Highmark Inc.

my Blue Access PPO Silver 2900

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $2,900 Family: $5,800 Per Person: $2,900
Prescription Drug Deductible	Individual: $0 Family: $0 Per Person: $0
Medical Out-of-Pocket Maximum	Individual: $7,800 Family: $15,600 Per Person: $7,800
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $50 Copay
Specialist	Standard: $50 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: $30 Copay
Non Preferred Brand Drugs	Standard: $150 Copay
Generic Drugs	Standard: $0 Copay
Specialty Drugs	Standard: 50% Coinsurance

Inpatient Coverage

Hospital Services	Standard: 30% Coinsurance after deductible
Inpatient Services	Standard: 30% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: $750 Copay after deductible

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