Third Party Administrator: Highmark BCBS WV

Coverage:
The coverage is effective the first day of month following your date of benefit eligible employment.

  • Dependent children covered to age 26
  • Three Tiers of coverage
  • Premiums paid bi-weekly (per pay)
  • Rates available in Ultimate

Deductibles

  • Annual, calendar year deductibles
    • Single: one individual meets deductible
    • Family: one individual must meet the single deductible and family members can make up the balance
  • Separate deductibles for each Tier
    • Tier I: $150 individual / $300 family
    • Tier II: $300 individual / $500 family
    • Tier III: $500 individual / $1,000 family

Tier I Providers

  • Ruby Memorial
  • Physician Office Center
  • Chestnut Ridge Center
  • Family Medicine
  • Mary Babb Randolph Cancer Center
  • Cheat Lake Physicians
  • WVU Urgent Care
  • HealthWorks
  • WVUH East
  • CamdenClark
  • UHA
  • Potomac Valley Hospital
  • UHC

All Three Tiers

Tier I
WVUHS/UHA Network
Tier II
Other PPO Network
Professional and Facility Providers
Tier III
Non-Network and PPO Network Competitor Facilities and Non-Network
Professional Providers
Inpatient and Outpatient Procedures
After Deductible: 100% After Deductible:
80% – Ancillary Services
such as: x-ray, labs, etc.
(of allowed amount)
After Deductible: 60%
(of allowed amount)
Office Visit After Deductible:
$15 co-pay
Primary Care Physician
$35 co-pay
Specialty Care Physician
After Deductible:
$25 co-pay
Primary Care Physician
$50 co-pay
Specialty Care Physician
After Deductible: 60%
Out of Pocket Maximum Single: $1,500
Family: $3,000
Single: $3,000
Family: $6,000
Single: $5,000
Family: $10,000
Emergency Room $100 co-pay if true emergency (co-pay waived if admitted, unless for observation) $100 co-pay if true emergency (co-pay waived if admitted, unless for observation) $100 co-pay if true emergency (co-pay waived if admitted, unless for observation)
Urgent Care After Deductible:
$25 co-pay
After Deductible:
$50 co-pay
After Deductible: 60%

Coverage is dependent upon where services are rendered in the three Tier chart above

Emergency services: Must be true emergency for coverage in this plan

Preventative Services: Tier I and Tier II only, (no Tier III coverage for these services)

  • One per calendar year
  • No deductible or co-pay for these visits
  • Covers annual pap smears, mammograms, routine exams, prostate screenings, well child visits

Specialist Services: Referrals not required

Prior Authorization: Some tests and procedures require a pre-certification before services are rendered

  • MRI, CT scan, etc.

Other Important Things to Note:

  • Once you enroll in Medical Insurance and receive your ID cards, there are many self-service options on Highmark’s website: highmarkbcbswv.com.

You can:

  • Look up physicians in the Highmark Network
  • Check claims status
  • Elect to receive your Explanation of Benefits (EOBs) online
  • Access a wealth of information on health and wellness topics
  • Request additional insurance cards

**For detailed information regarding your benefit coverage, please visit the HR website on connect.