State System of Higher Education

PPOBlue Benefit Summary*

Effective July 1, 2004

A PPO, or Preferred Provider Organization, offers two levels of benefits.  If you receive services from a provider who is in the PPO network, you’ll receive the highest level of benefits.  If you receive services from a provider who is not in the PPO network, you’ll receive the lower level of benefits.  In either case, you coordinate your own care.  There is no need to select a Primary Care Physician (PCP).  No referrals are needed for specialty care.  Below are specific benefit levels.

 

BENEFITS	IN-NETWORK	OUT-OF-NETWORK
Deductible Per Calendar Year	None	$250 Individual $500 Family Aggregate
Payment Level  Based on Provider’s Reasonable Charge (PRC)	100% PRC	80% PRC after deductible until out-of-pocket limit is met; then 100% PRC
Out-of-Pocket Limit Includes Coinsurance	Not Applicable	$1,500 Individual $3,000 Family Aggregate
Lifetime Maximum	Unlimited	$1,000,000/person
Ambulance	100% PRC	80% PRC after deductible
Assisted Fertilization Procedures	Not Covered	Not Covered
Dental Services Related to an Accidental Injury	100% PRC	80% PRC after deductible
Diabetes Treatment	100% PRC	80% PRC after deductible
Diagnostic Services   (Lab, X-ray, and Medical Tests)	100% PRC	80% PRC after deductible
Durable Medical Equipment, Orthotics and Prosthetics	100% PRC	80% PRC after deductible
Elective Abortion	Not Covered (except in cases of rape, incest, or to avert death of the mother)	Not Covered (except in cases of rape, incest, or to avert death of the mother)
Emergency Care Professional Services	100% PRC	100% PRC no deductible
Emergency Room Services Facility Services	100% PRC after $50 copayment – waived if admitted
Enteral Formulae	100% PRC	80% PRC no deductible
Home Health Care Excludes Respite Care	100% PRC	80% PRC after deductible
	60 visits/calendar year
Hospice Includes Respite Care	100% PRC	80% PRC after deductible
	180 days/lifetime maximum
Hospital Expenses Inpatient and Outpatient	100% PRC	80% PRC after deductible
	365 days 2 pint blood deductible/calendar year
Infertility Counseling, Testing and Treatment	100% PRC	80% PRC after deductible
Maternity Excludes Dependent Daughters	100% PRC	80% PRC after deductible
Medical Care Includes Inpatient Visits and Consultations	100% PRC	80% PRC after deductible
Mental Health – Inpatient * Includes Partial Hospitalization (2 for 1 trade)	100% PRC	80% PRC after deductible
	30 days/calendar year
Mental Health – Outpatient	100% PRC after $15 copayment	50% PRC after deductible
	60 visits/calendar year
Office Visits PCP and Specialists	100% PRC after $15 copayment	80% PRC after deductible
Oral Surgery	100% PRC	80% PRC after deductible

 

 

 

 

BENEFITS	IN-NETWORK	OUT-OF-NETWORK
Physical Therapy Outpatient	100% PRC after $15 copayment	80% PRC after deductible
	Unlimited
Preventive Care Routine Adult Services include:   Physical Exam	100% PRC after $15 copayment	80% PRC after deductible
Gynecological Exam & Pap Test	100% PRC after $15 copayment	80% PRC no deductible/lifetime maximum
Mammograms	100% PRC	80% PRC after deductible
Preventive Care 2000 Schedule	100% PRC	80% PRC after deductible
Routine Pediatric Services include:   Physical Exams	100% PRC after $15 copayment	80% PRC after deductible
Pediatric Immunizations	100% PRC	80% PRC no deductible/lifetime maximum
Preventive Care 2000 Schedule	100% PRC	80% PRC after deductible
Private Duty Nursing	100% PRC	80% PRC after deductible
	240 hours/calendar year
Skilled Nursing Facility Care	100% PRC	80% PRC after deductible
	100 days/calendar year
Speech & Occupational Therapy Outpatient	100% PRC after $15 copayment	80% PRC after deductible
	30 visits/calendar year per type of therapy
Spinal Manipulations	100% PRC after $15 copayment	80% PRC after deductible
	30 visits/calendar year
Substance Abuse  - Detoxification	100% PRC	80% PRC after deductible
	7 days/admission; 4 admissions/lifetime
Substance Abuse – Inpatient Rehabilitation Includes Partial Hospitalization (2 for 1 trade)	100% PRC	80% PRC after deductible
	30 days/calendar year; 90 days/lifetime
Substance Abuse  - Outpatient	100% PRC after $15 copayment	80% PRC after deductible
	60 visits/calendar year; 120 visits/lifetime
Surgical Expenses Includes Assistant Surgery, Anesthesia, Sterilization and Reversal Procedures, Excludes Neonatal Circumcision	100% PRC	80% PRC after deductible
Therapy Services Chemotherapy, Radiation Therapy, Dialysis, Infusion Therapy, Respiratory Therapy	100% PRC	80% PRC after deductible
Transplant Services	100% PRC	80% PRC after deductible
Precertification Requirements for Inpatient Admissions No Penalty for Non-compliance	Performed by Network Provider	Performed by Member
Condition Management	Case Management, Blues on Call, and Disease State Management

