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Medical Benefits

Customer Service 800.722.1471

Group Number: 4024205

Premera Medical Summary

Highlights of your Health Care Coverage

Any deductibles, copays, and coinsurance percentages shown are amounts for which you're responsible. Medical Benefits apply after the calendar-year deductible is met unless otherwise noted, or if the cost share is a copay.

PREMERA PREFERRED CHOICE: PPO - $1,000/20%/50%/$5,000/$30 - HERITAGE

MEDICAL COST SHARE OPTIONS HERITAGE IN-NETWORK OUT-OF-NETWORK
Individual Deductible PCY (Family embedded deductible 2X Individual)​ $1,000 $2,000
Coinsurance (Member's percentage of costs after deductible based on allowable charges) 20% 50%
Individual Out of Pocket Maximum PCY, includes deductible, coinsurance, copay and pharmacy if applicable (Family embedded OOP max 2X Individual) $5,000 Unlimited
Office Visit Cost Share $30 Copay, applies to the $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
PREVENTIVE CARE OPTIONS AND HEALTH EDUCATION HERITAGE IN-NETWORK OUT-OF-NETWORK
Preventive Office Visit (Unlimited, subject to standard medical guidelines) Covered in Full Not Covered
Immunizations (Unlimited, subject to standard medical guidelines) Covered in Full Not Covered
Health Education (HE) (Unlimited) Covered in Full Not Covered
Nicotine Dependency Programs (ND) (Unlimited) Covered in Full Not Covered
Diabetes Health Education (DE) (Unlimited)Diabetes Health Education (DE) (Unlimited) Covered in Full Not Covered
PROFESSIONAL CARE HERITAGE IN-NETWORK OUT-OF-NETWORK
Professional Office Visit $30 Copay, applies to the $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Telemedicine with Traditional Providers - General Medical $10 Copay, applies to the $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
VIRTUAL CARE SERVICES HERITAGE IN-NETWORK OUT-OF-NETWORK
Telemedicine - General Medical (Virtual Care Only) $1O Copay, applies to the $5,000 Out of Pocket Maximum Not Covered
Telemedicine - Mental Health (Virtual Care Only) Subject to Mental Health Outpatient Professional Care In-Network Cost Share Not Covered
Telemedicine - Chemical Dependency (Virtual Care Only) Subject to Chemical Dependency Outpatient Office Visit Not Covered
DIAGNOSTIC SERVICE OPTIONS HERITAGE IN-NETWORK OUT-OF-NETWORK
Preventive Professional Diagnostic Imaging and Laboratory Services - Including Mammogram and PAP/PSA Covered in Full $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Other Professional Diagnostic Imaging Waive Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Professional Diagnostic Major Imaging Waive Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Other Professional Diagnostic Laboratory/Pathology Waive Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Diagnostic Mammography Waive Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
FACILITY CARE OPTIONS HERITAGE IN-NETWORK OUT-OF-NETWORK
Inpatient Facility $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Inpatient Professional Services $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Outpatient Surgery Facility $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Skilled Nursing Facility (60 days PCY; includes room and board, and facility billed professional and ancillary fees) $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
HOSPICE & HOME HEALTH CARE HERITAGE IN-NETWORK OUT-OF-NETWORK
Hospice Inpatient Facility (10 days Inpatient; within the 6 month lifetime maximum) $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Hospice Care (Hospice Home Visits Unlimited; Respite: 240 hours; within the 6 month lifetime maximum) $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
MATERNITY & REPRODUCTIVE CARE HERITAGE IN-NETWORK OUT-OF-NETWORK
