Highmark Shared Cost Blue PPO 1200 a Community Blue Plan PA

Plan Information
Company Highmark Health Services
State PA
Metal Tier Gold
Plan Type PPO

Cost Sharing Benefits

Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $1,200 $2,400
Deductible (Family) $2,400 $4,800
Coinsurance 20% 50%
Out of Pocket Maximum (Individual) $3,700 $7,400
Out of Pocket Maximum (Family) $7,200 $14,800
Services In Network Out of Network
Primary Care Visit $20 50% coinsurance
Specialist Visit $30 50% coinsurance
In Patient Hospital Services 20% Coinsurance after deductible 50% coinsurance
Emergency Room Services 20% Coinsurance after deductible 20% coinsurance
Mental / Behavioral Health $30 copay 50% coinsurance
Imaging (CT/PET Scans, MRIs) 20% coinsurance 50% coinsurance
Rehabilitative Speech Therapy 20% coinsurance 50% coinsurance
Rehabilitative Occupational & Physical Therapy 20% coinsurance 50% coinsurance
Preventative Care $0 50% coinsurance
Laboratory Outpatient and Professional Services $20 copay 50% coinsurance
X-ray and Diagnostic Imaging $20 copay 50% coinsurance
Outpatient Facility 20% coinsurance 50% coinsurance
Outpatient Surgery 20% coinsurance 50% coinsurance
Prescription Drugs In Network Out of Network
Generic Rx $8
Preferred Brand Rx $45
Non Preferred Brand Rx $95
Specialty Drugs 25%

Other Plans

Other plans that are available in the state.

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