my Direct Blue EPO Gold 1700 HSA – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $20 copay after deductible
Specialist visit: $20 copay after deductible
Urgent care visit: $40 copay after deductible
Description
Health Care Plan Details
| Network type | EPO |
| 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 | $20 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/wpa/individual/I_33709PA0890004-01_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 |
