| PCY = Per Calendar Year |
In-Network |
Out-of-Network |
| Annual Deductible (per individual PCY1) |
$1,800 |
$3,600 |
| Coinsurance (what you pay) |
35% |
50% |
| Annual Coinsurance Maximum2 PCY |
$6,500 |
Unlimited |
| Covered Services (calendar year maximum $2 million) |
| Preventive Care |
| Preventive Care Exams |
Covered in Full3 |
Not covered |
Preventive Screenings
(including mammography, PAP smears, PSA testing, colonoscopies and cholesterol screening)4 |
50% |
| Immunizations |
Preventive not covered;
Seasonal covered in full3 |
| Professional Care |
Office Visits
Including Urgent Care |
35% |
50% |
| Other Outpatient Professional Services |
| Inpatient Professional Services |
| Pharmacy |
Retail: 30 day supply
Mail Order: 90 day supply |
Preferred Generics/Non-Preferred Generic
Retail: $15/50%;
Mail Order: $45/50%
|
| Vision |
| Routine Vision Exam |
Covered in Full3 (one exam per 2 calendar years) |
| Vision Hardware |
Covered in Full3 ($200 per 2 calendar years) |
| Diagnostic Services |
| Diagnostic X-ray & Laboratory Services |
35% |
50% |
| Facility Care |
Inpatient Facility
Copay waived if directly admited to an inpatient facility |
35% |
50% |
| Outpatient Surgery Facility |
| Skilled Nursing Facility |
35% (20 days PCY) |
50% |
| Emergency Care |
Emergency Care
Copay waived if directly admited to an inpatient facility |
$100 copay plus 35% |
| Ambulance Transportation |
35% ($5,000 PCY) |
| Other Services |
| Maternity Care |
35% |
50% |
| Spinal & Other Manipulations |
35% (12 visits PCY) |
50% (limit shared with in-network) |
| Acupuncture |
Supplies, Equipment and Prosthetics
|
35% |
| Home Health Care |
35% (130 Home Health visits PCY) |
Hospice Care
6 month maximum |
35% (Inpatient: 10 days max; Respite: 240 hrs. max) |
Rehabilitation
(including Physical, Occupational, Speech and Massage Therapy; Cardiac & Pulmonary Rehab; and Chronic Pain.) |
35% (Outpatient: 15 visits PCY; Inpatient: 10 days PCY) |
Transplants
12-month waiting period; Organ & Bone Marrow |
35% |
Not covered |
| Mental Health–Outpatient |
Deductible, then 50% |
| Mental Health–Inpatient |
This plan is "non-grandfathered" under federal healthcare reform legislation.
- No Family deductible.
- After the coinsurance maximum is met, in-network providers are covered in full.
- Benefits provided at 100% of allowable charges; not subject to deductible or coinsurance.
- A full list of preventive screenings, tests and other preventive services, is available on premera.com. You can receive these preventive services covered in full if you use preferred providers and are within the frequency, age, risk and gender guidelines outlined in the list.
Note: Deductible, coinsurance and copay represent what you pay.
Benefits apply after calendar year deductible is met, unless otherwise noted as “Deductible Waived,” “Copay” or “Covered in Full.”
All coinsurance amounts are based on allowable charges. Balance billing may apply if a provider is not contracted with Premera Blue Cross.
Please note that this is a general summary. Your individual health plan contract will describe the actual terms, conditions and exclusions of coverage.
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