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Highmark Blue Cross Blue Shield   -   Together Blue EPO Extra Savings Silver 0

Deductible & Out-of-Pocket
In Network
Out-of-Network
Deductible
Out-of-pocket max
Doctor Visit
In Network
Out-of-Network
Additional Information
Primary Care Visit
$1 Copay
100% Coinsurance
Specialist Visit
$1 Copay
100% Coinsurance
Other Practitioner Office Visit (Nurse, Physician Assistant)
$1 Copay
100% Coinsurance
Preventive Care/Screening/Immunization
No Charge
100% Coinsurance
Tests
In Network
Out-of-Network
Additional Information
Laboratory Outpatient and Professional Services
$5 Copay
100% Coinsurance
X-rays and Diagnostic Imaging
$5 Copay
100% Coinsurance
Imaging (CT/PET scans, MRIs)
$50 Copay
100% Coinsurance
Drugs
In Network
Out-of-Network
Additional Information
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
In Network
Out-of-Network
Additional Information
Outpatient Facility Fee
$50 Copay
100% Coinsurance
Outpatient Surgery Physician/Surgical Services
$50 Copay
100% Coinsurance
Urgent Care
In Network
Out-of-Network
Additional Information
Emergency Room Services
$75 Copay
$75 Copay
Emergency Transportation/Ambulance
10% Coinsurance
10% Coinsurance
Urgent Care
$5 Copay
$5 Copay
Hospital
In Network
Out-of-Network
Additional Information
Inpatient Hospital Services
$100 Copay per stay
100% Coinsurance
Inpatient Physician and Surgical Services
10% Coinsurance
100% Coinsurance
Mental / Behavioral Health
In Network
Out-of-Network
Additional Information
Mental/Behavioral Health Outpatient Services
$1 Copay
100% Coinsurance
Mental/Behavioral Health Inpatient Services
$100 Copay per stay
100% Coinsurance
Substance Abuse Disorder Outpatient Services
$1 Copay
100% Coinsurance
Substance Abuse Disorder Inpatient Services
$100 Copay per stay
100% Coinsurance
Pregnancy
In Network
Out-of-Network
Additional Information
Prenatal and postnatal care
10% Coinsurance
100% Coinsurance
Delivery and All Inpatient Services for Maternity Care
$100 Copay
100% Coinsurance
Other Special Needs
In Network
Out-of-Network
Additional Information
Home Healthcare Services
10% Coinsurance
100% Coinsurance
Outpatient Rehabilitation Services
$5 Copay
100% Coinsurance
Habilitation Services
$5 Copay
100% Coinsurance
Skilled Nursing Facility
$100 Copay per stay
100% Coinsurance
Durable Medical Equipment
10% Coinsurance
100% Coinsurance
Hospice Services
10% Coinsurance
100% Coinsurance
Chiropractic Care
$1 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
$5 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 after deductible
100% Coinsurance
Dental
In Network
Out-of-Network
Additional Information
Accidental Dental
10% Coinsurance
100% Coinsurance
Basic Dental Care (Adult)
Not covered
Not covered
Basic Dental Care (Child)
10% Coinsurance
100% Coinsurance
Dental Check Up (Child)
No Charge
100% Coinsurance
Major Dental Care (Adult)
Not covered
Not covered
Major Dental Care (Child)
10% Coinsurance
100% Coinsurance
Orthodontia (Adult)
Not covered
Not covered
Orthodontia (Child)
10% Coinsurance
100% Coinsurance
Routine Dental Services (Adult)
Not covered
Not covered

Carrier Notices

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