Together Blue EPO Gold 1700 HSA
Highmark Blue Cross Blue Shield
Plan overview
Medical deductible
Individual: $1700
Family: $3400
Per Person: $3400
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $7500
Family: $15000
Per Person: $7500
Office visit
Primary Doctor
CoPay:
CoInsurance:
Covered:
Benefit Explanation:
Specialist
CoPay:
CoInsurance:
Covered:
Prescription drug information
Preferred brand drugs
CoPay:
CoInsurance:
Covered:
Limit Quantity:
Limit Unit:
Benefit Explanation:
Non preferred brand drugs
CoPay:
CoInsurance:
Covered:
Limit Quantity:
Limit Unit:
Benefit Explanation:
Generic drugs
CoPay:
CoInsurance:
Covered:
Limit Quantity:
Limit Unit:
Benefit Explanation:
Specialty drugs
CoPay:
CoInsurance:
Covered:
Limit Quantity:
Limit Unit:
Benefit Explanation:
Inpatient coverage
Hospital services
CoPay:
CoInsurance:
Covered:
Inpatient services
CoPay:
CoInsurance:
Covered:
Emergency and urgent care
Emergency room
CoPay:
CoInsurance:
Covered:
Urgent care facility
CoPay:
CoInsurance:
Covered:
Benefit Explanation:
Maternity
Labor and delivery hospital stay
CoPay:
CoInsurance:
Covered:
Pre and Postnatal office visit
CoPay:
CoInsurance:
Covered:
Vision
Routine Eye Exams for Children
CoPay:
CoInsurance:
Covered:
Limit Quantity:
Limit Unit:
Major dental care
Routine dental checkups for children
CoPay:
CoInsurance:
Covered:
Limit Quantity:
Limit Unit:
Routine dental checkups for adults
CoPay:
CoInsurance:
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).