1
HIGHMARK BLUE CROSS BLUE SHIELD
WESTERN NEW YORK REGION
Plans that work
as hard for your
business as you do.
Small groups with 100
or fewer employees
Q1
32
Highmark has a plan
that’s right for your business.
Where is your company headquartered? .......................4
First quarter 2024 medical coverage .............................. 6
Dependent age 26 rates ..................................................8
Dependent age 30 rates ..................................................9
Dental coverage ............................................................. 10
Extra resources you won’t find in other plans ...............12
Available spending accounts ..........................................13
Annual benefit limits .......................................................13
Endless support to help your employees
on their journey to better health ................................... 14
The fundamentals of coverage ...................................... 15
Contact your broker or Highmark
small group representative to get started.
Insurance is offered by Highmark Blue Cross Blue Shield, a trade name
of Highmark Western and Northeastern New York Inc., an independent
licensee of the Blue Cross Blue Shield Association.
Your employees want more
from their health care.
Give your employees benefits that
make them want to stick around.
Turn the page for network options, plan descriptions,
and extra resources that come with our coverage.
54
• Apex
• Point of Service (POS)
• Preferred Provider
Organization (PPO)
• Expanded network (EX)
• Point of Service (POS)
• Preferred Provider
Organization (PPO)
• Expanded network (EX)
Based on where your company is headquartered,
you have the following plan options available:
Where is your company
headquartered?
FLEXIBILITY OF A LOCAL NETWORK WITH POS, AND APEX
Point of Service (POS)
• With a POS plan, your employees have in-network access to 99% of the
doctors in our eight-county service area. More than 700,000 members
are enrolled in our POS plans. They’re flexible and the most aordable
for those who get health care close to home.
Apex
• Apex is a high-performing network made up of primary care
providers (PCPs) and specialty groups who consistently
deliver high-quality care at lower costs.
• Members pay in-network cost shares for visiting PCP and specialty groups
that meet quality and eciency standards. All other providers
are considered out of network if visited for nonemergency care.
• Available to employers headquartered in Erie and Niagara counties.
• Prescription drugs are an important part of your employees’ coverage.
The list of drugs that a plan covers is called a formulary. These plans
oer the Essential Formulary, which has:
– A closed formulary, meaning the plan only pays for drugs on the
formulary; non-formulary drugs are not covered.
– Generics, brands, and specialty drugs are mixed between tiers.
– A $750 member cost share cap on Tier 3 drugs.
COVERAGE BEYOND WESTERN NEW YORK WITH PPO AND EX
Preferred Provider Organization (PPO)
• Our PPO network oers great local coverage and goes
the distance with employees who live or travel outside
our service area.
Expanded network (EX)
• The EX network oers great local coverage,
plus in-network access to doctors outside our region.
• It works best for those living or working in the eight-county service area,
but are receiving treatment or services elsewhere. Your employees must
choose a participating PCP in our service area who will coordinate
care in and outside the region.
NIAGARA
ORLEANS
GENESEE
ERIE
WYOMING
ALLEGANY
CATTARAUGUSCHAUTAUQUA
76
First quarter 2024 medical coverage
Platinum Classic Platinum Plus Gold Classic Gold 7100 Gold Complete Silver Classic
Silver 6100
(New for 2024)
Silver 7100 Silver 8100 Bronze Classic Bronze 8000
‡
Bronze Apex
Deductible
(single/family)
N/A N/A $600/$1,200 $1,600/$3,200 $3,500/$7,000 $2,000/$4,000 $2,000/$4,000 $2,750/$5,500 $3,500/$7,000 $5,000/$10,000 $7,500/$15,000 $8,500/$17,000
Coinsurance N/A N/A N/A N/A 0% FS N/A N/A N/A 40% FS 50% FS 0% FS 50% FS
Out-of-pocket
maximum
(single/family)
$3,000/$6,000 $5,000/$10,000 $5,500/$11,000 $6,250/$12,500 $3,500/$7,000 $9,450/$18,900 $7,500/$15,000 $7,500/$15,000 $7,500/$15,000 $9,100/$18,200 $7,500/$15,000 $9,100/$18,200
Deductible and
OOP max type
Embedded Embedded Embedded
True Family/
Embedded
True Family Embedded
True Family/
Embedded
True Family/
Embedded
True Family/
Embedded
Embedded Embedded Embedded
OON deductible
(single/family)
$5,000/$10,000 $5,000/$10,000 $5,000/$10,000 $5,000/$10,000 $5,000/$10,000 $5,000/$10,000 $5,000/$10,000 $5,000/$10,000 $5,000/$10,000 $10,000/$20,000 $10,000/$20,000 $10,000/$20,000
