my Blue Access PPO Gold 1700 HSA – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$1,700 per person $1,700 per person
Out-of-pocket max	$5,700 per person $11,400 per family
Metal tier	Gold

Visit Copay

Primary care visit	$20 copay after deductible
Specialist visit	$20 copay after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$40 copay after deductible
Emergency room	$175 copay after deductible
Ambulance	20% coinsurance after deductible
Hospital stay (facility)	$440 copay per Stay after deductible
Hospital stay (physician)	$10 copay after deductible
Outpatient procedure (facility)	$65 copay after deductible
Outpatient procedure (physician)	$65 copay after deductible
Physical rehabilitation	$17 copay after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	$440 copay after deductible

Pharmacy, Drugs, and Medication

Generic	No charge after deductible
Brand	$30 copay after deductible
Non-preferred Brand	$150 copay after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	$20 copay after deductible
Imaging (CT/PET/MRI)	$175 copay after deductible
Blood work	$20 copay after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$20 copay after deductible
Psychiatric hospital stay	$440 copay per Stay after deductible

Health Plan Provider Information

Health Plan Benefits	https://shop.highmark.com/content/dam/highmark/en/healthco/shopx/plan-documents/2024/sbcs/hmde/individual/I_76168DE0710003-01_20240101_SBC.pdf
Drug and medication plan formulary	https://client.formularynavigator.com/Search.aspx?siteCode=6571849149
Search doctor list	https://highmark.sapphirecareselect.com/?ci=hmbcbsde&network_id=402