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my Blue Access PPO Premier Platinum 0 + Adult Dental and Vision
Health Insurance Plan Details (2025 Plan)
by Highmark BCBSD Inc.
Monthly Premium
PPO
$ubsidy
Platinum
- Deductible
- $0 /yr
- Max Out-of-Pocket
- $5,000 /yr
Details
| Deductible (per individual) | $0 /yr |
| Deductible (per family) | $0 /yr |
| Max Out-of-Pocket (per individual) | $5,000 /yr |
| Max Out-of-Pocket (per family) | $10,000 /yr |
| Drug Deductible (per individual) | $0 |
| Drug Deductible (per family) | $0 |
| Drug Max Out-of-Pocket (per individual) | Included in Medical |
| Drug Max Out-of-Pocket (per family) | Included in Medical |
| Plan Type | PPO |
| Includes Child Dental? | Yes |
| Includes Adult Dental? | Yes |
Out-of-Pocket Costs
| Preventive Care | No Charge |
| Primary Care Visit | No Charge |
| Specialist Visit | No Charge |
| Emergency Room | $100 Copay |
| Inpatient Facility | $325 Copay per Stay |
| Inpatient Physician | No Charge |
| Generic Drugs | No Charge |
| Preferred Brand Drugs | $10 Copay |
| Non-preferred Brand Drugs | $50 Copay |
| Specialty Drugs | 50% Coinsurance |
Plan Documents
| Summary of Benefits and Coverage | SBC doc |
| Provider Directory | Doctor lookup |
| Drug Formulary List | drug list |
* Figures shown are only for in-network medical costs
** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible
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