Coverage Period: - Highmark Blue Cross Blue Shield: my Priority Blue Flex EPO Gold 800 - 2 Free PCP Visits Coverage for: Individual. Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services. All benefits are subject to the definitions, limitations, and exclusions set forth in the federal brochure. Priority Blue Flex EPO Gold 800 - 2 Free PCP Visits ONX Base Jan I79962PA0190006-0120200101SBC. Before making a final decision, please read the Plan’s federal brochure (RI 71-005). : Updated Individual PPO section to reflect worldwide emergency and urgently needed services and emergency transportation are subject to a combined 250 annual deductible, 20 coinsurance and a combined 50,000 lifetime maximum benefit. This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. The formulary and/or pharmacy network may change at any time. Enrollment in MPDP depends on contract renewal. The FEP Medicare Prescription Drug Program is a prescription drug plan with a Medicare contract. 3 You must be the contract holder or spouse, 18 or older, on a Standard or Basic Option Plan to earn incentive rewards.
2 If you have Medicare Part B primary, your costs for prescription drugs may be lower.1 Under Basic Option you pay 30% of our allowance for agents, drugs and/or supplies you receive during your care.^ What you’ll pay for a 30-day supply of covered drugs.Under Basic Option, benefits are not available for services performed by Non-preferred providers, except in certain situations such as emergency care.Ĭost sharing may not apply or may be different if Medicare is your primary coverage (it pays first). Tier 4 (Preferred specialty): $85 copay 2 Visit the Medicare page for more information. Tier 5 (Non-preferred specialty): $110 copay 2Īvailable to members with Medicare Part B primary only. Tier 4 (Preferred specialty): $85 copay 2 Tier 3 (Non-preferred brand): 60% of our allowance ( $90 minimum) 2 $0 for first 2 visits and all nutrition visits Nothing for covered preventive screenings, immunizations and services
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