Highmark Blue Shield health insurance plans are available through our website at the lowest available rates for residents in the 21 counties of Central Pennsylvania and the Lehigh Valley. Southeastern Pa is also covered under a separate plan. We make it easy to compare affordable individual and family policies and buy quality Marketplace coverage. All policies can be purchased on a monthly basis and we help you understand your subsidy calculation and how it impacts your Exchange enrollment.
Highmark BS is well-known for its trust, integrity and innovation. Through a large network of doctors, specialists and hospitals, you’ll always have a wide selection of providers. Most plans also allow you to use “out-of-network” facilities, although there is a higher out of pocket cost. Areas around Dauphin, Lancaster, Lebanon and Perry counties have especially high numbers of available medical facilities. More than 5 million persons are covered throughout Pennsylvania, West Virginia, and Delaware. Highmark BCBS typically covers Western Pa residents.
They also offer coverage to same-sex couples, since they received permission with the Center for Medicare and Medicaid Services. Delaware and other surrounding states already offer this benefit, and Highmark also offers LGBT-friendly plans. Prices are identical to similar plans for other couples. Lehigh Valley Health network facilities may be utilized by all members, along with with services from the Allegheny Health Network (AHN).
Senior Medicare Supplement and Advantage (MA) coverage is offered to persons that have reached age 65 and signed up for Parts A and B. Separate Part D prescription drug plans are also offered, and sometimes included in Advantage contracts. Although Medigap plans are standardized, you can often reduce your out-of-pocket costs, including deductibles and copays. Local seminars are routinely provided to help Seniors, and free tools designed to estimate your drug and medical costs are also available. A “high-deductible” Plan F Supplement plan offers low premiums for existing customers and a “high deductible” Plan G Supplement plan is available for newer applicants.
MA options include PPO, HMO, and HMO-POS options. HMO plans generally feature lower out-of-pocket costs while PPO plans offer more network physician and hospital choices at a higher cost of coverage. Advantage contracts often feature several additional ancillary benefits, including dental, vision, and hearing.
There are about 15 different policies offered for persons under age 65 and beyond. Determining which policy is best for you and your family depends on multiple factors. Some of the most prominent factors include your age, county of residence, smoking status and family income (for federal subsidy calculation). Of course, you will not be asked any medical questions. For a personalized confidential quote, simply contact us with this information. Dependent and spouse coverage is also offered.
Advanced premium tax credits (APTC) are instantly applied to reduce premiums for applicants under age 65 that qualify. Cost-sharing reductions (CSR) are available on Silver-Tier plans, and can substantially reduce deductibles, copays, and out-of-pocket expenses. Countrywide provide access is also available with the BlueCard. Additional benefits include $0 copays for Tier 1 drugs, free preventative screenings, vaccines and tests, adult vision and dental coverage, and additional resources for persons with chronic conditions.
BlueCard benefits extend to many out-of-state facilities, including Cleveland Clinic, Duke University Medical Center, Johns Hopkins Hospital, MD Anderson Cancer Center, University Of Maryland Medical Center, Winchester Medical Center, and Memorial Sloan Kettering Cancer Center.
my Direct Blue EPO and my Blue Access PPO plans are available in the following counties: Franklin, Cumberland, Perry, Adams, York, Dauphin, Lebanon, Lancaster, and Berks.
my Blue Access PPO plans are available in the following counties: Fulton, Centre, Mifflin, Juniata, Snyder, Union, Montour, Northumberland, and Columbia.
my Blue Access PPO and my Direct Blue Lehigh Valley EPO plans are available in the following counties: Schyuylkill, Lehigh, and Northampton.
Catastrophic Plans
my Direct Blue Lehigh Valley Major Events EPO 9450 – Three primary care physician (pcp) office visits provided at no cost. Deductible is $9,450 with maximum out-of-pocket expenses of $9,450 and 0% coinsurance. NOTE: Policy is only available to applicants under age 30. For lower income households, selecting a Bronze-tier plan may provide more benefits and a lower rate.
my Direct Blue Major Events EPO 9450 – Three primary care physician (pcp) office visits provided at no cost. Deductible is $9,450 with maximum out-of-pocket expenses of $9,450 and 0% coinsurance. NOTE: Policy is only available to applicants under age 30. For lower income households, selecting a Bronze-tier plan may provide more benefits and a lower rate.
my Blue Access Major Events PPO 9450 – Three primary care physician (pcp) office visits provided at no cost. Deductible is $9,450 with maximum out-of-pocket expenses of $9,450 and 0% coinsurance. NOTE: Policy is only available to applicants under age 30. For lower income households, selecting a Bronze-tier plan may provide more benefits and a lower rate.
