Highmark Inc. - my Blue Access PPO Premier Gold 0
Deductible
Separate Drug Deductible
Out-of-pocket max
Primary Care Visit
$15 Copay
50% Coinsurance after deductible
Specialist Visit
$15 Copay
50% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
$15 Copay
50% Coinsurance after deductible
Preventive Care/Screening/Immunization
No Charge
100% Coinsurance
Laboratory Outpatient and Professional Services
$30 Copay
50% Coinsurance after deductible
X-rays and Diagnostic Imaging
$30 Copay
50% Coinsurance after deductible
Imaging (CT/PET scans, MRIs)
$250 Copay
50% Coinsurance after deductible
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 Facility Fee
$175 Copay
50% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
$175 Copay
50% Coinsurance after deductible
Emergency Room Services
$250 Copay
$250 Copay
Emergency Transportation/Ambulance
20% Coinsurance
20% Coinsurance
Urgent Care
$30 Copay
$30 Copay
Inpatient Hospital Services
$375 Copay per stay
50% Coinsurance after deductible
Inpatient Physician and Surgical Services
20% Coinsurance
50% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
$15 Copay
50% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
$375 Copay per stay
50% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
$15 Copay
50% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
$375 Copay per stay
50% Coinsurance after deductible
Prenatal and postnatal care
20% Coinsurance
50% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
$375 Copay
50% Coinsurance after deductible
Home Healthcare Services
20% Coinsurance
50% Coinsurance after deductible
Outpatient Rehabilitation Services
$40 Copay
50% Coinsurance after deductible
Habilitation Services
$40 Copay
50% Coinsurance after deductible
Skilled Nursing Facility
$375 Copay per stay
50% Coinsurance after deductible
Durable Medical Equipment
20% Coinsurance
50% Coinsurance after deductible
Hospice Services
20% Coinsurance
50% Coinsurance after deductible
Chiropractic Care
$40 Copay
50% Coinsurance after deductible
Acupuncture
Not covered
Not covered
Rehabilitative Speech Therapy
$40 Copay
50% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy
$40 Copay
50% Coinsurance after deductible
Well Baby Visits and Care
No Charge
100% Coinsurance
Allergy Testing
$30 Copay
50% Coinsurance after deductible
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
20% Coinsurance
50% Coinsurance after deductible
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