Highmark Inc.

my Direct Blue Lehigh Valley EPO Premier Gold 0 + Adult Dental and Vision

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: 0 Family: 0 Per Person: 0
Prescription Drug Deductible	Individual: 0 Family: 0 Per Person: 0
Medical Out-of-Pocket Maximum	Individual: 6500 Family: 13000 Per Person: 6500
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $15 Copay
Specialist	Standard: $15 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: $25 Copay
Non Preferred Brand Drugs	Standard: $75 Copay
Generic Drugs	Standard: $0 Copay
Specialty Drugs	Standard: 50% Coinsurance

Inpatient Coverage

Hospital Services	Standard: $375 Copay per stay
Inpatient Services	Standard: 20% Coinsurance

Emergency and Urgent Care

Emergency Room

Standard: $250 Copay

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