OON coinsurance 40% FS 50% FS 50% FS 50% FS 30% FS 50% FS 50% FS 50% FS 50% FS 50% FS 30% FS 50% FS
OON out-of-pocket
maximum
(single/family)
$10,000/$20,000 $10,000/$20,000 $10,000/$20,000 $10,000/$20,000 $10,000/$20,000 $10,000/$20,000 $10,000/$20,000 $10,000/$20,000 $10,000/$20,000 $20,000/$40,000 $20,000/$40,000 $20,000/$40,000
PCP/specialist $15/$35 $10/$30
$25/$40 after
deductible
$20/$40 after
deductible
0% after
deductible
$30/$65 after
deductible
$35/$65 after
deductible
$30/$50 after
deductible
40% after
deductible
$50/$75 after
deductible
0% after
deductible
50% after
deductible
DME and orthotics/
external prosthetics
10% 50%
20% after
deductible
50% after
deductible
0% after
deductible
30% after
deductible
50% after
deductible
50% after
deductible
40% after
deductible
50% after
deductible
0% after
deductible
50% after
deductible
Laboratory services $35 $15
$40 after
deductible
$40 after
deductible
0% after
deductible
$65 after
deductible
$65 after
deductible
$50 after
deductible
40% after
deductible
50% after
deductible
0% after
deductible
50% after
deductible
Diagnostic X-rays
and radiology
$35 $30
$40 after
deductible
$40 after
deductible
0% after
deductible
$65 after
deductible
$65 after
deductible
$50 after
deductible
40% after
deductible
$75 after
deductible
0% after
deductible
50% after
deductible
Advanced imaging $70 $60
$80 after
deductible
$80 after
deductible
0% after
deductible
$130 after
deductible
$130 after
deductible
$100 after
deductible
40% after
deductible
50% after
deductible
0% after
deductible
50% after
deductible
Telemedicine $0 $0
$0 not subject
to deductible
$0 after
deductible
0% after
deductible
$0 not subject
to deductible
$0 after
deductible
$0 after
deductible
$0 after
deductible
$0 not subject
to deductible
0% after
deductible
$0 not subject
to deductible
Diabetic equipment
and supplies
†
$15 $10
$25 after
deductible
$20 after
deductible
0% after
deductible
$30 after
deductible
$35 after
deductible
$30 after
deductible
40% after
deductible
$50 after
deductible
0% after
deductible
50% after
deductible
Inpatient hospital
(per admission)
$500 $500
$1,000 after
deductible
$500 after
deductible
0% after
deductible
$1,500 after
deductible
$1,000 after
deductible
$1,500 after
deductible
40% after
deductible
50% after
deductible
0% after
deductible
50% after
deductible
Outpatient facility $250 $250
$250 after
deductible
$250 after
deductible
0% after
deductible
$250 after
deductible
$250 after
deductible
$250 after
deductible
40% after
deductible
50% after
deductible
0% after
deductible
50% after
deductible
Emergency room
and ambulance
$100 $250
$150 after
deductible
$200 after
deductible
0% after
deductible
$500 after
deductible
$250 after
deductible
$500 after
deductible
40% after
deductible
50% after
deductible
0% after
deductible
50% after
deductible
Urgent care $55 $100
$60 after
deductible
$50 after
deductible
0% after
deductible
$70 after
deductible
$75 after
deductible
$75 after
deductible
40% after
deductible
50% after
deductible
0% after
deductible
50% after
deductible
Generic/formulary/
nonformulary
$10/$30/$60 $5/$30/50%
$10/$35/$80 not
subject to deductible
$5/$30/50%
after deductible
0%/0%/0%
after deductible
$15/$40/$100 not
subject to deductible
$15/$50/$100
after deductible
$10/$40/50%
after deductible
$10/$40/50%
after deductible
$10/$35/$70
after deductible
0%/0%/0%
after deductible
$10/50%/50%
after deductible
Preventive
enhanced drug list**
No No No Yes Yes No Yes Yes Yes No No No
Pediatric annual
exam (routine) and
vision equipment
$0 $0
$0 not subject to
deductible
$0 after
deductible
0% after
deductible
$0 not subject
to deductible
$0 after
deductible
$0 after
deductible
0% after
deductible
0% not subject
to deductible
0% after
deductible
0% not subject
to deductible
HSA-eligible Not eligible Not eligible Not eligible Eligible Eligible Not eligible Eligible Eligible Eligible Not eligible Eligible Not eligible
Creditable coverage Yes Yes Yes Yes Ye s Ye s Yes Yes Yes No Yes No
Away From
Home Care
Eligible
Eligible for
POS and Apex
Eligible Not eligible Not eligible Not eligible Not eligible Not eligible Not eligible Not eligible Not eligible Not eligible
Age 26 single coverage only*
PPO N/A N/A N/A N/A N/A N/A N/A $780.56 $729.55 N/A N/A N/A
EX N/A $863.87 N/A $724.83 N/A N/A $668.61 $636.96 $591.99 N/A $541.29 N/A
POS $841.61 $827.93 $743.81 $694.51 $673.36 $638.14 $640.58 $610.21 $567.06 $519.38 $521.14 N/A
Apex N/A $782.17 N/A $655.93 N/A N/A $598.68 $576.16 $535.33 N/A $486.77 $481.91
* Refer to page 8 for a complete list of rates.
