Highmark Advance Blue individual health insurance is no longer available in Western Pennsylvania. But affordable alternatives (my Connect Blue EPO 6500B and my Connect Blue EPO 1750s) are offered. The Advance Blue plan was a comprehensive policy that offered extensive coverage at an affordable rate for both individuals and families. Covered benefits included coverage that was often found in expensive group plans. However, premiums were very low on this particular plan.

We liked this policy because you did not have to meet the deductible to use the office visit and prescription benefits. The old Highmark DirectBlue and PPOBlue policies placed a deductible on those two coverages. Compared to many other available plans in the Keystone State, the Advance Blue policy was able to potentially reduce your total out-of-pocket cash outlay, since most claims were covered with small payments. Whether you had children or no dependents, it was a good choice.

So…since it is no longer available, what is the most affordable similar option? Meet “my Connect Blue EPO 250G,”  which is a Community Blue Flex (ONX) plan. Of course, there are no longer any medical questions to answer, since all Exchange policies are guaranteed-approval with no risk of denial because of pre-existing conditions. Possible legislative changes may provide additional low-cost option by 2019, depending if Congress can agree to revisions to The Affordable Care Act.

If you need help with understanding the ACA Legislation, or other laws in Pa, we published a special page here that will provide specific and helpful information. You can learn about what is staying the same, what is changing, and how to easily enroll for a policy that you can afford.

Benefits of the Highmark BCBS my Connect Blue EPO 250G

Visits (Utilizing Preferred Value Network Provider) to a primary care physician (pcp) are subject to only a $10 copay. Thus, if the cost was $180, your out-of-pocket cost would be $10. There is also no limitation on the number of visits you or any family member can incur per year. Visits to specialists are covered with a $60 copay, and also with no limitations. If an Enhaced Value Network is used, the copays are $40 and $85.  Specialists include allergist, cardiologist, dermatologist, gastroenterologist, gynecologist, hematologist, internist, neonatologist, neurologist, oncologist, psychiatrist, pulmonologist, and urologist.

Preventive-related expenses and immunizations are not subject to any copay or coinsurance. All “qualified” plans provide this feature, including all of the available Highmark policies. Other diagnostic testing and x-rays also do not have to meet a deductible.  Instead, a $25 copay applies to non-hospital visits for diagnostic tests, x-rays, and blood work. The copay is doubled to $50 for in-hospital visits. For imaging (MRI or CET/PET scan), a $50 copay applies for non-hospital visits, while a $100 copay applies to in-hospital visits.

Prescription Drug Coverage

Formulary low-cost generic drugs receive the lowest copays. Retail drugs are subject to 15% coinsurance with a $3/$6/$9 minimum charge, and a $10/$20/$30 maximum charge per prescription. Mail order are subject to 15% coinsurance with a $6 minimum charge, and $20 maximum per prescription. Formulary medium-cost generic drugs and low-cost brand drugs receive the second-lowest copays.  Retail drugs are subject to 25% coinsurance with a $20/$40/$60 minimum charge, and a $75/$150/$225 maximum charge per prescription. Mail order are subject to 25% coinsurance with a $40 minimum charge, and $150 maximum per prescription.

Mental and/or behavioral and substance abuse outpatient services are subject to only a $60 copay. Typically, if treatment is inpatient,a $500 copay applies, subject to a three-day maximum. If you are pregnant, a 10% coinsurance applies to prenatal and postnatal treatment. Inpatient treatment (including delivery) is also subject to a $500 copay per day, subject to a three-day maximum. Rehabilitation services must meet a $40 copay and  skilled nursing care, hospice services, and durable medical equipment are also subject to coinsurance (10%).

Need dental or vision benefits for your child? It’s covered! One routine eye exam, a pair of frames, and two dental exams are provided each year without a copay or coinsurance. But you must use a Highmark-approved provider. If fraud is suspected, a special page has been set up to allow Highmark to investigate the claim or issue.

What’s Not Covered?

Even under the Affordable Care Act, many items are often not covered. Some of the excluded benefits of the Highmark policy are private-duty nurses, acupuncture, cosmetic and bariatric surgeries, hearing aids, infertility treatment, and long-term care (which is available through individual policies). Although there are other exclusions, these are among the most likely to be used.

Of course, the mandatory “minimum essential coverage” is included, as required by ACA legislation. Although some of these benefits, such as mental illness and maternity, may never be used, they can not be removed from the contract. It’s possible that future legislative changes could allow policyholders to choose policies that don’t contain benefits like these that may not be needed.

What About The Rates?

Provided below are an assortment of scenarios, so you can understand how affordable prices are in Western Pa. We used Allegheny County for our analysis.

Individual Prices

25 year-old  $23,000 income  Rate is $131 per month.

35 year-old  $28,000 income  Rate is $196 per month.

45 year-old  $32,000 income  Rate is $254 per month.

55 year-old  $32,000 income  Rate is $265 per month.

Family Prices

25 year-old husband and wife – $30,000 income  Rate is $173 per month.

35 year-old husband and wife – $30,000 income  Rate is $179 per month.

45 year-old husband and wife – $40,000 income  Rate is $313 per month.

55 year-old husband and wife – $40,000 income  Rate is $335 per month.

55 year-old husband and wife – $75,000 income  Rate is $403 per month.

Subsidies were included in all of the example above. The level and amount of your subsidy solely depends on your household income (including pensions and social security) and the number of persons in your household, including those that will not be covered. Upon request, we will calculate your amount of eligible financial aid and the policies that best utilize that help.