Customized

 

 

* This program applies to all active employees and annuitants under the age of 65 retired on or after July 1, 2004

 

 

This exhibit provides only general information.  More detailed information about benefits and eligibility are contained in the Plan Document.  If there is a difference between this summary and the Plan Document, the Plan Document will govern.
 

Health Benefit Exclusions

 

Below is a list of services that are typically excluded from coverage unless they are specifically added to the final contract. As exclusion, no benefits will be provided for services, supplies or charges:

 

1.             Which are not medically necessary and appropriate as determined by the plan;

2.             Which are not prescribed by or performed by or upon the direction of a professional provider;

3.             Rendered by other than providers;

4.             Which are experimental/investigative in nature;

5.             Rendered prior to the member's effective date;

6.             Incurred after the date of termination of the member's coverage;

7.             For any illness or injury suffered after the member's effective date as a result of any act of war;

8.             For which a member would have no legal obligation to pay;

9.             Received from a dental or medical department maintained, in whole or in part, by or on behalf of an employer, a mutual benefit association, labor union, trust, or similar person or group;

10.         To the extent payment has been made under Medicare when Medicare is primary; however, this exclusion shall not apply when the group is obligated by law to offer the member all the benefits and the member so elects this coverage as primary;

11.         For any amounts the member is required to pay under the deductible and/or coinsurance provisions of Medicare or any Medicare complementary program;

12.         For any illness or bodily injury which occurs in the course of employment if benefits or compensation are available, in whole or in part, under the provisions of any federal, state, or local government’s workers’ compensation, occupational disease, or similar type legislation.  This exclusion applies whether or not the member files a claim for said benefits or compensation;

13.         To the extent benefits are provided to members of the armed forces and the National Health Service or to patients in Veteran's Administration facilities for service‑connected illness or injury, unless the member has a legal obligation to pay;

14.         For treatment or services for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is paid or payable under a plan or policy of motor vehicle insurance, including a certified or qualified plan of self‑insurance, or any fund or program for the payment of extraordinary medical benefits established by law, including any medical benefits payable in any manner under the Pennsylvania Motor Vehicle Financial Responsibility Act;

15.         For prescription drugs and medications, except those which are administered to an inpatient in a facility provider;

16.         Which are submitted by a certified registered nurse and another professional provider or other provider for the same services performed on the same date for the same member;

17.         Rendered by a provider who is a member of the member's immediate family;

18.         Performed by a professional provider or other provider enrolled in an education or training program when such services are related to the education or training program; 

19.         For operations for cosmetic purposes done to improve the appearance of any portion of the body, and from which no improvement in physiological function can be expected, except as otherwise required by law or provider.  Other exceptions to this exclusion are: a) Surgery to correct a condition resulting from an accident; b) Surgery to correct congenital birth defects; and c) Surgery to correct functional impairment which results from a covered disease or injury;

20.         For telephone consultations, charges for failure to keep a scheduled visit, or charges for completion of a claim form;

21.         For personal hygiene and convenience items such as, but not limited to, air conditioners, humidifiers, or physical fitness equipment, stair glides, elevators/lifts or "barrier-free" home modifications, whether or not specifically recommended by a professional provider or other provider;