** All plans include Aordable Care Act (ACA) preventive drug coverage.
† For plans with a deductible, insulin is subject to cost-sharing but capped at $100 for a 30-day supply.
‡ Out-of-network benefits displayed do not apply to the Bronze 8000EX option.
Highlighted items are changes for 2024
98
Dependent age 26 rates Dependent age 30 rates
Single
Subscriber
and spouse
Subscriber
and child(ren)
Family Single
Subscriber
and spouse
Subscriber
and child(ren)
Family
Platinum Classic $841.61 $1,683.22 $1,430.73 $2,398.58 Platinum Classic $845.61 $1,691.23 $1,437.54 $2,410
Platinum POS Plus $827.93 $1,655.86 $1,407.48 $2,359.60 Platinum POS Plus $831.87 $1,663.74 $1,414.18 $2,370.83
Platinum EX Plus $863.87 $1,727.75 $1,468.59 $2,462.04 Platinum EX Plus $867.98 $1,735.97 $1,475.57 $2,473.75
Platinum Apex Plus $782.17 $1,564.34 $1,329.69 $2,229.19 Platinum Apex Plus $785.90 $1,571.80 $1,336.03 $2,239.82
Gold Classic $743.81 $1,487.61 $1,264.47 $2,119.85 Gold Classic $747.36 $1,494.72 $1,270.51 $2,129.97
Gold POS 7100 $694.51 $1,389.03 $1,180.67 $1,979.36 Gold POS 7100 $697.84 $1,395.67 $1,186.32 $1,988.84
Gold 7100EX $724.83 $1,449.65 $1,232.20 $2,065.75 Gold 7100EX $728.29 $1,456.58 $1,238.09 $2,075.62
Gold Apex 7100 $655.93 $1,311.86 $1,115.08 $1,869.40 Gold Apex 7100 $659.07 $1,318.15 $1,120.43 $1,878.36
Gold Complete $673.36 $1,346.73 $1,144.72 $1,919.09 Gold Complete $676.59 $1,353.18 $1,150.20 $1,928.28
Silver Classic $638.14 $1,276.27 $1,084.83 $1,818.69 Silver Classic $641.20 $1,282.40 $1,090.04 $1,827.42
Silver POS 6100 $640.58 $1,281.16 $1,088.98 $1,825.65 Silver POS 6100 $643.65 $1,287.31 $1,094.21 $1,834.41
Silver 6100 EX $668.61 $1,337.23 $1,136.64 $1,905.55 Silver 6100 EX $671.82 $1,343.63 $1,142.09 $1,914.68
Silver Apex 6100 $598.68 $1,197.35 $1,017.75 $1,706.22 Silver Apex 6100 $601.56 $1,203.11 $1,022.64 $1,714.43
Silver PPO 7100 $780.56 $1,561.12 $1,326.95 $2,224.59 Silver PPO 7100 $784.28 $1,568.56 $1,333.28 $2,235.20
Silver POS 7100 $610.21 $1,220.42 $1,037.36 $1,739.10 Silver POS 7100 $613.15 $1,226.29 $1,042.35 $1,747.46
Silver 7100EX $636.96 $1,273.93 $1,082.84 $1,815.35 Silver 7100EX $640.02 $1,280.04 $1,088.03 $1,824.06
Silver Apex 7100 $576.16 $1,152.32 $979.47 $1,642.05 Silver Apex 7100 $578.93 $1,157.87 $984.19 $1,649.96
Silver PPO 8100 $729.55 $1,459.09 $1,240.23 $2,079.21 Silver PPO 8100 $733.03 $1,466.07 $1,246.16 $2,089.14
Silver POS 8100 $567.06 $1,134.12 $964 $1,616.12 Silver POS 8100 $569.79 $1,139.59 $968.65 $1,623.91
Silver 8100EX $591.99 $1,183.98 $1,006.38 $1,687.17 Silver 8100EX $594.84 $1,189.68 $1,011.22 $1,695.29
Silver Apex 8100 $535.33 $1,070.65 $910.06 $1,525.68 Silver Apex 8100 $537.91 $1,075.83 $914.45 $1,533.05
Bronze Classic $519.38 $1,038.77 $882.95 $1,480.24 Bronze Classic $521.90 $1,043.79 $887.22 $1,487.40
Bronze 8000EX $541.29 $1,082.58 $920.19 $1,542.67 Bronze 8000EX $543.90 $1,087.81 $924.64 $1,550.12
Bronze POS 8000 $521.14 $1,042.27 $885.93 $1,485.24 Bronze POS 8000 $523.66 $1,047.31 $890.22 $1,492.42
Bronze Apex 8000 $486.77 $973.54 $827.51 $1,387.30 Bronze Apex 8000 $489.13 $978.27 $831.53 $1,394.03
Bronze Apex $481.91 $963.82 $819.24 $1,373.44 Bronze Apex $484.25 $968.50 $823.22 $1,380.11
1110
Dental coverage