Bronze Plans
my Direct Blue EPO Bronze 3800 – $3,800 deductible with $9,200 maximum out-of-pocket expenses and 50% coinsurance. $65 office visit copays. $100 Urgent Care copay. Diagnostic lab services and x-ray copays are $65 and $150. All prescription drugs are subject to deductible and copay.
my Blue Access PPO Bronze 3800 – $3,800 deductible with $9,200 maximum out-of-pocket expenses and 50% coinsurance. $65 office visit copays. $100 Urgent Care copay. Diagnostic lab services and x-ray copays are $65 and $150. All prescription drugs are subject to deductible and copay.
my Direct Blue Lehigh Valley EPO Bronze 3800 – $3,800 deductible with $9,200 maximum out-of-pocket expenses and 50% coinsurance. $65 office visit copays. $100 Urgent Care copay. Diagnostic lab services and x-ray copays are $65 and $150. All prescription drugs are subject to deductible and copay.
my Direct Blue EPO Bronze 7100 HSA – $6,900 deductible wit7,1h $6,900 maximum out-of-pocket expenses and 0% coinsurance. Policy is HSA-eligible.
my Blue Access PPO Bronze 7100 HSA – $6,900 deductible with $7,100 maximum out-of-pocket expenses and 0% coinsurance. Policy is HSA-eligible.
my Direct Blue Lehigh Valley EPO Bronze 7100 HSA – $6,900 deductible with $7,100 maximum out-of-pocket expenses and 0% coinsurance. Policy is HSA-eligible.
my Direct Blue EPO Bronze 8900 – $8,900 deductible with $8,900 maximum out-of-pocket expenses and 0% coinsurance.
my Blue Access PPO Bronze 8900 – $8,900 deductible with $8,900 maximum out-of-pocket expenses and 0% coinsurance.
my Direct Blue Lehigh Valley EPO Bronze 8900 – $8,900 deductible with $8,900 maximum out-of-pocket expenses and 0% coinsurance.
Silver Plans
my Direct Blue EPO Premier Silver 2900 – $2,900 deductible with $8,500 maximum out-of-pocket expenses and 30% coinsurance. $75 office visit copays and $100 Urgent Care copay. $20 copay for telemedicine service. Tier 1 and Tier 2 drug copays are $0 and $30. The Tier 3 copay is $150. $75 copay for diagnostic tests.
my Blue Access PPO Premier Silver 2900 – $2,900 deductible with $8,500 maximum out-of-pocket expenses and 30% coinsurance. $75 office visit copays and $100 Urgent Care copay. $20 copay for telemedicine service. Tier 1 and Tier 2 drug copays are $0 and $30. The Tier 3 copay is $150. $75 copay for diagnostic tests.
my Direct Blue Lehigh Valley EPO Premier Silver 2900 – $2,900 deductible with $8,500 maximum out-of-pocket expenses and 30% coinsurance. $75 office visit copays and $100 Urgent Care copay. $20 copay for telemedicine service. Tier 1 and Tier 2 drug copays are $0 and $30. The Tier 3 copay is $150. $75 copay for diagnostic tests.
my Direct Blue EPO Silver 3500 – $3,500 deductible with $9,350 maximum out-of-pocket expenses and 30% coinsurance. $45 office visit copays and $90 Urgent Care copay. The Lab services and diagnostic testing copay is $75. Tier 1, Tier 2, and Tier 3 drug copays are $0, $30, and $150.
my Blue Access PPO Silver 3500 – $3,500 deductible with $9,350 maximum out-of-pocket expenses and 30% coinsurance. $45 office visit copays and $90 Urgent Care copay. The Lab services and diagnostic testing copay is $75. Tier 1, Tier 2, and Tier 3 drug copays are $0, $30, and $150.
my Direct Blue Lehigh Valley EPO Silver 3500 – $3,500 deductible with $9,350 maximum out-of-pocket expenses and 30% coinsurance. $45 office visit copays and $90 Urgent Care copay. The Lab services and diagnostic testing copay is $75. Tier 1, Tier 2, and Tier 3 drug copays are $0, $30, and $150.