Contraceptive Management Services (Unlimited) Covered in Full $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Sterilization - Female (Unlimited) Covered in Full $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Sterilization - Male (Unlimited) Covered in Full $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
PREMERA DESIGNATED CENTERS OF EXCELLENCE HERITAGE IN-NETWORK OUT-OF-NETWORK
Centers of Excellence Packaged Services (Eligible Services Include: Total Joint Replacement (Knee & Hip Replacement)) Covered in Full Covered as any other service
Centers of Excellence for Radiology (Member Outreach Included) Covered as any other service Covered as any other service
MEDICAL TRANSPORTATION BENEFITS HERITAGE IN-NETWORK OUT-OF-NETWORK
Centers of Excellence Travel and Care Coordination (Limited to IRS Guidelines) Covered in Full Covered in Full
EMERGENCY CARE AND TRANSPORTATION OPTION HERITAGE IN-NETWORK OUT-OF-NETWORK
Emergency Care (If applicable, waive copay if admitted to inpatient facility) $150 Copay then $1,000 Deductible and 20% Coinsurance; all cost shares apply to the $5,000 Out of Pocket Maximum $150 Copay then $1,000 Deductible and 20% Coinsurance; all cost shares apply to the $5,000 Out of Pocket Maximum
Emergency Room Physician $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum
Urgent Care Center $30 Copay, applies to the $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Ambulance Transportation (Unlimited) $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum
ALTERNATIVE CARE HERITAGE IN-NETWORK OUT-OF-NETWORK
Acupuncture (12 visits PCY) $30 Copay, applies to the $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Manipulations (Spinal and other) (12 visits PCY) $30 Copay, applies to the $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
CHEMICAL DEPENDENCY & MENTAL HEALTH HERITAGE IN-NETWORK OUT-OF-NETWORK
Chemical Dependency Inpatient Facility Care (Unlimited) $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Chemical Dependency Outpatient Professional Care (Unlimited) $30 Copay, applies to the $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Mental Health Inpatient Facility Care (Unlimited) $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Mental Health Outpatient Professional Care (Unlimited) $30 Copay, applies to the $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
REHABILITATION & NEURO HERITAGE IN-NETWORK OUT-OF-NETWORK
Rehab Inpatient Facility (30 days PCY) $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Rehab Outpatient Care, Including Physical, Occupational, Speech and Massage Therapy, and Chronic Pain (45 visits PCY) $30 Copay, applies to the $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Rehab Outpatient Care Chronic Conditions, Including Cardiac, Pulmonary Rehab, and Cancer $30 Copay, applies to the $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
OTHER SERVICES HERITAGE IN-NETWORK OUT-OF-NETWORK
Allergy/Therapeutic Injections Covered in Full $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Medical Supplies, Equipment, Prosthetics (Unlimited) $1,000 Deductible, then 20% Coinsurance, applies to $5,000 Out of Pocket Maximum $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Transplants (Unlimited; $7,500 travel and lodging limits) Covered as any other service Not Covered
SUPPLEMENTAL BENEFITS HERITAGE IN-NETWORK OUT-OF-NETWORK
Routine Vision Exam (7 PCY) $25 Copay $25 Copay
Vision Hardware ($150 every 2 consecutive calendar years) Covered in Full Covered in Full
Pediatric Vision Exam (7 PCY under age 19) $25 Copay, applies to the $5,000 Out of Pocket Maximum $25 Copay, applies to the $5,000 Out of Pocket Maximum
Pediatric Vision Hardware (Under age 19 One pair of glasses PCY (frames & lenses). 12 month supply of contacts PCY, in lieu of glasses (frames & lenses).) Covered in Full Covered in Full
ANNUAL PLAN MAXIMUM HERITAGE IN-NETWORK OUT-OF-NETWORK
Annual Plan Maximum Unlimited Unlimited

