FORMTEXT
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.
State System of Higher
Education
Preventive Care 2000
Preventive Care 2000 enhances your benefit
package by providing coverage for adult and pediatric preventive care.
These preventive measures may help members avoid some diseases and
conditions, or detect them early when they can be treated more effectively.
Please refer to your benefit booklet for any applicable cost sharing
features.
Pediatric Care (Birth
through age 17)
|
Periodic Physical Exam
|
0 to 1 month
2 to 3
months
4 to 5
months
6 to 8
months
9 to 11
months
12 to 14
months |
15 to 17
months
18 to 24
months
2 to 5 years
(annually)
6 to 7 years
8 to 9 years
10 to 17
years (annually) |
|
(One exam at
each age range unless otherwise indicated) |
Urinalysis
|
Birth – 6
years
11 – 17
years |
(one test
during each
age range) |
Hemoglobin or Hematocrit
|
Birth – 12
months
1 – 4 years
5 – 12 years
13-17 years |
(one test
during each
age range) |
Rubella Titer Test
|
11 – 17
years |
(one per
lifetime) |
Tuberculosis (TB) Test
|
4 – 7 years
13-15 years
|
(one test during each
age range)
|
Childhood Immunizations
(Childhood
immunizations such as the following, as required by Pennsylvania
state law) |
Diphtheria,
Tetanus
Pertussis
(DTP)
Measles,
Mumps & Rubella Meningitis |
Polio
Hepatitis B
Hemophilus
(Hib)
Varicella
(Chicken Pox) |
Adult Care (Ages 18 and
over)
|
Periodic
Physical Exam
|
18 - 49
years
50 years and
older |
(once every
three years)
(one exam
every year) |
Fecal Occult Blood Test
|
50 years and
older |
(one test
every year) |
Blood Cholesterol Test
|
18 – 49
years
50 years and
older |
(one test
every three years) (one test every year) |
Adult Tetanus and Diphtheria Toxoid (Td)
|
18 years and
older |
(once every
10 years) |
Rubella Titer Test and Immunization
|
18 – 49
years |
(once per
lifetime) |
Influenza Vaccine
|
50 years and
older |
(once every
year) |
Pneumococcal Vaccine
|
65 years and
older |
(once every
five years) |
Urinalysis
|
18 – 49
years
50 years and
older |
(once every
three years)
(one test
every year) |
Complete Blood Count (CBC)
|
18 – 49
years
50 years and
older |
(once every
three years)
(one test
every year) |
Flexible Sigmoidoscopy
|
50 years and
older |
(one test
every year) |
Prostatic Specific Antigen (PSA)
|
50 years and
older |
(one test
every year) |
Screening Mammography
(As required
by Pennsylvania state law) |
40 years and
older |
(one test
every year) |
Routine Gynecological Exam and Pap Test (As required by Pennsylvania
state law)
|
No age limit |
(one exam
and test every year) |
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
