - Not Physician Network. Prescriptions filled at a non-network pharmacy are not covered. Your plan uses the Comprehensive Formulary with an Incentive Benefit Design. | Retail Drugs (31-day Supply) 20% Coinsurance with $10 Minimum/$100 Maximum Maintenance Drugs through Mail Order (90-day Supply) 20% Coinsurance with $20 Minimum/$200 Maximum |
| Preventive Medications. Defined by Premier Pharmacy Network - Not Physician Network. Prescriptions filled at a non-network pharmacy are not covered. | Preventive Prescription Drugs – Premier Retail Drugs (31-day Supply) 20% (deductible does not apply) $10 Minimum/ $100 Maximum per Prescription Maintenance Drugs through Mail Order (90-day Supply) 20% (deductible does not apply) $20 Minimum/ $200 Maximum per Prescription |
Footnotes
This is not a contract. This benefits summary presents plan highlights only. Please refer to the policy/ plan documents, as limitations and exclusions apply. The policy/ plan documents control in the event of a conflict with this benefits summary.
- Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's effective date. Contact your employer to determine the effective date applicable to your program.
- 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. If you are enrolled in a "Family" plan, with your non-embedded deductible, the entire family deductible must be satisfied before claims reimbursement begins. In addition, with your non-embedded out-of-pocket limit, the entire family out-of-pocket limit must be satisfied before additional claims reimbursement begins. Finally, with your embedded TMOOP, once any eligible family member satisfies his/her individual TMOOP, claims will pay at 100% of the plan allowance for covered expenses for the family, for the rest of the plan year.
- 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 benefit.
- Services are limited to those listed on the Highmark Preventive Schedule (Women's Health Preventive Schedule may apply).
- Coverage for eligible members to age 21. After initial analysis, 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 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.
- At a retail or mail-order pharmacy, if your deductible has not been met, you pay the entire cost for your prescription drug at the discounted rate Highmark has negotiated. The amount you paid for your prescription will be applied to your deductible. If your deductible has been met, you will only pay any member responsibility based on the benefit level indicated above. You will pay this amount at the pharmacy when you have your prescription filled. The Highmark formulary is an extensive list of Food and Drug Administration (FDA) approved prescription drugs selected for their quality, safety and effectiveness. The formulary was developed by Highmark Pharmacy Services and approved by the Highmark Pharmacy and Therapeutics Committee made up of clinical pharmacists and physicians. All plan formularies include products in every major therapeutic category. Plan formularies vary by the number of different drugs they cover and in the cost-sharing requirements. Your program includes coverage for both formulary and non-formulary drugs at the copayment or coinsurance amounts listed above.
Discrimination is Against the Law
The Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex, including sex stereotypes and gender identity. The Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex assigned at birth, gender identity or recorded gender. Furthermore, the Plan will not deny or limit coverage to any health service based on the fact that an individual’s sex assigned at birth, gender identity, or recorded gender is different from the one to which such health service is ordinarily available. The Plan will not deny or limit coverage for a specific health service related to gender transition if such denial or limitation results in discriminating against a transgender individual. The Plan:
- Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as: – Qualified interpreters
- Qualified interpreters
- Information written in other languages
If you need these services, contact the Civil Rights Coordinator. If you believe that the Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
If you speak English, language assistance services, free of charge, are available to you. Call 1-888-269-8412.
Si usted habla español, servicios de asistence lingüística, de forma gratuita, están disponibles para usted. Llame al 1-888-269-8412.