Highlights of your Health Care Coverage

Any deductibles, copays, and coinsurance percentages shown are amounts for which you're responsible. Medical Benefits apply after the calendar-year deductible is met unless otherwise noted, or if the cost share is a copay.

PREMERA PREFERRED CHOICE: AGG HSA - $1,500/20%/50%/$4,000/DED.COINS (MAC) HERITAGE

MEDICAL COST SHARE OPTIONS HERITAGE IN-NETWORK OUT-OF-NETWORK
Individual Deductible PCY (Family aggregate deductible 2x Individual) $1,500/$3,000 $3,000/$6,000
Coinsurance (Member's percentage of costs after deductible based on allowable charges) 20% 50%
Individual Out of Pocket Maximum PCY, includes deductible, coinsurance, copay and pharmacy if applicable (Family embedded OOP max 2X Individual) $4,000 Unlimited
Office Visit Cost Share $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
PREVENTIVE CARE OPTIONS AND HEALTH EDUCATION HERITAGE IN-NETWORK OUT-OF-NETWORK
Preventive Office Visit (Unlimited, subject to standard medical guidelines) Covered in Full Not Covered
Immunizations (Unlimited, subject to standard medical guidelines) Covered in Full Not Covered
Health Education (HE) (Unlimited) Covered in Full Not Covered
Nicotine Dependency Programs (ND) (Unlimited) Covered in Full Not Covered
Diabetes Health Education (DE) (Unlimited) Covered in Full Not Covered
PROFESSIONAL CARE HERITAGE IN-NETWORK OUT-OF-NETWORK
Professional Office Visit $7,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Telemedicine with Traditional Providers - General Medical $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
VIRTUAL CARE SERVICES HERITAGE IN-NETWORK OUT-OF-NETWORK
Telemedicine - General Medical (Virtual Care Only) $7,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum Not Covered
Telemedicine - Mental Health (Virtual Care Only) Subject to Mental Health Outpatient Professional Care In-Network Cost Share Not Covered
Telemedicine - Chemical Dependency (Virtual Care Only) Subject to Chemical Dependency Outpatient Office Visit Not Covered
DIAGNOSTIC SERVICE OPTIONS HERITAGE IN-NETWORK OUT-OF-NETWORK
Preventive Professional Diagnostic Imaging and Laboratory Services - Including Mammogram and PAP/PSA Covered in Full $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Other Professional Diagnostic Imaging $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Professional Diagnostic Major Imaging $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Other Professional Diagnostic Laboratory/Pathology $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Diagnostic Mammography $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
FACILITY CARE OPTIONS HERITAGE IN-NETWORK OUT-OF-NETWORK
Inpatient Facility $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Inpatient Professional Services $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Outpatient Surgery Facility $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Skilled Nursing Facility (60 days PCY; includes room and board, and facility billed professional and ancillary fees) $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
HOSPICE & HOME HEALTH CARE HERITAGE IN-NETWORK OUT-OF-NETWORK
Hospice Inpatient Facility (10 days Inpatient; within the 6 month lifetime maximum) $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Hospice Care (Hospice Home Visits Unlimited; Respite: 240 hours; within the 6 month lifetime maximum) $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
MATERNITY & REPRODUCTIVE CARE HERITAGE IN-NETWORK OUT-OF-NETWORK
Contraceptive Management Services (Unlimited) Covered in Full $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Sterilization - Female (Unlimited) Covered in Full $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Sterilization - Male (Unlimited) Subject to the IRS Minimum Deductibles, then 0% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
PREMERA DESIGNATED CENTERS OF EXCELLENCE HERITAGE IN-NETWORK OUT-OF-NETWORK
Centers of Excellence Packaged Services (Eligible Services Include: Total Joint Replacement (Knee & Hip Replacement)) $1,500/$3,000 Deductible, 0% Coinsurance, applies to $4,000 Out of Pocket Maximum Covered as any other service
Centers of Excellence for Radiology (Member Outreach Included) Covered as any other service Covered as any other service
MEDICAL TRANSPORTATION BENEFITS HERITAGE IN-NETWORK OUT-OF-NETWORK