my Direct Blue EPO Silver 7000 – $7,000 deductible with $9,450 maximum out-of-pocket expenses and 30% coinsurance. $55 office visit copays and $100 Urgent Care copay. The Lab services and diagnostic testing copay is $75. Tier 1, Tier 2, and Tier 3 drug copays are $0, $30, and $150.
my Blue Access PPO Silver 7000 – $7,000 deductible with $9,450 maximum out-of-pocket expenses and 30% coinsurance. $55 office visit copays and $100 Urgent Care copay. The Lab services and diagnostic testing copay is $75. Tier 1, Tier 2, and Tier 3 drug copays are $0, $30, and $150.
my Direct Blue Lehigh Valley EPO Silver 7000 – $7,000 deductible with $9,450 maximum out-of-pocket expenses and 30% coinsurance. $55 office visit copays and $100 Urgent Care copay. The Lab services and diagnostic testing copay is $75. Tier 1, Tier 2, and Tier 3 drug copays are $0, $30, and $150.
Gold Plans
my Direct Blue EPO Gold 0 – $0 deductible with maximum out-of-pocket expenses of $7,500. $20 office visit copays and $40 copay for Urgent Care visits. Lab tests subject to $35 copay, and basic diagnostic services subject to $35 copay. Tier 1 and Tier 2 drug copays are $0 and $30. The Tier 3 copay is $150. $45 outpatient therapy copay. $45 outpatient therapy copay.
my Blue Access PPO Gold 0 – $0 deductible with maximum out-of-pocket expenses of $7,500. $20 office visit copays and $40 copay for Urgent Care visits. Lab tests subject to $35 copay, and basic diagnostic services subject to $35 copay. Tier 1 and Tier 2 drug copays are $0 and $30. The Tier 3 copay is $150. $45 outpatient therapy copay.
my Direct Blue Lehigh Valley EPO Gold 0 – $0 deductible with maximum out-of-pocket expenses of $7,500. $20 office visit copays and $40 copay for Urgent Care visits. Lab tests subject to $35 copay, and basic diagnostic services subject to $35 copay. Tier 1 and Tier 2 drug copays are $0 and $30. The Tier 3 copay is $150. $45 outpatient therapy copay.
my Direct Blue EPO Premier Gold 0 – $0 deductible with maximum out-of-pocket expenses of $6,500. $15 office visit copays and $30 copay for Urgent Care visits. Lab tests subject to $30 copay, and basic diagnostic services subject to $30 copay. Tier 1 and Tier 2 drug copays are $0 and $25. The Tier 3 copay is $75. $250 ER copay. $40 outpatient therapy copay.
my Blue Access PPO Premier Gold 0 – $0 deductible with maximum out-of-pocket expenses of $6,500. $15 office visit copays and $30 copay for Urgent Care visits. Lab tests subject to $30 copay, and basic diagnostic services subject to $30 copay. Tier 1 and Tier 2 drug copays are $0 and $25. The Tier 3 copay is $75. $250 ER copay. $40 outpatient therapy copay.
my Direct Blue Lehigh Valley EPO Premier Gold 0 – $0 deductible with maximum out-of-pocket expenses of $6,500. $15 office visit copays and $30 copay for Urgent Care visits. Lab tests subject to $30 copay, and basic diagnostic services subject to $30 copay. Tier 1 and Tier 2 drug copays are $0 and $25. The Tier 3 copay is $75. $250 ER copay. $40 outpatient therapy copay.
my Direct Blue EPO Gold 1700 HSA – $1,700 deductible with maximum out-of-pocket expenses of $5,700. 20% coinsurance and plan is HSA-eligible.
my Blue Access PPO Gold 1700 HSA – $1,700 deductible with maximum out-of-pocket expenses of $5,700. 20% coinsurance and plan is HSA-eligible.
my Direct Blue Lehigh Valley EPO Gold 1700 HSA – $1,700 deductible with maximum out-of-pocket expenses of $5,700. 20% coinsurance and plan is HSA-eligible.
Pa Health Exchange Plans
We continue to be a point of reference for you so you can quickly view and compare plans and if you wish, speak to an experienced professional. This could save time and aggravation of having to deal directly with a new government-run website and inexperienced newly-hired workers. Pennie is the state-government-run state Exchange that was created two years ago.