Dental plans have no participation requirements and can be added to your medical plan or
purchased separately. Groups can choose one dental plan to oer their employees.
Pediatric dental is included with all medical plans at no additional charge.
BCBSWNY
Blue Pediatric Dental Embedded in Medical
Medical Product
HSA Qualified
Medical Products
HSA Qualified Gold Complete
and Bronze 8000 Plans
Non-HSA Qualified
Medical Products
Annual Deductible
Follows In-Network
Medical Deductible
Follows In-Network
Medical Deductible
Not Subject to
Medical Deductible
Annual Out-of-Pocket Maximum
Follows In-Network Medical
Out-of-Pocket Maximum
Follows In-Network Medical
Out-of-Pocket Maximum
Follows In-Network Medical
Out-of-Pocket Maximum
Description of Service Member Pays Member Pays Member Pays
Oral Evaluations (Exams) $25 copay $25 copay $25 copay
Consultations $25 copay $25 copay $25 copay
Radiographs (Bitewings, Full mouth,
Occlusal and Periapical Films)
$25 copay $25 copay $25 copay
Prophylaxis (Cleanings) $25 copay $25 copay $25 copay
Fluoride Treatments $25 copay $25 copay $25 copay
Palliative Treatment (Emergency) $25 copay $25 copay $25 copay
Sealants $25 copay $25 copay $25 copay
Space Maintainers $25 copay $25 copay $25 copay
Repairs of Crowns, Inlays, Onlays,
Fixed Partial Dentures and Dentures
50% after deductible 0% after deductible 50%
Resin-Based Composite–Anterior (White Fillings) 50% after deductible 0% after deductible 50%
Resin-Based Composite–Posterior (White Filling) 50% after deductible 0% after deductible 50%
Amalgam Restorations 50% after deductible 0% after deductible 50%
Simple Extractions 50% after deductible 0% after deductible 50%
Surgical Extractions 50% after deductible 0% after deductible 50%
Complex Oral Surgery 50% after deductible 0% after deductible 50%
Endodontics (Root canals, etc.) 50% after deductible 0% after deductible 50%
General Anesthesia and/or
Nitrous Oxide and/or IV Sedation
50% after deductible 0% after deductible 50%
Nonsurgical Periodontics 50% after deductible 0% after deductible 50%
Periodontal Maintenance 50% after deductible 0% after deductible 50%
Surgical Periodontics 50% after deductible 0% after deductible 50%
Adjustments and Repairs of Prosthetics 50% after deductible 0% after deductible 50%
Crowns, Inlays, Onlays 50% after deductible 0% after deductible 50%
Prosthetics (Fixed Partial Dentures, Dentures) 50% after deductible 0% after deductible 50%
Implant Services Not covered Not covered Not covered
Medically Necessary Orthodontics 50% after deductible 0% after deductible 50%
Cosmetic Orthodontics Not covered Not covered Not covered
Blue Edge Dental F-2W* Blue Edge Dental F-3W* Blue Edge Dental F-3Wo*
Annual Deductible (Individual/Family) $50/$150 $50/$150 $50/$150
Annual Benefit Maximum Per Person $1,000 $1,500 $2,000
Network Elite Prime Western New York
Description of Service Member Pays Member Pays Member Pays
Oral Evaluations (Exams) Covered in full Covered in full Covered in full
Consultations Covered in full Covered in full Covered in full
Radiographs (Bitewings, Full mouth,
Occlusal and Periapical Films)
Covered in full Covered in full Covered in full
Prophylaxis (Cleanings) Covered in full Covered in full Covered in full
Fluoride Treatments Covered in full Covered in full Covered in full
