Page 5 - Drive DeVilbiss - 2022 Union Guide

Medical and pharmacy coverage

Highmark PPO
Medical Plan Provisions In-Network Out-of-Network

Annual Deductible
(Individual/Family) $500/$1,000 $2,500/$5,000

Out-of-Pocket Maximum None $5,000/$10,000
Total Out-of-Pocket Maximum
(Includes Deductible, Copays & Rx) $6,600/$13,200 N/A

Preventive Care Covered at 100% Not Covered

Primary Care Provider
Office Visit $20 Copay 60% after deductible

Specialist Office Visit $20 Copay 60% after deductible
X-Ray and Lab No Charge after deductible 60% after deductible

Inpatient Hospital Services No Charge after deductible 60% after deductible

Outpatient Hospital Services No Charge after deductible 60% after deductible

Emergency Room $125 Copay

Virtual Visits/TeleHealth Benefits No Charge Not Covered
Retail pharmacy (up to a 30-day supply)

Generic $5

Brand Preferred $20
Not Covered
Brand Non-Preferred $40

Specialty 50% up to $250
Mail Order Pharmacy (90-day supply)

Generic $10
Brand Preferred $40 Not Covered

Brand Non-Preferred $80

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