INDIVIDUAL COMPREHENSIVE MAJOR MEDICAL EXCLUSIVE PROVIDER SUBSCRIPTION AGREEMENT IDENTIFIED AS MY CONNECT BLUE EPO,Individual Comprehensive Major Medical Exclusive Provider Subscription Agreement • October 28th, 2016
DESCRIPTION OF COVERAGE: This Agreement sets forth a comprehensive program of inpatient and outpatient facility, professional and ancillary provider benefits. Cost-sharing options are available such as deductible, copayments and/or coinsurance. Except for emergency care services, benefits are only provided for services performed by network providers as defined in this Agreement. If covered services are not available from a network provider, preauthorization from the plan must be obtained to receive services from an out-of-network provider. Benefits for covered services are based on the network level at which the provider rendering such services is participating. Network providers can participate at the standard value, enhanced value or preferred value levels and benefits are increased at each level, respectively. Network services are limited to the Community Blue Network, the PremierBlue Shield Preferred Professional Provider Network, the Highmark Blue Shield Participating Facility Pro
