my Direct Blue EPO Bronze 3800 + Adult Dental and Vision – EPO
Network type: EPO
Coverage tier: Expanded Bronze
Primary care visit: $65 copay
Specialist visit: $65 copay
Urgent care visit: $100 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $3,800 per person $3,800 per person |
| Out-of-pocket max | $9,200 per person $18,400 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $65 copay |
| Specialist visit | $65 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $100 copay |
| Emergency room | 50% coinsurance after deductible |
| Ambulance | 50% coinsurance after deductible |
| Hospital stay (facility) | 50% coinsurance after deductible |
| Hospital stay (physician) | 50% coinsurance after deductible |
| Outpatient procedure (facility) | $375 copay after deductible |
| Outpatient procedure (physician) | $375 copay after deductible |
| Physical rehabilitation | $65 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 50% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | 50% coinsurance after deductible |
| Brand | 50% coinsurance after deductible |
| Non-preferred Brand | 50% coinsurance after deductible |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $150 copay |
| Imaging (CT/PET/MRI) | 50% coinsurance after deductible |
| Blood work | $65 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $65 copay |
| Psychiatric hospital stay | 50% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://shop.highmark.com/content/dam/highmark/en/healthco/shopx/plan-documents/2024/sbcs/cpa/individual/I_33709PA1120001-01_20240101_SBC.pdf |
| Drug and medication plan formulary | http://client.formularynavigator.com/Search.aspx?siteCode=6571849149 |
| Search doctor list | https://www.highmarkbcbs.com/login/#/find-a-doctor |
