Highmark Blue Cross Blue Shield Delaware

my Blue Access PPO Gold 1700 HSA

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $1,700.00 Family: $3400 Per Person: $3400
Combined Medical and Drug Out of Pocket Maximum	Individual: $5,700.00 Family: $11400 Per Person: $5700

Office Visit

Primary Doctor	CoPay: $20.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $20.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $30.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $150.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Generic Drugs	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: $450.00 Copay per Stay after deductible CoInsurance: Not Applicable Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: No Charge Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $175.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $40.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: The copayment, if any, does not apply to urgent care services prescribed for the treatment of mental illness or substance abuse.

Maternity

Labor and Delivery Hospital Stay	CoPay: $450.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: No Charge Covered: Covered

Vision

Routine Eye Exams for Children

CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year

Major Dental Care

Routine Dental Checkups for Children	CoPay: Not Applicable CoInsurance: No Charge Covered: Covered Limit Quantity: 1 Limit Unit : Exam(s) per 6 Months
Routine Dental Checkups for Adults	Covered: Not Covered