Highmark Inc. - my Direct Blue Lehigh Valley EPO Extra Savings Silver 100 + Adult Dental and Vision
Deductible
Separate Drug Deductible
Out-of-pocket max
Primary Care Visit
$5 Copay
100% Coinsurance
Specialist Visit
$5 Copay
100% Coinsurance
Other Practitioner Office Visit (Nurse, Physician Assistant)
$5 Copay
100% Coinsurance
Preventive Care/Screening/Immunization
No Charge
100% Coinsurance
Laboratory Outpatient and Professional Services
$15 Copay
100% Coinsurance
X-rays and Diagnostic Imaging
$15 Copay
100% Coinsurance
Imaging (CT/PET scans, MRIs)
10% Coinsurance after deductible
100% Coinsurance
Generic Drugs
$0 Copay
100% Coinsurance
Preferred Brand Drugs
$5 Copay
100% Coinsurance
Non-Preferred Brand Drugs
$15 Copay
100% Coinsurance
Specialty drugs
50% Coinsurance
100% Coinsurance
Outpatient Facility Fee
$55 Copay after deductible
100% Coinsurance
Outpatient Surgery Physician/Surgical Services
$55 Copay after deductible
100% Coinsurance
Emergency Room Services
$100 Copay after deductible
$100 Copay after deductible
Emergency Transportation/Ambulance
10% Coinsurance after deductible
10% Coinsurance after deductible
Urgent Care
$10 Copay
$10 Copay
Inpatient Hospital Services
10% Coinsurance after deductible
100% Coinsurance
Inpatient Physician and Surgical Services
10% Coinsurance after deductible
100% Coinsurance
Mental/Behavioral Health Outpatient Services
$5 Copay
100% Coinsurance
Mental/Behavioral Health Inpatient Services
10% Coinsurance after deductible
100% Coinsurance
Substance Abuse Disorder Outpatient Services
$5 Copay
100% Coinsurance
Substance Abuse Disorder Inpatient Services
10% Coinsurance after deductible
100% Coinsurance
Prenatal and postnatal care
10% Coinsurance after deductible
100% Coinsurance
Delivery and All Inpatient Services for Maternity Care
10% Coinsurance after deductible
100% Coinsurance
Home Healthcare Services
10% Coinsurance after deductible
100% Coinsurance
Outpatient Rehabilitation Services
$5 Copay
100% Coinsurance
Habilitation Services
$5 Copay
100% Coinsurance
Skilled Nursing Facility
10% Coinsurance after deductible
100% Coinsurance
Durable Medical Equipment
10% Coinsurance after deductible
100% Coinsurance
Hospice Services
10% Coinsurance after deductible
100% Coinsurance
Chiropractic Care
$5 Copay
100% Coinsurance
Acupuncture
Not covered
Not covered
Rehabilitative Speech Therapy
$5 Copay
100% Coinsurance
Rehabilitative Occupational and Rehabilitative Physical Therapy
$5 Copay
100% Coinsurance
Well Baby Visits and Care
No Charge
100% Coinsurance
Allergy Testing
$15 Copay
100% Coinsurance
Diabetes Education
No Charge
100% Coinsurance
Nutritional Counseling
No Charge
100% Coinsurance
Eye Exam for Children
No Charge
100% Coinsurance
Eye Glasses for Children
No Charge
100% Coinsurance
Accidental Dental
10% Coinsurance after deductible
100% Coinsurance
Basic Dental Care (Adult)
50% Coinsurance after deductible
100% Coinsurance
Basic Dental Care (Child)
50% Coinsurance
100% Coinsurance
Dental Check Up (Child)
No Charge
100% Coinsurance
Major Dental Care (Adult)
Not covered
Not covered
Major Dental Care (Child)
50% Coinsurance
100% Coinsurance
Orthodontia (Adult)
Not covered
Not covered
Orthodontia (Child)
50% Coinsurance
100% Coinsurance
Routine Dental Services (Adult)
No Charge after deductible
100% Coinsurance