Palliative Treatment (Emergency) Covered in full Covered in full Covered in full
Sealants Covered in full Covered in full Covered in full
Space Maintainers Covered in full Covered in full Covered in full
Repairs of Crowns, Inlays, Onlays,
Fixed Partial Dentures and Dentures
20% after deductible 20% after deductible 20% after deductible
Resin-Based Composite–Anterior
(White Fillings)
20% after deductible 20% after deductible 20% after deductible
Resin-Based Composite–Posterior
(White Filling)
20% after deductible 20% after deductible 20% after deductible
Amalgam Restorations 20% after deductible 20% after deductible 20% after deductible
Simple Extractions 20% after deductible 20% after deductible 20% after deductible
Surgical Extractions 20% after deductible 20% after deductible 20% after deductible
Complex Oral Surgery 20% after deductible 20% after deductible 20% after deductible
Endodontics (Root canals, etc.) 20% after deductible 20% after deductible 20% after deductible
General Anesthesia and/or
Nitrous Oxide and/or IV Sedation
20% after deductible 20% after deductible 20% after deductible
Nonsurgical Periodontics 20% after deductible 20% after deductible 20% after deductible
Periodontal Maintenance 20% after deductible 20% after deductible 20% after deductible
Surgical Periodontics 20% after deductible 20% after deductible 20% after deductible
Adjustments and Repairs of Prosthetics 20% after deductible 20% after deductible 20% after deductible
Crowns, Inlays, Onlays Not covered 50% after deductible 50% after deductible
Prosthetics (Fixed Partial Dentures, Dentures) Not covered 50% after deductible 50% after deductible
Implant Services Not covered Not covered Not covered
Medically Necessary Orthodontics Not covered Not covered
Covered;
see Cosmetic Orthodontics
Cosmetic Orthodontics Not covered Not covered
50% after deductible up to a
$1,000 lifetime maximum;
under age 19 only
Age 26 Rates Blue Edge Dental F-2W Blue Edge Dental F-3W Blue Edge Dental F-3Wo
Subscriber $19.61 $25.44 $27.61
Subscriber and Spouse/Domestic Partner $36.32 $47.98 $52.32
Subscriber and Child(ren) $44.58 $59.10 $69.06
Family $66.28 $88.38 $103.27
Age 30 Rates Blue Edge Dental F-2W Blue Edge Dental F-3W Blue Edge Dental F-3Wo
Subscriber $19.61 $25.44 $27.61
Subscriber and Spouse/Domestic Partner $36.32 $47.98 $52.32
Subscriber and Child(ren) $44.71 $59.29 $69.26
Family $66.49 $88.66 $103.58
* Smile for Health–Wellness® and the Pregnancy Benet are included with Blue Edge Dental plans, which oer enhanced benets for members with gum
disease who have chronic conditions or are pregnant.
Participating dentists accept the Allowed Amount as payment in full. Non-participating dentists may bill you for the dierence between their charge
and the Allowed Amount paid by the certicate. All services listed may be subject to exclusions and limitations. Blue Edge Dental does not include
New York State Essential Health Pediatric Dental benets. These plans are not considered qualied dental plans. Waiting periods do not apply to these plans.
Smile for Health–Wellness is built into any Blue Edge Dental plan that covers periodontics.
1312
BLUECARD
®
AND BLUE CROSS
BLUE SHIELD GLOBAL CORE PROGRAM
Coverage that goes
where your employees go.
