Highmark Blue Cross Blue Shield West Virginia

my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $7,400.00 Family: $14800 Per Person: $7400
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,400.00 Family: $14800 Per Person: $7400

Office Visit

Primary Doctor	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Select drugs are covered at a $0 copay. Deductible does not apply. Please visit: https://highmark.link/6th6 for a complete listing.
Non Preferred Brand Drugs	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Select drugs are covered at a $0 copay. Deductible does not apply. Please visit: https://highmark.link/6th6 for a complete listing.
Generic Drugs	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Select drugs are covered at a $0 copay. Deductible does not apply. Please visit: https://highmark.link/6th6 for a complete listing.
Specialty Drugs	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: No Charge 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 use disorder.

Maternity

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