Since every applicant is accepted when they apply for a policy, it is most important to review all of the available choices. Four metal options (Platinum, Gold, Silver and Bronze) are offered along with special “SHOP” policies for small business owners and their employees. Each year, prices are reset, and new plans can be offered by carriers to meet the changing needs of consumers. Highmark Group coverage information is available for employers and workers. Note: A federal subsidy is generally not offered to applicants who are eligible for group health benefits.
Also, since all submitted applications are approved with medical questions no longer asked, Highmark no longer offers many of the older Guaranteed-issue (GI) policies from 2013 and earlier. However, when policies are purchased outside Open Enrollment periods (other than approved exceptions, such as divorce, loss of job, baby or dependent reaching age 26), medical questions may be asked on short-term or limited-benefit policies. Temporary plans feature very low premiums, but are designed to provide stopgap coverage and not long-term benefits.
The current federal subsidy is based on household income eligibility. For example, a family of four (parents both age 50 with two children) residing in Lancaster County with household income of $100,000, receive a subsidy of $1,239 per month. A married couple (ages 60) with household income of $60,000, receive a federal subsidy of $1,613 per month.
The official Federal Poverty Guidelines (FPL) levels are listed below. (Credit to Impact CA for providing the graph) These guidelines are used for 2023 effective dates. The earnings amounts increased about 1.5% due to inflation. If your total household income is below 138% of the FPL, Medicaid and/or CHIP may be available, and you would not be able to apply for a Pa Health Exchange plan. Previously, Medicaid eligibility requirements were expanded. Thus, many affordable Central Pa medical plans are offered, especially, if you qualify for Medicaid.
So…which Highmark Under-65 contract is best for you? Of course, there is no right answer, but generally, if you like copays, the Silver plans may be your best choice. If you like Health Savings Accounts, the PPO HDHP options are the best choices. If you need help, call or contact us and we will show you which policy fits your needs the best. If you need help finding a provider in your area, we can help verify if your doctor or hospital is “in-network.”
Highmark BC Medicare Coverage
For Seniors in Pennsylvania, there are three types of policies available for purchase. They are Medicare Advantage (Part C), prescription drug coverage (Part D) and Medicare Supplement (Medigap). Policies are generally medically underwritten although during Open Enrollment periods, acceptance is often guaranteed. Open Enrollment dates for persons age 65 and over, differ than the dates for persons under age 65.
2024 Medicare Advantage Plans
Community Blue Medicare HMO Signature – $6,500 maximum out-of-pocket expenses with $0 pcp and specialist office visit copays. Lab/diagnostic test and x-ray copays are $0 and $10. Advanced imaging copay is $200. ER and Urgent Care copays are $100 and $0. The inpatient hospital stay copay is $250. Preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $0, $0, $47, $100, and 33%. The deductible on this plan is $0 and the monthly premium is $0. Outpatient hospital visits are covered with a $175 copay.
Community Blue Medicare PPO Signature – $7,950 maximum out-of-pocket expenses with $0 and $25 pcp and specialist office visit copays. Lab/diagnostic test and x-ray copays are $0-$10 and $20. Advanced imaging copay is $195. ER and Urgent Care copays are $100 and $30. The inpatient hospital stay copay is $325. Preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $0, $5, $47, $100, and 33%. The deductible on this plan is $0 and the monthly premium is $0. Outpatient hospital visits are covered with a $350 copay.
Community Blue Medicare PPO Distinct – $5,500 maximum out-of-pocket expenses with $0 and $15 pcp and specialist office visit copays. Lab/diagnostic test and x-ray copays are $0 and $20. Advanced imaging copay is $175. ER and Urgent Care copays are $100 and $30. The inpatient hospital stay copay is $200. Preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $0, $0, $42, $100, and 33%. The deductible on this plan is $0 and the monthly premium is $27. Outpatient hospital visits are covered with a $245 copay.
Freedom Blue PPO Basic – $5,900 maximum out-of-pocket expenses with $0 and $35 pcp and specialist office visit copays. Lab/diagnostic test and x-ray copays are $0-$20 and $25. Advanced imaging copay is $150. ER and Urgent Care copays are $100 and $50. The inpatient hospital stay copay is $340. Preferred drug benefits are not included. The monthly premium is $64. Outpatient hospital visits are covered with a $200 copay.