Around town or coast to coast, your employees
get access to 1.8 million providers and 97%
of hospitals in the U.S. And they’re even
covered in 190 countries.*
WELL360 VIRTUAL HEALTH
Personalized care where and
when employees need it.
Your employees can get care from wherever
they are with 24/7 access to virtual urgent
care and scheduled therapy and psychiatry
appointments. In 2024, they’ll also have access
to virtual primary care providers, dermatology
services, and specialized women’s health clinics
for medical, therapy, and lactation consulting.
Beginning in 2024, Well360 Virtual Health will
be exclusively available through My Highmark,
under the Get Care section of your account.
BLUE DISTINCTION
®
See specialists who get results.
Only doctors who consistently deliver safe,
effective treatments make our Blue Distinction
list. When your employees use our Find a
Doctor tool, a special logo will appear by the
provider’s name.
DIABETES MANAGEMENT
POWERED BY ONDUO
Personalized support
to control diabetes.
Tools to help your employees track their
blood sugar and manage diabetes from
wherever they are.
BLUES ON CALL
Answers from a health pro, 24/7.
For medical concerns after hours, your employees
can get guidance at any time from a registered
nurse or a health coach.
$250 WELLNESS CARD
Redeemable for
gym memberships.
Consider it a little something extra
for the journey to good health.
$0 PREVENTIVE RX
On more than 600 brand-
name and generic drugs.
Includes enhanced coverage on all Gold and
Silver HSA-qualified plans to provide $0 drugs
not subject to the deductible. Eligible plans
include: Gold 7100, Gold Complete, Silver 7100,
Silver 6100, and Silver 8100 plans.
Non-HSA qualified plans include the Federal
ACA Preventive Drug List with over 350 covered
drugs at no additional cost to members.
Extra resources you
won’t find in other plans
* According to the Blue Cross Blue Shield Association, an association of Blue Cross and Blue Shield plans.
Available spending
accounts
Rehabilitation and habilitation,
outpatient (PT/OT/ST)
60 combined visits per plan year
Rehabilitation and habilitation,
inpatient (PT/OT/ST)
Unlimited
Home health care
40 visits per plan year
Hearing aids
Single purchase every three years
• Members must choose hearing aids from
John R. Oishei Children’s Hospital or
Beckes Optical and Hearing Aids
• Members are entitled to discounts
through TruHearing
®
Hospice
Unlimited, five visits per plan year
for family bereavement
Substance abuse, outpatient
Unlimited, 20 visits per plan year for
family counseling
Skilled nursing facility
Unlimited
HEALTH SAVINGS ACCOUNT HSA
FLEXIBLE SPENDING ACCOUNT FSA
TRANSIT EXPENSE ADMINISTRATION TEA
Worry-free administration
• Turnkey implementation and support
• Resources to make it easy to update employees on key benefit details
• Real-time reporting with rich data insights
A streamlined employee experience
• View balances, pay expenses, see recent transactions, and more — right on their phones
• Real-time text or email alerts to easily manage their account
• Support when they need it
Annual benefit limits
Questions?
Contact your broker or
Highmark Blue Cross Blue Shield
client manager.
1514
HEALTH COACHES
Personalized support for
health goals.
Looking to lose weight? Quit smoking?
Be more active? A wellness coach can create
a personalized plan for your employees, right
over the phone, on their schedule. Sessions are
free and confidential.
BLUE365
Discounts to help your
employees stay healthy
and active.
From workout gear to personal wellness to
healthy meal services, we’ll take a little off
the top while they’re taking a little off their
middle. Member-only deals are at
blue365deals.com/bcbswny.
VIRTUAL PHYSICAL CARE PROGRAM
POWERED BY SWORD
Virtual physical care —
anytime and anywhere you
happen to be.
Sword puts technology and the expertise of
a physical therapist at your fingertips to help
you overcome joint and muscle pain.
MENTAL WELLBEING
Give your members care that
meets them where they are.
Mental Well-Being is a solution that provides
mental health support tailored to each
individual member. And it’s available on
our app and website.
Endless support to help your employees
on their journey to better health
The fundamentals
of coverage
MEMBER SERVICE
Total support, day or night.
Whether it’s 24/7 answers from registered
nurses, a diagnosis or prescription via video
visit, or just some help booking their doctor
visits, when they need us, we’re there.
MEMBER APP AND WEBSITE
My Highmark helps your
employees take care of
their health.
