Highmark Blue Cross Blue Shield Delaware

my Blue Access PPO Premier Gold 0 + Adult Dental and Vision

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $0.00 Family: $0 Per Person: $0
Prescription Drug Deductible	Individual: $0.00 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $6,700.00 Family: $13400 Per Person: $6700

Office Visit

Primary Doctor	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $75.00 CoInsurance: Not Applicable Covered: Covered
Generic Drugs	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered

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: $280.00 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 abuse.

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: Not Applicable CoInsurance: No Charge Covered: Covered Benefit Explanation: Adult dental services have a separate $50 deductible and $1,250 annual maximum per person.