Freedom Blue PPO Valor – $6,000 maximum out-of-pocket expenses with $0 and $10 pcp and specialist office visit copays. Lab/diagnostic test and x-ray copays are $0 and $20. Advanced imaging copay is $325. ER and Urgent Care copays are $100 and $50. The inpatient hospital stay copay is $275 Preferred drug benefits are not included. The monthly premium is $0. Outpatient hospital visits are covered with a $245 copay.
Freedom Blue PPO ValueRx – $5,500 maximum out-of-pocket expenses with $0 and $40 pcp and specialist office visit copays. Lab/diagnostic test and x-ray copays are $0-$20 and $25. Advanced imaging copay is $175. ER and Urgent Care copays are $100 and $5. The inpatient hospital stay copay is $245 for 5 days. Preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $0, $13, $45, $95, and 33%. The deductible on this plan is $0 and the monthly premium is $58. Outpatient hospital visits are covered with a $225 copay.
Freedom Blue PPO Standard – $5,000 maximum out-of-pocket expenses with $0 and $35 pcp and specialist office visit copays. Lab/diagnostic test and x-ray copays are $0-$15 and $20. Advanced imaging copay is $125. ER and Urgent Care copays are $100 and $5. The inpatient hospital stay copay is $475. Preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $0, $13, $45, $95, and 33%. The deductible on this plan is $0 and the monthly premium is $164. Outpatient hospital visits are covered with a $200 copay.
Freedom Blue PPO Deluxe – $4,500 maximum out-of-pocket expenses with $0 and $30 pcp and specialist office visit copays. Lab/diagnostic test and x-ray copays are $0-10 and $10. Advanced imaging copay is $75. ER and Urgent Care copays are $100 and $5. The inpatient hospital stay copay is $235. Preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $0, $13, $45, $95, and 33%. The deductible on this plan is $0 and the monthly premium is $278. Outpatient hospital visits are covered with a $175 copay.
Medicare Supplement (Medigap) Plans
The six available plans are F, A, N, B, C and F (HD). Plans C and F are the most expensive because most out-of-office expenses are paid in full. The other plans will save money, unless their is high usage.
Highmark Medigap Blue Medicare Supplement Rates (Monthly)
65 Year-Old Dauphin, Lebanon, Berks, Lehigh, York, Adams, Franklin, Fulton, And Lancaster Counties
$84 – Plan F (High Deductible)
$117 – Plan D
$118 – Plan A
$121 – Plan G
$122 – Plan B
$132 – Plan N
$182 – Plan F
$182 – Plan C
70 Year-Old Dauphin, Lebanon, Berks, Lehigh, York, Adams, Franklin, Fulton, And Lancaster Counties
$100 – Plan F (High Deductible)
$130 – Plan D
$132 – Plan G
$141 – Plan A
$147 – Plan B
$159 – Plan N
$220 – Plan F
$220 – Plan C
75 Year-Old Dauphin, Lebanon, Berks, Lehigh, York, Adams, Franklin, Fulton, And Lancaster Counties
$114 – Plan F (High Deductible)
$150 – Plan D
$153 – Plan G
$166 – Plan A
$173 – Plan B
$186 – Plan N
$260 – Plan C
$260 – Plan F
65 Year-Old Luzerne, Sullivan, Bradford, Susquehanna, And Wyoming Counties
$91 – Plan A
$101 – Plan F (High Deductible)
$111 – Plan N
$115 – Plan B
$116 – Plan D
$122 – Plan G
$158 – Plan C
$190 – Plan F
70 Year-Old Luzerne, Sullivan, Bradford, Susquehanna, And Wyoming Counties
$107 – Plan A
$109 – Plan F (High Deductible)
$119 – Plan N
$127 – Plan D
$133 – Plan G
$135 – Plan B
$187 – Plan C
$210 – Plan F
75 Year-Old Luzerne, Sullivan, Bradford, Susquehanna, And Wyoming Counties
$125 – Plan A
$128 – Plan F (High Deductible)
$140 – Plan N
$147 – Plan D
$154 – Plan G
$160 – Plan B
$224 – Plan C
$248 – Plan F
Whole Health Balance Program
Anyone enrolled in a Highmark Medigap Blue Medicare Supplement plan is eligible to purchase the Whole Health Balance Program for a monthly cost of $34.50. Benefits are shown below:
Fitness – Basic amenities included along with fitness classes. SilverSneakers classes also included.
Dental – Cleaning exam every 6 months subject to $30 copay. One annual x-ray subject to $25 copay.
