Together Blue EPO Premier Gold 0 + Adult Dental and Vision – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $15 copay
Specialist visit: $15 copay
Urgent care visit: $30 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $6,550 per person $13,100 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | $15 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $30 copay |
| Emergency room | $280 copay |
| Ambulance | 20% coinsurance |
| Hospital stay (facility) | $515 copay per Stay |
| Hospital stay (physician) | $10 copay |
| Outpatient procedure (facility) | $200 copay |
| Outpatient procedure (physician) | $200 copay |
| Physical rehabilitation | $40 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $515 copay |
Pharmacy, Drugs, and Medication
| Generic | No charge |
| Brand | $25 copay |
| Non-preferred Brand | $75 copay |
| Specialty | 50% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | $45 copay |
| Imaging (CT/PET/MRI) | $350 copay |
| Blood work | $45 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $15 copay |
| Psychiatric hospital stay | $515 copay per Stay |
Health Plan Provider Information
| Health Plan Benefits | https://shop.highmark.com/content/dam/highmark/en/healthco/shopx/plan-documents/2024/sbcs/wpa/individual/I_79279PA0150001-01_20240101_SBC.pdf |
| Drug and medication plan formulary | http://client.formularynavigator.com/Search.aspx?siteCode=6571849149 |
| Search doctor list | https://highmark.sapphirecareselect.com/?ci=bcbswpanepa&network_id=190 |
