Highmark Inc.

my Direct Blue EPO Gold 1500

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Medical Deductible	Individual: $1,500 Family: $3,000 Per Person: $1,500
Prescription Drug Deductible	Individual: $0 Family: $0 Per Person: $0
Medical Out-of-Pocket Maximum	Individual: $8,300 Family: $16,600 Per Person: $8,300
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Primary Doctor	Standard: $35 Copay
Specialist	Standard: $35 Copay

Hospital Services	Standard: $725 Copay per stay after deductible
Inpatient Services	Standard: No Charge after deductible

Emergency Room