my Blue Access WV PPO Standard Bronze 7500

Highmark Blue Cross Blue Shield West Virginia

Expanded BronzeHSA eligible

Ind. deductible: $7,500
Family deductible: $7,500
Ind. OOP max: $10,000
Family OOP max: $10,000

Other cost-sharing reduction variants for this plan:

Limited Cost Sharing Plan Variation Standard Bronze Off Exchange Plan Zero Cost Sharing Plan Variation

Monthly premiums by age

Age	Individual	Individual + tobacco
21	$630	—
30	$715	—
40	$805	—
50	$1,125	—
60	$1,710	—

Live premium estimate

Benefits & cost sharing

Primary Care

Benefit	In-network
Preventive Care/Screening/Immunization	No charge
Primary Care Visit to Treat an Injury or Illness	$50.00

Specialist

Benefit	In-network
Specialist Visit	$100.00

Hospital

Benefit	In-network
Emergency Room Services	50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services	50.00% Coinsurance after deductible
Urgent Care Centers or Facilities	No charge

Pharmacy

Benefit	In-network
Generic Drugs	$25.00
Non-Preferred Brand Drugs	No charge
Preferred Brand Drugs	No charge
Specialty Drugs	$500.00 Copay after deductible

Mental Health

Benefit	In-network
Mental Health Other	50.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services	No charge
Mental/Behavioral Health Outpatient Services	No charge

Other

Benefit	In-network
Orthodontia - Child	No charge
Abortion for Which Public Funding is Prohibited	Not covered
Accidental Dental	50.00% Coinsurance after deductible
Acupuncture	Not covered
Allergy Testing	No charge
Bariatric Surgery	50.00% Coinsurance after deductible
Basic Dental Care - Adult	Not covered
Basic Dental Care - Child	50.00%
Chemotherapy	50.00% Coinsurance after deductible
Chiropractic Care	$50.00
Clinical Trials	No charge
Cosmetic Surgery	50.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care	50.00% Coinsurance after deductible
Dental Anesthesia	No charge
Dental Check-Up for Children	No charge
Diabetes Care Management	No charge
Diabetes Education	No charge
Dialysis	50.00% Coinsurance after deductible
Durable Medical Equipment	50.00% Coinsurance after deductible
Emergency Transportation/Ambulance	50.00% Coinsurance after deductible
Eye Glasses for Children	No charge
Habilitation Services	$50.00
Hearing Aids	Not covered
Home Health Care Services	50.00% Coinsurance after deductible
Hospice Services	50.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)	50.00% Coinsurance after deductible
Infertility Treatment	50.00% Coinsurance after deductible
Infusion Therapy	50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services	50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services	50.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care	Not covered
Major Dental Care - Adult	Not covered
Major Dental Care - Child	50.00%
Nutritional Counseling	No charge
Orthodontia - Adult	Not covered
Other Practitioner Office Visit (Nurse, Physician Assistant)	$50.00
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	50.00% Coinsurance after deductible
Outpatient Rehabilitation Services	No charge
Prenatal and Postnatal Care	No charge
Private-Duty Nursing	50.00% Coinsurance after deductible
Prosthetic Devices	No charge
Radiation	50.00% Coinsurance after deductible
Reconstructive Surgery	50.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy	$50.00
Rehabilitative Speech Therapy	$50.00
Routine Dental Services (Adult)	Not covered
Routine Eye Exam (Adult)	Not covered
Routine Eye Exam for Children	No charge
Routine Foot Care	Not covered
Skilled Nursing Facility	50.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services	No charge
Substance Abuse Disorder Outpatient Services	No charge
Transplant	50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders	50.00% Coinsurance after deductible
Weight Loss Programs	Not covered
Well Baby Visits and Care	No charge
X-rays and Diagnostic Imaging	No charge

Plan rules

Service area

This plan covers 1 geographic area.