Third-Party Administrator: Highmark BCBS WV Plan

Coverage:

  • Begins the first day of benefit eligible employment
  • Dependent children covered to age 26

Deductibles

  • Annual, calendar year deductibles
  • Separate deductibles for each Tier
    • Tier I: $1,000 individual / $2,000 family
    • Tier II: $1,500 individual / $3,000 family
    • Tier III: $2,500 individual / $5,000 family

Tier I Providers:
•    Ruby Memorial
•    Physician Office Center
•    Chestnut Ridge Center
•    Family Medicine
•    Mary Babb Randolph Cancer Center
•    WVU Cheat Lake Physicians
•    WVU Urgent Care
•    HealthWorks
•    WVUH-East
•    Camden Clark
•    UHA
•    Potomac Valley Hospital
•    UHC

Coverage is dependent on where services are rendered in our three-tier structure (see below).

Tier I:
WVUHS/UHA Network
Tier II:
Other PPO Network Professional Providers
Tier III:
Non-Network and PPO Network Facilities and Non-Network Professional Providers
Inpatient & Outpatient Procedures After Deductible 80% After Deductible
80% – Ancillary Services (x-rays, labs)
(of Professional Allowance)
After Deductible
60% (of Professional Allowance)
Office Visit After Deductible
$25 co-pay –
Primary Care Physician
$40 co-pay –
Specialty Care Physician
After Deductible
$35 co-pay –
Primary Care Physician
$60 co-pay –
Specialty Care Physician
After Deductible 60%
Emergency
Room
$200 co-pay if true emergency (co-pay waived if admitted, unless for

observation)

$200 co-pay if true emergency (co-pay waived if admitted, unless for

observation)

$200 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% co-insurance

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