Highmark Shared Cost Blue PPO 1500 (Pennsylvania)

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Company Highmark Health Insurance Company
Plan Year 2014
State Pennsylvania
Metal Tier Gold
Plan Type PPO
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Cost Sharing Benefits (In Network)

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.

Deductible (Individual) $1,500
Deductible (Family) $3,000
Coinsurance 10%
Out of Pocket Maximum (Individual) $4,000
Out of Pocket Maximum (Family) $8,000

Doctors Visits

Primary Care Visit $20
Specialist Visit $40
In Patient Hospital Services 10% Coinsurance after deductible
Emergency Room Services 10% Coinsurance after deductible

Tests and Imaging

Imaging (CT/PET Scans, MRIs) 10% coinsurance
Laboratory Outpatient and Professional Services $20 copay
X-ray and Diagnostic Imaging $20 copay


Mental / Behavioral Health $40 copay
Rehabilitative Speech Therapy 10% coinsurance
Rehabilitative Occupational & Physical Therapy 10% coinsurance
Outpatient Facility 10% coinsurance
Outpatient Surgery 10% coinsurance

Prescription Drugs

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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