Pennsylvania 1-3 - Retired Employees

"Bold" print identifies plan changes effective 1/1/2003
Plan Name	BlueCard PPO In-Network	BlueCard PPO Out-of-Network	Keystone Heath Plan West
Web Site	www.bluecares.com	www.bluecares.com	www.highmark.com
Member Service Number	1-800-810-BLUE	1-800-810-BLUE	1-800-241-5704 or 1-800-547-9378
Individual Lifetime Maximum Benefits	$1 Million	$500,000	None
Annual Deductible
Individual	None	$200	None
Family	None	$400	None
Coinsurance	None	25%	None
Annual Out-of-Pocket Maximum
Individual	None	$2,000	None
Family	None	$4,000	None
Inpatient Hospital	100% covered	75% after deductible; 90 days per calendar year	100% covered
Physician Services: PCP Office Visit	$10 copay	75% after deductible	$15 copay
Emergency Care: In-area Hospital	100% after $25 copay waived if admitted	100% after $25 copay - waived if admitted	$35 copay
Outpatient X-Ray and Lab	100% covered	75% after deductible	100% covered
Durable Medical Equipment	100% with precertification	75% after deductible	100% covered, No Maximum
Retail Prescription Coverage
Generic	15% (Represented) 20% (Salaried)	15% (Represented) 20% (Salaried)	$12 copay for 30-day supply
Brand Name	25% if generic unavailable; 30% if generic available and medically necessary (Represented) 30% if generic unavailable; 50% if generic available and medically necessary (Salaried)	25% if generic unavailable; 30% if generic available and medically necessary (Represented) 30% if generic unavailable; 50% if generic available and medically necessary (Salaried)	$20 copay for Preferred Brand Names; $35 copay for a 30-day supply of Non-Preferred Brand Names
Mail-Order Prescription Coverage
Generic	10% generic; 20% brand if generic unavailable; 25% if generic available and medically necessary (Represented) 10% generic; 20% brand if generic unavailable; 40% if generic available and medically necessary (Salaried)	10% generic; 20% brand if generic unavailable; 25% if generic available and medically necessary (Represented) 10% generic; 20% brand if generic unavailable; 40% if generic available and medically necessary (Salaried)	$24 copay for a 90-day supply
Brand Name	See Above	See Above	$40 copay for 90 -day supply of Preferred Brand Names; $70 copay for 90-day supply of Non-Preferred Brand Names
Diabetic Benefits
Insulin	Covered Under Pharmacy Benefit	Covered Under Pharmacy Benefit	Covered Under Pharmacy Benefit
Chem. Strips/Lancets	Covered Under Pharmacy Benefit	Covered Under Pharmacy Benefit	Covered Under Pharmacy Benefit
Home Health Care	100% for 100 visits per calendar year	75% after deductible; 100 visits per calendar year	100% covered
Mental Health
Inpatient	100% up to 30 days per calendar year	75% up to 10 days per calendar year	100% covered for up to 30 days per calendar year
Outpatient	$10 copay up to 20 visits per calendar year	75% up to 20 visits per calendar year	$25 copay for up to 20 days per calendar year
Substance Abuse
Inpatient	100%; 28 days + 5 detox; 2 courses of treatment per lifetime	75%; 28 days + 5 detox/ 2 course of treatment per lifetime	30 days per 12 months lifetime limit 90 days
Outpatient	100%; 28 days + 5 detox;2 courses of treatment per lifetime	75% - 30 visits; 7 detox - two course of treatment per lifetime	First course 100% covered; thereafter $25 copay or 50% of charge; 60 session per year; 120 session per lifetime
Vision Care
Routine Eye Exam	Not Covered	Not Covered	One eye exam every two(2) years
Eyeglasses and Contact Lenses	Not Covered	Not Covered	Not Covered
Hearing Care
Exam	Covered through National Ear Care Plan	Nor Covered	Not Covered
Hearing Aids	Covered through National Ear Care Plan	Not Covered	Not Covered
Dental Care
Basic Services	Not Covered	Not Covered	Not Covered
Major Services	Not Covered	Not Covered	Not Covered
Preventive Services	Not Covered	$30 copay	Not Covered
Wellness Benefits	$10 copay	Not Covered	Yes