my Blue Access WV PPO Premier Gold 0
Highmark Blue Cross Blue Shield West Virginia
Plan overview
Medical deductible
Individual: $0
Family: $0
Per Person: $0
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $7000
Family: $14000
Per Person: $7000
Office visit
Primary Doctor
CoPay: $15.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Specialist
CoPay: $15.00
CoInsurance: Not Applicable
Covered: Covered
Prescription drug information
Preferred brand drugs
CoPay: $25.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
Non preferred brand drugs
CoPay: $75.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Your Prescription Drug benefits may include a Formulary ... which is a list of Brand Name Prescription Drugs that are preferred by your Plan. We may remind your Physician or Professional Other Provider when a Formulary medication is available for a medication that is not on your Formulary. This may result in a change in your Prescription. However, your Physician or Professional Other Provider will always make the final decision on your medication.
Generic drugs
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
Specialty drugs
CoPay: Not Applicable
CoInsurance: 50.00%
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
Inpatient coverage
Hospital services
CoPay: $525.00 Copay per Stay
CoInsurance: Not Applicable
Covered: Covered
Inpatient services
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Emergency and urgent care
Emergency room
CoPay: $350.00
CoInsurance: Not Applicable
Covered: Covered
Urgent care facility
CoPay: $30.00
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: $525.00
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
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).