Hearing – One annaul routine exam provided with a $40 copay. $699 copay for TrueHearing Advanced Hearing Aid. $999 copay for TrueHearing Premium Hearing Aid.
Vision – $0 copay for annual eye exam. Contact lens fitting and exam also receives a $0 copay. Selected Davis Vision Fashion Collection lenses, frames, and contact lenses covered at 100%. $100 benefit provided for other lenses, frames, and contact lenses.
Sample Highmark Blue Medicare Advantage Monthly Rates (Part C)
65 Year-Old Dauphin, Cumberland, Perry, Lebanon, Adams, York, Bradford, Snyder, Union, Lancaster, Schuylkill, Northampton, and Juniata Counties
$0 – Community Blue HMO Signature
$0 – Community Blue PPO Signature
$25 – Community Blue Medicare PPO Distinct
$65 – Freedom Blue PPO Basic
$69 – Freedom Blue PPO ValueRx
$174 – Freedom Blue PPO Standard
$288 – Freedom Blue PPO Deluxe
65 Year-Old Erie and Potter Counties
$0 – Community Blue PPO Signature
$0 – Community Blue HMO Signature
$25 – Complete Blue PPO Distinct
$52 – Security Blue HMO-POS Basic
$57 – Security Blue HMO-POS ValueRx
$64 – Security Blue HMO-POS Standard
$71 – Freedom Blue PPO ValueRx
$130 – Freedom Blue PPO Select
$224 – Security Blue HMO-POS Deluxe
$253 – Freedom Blue PPO Classic
65 Year-Old Lycoming, Sullivan, Clinton, Northumberland, Columbia, Montour, and Tioga Counties
$0 – Community Blue PPO Signature
$25 – Community Blue Medicare PPO Distinct
$65 – Freedom Blue PPO Basic
$69 – Freedom Blue PPO ValueRx
$174 – Freedom Blue PPO Standard
$288 – Freedom Blue PPO Deluxe
Senior Prescription Drug Coverage (Stand-Alone)
The “preferred” and “standard” pharmacy networks are available. The “preferred” option offers lower out-of-pocket costs. Part B premiums must still continue to be paid. A “Gap Discount” may also be available to the lower the cost of brand name drugs. The discount may be as much as 50%, if other assistance is not being received.
Primary coverage is $4,020 of drug expenses. For coverage gap ($6,350 out-of-pocket expenses vs. $4,020), coinsurance is 25% for generic and 25% for brand. After the $6,350 out-of-pocket expense limit has been met, generic and multi-source drugs are subject to higher of 5% coinsurance or $3.60 copay. Others are subject to $8.95 copay.
Blue RX PDP Plus – $108.80 monthly premium. $545 deductible. Preferred network offers $0 copay for preferred generic drugs and $7 copay for generic drugs. 20%, 40%, and 25% coinsurance applies to preferred brand, non-preferred brand, and specialty drugs respectively. Standard network offers $5 copay for preferred generic drugs and $12 copay for generic drugs. 25%, 50%, and 25% coinsurance applies to preferred brand, non-preferred brand, and specialty drugs respectively. Preferred mail-order copays are $0, $17.50, 20%, 40%, and 25%. 4,990 members are enrolled in the state and 10,981 members are enrolled in the US.
Blue RX PDP Complete – $195.10 monthly premium. $0 deductible. Preferred network offers $0 copay for preferred generic drugs and $5 copay for generic drugs. The preferred brand drug copay is $40. 35%, and 33% coinsurance applies to non-preferred brand, and specialty drugs respectively. Standard network offers $4 copay for preferred generic drugs and $10 copay for generic drugs. The preferred brand drug copay is $45. 50%, and 33% coinsurance applies to non-preferred brand, and specialty drugs respectively. Preferred mail-order copays are $0, $12.50, $100, 35%, and n/a. 2,847 members are enrolled in the state and 6,587 members are enrolled in the US.
