my Blue Access PPO Silver 5900

76168DE0690007
Silver
PPO

my Blue Access PPO Silver 5900 is a Silver PPO plan by Highmark Blue Cross Blue Shield Delaware.

IMPORTANT: You are viewing the 2023 version of my Blue Access PPO Silver 5900 76168DE0690007. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

my Blue Access PPO Silver 5900 is offered in the following counties.

No data was found

Plan Overview

This is a plan overview for 2023 version of my Blue Access PPO Silver 5900 76168DE0690007.
Insurer: Highmark Blue Cross Blue Shield Delaware
Network Type: PPO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 76168DE0690007

Cost-Sharing Overview

my Blue Access PPO Silver 5900 offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for my Blue Access PPO Silver 5900?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

my Blue Access PPO Silver 5900 offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what my Blue Access PPO Silver 5900 covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Coverage is provided through the Blue Cross Blue Shield Global Core when a Member requires Emergency Care Services or Urgent Care Services while traveling or living outside the United States. All Emergency Care Services and Urgent Care Services are covered in accordance within the Member’s Agreement.
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: If a member receives non-emergency medically necessary and appropriate care from an out of area Blue Card provider, benefits will be paid in accordance with the contract.  If a member receives non-emergency care from a non-Blue Card provider, services will be covered at the lower, out-of-network level and the member will be financially responsible for the difference between the plan’s payment and the full amount of the Out-of-Area provider’s charge.
National Network: Yes

Additional Benefits and Cost-Sharing

my Blue Access PPO Silver 5900 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$55.00 50.00% Coinsurance after deductible
Specialist Visit
Covered
$55.00 50.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$55.00 50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
$250.00 Copay after deductible 50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
Covered
$250.00 Copay after deductible 50.00% Coinsurance after deductible
Hospice Services
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible240 Hours per Benefit Period Outpatient not covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$110.00 $110.00 The copayment, if any, does not apply to urgent care services prescribed for the treatment of mental illness or substance abuse.
Home Health Care Services
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible100 Visit(s) per Benefit Period Aggregate with Visiting Nurse
Emergency Room Services
Covered
$750.00 Copay after deductible $750.00 Copay after deductible
Emergency Transportation/Ambulance
Covered
30.00% Coinsurance after deductible 30.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
$900.00 Copay per Stay after deductible 50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
Covered
$10.00 Copay after deductible 50.00% Coinsurance after deductible
Bariatric Surgery
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
$900.00 Copay per Stay after deductible 50.00% Coinsurance after deductible120 Days per Benefit Period
Prenatal and Postnatal Care
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
Covered
$900.00 Copay after deductible 50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
Covered
$55.00 50.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
Covered
$900.00 Copay per Stay after deductible 50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
Covered
$55.00 50.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
Covered
$900.00 Copay per Stay after deductible 50.00% Coinsurance after deductible
Generic Drugs
Covered
$0.00 100.00%
Preferred Brand Drugs
Covered
$30.00 100.00%
Non-Preferred Brand Drugs
Covered
$150.00 100.00%
Specialty Drugs
Covered
50.00% 100.00%
Outpatient Rehabilitation Services
Covered
$17.00 25.00% Coinsurance after deductible30 Visit(s) per Benefit Period
Habilitation Services
Covered
$17.00 25.00% Coinsurance after deductible30 Visit(s) per Benefit Period In parity with and comparable to outpatient rehabilitation services; 30 visits combined PT/OT and 30 visits speech therapy.
Chiropractic Care
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible30 Visit(s) per Benefit Period
Durable Medical Equipment
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Hearing Aids
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible1 Item(s) per 3 Years Limited to one hearing aid, per person, per ear, every three years for members under age 24
Imaging (CT/PET Scans, MRIs)
Covered
$600.00 Copay after deductible 50.00% Coinsurance after deductible Copayments, if any, do not apply to diagnostic services prescribed for the treatment of mental illness or substance abuse.
Preventive Care/Screening/Immunization
Covered
No Charge 100.00%
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge 100.00%1 Exam(s) per Year
Eye Glasses for Children
Covered
No Charge 100.00%1 Item(s) per Year
Dental Check-Up for Children
Covered
No Charge 100.00%1 Exam(s) per 6 Months
Rehabilitative Speech Therapy
Covered
$17.00 25.00% Coinsurance after deductible30 Visit(s) per Benefit Period Limited to thirty (30) Outpatient Visits for rehabilitative purposes per Benefit Period and thirty (30) Outpatient Visits for habilitative purposes per Benefit Period. This limit does not apply when therapy services are prescribed for the treatment of Mental Illness or Substance Abuse.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$17.00 25.00% Coinsurance after deductible30 Visit(s) per Benefit Period Limited to a combined total of thirty (30) Outpatient Visits for rehabilitative purposes per Benefit Period and a combined total of thirty (30) Outpatient Visits for habilitative purposes per Benefit Period. This limit does not apply when therapy services are prescribed for the treatment of Mental Illness or Substance Abuse.
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
$75.00 50.00% Coinsurance after deductible Copayments, if any, do not apply to diagnostic services prescribed for the treatment of mental illness or substance abuse.
X-rays and Diagnostic Imaging
Covered
$75.00 50.00% Coinsurance after deductible Copayments, if any, do not apply to diagnostic services prescribed for the treatment of mental illness or substance abuse.
Basic Dental Care – Child
Covered
50.00% 100.00%
Orthodontia – Child
Covered
50.00% 100.00%
Major Dental Care – Child
Covered
50.00% 100.00%
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Accidental Dental
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Dialysis
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Allergy Testing
Covered
$75.00 50.00% Coinsurance after deductible
Chemotherapy
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Radiation
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Diabetes Education
Covered
No Charge 100.00%
Prosthetic Devices
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Infusion Therapy
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible Limited to Services to Determine Initial Diagnosis. Exclude Treatment Coverage when TMJ or Related Diagnosis Is only Reason for Treatment
Nutritional Counseling
Covered
No Charge 100.00%
Reconstructive Surgery
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Gender Affirming Care
Clinical Trials
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Diabetes Care Management
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Inherited Metabolic Disorder – PKU
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible

Free Preventive Services

There is no copayment or coinsurance for any of the following my Blue Access PPO Silver 5900 preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for my Blue Access PPO Silver 5900 including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for my Blue Access PPO Silver 5900?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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