It’s the one-stop digital experience that
allows members to easily access their
benefit coverage and care all in one place.
Visit myhighmark.com to learn more.
CARE COST ESTIMATOR
Employees can know what
they’ll owe for care.
Before making an appointment for a test, scan,
or procedure, your employees can use our Care
Cost Estimator to estimate their bill.
Any health plan you
choose should include
resources that help your
employees manage their
health. Ours make the
process seamless.
1716
1 Primary care cost-sharing amounts
also apply to outpatient: mental health,
behavioral health, substance abuse,
chiropractic, physical therapy, speech
therapy, and occupational therapy
oce visits.
2 Rx information displayed: Retail up to
31-day supply. NOTE: Member’s maximum
coinsurance payment for a Tier 3 Rx is $750
on Apex plans only.
3 Integrated Rx plans include all medical and
prescription claims accumulating toward
one overall deductible.
4 Embedded plans: In this approach, an
individual family member can be eligible
for payment of benefits upon meeting
the individual deductible amount (even
if the rest of the family has not met the
family deductible amount). Additionally, an
individual family member’s out-of-pocket
(OOP) maximum will be the same as that of
a member purchasing individual coverage
for the specified health plan.
This is not a contract. This benefits summary presents plan highlights only. Contract limitations and exclusions apply. Please refer to the member contract
for complete information. To determine the availability of services under your health plan, please review your contract for details on benefits, conditions,
and exclusions or call the number on the back of your member ID card. Information above presents in-network plan highlights only. PPO and POS plans also
provide benefits for many out-of-network services, generally with higher member cost sharing. Please see plan materials for information.
5 A health savings account (HSA) is available
to employees. Employer contributions in
amounts that exceed annual federally
mandated maximum(s) may result in
actuarial value changes that may impact
compliance as a qualified health plan.
6 Non-embedded plans: In this approach, the
entire family deductible must be met before
any family member is eligible for payment
of benefits. Additionally, the entire family
out-of-pocket (maximum) must be met
before the plan begins paying 100%. One
family member may satisfy the entire family
deductible and/or OOP.
Important plan details
Out-of-pocket maximum calculation includes deductible, copayment, and coinsurance.
Notes
1918
Highmark Western and Northeastern New York Inc. d/b/a Highmark
Blue Cross Blue Shield is an independent licensee of the Blue Cross
Blue Shield Association.
All references to “Highmark” in this document are references to the
Highmark company that is providing the member’s health benefits or
health benefit administration and/or to one or more of its affiliated
Blue companies.
Sword Health, Inc. does not provide health care services. Sword Health,
Inc. is an independent company that provides wellness services for your
health plan. Sword Health Professionals provides its services through a
group of independently owned professional practices consisting of Sword
Health Care Providers, P.A., Sword Health Care Providers of NJ, P.C., and
Sword Health Care Physical Therapy Providers of CA, P.C. The Sword virtual
physical care program is made available with support from Sword Health.
Amwell is an independent company that provide telemedicine services.
Amwell does not provide Blue Cross and/or Blue Shield products or services
and it is solely responsible for its telemedicine services.
United Concordia provides the provider network for Blue Edge Dental and
is a separate company that administers dental benefits.
Onduo is a separate company that provides a virtual diabetes care program
for Highmark members.
Smile for Health – Wellness is a registered mark of United Concordia, Inc.
Blue Cross Blue Shield Global® Core is a registered mark of the Blue Cross
Blue Shield Association.
Blues On Call is a service mark of the Blue Cross Blue Shield Association.
Blue365 is a registered mark of the Blue Cross Blue Shield Association.
Blue Distinction® Specialty Care is a registered mark of the Blue Cross Blue
Shield Association. Blue Distinction Centers (BDC) met overall quality
measures, developed with input from the medical community. A Local Blue
Plan may require additional criteria for providers located in its own service
area; for details, contact your Local Blue Plan. Blue Distinction Centers+
(BDC+) also met cost measures that address consumers’ need for affordable
health care. Each provider’s cost of care is evaluated using data from its
Local Blue Plan. Providers in CA, ID, NY, PA, and WA may lie in two Local
Blue Plans’ areas, resulting in two evaluations for cost of care; and their own
Local Blue Plans decide whether one or both cost of care evaluation(s) must
meet BDC+ national criteria. Total Care (“Total Care”) providers have met
national criteria based on provider commitment to deliver value-based care
to a population of Blue members. Total Care+ providers also met a goal
of delivering quality care at a lower total cost relative to other providers
in their area. Program details are displayed on www.bcbs.com. Individual
outcomes may vary. For details on a provider’s in-network status or your
own policy’s coverage, contact your Local Blue Plan and ask your provider
before making an appointment. Neither Blue Cross and Blue Shield
Association nor any Blue Plans are responsible for non-covered charges or
other losses or damages resulting from Blue Distinction, Total Care, or other
provider finder information or care received from Blue Distinction, Total
Care, or other providers.
