Premera Blue Cross PPO Plan

Benefit
 In-Network
 Out-of-Network
Deductible
$350 individual/$700 family
Annual Out of Pocket Max
$2,850 individual/$5,700 family
(includes deductible)
Lifetime maximum benefit
Unlimited
Office Visits
100% after $20 copay
Deductible/
Coinsurance
Preventive Care
Immunizations
 100%
60% after deductible
Routine adult physicals
100%
60% after deductible
Well-woman exams/ screenings
100%
60% after deductible
Well-baby exams
100%
60% after deductible
Other Services  In-Network Out-of-Network
Emergency Room
(copay waived if admitted)
$100 copay, then deductible/coinsurance
Inpatient hospital services
90% after deductible
60% after deductible
Outpatient hospital services
90% after deductible
60% after deductible
Outpatient surgical center
90% after deductible
60% after deductible
Prescription drugs (retail/pharmacy)
 30-day supply
Generic
$10 copay
Brand formulary
$25 copay
Nonformulary
$50 copay
Prescription drugs
(mail order)
90-day supply
 
Generic  
$20 copay
 
Brand formulary  
$50 copay
 
Nonformulary  
$100 copay
 

This is a brief outline of the benefits provided. Refer to the Summary of Coverage for a comprehensive description of plan benefits. Under all circumstances, the Summary of Coverage will take precedence over information contained on this website. The Premera Blue Cross 2013 Summary of Coverage is at: 2014 Premera Summary of Coverage.

 

Last modified on Wednesday, August 06, 2014