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Doctor Visits and Outpatient Care

To locate network providers

  - visit the Find a Doctor or Rx section of highmarkbcbs.com;

  - call Highmark at 888-835-2959; or

  - call your provider's office.

Medical coverage for active members is administered by Highmark Blue Cross Blue Shield (BCBS), giving you access to the BlueCard PPO network of physicians, hospitals, and other medical facilities and licensed providers with which the plan has a contractual relationship; these participating providers are called network providers.

Coverage for Network Provider Visits

PPO Option: You can see any primary care physician or specialist you wish, including for behavioral health or substance use disorder treatment, without a referral from your primary care physician. However, using network providers costs less — sometimes significantly less — than if you see an out-of-network provider. To maximize your benefit, check in advance that any provider you plan to visit participates in the network.

PPO members and their enrolled family members who use network providers (as well as PPO members and their enrolled family members who live in a non-network area) are responsible for the following office visit copays:

  • $0 for annual covered preventive care visits to primary care physicians and gynecologists;
  • $10 for a telemedicine visit with a doctor through Teladoc, provided through Highmark;
  • $25 for a primary care, family practice, or internal medicine physician's office visit or behavioral health counseling session;
  • $45 for an office visit to a specialist.

Get your flu shot!

It’s covered and convenient. 

Whether you and your family get your seasonal flu shots at a participating retail pharmacy or the doctor’s office, they are covered at 100 percent.

Going to the pharmacy? Get your flu shot while you’re there. Just show your OptumRx ID card. To locate a participating retail pharmacy,

Visiting the doctor? Ask for your shot while you’re there. If you have coverage under Highmark, the physician’s office will submit the charges to them. If you are on the Medicare Supplement Plan, the charges will be sent to Medicare.

And for active plan members, the immunization will be added to your Personal Health Record (PHR) automatically. If you are an active member and aren’t taking advantage of your PHR yet, launch yours today. It’s a great tool for managing your health history.

*Check with your pharmacy to find out if your state requires a prescription from a physician and/or has age restrictions for dispensing immunizations at retail facilities.  

The amount you pay for office visits is not applied to your deductible or copayment maximum*; you are responsible for office visit copays even if you have satisfied your copayment maximum for the year.

All tests and procedures performed in the course of an office visit are subject to the plan's deductible and copayment provisions.

EPO Option: Under this option, you must see a network provider to access your benefits.

EPO members and their enrolled family members who use network providers (as well as EPO members and their enrolled family members who live in a non-network area) are responsible for the following office visit copays:

  • $0 for annual covered preventive care visits to primary care physicians and gynecologists;
  • $10 for a telemedicine visit with a doctor through Teladoc, provided through Highmark;
  • $40 for a primary care, family practice, or internal medicine physician's office visit or behavioral health counseling session;
  • $60 for an office visit to a specialist.

All tests and procedures performed in the course of an office visit are subject to the plan's copay provisions (see the 2018 Key Provisions: EPO chart).

Coverage for Out-of-Network Providers

PPO Option: For PPO members who live in a network area and use out-of-network providers, the plan pays for out-of-network office visits at 50 percent of the contracted rate, up to the plan allowance. The member is responsible for the remaining 50 percent of the contracted rate plus 100 percent of any charges billed by the physician that exceed the plan allowance.

EPO Option: This option does not cover out-of-network providers (except in the case of an emergency). If you visit an out-of-network provider when you have access to a provider that participates in the network, you are responsible for all costs incurred.

Coverage for Outpatient Care

PPO Option: Under the PPO, deductibles and copayment maximums for outpatient care vary according to the member’s salary range. The Medical Plan’s payment for services by physicians and other providers is based on the contracted rate in the area for each particular procedure or service.

EPO Option: The EPO has fixed deductibles and copay amounts for outpatient services; see the 2018 Key Provisions: EPO chart.

For lists of expenses that are covered and those that are not covered, refer to Guide to Your Healthcare Benefits (see Booklets & Publications, above right).

Pre-Certification

For both the PPO and EPO options, the plan requires pre-certification review and approval before certain procedures and tests will be covered. For more information on pre-certification, see the Pre-Certification page on pensions.org.

* Except for copays for office visits and your deductible, your portion of eligible expenses accumulates until you reach the copayment maximum. After you reach your copayment maximum, the plan pays 100 percent of the allowable costs for the remainder of the year. For deductible and copayment maximum details, refer to Guide to Your Healthcare Benefits (see Booklets & Publications, above right).