Highmark Blue Cross Blue Shield West Virginia

my Blue Access WV Major Events EPO 8700 - 3 Free PCP Visits

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $8,700.00 Family: $17,400 Per Person: $8,700
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700.00 Family: $17,400 Per Person: $8,700

Office Visit

Primary Doctor	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered
Specialist	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $0.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $0.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Your Prescription Drug benefits may include a Formulary ... which is a list of Brand Name Prescription Drugs that are preferred by your Plan. We may remind your Physician or Professional Other Provider when a Formulary medication is available for a medication that is not on your Formulary. This may result in a change in your Prescription. However, your Physician or Professional Other Provider will always make the final decision on your medication.'
Generic Drugs	CoPay: $0.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: $0.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered
Urgent Care Facility	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: Not Applicable
CoInsurance: No Charge after deductible
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 after deductible Covered: Covered Limit Quantity: 2 Limit Unit : Visit(s) per Year
Routine Dental Checkups for Adults	Covered: Not Covered

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