22.         For inpatient admissions which are primarily for diagnostic studies;

23.         For inpatient admissions which are primarily for physical therapy;

24.         For custodial care, domiciliary care, residential care, protective and supportive care including educational services, rest cures and convalescent care;

25.         Directly related to the care, filling, removal or replacement of teeth, the treatment of injuries to or diseases of the teeth, gums or structures directly supporting or attached to the teeth.  These include, but are not limited to, apicoectomy (dental root resection), root canal treatments, soft tissue impactions, alveolectomy and treatment of periodontal disease, except orthodontic treatment for congenital cleft palates;

26.         For oral surgery procedures, except for the treatment of accidental injury to the jaw, sound and natural teeth, mouth or face, unless specifically provided;

27.         For treatment of temporomandibular joint (jaw hinge) syndrome with intra‑oral prosthetic devices, or any other method to alter vertical dimensions and/or restore or maintain the occlusion and treatment of temporomandibular joint dysfunction not caused by documented organic joint disease or physical trauma;

28.         For palliative or cosmetic foot care including flat foot conditions, supportive devices for the foot, corrective shoes, the treatment of subluxations of the foot, care of corns, bunions (except capsular or bone surgery), calluses, toe nails, fallen arches, weak feet, chronic foot strain, and symptomatic complaints of the feet;

29.         For hearing aid devices, tinnitus maskers, or examinations for the prescription or fitting of hearing aids, unless specifically provided;

30.         For any treatment leading to or in connection with transsexual surgery, except for sickness or injury resulting from such treatment or surgery;

31.         For artificial insemination;

32.         Related to treatment provided specifically for the purpose of assisted fertilization; including pharmacological or hormonal treatments used in conjunction with assisted fertilization, unless mandated or required by law;

33.         For routine neonatal circumcision;

34.         For eyeglasses or contact lenses and the vision examination for prescribing or fitting eyeglasses or contact lenses, (except for aphakic patients and soft lenses or sclera shells intended for use in the treatment of disease or injury);

35.         For correction of myopia or hyperopia by means of corneal microsurgery, such as keratomileusis, keratophakia, and radial keratotomy and all related Services; 

36.         For treatment of obesity, except for medical and surgical treatment of morbid obesity when weight is at least twice the ideal weight specified for frame, age, height and sex;

37.         For nutritional counseling and services intended to produce weight loss;

38.         For any food including, but not limited to, enteral formulae, infant formulas, supplements, substances, products, enteral solutions or compounds used to provide nourishment through the gastrointestinal tract whether ingested orally or provided by tube, whether utilized as a sole or supplemental source of nutrition and when provided on an outpatient basis.  This does not include enteral formulae prescribed solely for the therapeutic treatment of phenylketonuria, branched-chain ketonuria, galactosemia and homocystinuria;

39.         For preventive care services, wellness services or programs, except as provided in the final contract or as mandated by law;

40.         For well‑baby care visits, except as provided in the final contract;

41.         For routine or periodic physical examinations, the completion of forms, and the preparation of specialized reports solely for insurance, licensing, employment or other non-preventive purposes, such as pre-marital examinations, physicals for school, camp, sports or travel, which are not medically necessary and appropriate, except as provided in the final contract or mandated by law;

42.         For screening examinations including X-ray examinations made without film, except as provided in the final contract;

43.         For immunizations required for foreign travel;

44.         For the treatment of sexual dysfunction that is not related to organic disease or injury;

45.         For any care related to autistic disease of childhood, hyperkinetic syndromes, learning disabilities, behavioral problems, and mental retardation, which extends beyond traditional medical management or for inpatient confinement for environmental change;

46.         For any care, treatment, or service which has been disallowed under the provisions of the Health Care Management Services program;

47.         For otherwise covered services ordered by a court or other tribunal as part of the member’s or dependent’s sentence;

48.         For therapy services for which there is  no expectation of restoring or improving a level of function exists, or for maintenance treatment, when no additional functional progress is expected to occur, unless Medically Necessary and Appropriate;

49.         For any illness or injury suffered after the member’s effective date during the member’s commission of a felony;

50.         For elective abortions, except those abortions necessary to avert the death of the Mother, or to terminate pregnancies caused by rape or incest;

51.         For maternity services for Dependent daughters except for complications of pregnancy; and

52.         For any other medical or dental service or treatment except as provided in the final contract or as mandated by law.