Highmark BC Blue Edge Dental Plans
Affordable dental benefits are offered to individuals, families, and small groups, at any time throughout the year. Current enrollment in a healthcare plan is not required, and applying for coverage is simple and quick. An online application is available. Once an application is completed and submitted, the policy effective date will be the first day of the following month. The United Concordia network is utilized, which provides more than 90,000 dentists countrywide. Four plan options are available, which are described below:
Premier – Provides the most comprehensive benefits with the lowest out-of-pocket expenses. $50 annual deductible with $1,250 maximum benefits per person. 100% coverage is provided for for oral evaluations, radiograph, cleanings, fluoride treatment, emergency palliative treatment, sealant, and space maintainers. 80% coverage is provided for for crown, inlay, outlay, and denture repair, anterior and posterior resin-based white fillings, repair and adjustment of prosthetics, amalgam restorations, and simple extractions. 50% coverage is provided for surgical extractions, complex oral surgery, root canals, general anesthesia, nitrous oxide, IV sedation, periodontics, crowns, inlays, onlays, and prosthetics.
High – Provides the second-most comprehensive benefits. $100 annual deductible with $1,000 maximum benefits per person. 100% coverage is provided for for oral evaluations, radiograph, cleanings, fluoride treatment, emergency palliative treatment, sealant, and space maintainers. 50% coverage is provided for for crown, inlay, outlay, and denture repair, anterior and posterior resin-based white fillings, repair and adjustment of prosthetics, amalgam restorations, and simple extractions. 30% coverage is provided for surgical extractions, complex oral surgery, root canals, general anesthesia, nitrous oxide, IV sedation, periodontics, crowns, inlays, onlays, and prosthetics.
Value – For applicants that rarely use comprehensive benefits. $25 annual deductible with $1,000 maximum benefits per person. 100% coverage is provided for for oral evaluations, radiograph, cleanings, fluoride treatment, emergency palliative treatment, sealant, and space maintainers. 50% coverage is provided for for crown, inlay, outlay, and denture repair, general anesthesia, nitrous oxide, IV sedation, anterior and posterior resin-based white fillings, repair and adjustment of prosthetics, amalgam restorations, and simple extractions. No coverage is provided for surgical extractions, complex oral surgery, root canals, periodontics, crowns, inlays, onlays, and prosthetics.
Basic – The least expensive option. $0 annual deductible with $1,000 maximum benefits per person. 100% coverage is provided for for oral evaluations, consultations, radiograph, cleanings, fluoride treatment, emergency palliative treatment, sealant, and space maintainers.
The PALS Program For Seniors
PALS (People Able To Lend Support) is a free program offered to all Highmark members. Free help is available to persons that may need physical or mental assistance with common and uncommon daily activities. Providers include existing customers, their relatives, and other volunteers in the area. There is no cost or obligation to utilize the free help. Comprehensive training is required for all volunteers. Several helpful services that are provided include:
Companionship provided in-person or via telephone.
Assistance with pets and animals, including feeding, walking, and checking general health.
Help with minor house repairs (inside and outside).
Shop for food and other essential items.
Assist with work in and outside of the home.
Group Insurance For Employees
Highmark employer-provided plans offer more than medical benefits. Health and wellness programs, online tools, member discounts, employee education, and “Blues On Call” provide a wide range of policy enhancements. On-demand health coaching is also available to provide confidential counseling, manage chronic conditions, and help with living a healthy lifestyle. A member portal helps find local providers and shows your spending and claims information.
“Blue365” is for members only, and provides many services and discounts, including walking, running, and fitness programs. Nutrition, weight-loss, yoga, and massage therapy is offered to members. The portal also provides services to residents in Delaware and West Virginia. Ten Group options are listed below:
Choice Blue – Two available provider network levels.
PPO Plans – Wide choice of doctors, specialists, and hospitals.
EPO Plans – Pennsylvania and Delaware only.
Traditional Plans – Traditional benefits.
Community Blue Premier Flex – 90% of US hospitals included in provider network.
Lehigh Valley Flex Blue – Two levels of coverage.
Penn State Health – Penn State Health and Highmark BS provide coverage.
Travel Insurance
When you travel outside of the United States, your current plan may not cover specific expenses. However, GeoBlue provides preventative benefits, along with coverage for pre-existing conditions, and unexpected accidents and illnesses. Physicians, specialists, and other healthcare providers that speak English can be utilized. Urgent-Care, ER, evacuation, and in-hospital and outpatient hospital expenses can be covered. Worldwide Insurance Services LL Operates GeoBlue, which is licensed by BCBS. 24/7 access to live help and coverage verification are also provided.
Several popular plans are listed below:
VOYAGER – Used mostly for business or missionary trips since duration must not exceed six months and coverage is for a single trip. Voyager Essential and Voyager Choice are two plan options. “Essential” does not require a primary plan and the maximum covered age is 74. “Choice” covers pre-existing conditions, and requires a primary plan. The maximum covered age is 84.
