Premera Blue Cross PPO Plan
> Partnering with Premera - Questions and Answers
| 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%
|
| Routine physicals |
100%
|
| Well-woman exams/screenings |
100%
|
| Well-baby exams |
100%
|
| 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: 2013 Premera Summary of Coverage.
Last modified on Monday, March 25, 2013