TruHearing® is a registered trademark of TruHearing, Inc. TruHearing is an
independent company that administers the routine hearing exam and
hearing-aid benefit.
Notice of Nondiscrimination
The plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color,
national origin, age, disability, or sex. The plan does not exclude people or treat them differently because of
race, color, national origin, age, disability, or sex.
The plan provides:
• Free aids and services to people with disabilities to communicate effectively with us, such as:
• Qualified sign language interpreters
• Written information in other formats (large print, audio, accessible electronic formats, other)
• Free language services to people whose primary language is not English, such as:
• Qualified interpreters
• Information written in other languages
If you need these services, please call the customer service number on the back of your member ID card or
contact the Civil Rights Coordinator.
If you believe that the plan has failed to provide these services or discriminated in another way on the basis of
race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, PO Box
22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 (TTY 711), Fax: 1-412-544-2475, email:
CivilRightsCoordinator@highmarkhealth.org
You can file a grievance in person or by mail, fax, or email. You can also file a civil rights complaint with the US
Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil
Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at US
Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building,
Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
For assistance in English, call the customer service number listed on your member ID card.
Para obtener asistencia en español, llame al servicio de atención al cliente al número que aparece en su
tarjeta de identificación.
請撥打您 ID 卡上的客服號碼以尋求中文協助。
Обратитесь по номеру телефона обслуживания клиентов, указанному на Вашей
идентификационной карточке, для помощи на русском языке.
פאר ה י לף אי ן א י ד יש, ר ו פט די קאסט ו מער סער ו ו י ס או יפן נ ו מער ו ו אס שט י י ט או יף א י י ער ID קארטל .
,
한국어로 도움을 받고 싶으시면 ID 카드에 있는 고객 서비스 전화번호로 문의해 주십시오.
Aby uzyskać pomoc w języku polskim, należy zadzwonić do działu obsługi klienta pod numer podany
na identyfikatorze.
اردو ﻣﯾں ﻣدد ﮐﮯ ﻟﯾﮯ، ﮐﺳ ﭨ ﻣر ﺳ ر وس آپ ﮐﮯ ﺷﻧ ﺎﺧﺗﯽ ﮐ ﺎرڈ ﭘر د رج ﮐرد ه ﻧﻣﺑر ﭘر ﮐ ﺎل ﮐر ﯾں
Pour une assistance en français, composez le numéro de téléphone du service à la clientèle figurant
sur votre carte d’identification.
ا ردو زﺑ ﺎن ﻣﯾں ﻣدد ﮐﮯ ﻟ ﺋﮯ، ﮐﺳﭨ ﻣر ﺳ ر وس ﮐو ا ﭘ ﻧﮯ آﺋﯽ ڈی ﮐ ﺎ رڈ ﭘر د رج ﻧﻣﺑر ﭘر ﮐﺎل ﮐر ﯾں۔
Para sa tulong sa Tagalog, tumawag sa numero ng serbisyo sa customer na nasa inyong ID card.
Για βοήθεια στα ελληνικά, καλέστε το τμήμα εξυπηρέτησης πελατών στον αριθμό που
αναφέρεται στην ταυτότητά σας.
Për ndihmë në gjuhën shqipe, merrni në telefon shërbimin klientor në numrin e renditur në
kartën tuaj të identitetit.
Rele nimewo sèvis kliyantèl ki nan kat ID ou pou jwenn èd nan Kreyòl Ayisyen.
Per assistenza in italiano chiamate il numero del servizio clienti riportato nella vostra scheda identificativa.
Diné k´ehjí yá´áti´bee shíká adoowot nohsingo naaltsoos nihaa halne´go nidaahtinígíí bine´déé´
Customer Service bibéésh bee hane´é biká'ígíí bich´j´dahodootnih.
11699_09_21
There’s a whole lot of legalese around these plans.
We put it all in one place for you.
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10/23 Z MX2988322
