my Blue Access WV EPO Premier Gold 0 + Adult Dental and Vision
31274WV0540001
Gold
EPO
my Blue Access WV EPO Premier Gold 0 + Adult Dental and Vision is a Gold EPO plan by Highmark Blue Cross Blue Shield West Virginia.
Locations
my Blue Access WV EPO Premier Gold 0 + Adult Dental and Vision is offered in the following counties.
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Plan Overview
This is a plan overview for 2022 version of my Blue Access WV EPO Premier Gold 0 + Adult Dental and Vision 31274WV0540001.
| Insurer: | Highmark Blue Cross Blue Shield West Virginia |
| Network Type: | EPO |
| Metal Type: | Gold |
| HSA Eligible?: | No |
| Plan ID: | 31274WV0540001 |
Cost-Sharing Overview
my Blue Access WV EPO Premier Gold 0 + Adult Dental and Vision offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for my Blue Access WV EPO Premier Gold 0 + Adult Dental and Vision includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | 6500 | 13000 |
| Deductible: | 0 | 0 |
| Coinsurance: | 0 | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for my Blue Access WV EPO Premier Gold 0 + Adult Dental and Vision will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | ||
| Out-of-Network Deductible: |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | 0 |
| Copayment: | 900 |
| Coinsurance: | 800 |
| Limit: | 60 |
| Deductible: | 0 |
| Copayment: | 1200 |
| Coinsurance: | 200 |
| Limit: | 20 |
| Deductible: | 0 |
| Copayment: | 400 |
| Coinsurance: | 300 |
| Limit: | 0 |
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 WV EPO Premier Gold 0 + Adult Dental and Vision?
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 WV EPO Premier Gold 0 + Adult Dental and Vision 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 WV EPO Premier Gold 0 + Adult Dental and Vision 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: | The Plan covers only limited health care services received by a non-Blue Card (out-of-network) provider. Out-of-Network Covered Services include Emergency Care Services and Urgent Care Services. Any other Out-of-Network services will not be covered unless authorized by the Plan. |
| National Network: | Yes |
Additional Benefits and Cost-Sharing
my Blue Access WV EPO Premier Gold 0 + Adult Dental and Vision 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 | $15.00 / N/A | / | |
| Specialist Visit Covered | $15.00 / N/A | / | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $15.00 / N/A | / | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | $175.00 / N/A | / | |
| Outpatient Surgery Physician/Surgical Services Covered | $175.00 / N/A | / | |
| Hospice Services Covered | N/A / 20.00% | / | Life expectancy 6 months or less |
| Routine Dental Services (Adult) Covered | N/A / No Charge | / | Adult dental services have a separate $50 deductible |
| Infertility Treatment Covered | N/A / 20.00% | / | Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered depending on your group?s prescription drug program |
| Long-Term/Custodial Nursing Home Care Not Covered | / | / | |
| Private-Duty Nursing Covered | N/A / 20.00% | / | 35 Visit(s) per Benefit Period |
| Routine Eye Exam (Adult) Covered | N/A / No Charge | / | 1 Exam(s) per Year |
| Urgent Care Centers or Facilities Covered | $30.00 / N/A | / | |
| Home Health Care Services Covered | N/A / 20.00% | / | 100 Visit(s) per Benefit Period The following are Covered Services when you are Homebound and receive them from a Hospital or a Home Health Care Agency: Intermittent Skilled Care rendered by a registered or licensed practical nurse or nurse-midwife; Physical therapy, occupational therapy or speech therapy; Medical and surgical supplies; Prescription Drugs; Oxygen and its administration; Medical social Services; Home health aide visits when you are also receiving Skilled Care or Therapy Services; Laboratory tests; Home infusion therapy. |
| Emergency Room Services Covered | $250.00 / N/A | / | |
| Emergency Transportation/Ambulance Covered | N/A / 20.00% | / | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | $375.00 Copay per Stay / N/A | / | |
| Inpatient Physician and Surgical Services Covered | N/A / 20.00% | / | |
| Bariatric Surgery Covered | N/A / 20.00% | / | Surgery determined to be Medically Necessary is covered. |
| Cosmetic Surgery Covered | N/A / 20.00% | / | Limited to reconstruction to restore body function or malformation caused by disease, trauma, birth defects, growth defects, prior therapeutic processes or as a result of an act of family violence |
| Skilled Nursing Facility Covered | $375.00 Copay per Stay / N/A | / | |
| Prenatal and Postnatal Care Covered | N/A / 20.00% | / | |
| Delivery and All Inpatient Services for Maternity Care Covered | $375.00 / N/A | / | |
| Mental/Behavioral Health Outpatient Services Covered | $15.00 / N/A | / | |
| Mental/Behavioral Health Inpatient Services Covered | $375.00 Copay per Stay / N/A | / | |
| Substance Abuse Disorder Outpatient Services Covered | $15.00 / N/A | / | |
| Substance Abuse Disorder Inpatient Services Covered | $375.00 Copay per Stay / N/A | / | |
| Generic Drugs Covered | $0.00 / N/A | / | |
| Preferred Brand Drugs Covered | $25.00 / N/A | / | |
