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Highmark Inc.   -   my Direct Blue EPO Premier Gold 0

Deductible & Out-of-Pocket
In Network
Out-of-Network
Deductible
Separate Drug Deductible
Out-of-pocket max
Doctor Visit
In Network
Out-of-Network
Additional Information
Primary Care Visit
$15 Copay
100% Coinsurance
Specialist Visit
$15 Copay
100% Coinsurance
Other Practitioner Office Visit (Nurse, Physician Assistant)
$15 Copay
100% Coinsurance
Preventive Care/Screening/Immunization
No Charge
100% Coinsurance
Tests
In Network
Out-of-Network
Additional Information
Laboratory Outpatient and Professional Services
$30 Copay
100% Coinsurance
X-rays and Diagnostic Imaging
$30 Copay
100% Coinsurance
Imaging (CT/PET scans, MRIs)
$250 Copay
100% Coinsurance
Drugs
In Network
Out-of-Network
Additional Information
Generic Drugs
$0 Copay
100% Coinsurance
Preferred Brand Drugs
$25 Copay
100% Coinsurance
Non-Preferred Brand Drugs
$75 Copay
100% Coinsurance
Specialty drugs
50% Coinsurance
100% Coinsurance
Outpatient
In Network
Out-of-Network
Additional Information
Outpatient Facility Fee
$175 Copay
100% Coinsurance
Outpatient Surgery Physician/Surgical Services
$175 Copay
100% Coinsurance
Urgent Care
In Network
Out-of-Network
Additional Information
Emergency Room Services
$250 Copay
$250 Copay
Emergency Transportation/Ambulance
20% Coinsurance
20% Coinsurance
Urgent Care
$30 Copay
$30 Copay
Hospital
In Network
Out-of-Network
Additional Information
Inpatient Hospital Services
$375 Copay per stay
100% Coinsurance
Inpatient Physician and Surgical Services
20% Coinsurance
100% Coinsurance
Mental / Behavioral Health
In Network
Out-of-Network
Additional Information
Mental/Behavioral Health Outpatient Services
$15 Copay
100% Coinsurance
Mental/Behavioral Health Inpatient Services
$375 Copay per stay
100% Coinsurance
Substance Abuse Disorder Outpatient Services
$15 Copay
100% Coinsurance
Substance Abuse Disorder Inpatient Services
$375 Copay per stay
100% Coinsurance
Pregnancy
In Network
Out-of-Network
Additional Information
Prenatal and postnatal care
20% Coinsurance
100% Coinsurance
Delivery and All Inpatient Services for Maternity Care
$375 Copay
100% Coinsurance
Other Special Needs
In Network
Out-of-Network
Additional Information
Home Healthcare Services
20% Coinsurance
100% Coinsurance
Outpatient Rehabilitation Services
$40 Copay
100% Coinsurance
Habilitation Services
$40 Copay
100% Coinsurance
Skilled Nursing Facility
$375 Copay per stay
100% Coinsurance
Durable Medical Equipment
20% Coinsurance
100% Coinsurance
Hospice Services
20% Coinsurance
100% Coinsurance
Chiropractic Care
$40 Copay
100% Coinsurance
Acupuncture
Not covered
Not covered
Rehabilitative Speech Therapy
$40 Copay
100% Coinsurance
Rehabilitative Occupational and Rehabilitative Physical Therapy
$40 Copay
100% Coinsurance
Well Baby Visits and Care
No Charge
100% Coinsurance
Allergy Testing
$30 Copay
100% Coinsurance
Diabetes Education
No Charge
100% Coinsurance
Nutritional Counseling
No Charge
100% Coinsurance
Children's Vision
In Network
Out-of-Network
Additional Information
Eye Exam for Children
No Charge
100% Coinsurance
Eye Glasses for Children
No Charge
100% Coinsurance
Dental
In Network
Out-of-Network
Additional Information
Accidental Dental
20% Coinsurance
100% Coinsurance
Basic Dental Care (Adult)
Not covered
Not covered
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)
Not covered
Not covered

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