Highmark Inc.

my Direct Blue EPO Gold 1700 HSA

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $1,700 Family: $3,400 Per Person: $3,400
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $5,700 Family: $11,400 Per Person: $5,700
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $20 Copay after deductible
Specialist	Standard: $20 Copay after deductible

Prescription Drug Information

Preferred Brand Drugs	Standard: $30 Copay after deductible
Non Preferred Brand Drugs	Standard: $150 Copay after deductible
Generic Drugs	Standard: $0 Copay after deductible
Specialty Drugs	Standard: 50% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: $450 Copay per stay after deductible
Inpatient Services	Standard: No Charge after deductible

Emergency and Urgent Care

Emergency Room

Standard: $175 Copay after deductible