| Non-Preferred Brand Drugs Covered | $75.00 / N/A | / | Your Prescription Drug benefits may include a Formulary … which is a list of Brand Name Prescription Drugs that are preferred by your Plan. We may remind your Physician or Professional Other Provider when a Formulary medication is available for a medication that is not on your Formulary. This may result in a change in your Prescription. However, your Physician or Professional Other Provider will always make the final decision on your medication.’ |
| Specialty Drugs Covered | N/A / 50.00% | / | |
| Outpatient Rehabilitation Services Covered | $15.00 / N/A | / | |
| Habilitation Services Covered | $15.00 / N/A | / | 30 Visit(s) per Benefit Period Limit does not apply to Habilitative services for the treatment of a Mental Health or Substance Abuse diagnosis. |
| Chiropractic Care Covered | $15.00 / N/A | / | 30 Visit(s) per Benefit Period 30 visits per benefit period for other than chronic pain 20 visits per event for chronic pain (visit limits are combined for physical therapy, occupational therapy and spinal manipulations) |
| Durable Medical Equipment Covered | N/A / 20.00% | / | |
| Hearing Aids Covered | $999.00 / N/A | / | 2 Item(s) per Benefit Period Copay applies per each hearing aid |
| Imaging (CT/PET Scans, MRIs) Covered | $250.00 / N/A | / | |
| Preventive Care/Screening/Immunization Covered | N/A / No Charge | / | |
| Routine Foot Care Not Covered | / | / | |
| Acupuncture Not Covered | / | / | |
| Weight Loss Programs Not Covered | / | / | |
| Routine Eye Exam for Children Covered | N/A / No Charge | / | 1 Exam(s) per Year |
| Eye Glasses for Children Covered | N/A / No Charge | / | 1 Item(s) per Year |
| Dental Check-Up for Children Covered | N/A / No Charge | / | 2 Visit(s) per Year |
| Rehabilitative Speech Therapy Covered | $15.00 / N/A | / | |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $15.00 / N/A | / | 30 Visit(s) per Benefit Period 30 Rehab and 30 Habilitative/benefit period for other than chronic pain. Limit: 20 Rehab and 20 Habilitative/event for chronic pain (limits combined for PT, OT and spinal manipulations). Limit does not apply to Habilitative services for mental health or substance abuse. |
| Well Baby Visits and Care Covered | N/A / No Charge | / | |
| Laboratory Outpatient and Professional Services Covered | $40.00 / N/A | / | |
| X-rays and Diagnostic Imaging Covered | $40.00 / N/A | / | |
| Basic Dental Care – Child Covered | N/A / 50.00% | / | Oral Evaluations (Exams), Prophylaxis (cleanings), Fluoride Treatments, Sealants, Consultations |
| Orthodontia – Child Covered | N/A / 50.00% | / | Medically Necessary Orthodontics, with prior approval and written plan of care |
| Major Dental Care – Child Covered | N/A / 50.00% | / | Radiographs (all x-rays), space maintainers, amalgam restorations (metal filings), resin based composite filings (white fillings), crowns, inlays, onlays, crown repair, endodontic therapy (root canals, etc.), other endodontic services, surgical periodontics, non-surgical periodontics, periodontal maintenance, prosthetics (complete or fixed partial dentures), adjustments and repair of prosthetics, other prosthetic services, implant services, simple extractions, surgical extractions, oral surgery, general anesthesia, nitrous oxide and/or IV sedation |
| Basic Dental Care – Adult Covered | N/A / 50.00% | / | Adult dental services have a separate $50 deductible |
| Orthodontia – Adult Not Covered | / | / | |
| Major Dental Care – Adult Not Covered | / | / | |
| Abortion for Which Public Funding is Prohibited Not Covered | / | / | |
| Transplant Covered | N/A / 20.00% | / | |
| Accidental Dental Covered | N/A / 20.00% | / | |
| Dialysis Covered | N/A / 20.00% | / | |
| Allergy Testing Covered | $40.00 / N/A | / | |
| Chemotherapy Covered | N/A / 20.00% | / | |
| Radiation Covered | N/A / 20.00% | / | |
| Diabetes Education Covered | N/A / No Charge | / | |
| Prosthetic Devices Covered | N/A / 20.00% | / | |
| Infusion Therapy Covered | N/A / 20.00% | / | |
| Treatment for Temporomandibular Joint Disorders Covered | N/A / 20.00% | / | Orthotics, splints and appliances are limited to one every 3 years |
| Nutritional Counseling Covered | N/A / No Charge | / | |
| Reconstructive Surgery Covered | N/A / 20.00% | / | (a) only those that restore a body function or which were caused by disease, trauma, birth defects, growth defects, prior therapeutic processes; or (b) reconstructive Surgery following Covered Services for a mastectomy, including reconstruction of the other breast for the purpose of restoring symmetry; or (c) reconstructive or cosmetic Surgery necessary as a result of an act of family violence. |
| Clinical Trials Covered | N/A / 20.00% | / | |
| Diabetes Care Management Covered | N/A / 20.00% | / | |
| Dental Anesthesia Covered | N/A / 20.00% | / | |
| Mental Health Other Covered | N/A / 20.00% | / |
Free Preventive Services
There is no copayment or coinsurance for any of the following my Blue Access WV EPO Premier Gold 0 + Adult Dental and Vision 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.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for my Blue Access WV EPO Premier Gold 0 + Adult Dental and Vision 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 WV EPO Premier Gold 0 + Adult Dental and Vision?
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