Highmark Inc.

my Direct Blue EPO Bronze 7400 HSA - Custom Drug Benefit

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $7,400 Family: $14,800 Per Person: $7,400
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $7,400 Family: $14,800 Per Person: $7,400
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: No Charge after deductible
Specialist	Standard: No Charge after deductible

Prescription Drug Information

Preferred Brand Drugs	Standard: No Charge after deductible
Non Preferred Brand Drugs	Standard: No Charge after deductible
Generic Drugs	Standard: No Charge after deductible
Specialty Drugs	Standard: No Charge after deductible

Inpatient Coverage

Hospital Services	Standard: No Charge after deductible
Inpatient Services	Standard: No Charge after deductible

Emergency and Urgent Care

Emergency Room

Standard: No Charge after deductible