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I Indemnity Traditional fee-for-service health coverage in which covered health care services received from participating providers are paid-in-full after any applied deductibles, copayments or coinsurance costs have been met. M Maintenance Drugs A prescription drug prescribed for the control of a chronic disease or illness, or to alleviate the pain and discomfort associated with a chronic disease or illness.

Managed Care Health care coverage offered by health plans where there is an organized way for contracting with providers, and processes in place to manage costs, use of services and the quality of the delivery of health care.

Maximum The greatest amount of benefits that the health plan will provide for covered services within a prescribed period of time. This could be expressed in dollars, number of days or number of services. Medically Underwritten Plans that base acceptance for enrollment on health status, determined by the answers given on a medical questionnaire. N Network Group of physicians, hospitals and other health care providers and suppliers contracted with the health plan to offer health care services at negotiated rates.

O Open Enrollment A period each year when a member has the opportunity to change or elect their health care coverage. Out-Of-Network Provider Physicians, hospitals or other health care providers who do not contract with a health plan. Out-of-Pocket Maximum The maximum dollar amount a member is required to contribute towards the cost of covered services in a benefit period.

This limit protects a member from very high costs by capping the total amount they will have to pay for covered health care services. The out-of-pocket limit always includes coinsurance, and may include other cost-sharing amounts such as copayments or deductibles. Some services may be excluded from the out-of-pocket limit such as prescription drug expenses.

P Participating Provider A health care provider who has been contracted to give medical services or supplies to health plan members for a pre-negotiated fee on indemnity health care plans. Pre-Authorization The process in which a member or provider must contact the health plan prior to a non-emergency hospitalization or other selected services, in order to receive authorization for these services.

Pre-existing Condition A condition for which medical advice, care, treatment or diagnosis has been recommended or received from a provider within a designated time period immediately preceding the effective date of coverage. Pre-existing Waiting Period A specified period of time when the health plan does not cover a member's pre-existing condition s. Preferred-Provider Organization PPO Health care coverage that does not require the selection of a primary care physician, but is based on a provider network made up of physicians, hospitals and other health care providers.

A PPO program has two levels of benefits: If a member uses the providers within the network, claims are paid at the higher in-network level of benefits. Services received outside of the network will be reimbursed at the lower, out-of-network level of benefits. Premium Payment or series of payments made to a health plan by a group, an employer or a member for health care benefits.

Preventive Care Preventive benefits that are offered in accordance with a predefined schedule based on age, sex and certain risk factors. Benefits are provided for periodic physical examinations, immunizations and selected diagnostic tests and are covered regardless of medical necessity but have proven clinical value when performed on a routine basis.

Primary Care Provider PCP A health care provider who often serves as a member's first contact with a health plan's health care system and who may supervise, coordinate and provide specific basic medical services while maintaining continuity of patient care.

Also known as a primary care physician, personal care physician, or personal care provider. Programs Based on Income Plans for which the plan member's eligibility is based on income guidelines. Provider A provider is any doctor, specialist, hospital or rehabilitation facility, for example, where a patient gets health care.

Provider's Reasonable Charge Allowable Charge The allowance or payment that the health plan has determined is reasonable for covered services based on the provider who renders such services. The Provider's Reasonable Charge is the portion of the provider's billed charge that is used by the health plan to calculate the payment to that provider and the member's liability. W Wellness Office Visit A physician's office visit which is not prompted by sickness or injury.

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For accommodations of persons with special needs at meetings call and TTY may call There is no obligation to enroll. Call your local Highmark Direct Retail Store or click the link above to schedule an appointment. Health Plan The health insurance company. Highmark offers a wide range of products to our Clients and Members. In an emergency situation, you should always go to the closest emergency room. As part of the agreement between Highmark and UPMC, reasonable out of network rates were negotiated that will be accepted as payment in full.

You will only be responsible for any applicable deductible, co-insurance, or copayment. Any follow up care coordinated with in-network facilities and providers would also be considered in-network. Please contact us for any questions you may have to ensure that your follow up care is with in-network providers. The new agreement includes a year extension of Western Psychiatric Institute and Clinic starting on July 1, Highmark is committed to its strategy of bringing access to community-based, close-to-home care to its members.

Community hospitals will continue to play an important role in serving the needs of our members going forward. A contract with UPMC does not change that. These plans will continue. The enterprise is committed to driving change in how care is delivered at the community level. Not at all.

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36 Blue Cross Blue Shield Health Insurance Companies Explained

NEW! PERFORMANCE BLUE AND PERFORMANCE FLEX BLUE PRODUCTS On January 1, Highmark is introducing two High Performance Network products: Performance Blue and Performance Flex Blue. This n etwork not only delivers quality care at a lower cost, but accelerates an industry-wide shift toward better outcomes and value through collaboration with. Dec 31, †∑ Community Blue Medicare PPO Distinct Community Blue Medicare PPO Signature Complete Blue PPO Distinct Complete Blue PPO Signature Freedom Blue PPO Distinct (DE and WV) Freedom Blue PPO Signature (DE and WV) Freedom Blue PPO Standard (WV) Freedom Blue PPO ValueRx Security Blue HMO-POS ValueRx Venture Formulary . Jan 1, †∑ Priority Blue Flex EPO Gold - 2 Free PCP Visits ONX Base Jan I_PA__SBC. Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services. Coverage Period: 01/01/ - 12/31/ Highmark Blue Cross Blue Shield: my Priority Blue Flex EPO Gold - 2 Free PCP Visits .