Premera Blue Cross

Preferred Bronze Benefits
  PCY = per calendar year   Heritage Signature providers
  Plan Type Describes how you can use your plan PPO
  Schedule of Benefits Benefits, exclusions and definitions Click here to view
  Provider network Signature Heritage Doctors/Hospitals/Pharmacy
Dentists
  Annual Deductible PCY (choose one)
Family = 2x individual (In-network only)
$5,500 / $6,350
  Coinsurance Amount you pay after your deductible is met 20% / $0
  Out-of-pocket maximum Includes deductible, coinsurance & copays
Family = 2x individual (In-network only)
$6,350
  Office Visits Designated PCP office visit
Non-designated PCP or specialist office visit
$15 / $20 copay
$45 / $50 copay
  10 Essential Benefits Covered Services  
1 Ambulatory Patient Services Outpatient Deductible, then coinsurance
Spinal manipulation (10 visits PCY);
Acupuncture (12 visits PCY)
$15 / $20 copay
2 Emergency Services Emergency Room - Copay waived if directly admitted to an inpatient facility $250 copay, then deductible, then coinsurance
Ambulance deductible, then coinsurance
3 Hospitalization Inpatient Deductible, then coinsurance
Organ and tissue transplants, inpatient unlimited, except $20,000 donor coverage limit and $5,000 travel and lodging per transplant Deductible, then coinsurance
Hospice: unlimited. Respite care: 14 days lifetime Deductible, then coinsurance
4 Maternity & Newborn Care Prenatal, delivery, postnatal Deductible, then coinsurance
5 Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment Office visit $45 / $50 copay
Inpatient hospital: mental/behavioral health Deductible, then coinsurance
Outpatient services Deductible, then coinsurance
6 Prescription Drugs Tier 1 (generic) 5500 plan - $25 copay
6350 plan - deductible, then 0%
Tier 2 (brand) 5500 plan - deductible, then 50%
6350 plan - deductible, then 0%
Tier 3 (specialty) 5500 plan - deductible, then 20%
6350 plan - deductible, then 0%
7 Rehabilitative & Habilitative Services & Devices Therapy Inpatient rehabilitation: 30 days PCY Deductible, then coinsurance
Physical, speech, occupational, massage therapy: 25 visits PCY Deductible, then coinsurance
Durable medical equipment Deductible, then coinsurance
Skilled nursing facility: 60 days PCY Deductible, then coinsurance
8 Laboratory Services Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET Deductible, then coinsurance
9 Preventive/Wellness Services & Chronic Disease Management Screenings
Covered in full
Exams and immunizations Covered in full
10 Pediatric Services, including Oral & Vision Care
Under 19 years of age
Eye exam: 1 PCY $45 / $50 copay
Eyewear: 1 pair lenses/contacts and 1 pair frames PCY Covered in full
Dental: preventive/basic/major 5500 plan – Deductible, then 10% / 20% / 50%;
6350 plan – Deductible then 0%
Orthodontia (medically necessary only) 5500 plan – Deductible, then 50%;
6350 plan – Deductible, then 0%
 

Note: This is a benefit summary only. For a complete description of benefits, refer to your Policy.