TREKKER – Unlimited trips over a 12-month period are allowed. Pre-existing conditions are covered, and a primary health plan is required. Essential plan provides up to $50,000 of international coverage while Choice option provides up to $250,000 of international coverage. Choice plan also includes up to $25,000 of accidental, death and dismemberment coverage.
EXPLORER – International coverage that can also provide benefits in the US. There are no annual or lifetime maximum limits, and preventative care for babies, children, and adults is covered at 100%. Pcp office visits are subject to only a $10 copay. Deductible options are $0, $1,000, $2,500, and $5,000. Coinsurance maximum options are $2,000, $8,000, and $10,000. Additional benefits include hospice, skilled nursing facility, and home health care. 100% coverage after deductible is included for many expenses, including surgery, anesthesia, diagnostic x-rays, lab work, in-patient drugs, ambulance service, durable medical equipment, and basic prescriptions ($1,000 maximum).
Fertility Coverage
Fertility treatment programs help young couples have a baby. WINFertility provides up to a 40% discount on the cost of drugs, and IVF treatment. A coach/nurse is available to provide support during the entire process, and there are no enrollment fees. A free prenatal program designed to reduce the risk of birth defects is also included. After meeting with a specialist, a price quote is provided for the medical services and drug therapies. Treatment packages are designed to provide comprehensive coverage throughout the entire process. A prenatal program helps reduce the risk of birth defects.
Free information and counseling is also provided for the following topics: Conditions For Assisted Hatching, Getting Pregnant, Donor Eggs, Egg Freezing, Embryo Adoption, Endometriosis, Female Infertility, Infertility Medications And Treatment, IVF, Male Infertility, INVOcell, Oncofertlity, PGD, Same Sec Couples Wanting Children, Secondary Infertility, Surrogacy, Transgender Issues, and Methods To Conceive. The local facility is the AHN Center for Reproductive Medicine located on McKnight Road. Fertility financing is offered, with 60-month terms available to pay for expenses. NOTE: WINFertility is not a subsidiary of Highmark BS.
Educational Manuals are offered to policyholdersat no cost. Several topics include preventative health guidelines, provider manuals, practice site resources, behavioral health authorization submission manual, provider and member educational resources, geriatric resource binder, HEDIS, health quality and equity services, NaviNet guide, and data accuracy compliance.
Updates From The Past:
As a direct result of the Affordable Care Act legislation, Highmark will be terminating about 175,000 personal policies in Western Pa. Unfortunately, for many of these policyholders, rates will increase because of forced mandates under the new law. However some customers will see price reductions, especially if they qualify for the federal Obamacare subsidy.
Open Enrollment, which began on October 1st, continues through the end of March. During this time, you can not be turned down for medical conditions and government subsidies will instantly reduce premiums, if your income is below 400% of the Federal Poverty Level.
Highmark has enrolled more than 40,000 persons in Exchange plans. And yes, our website has been a big part of the process. This number far outpaces both Geisinger and Capital Blue Cross. However, both of those carriers are regional companies that don’t extend coverage in as many counties.
The Community Blue Silver policies are extremely popular because of the competitive pricing, and the cost-sharing features that lower deductibles and copays for many qualified applicants. A nationwide policy would be an alternative selection for persons that spend much of the year outside of Pennsylvania.
Highmark signed up approximately 150,000 new customers during Open Enrollment, which ended on March 31st. Exchange plans are still available to applicants that qualify for one of several approved exceptions. Not all of the persons that signed up have paid premiums and about half were previously uninsured or had coverage with a different carrier.
Three new policy designs will be available for effective dates. Specific details may not be available until November when Open Enrollment begins. Policy changes and prices have been submitted to the Pa Department of Insurance, but have not been approved yet. Also, non-grandfathered plans that are being terminated will end on December 31st.
Shared Cost Blue PPO 6000 is one of the most popular Highmark plans for Central Pennsylvania. Although copays are high for primary-care physician and specialist visits, the deductible does not have to be met.
Fewer consumer choices are available in many Central Pa counties, since Aetna and UnitedHealthcare have exited the market. For instance, in the Harrisburg area, only Geisinger, Capital BC, and Highmark offer plans.
Open Enrollments for persons under age 65 declined. Higher rates and the temporary decision to eliminate broker assistance contributed to the reduction in new policies issued.