Centers of Excellence Travel and Care Coordination (Limited to IRS Guidelines) $1,500/$3,000 Deductible, 0% Coinsurance, applies to $4,000 Out of Pocket Maximum $1,500/$3,000 Deductible, 0% Coinsurance, applies to $4,000 Out of Pocket Maximum
EMERGENCY CARE AND TRANSPORTATION OPTION HERITAGE IN-NETWORK OUT-OF-NETWORK
Emergency Care $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum
Emergency Room Physician $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum
Urgent Care Center $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum
Ambulance Transportation (Unlimited) $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum
ALTERNATIVE CARE HERITAGE IN-NETWORK OUT-OF-NETWORK
Acupuncture (7 2 visits PCY) $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Manipulations {Spinal and other) (7 2 visits PCY) $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
CHEMICAL DEPENDENCY & MENTAL HEALTH HERITAGE IN-NETWORK OUT-OF-NETWORK
Chemical Dependency Inpatient Facility Care (Unlimited) $7,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Chemical Dependency Outpatient Professional Care (Unlimited) $7,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Mental Health Inpatient Facility Care (Unlimited) $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum
Mental Health Outpatient Professional Care (Unlimited) $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
REHABILITATION & NEURO HERITAGE IN-NETWORK OUT-OF-NETWORK
Rehab Inpatient Facility (30 days PCY) $7,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Rehab Outpatient Care, Including Physical, Occupational, Speech and Massage Therapy, and Chronic Pain (45 visits PCY) $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Rehab Outpatient Care Chronic Conditions, Including Cardiac, Pulmonary Rehab, and Cancer $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
OTHER SERVICES HERITAGE IN-NETWORK OUT-OF-NETWORK
Allergy/Therapeutic Injections $7,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Medical Supplies, Equipment, Prosthetics (Unlimited) $1,500/$3,000 Deductible, then 20% Coinsurance, applies to $4,000 Out of Pocket Maximum $3,000/$6,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Transplants (Unlimited; $7,500 travel and lodging limits) Covered as any other service Not Covered
PHARMACY HERITAGE IN-NETWORK OUT-OF-NETWORK
Prescription Drugs - Retail (Specific preventive drugs and legend Retail 90 day supply/Mail 90 day supply/Specialty 30 day supply) $7,500/$3,000 Deductible, then 20% Coinsurance, applies to the $4,000 Out of Pocket Maximum $7,500/$3,000 Deductible, then 20% Coinsurance, applies to the $4,000 Out of Pocket Maximum
Prescription Drugs - Mail (Specific preventive drugs and legend Retail: 90 day supply/Mail: 90 day supply/Specialty: 30 day supply) $1,500/$3,000 Deductible, then 20% Coinsurance, applies to the $4,000 Out of Pocket Maximum Not Covered
Drug List Open A1 No Tiers Open A1 No Tiers
Specialty Pharmacy (Mandatory- Exclusive) $7,500/$3,000 Deductible, then 20% Coinsurance, applies to the $4,000 Out of Pocket Maximum Not Covered
SUPPLEMENTAL BENEFITS HERITAGE IN-NETWORK OUT-OF-NETWORK
Routine Vision Exam (7 PCY) $25 Copay $25 Copay
Vision Hardware ($150 every 2 consecutive calendar years) Covered in Full Covered in Full
Pediatric Vision Exam (7 PCY under age 19) $25 Copay, applies to the $4,000 Out of Pocket Maximum $25 Copay, applies to the $4,000 Out of Pocket Maximum
Pediatric Vision Hardware (Under age 19 One pair of glasses PCY (frames & lenses). 12 month supply of contacts PCY, in lieu of glasses (frames & lenses).) Covered in Full Covered in Full
ANNUAL PLAN MAXIMUM HERITAGE IN-NETWORK OUT-OF-NETWORK
Annual Plan Maximum Unlimited Unlimited

COVID tests

Here is the link to our COVID FAQ on the Employer website for them to reference. Premera Blue Cross Response to COVID-19 | Employer | Premera Blue Cross

As a Premera Blue Cross member, you have several ways to get tested for COVID-19 at no out-of-pocket cost.

Get free, at-home test kits

  • At an in-network pharmacy. Find an in-network pharmacy near you by signing in to your account on premera.com and searching Find a Doctor. You must present your Premera ID card at the pharmacy counter to obtain tests at no cost.
  • In Washington state, online at https://sayyescovidhometest.org/.
  • Online through ExpressScripts. Set up an account and get a kit shipped to your home. Additionally, Nomi Health is offering FDA-certified, at-home COVID tests for all Premera members. Order your test today
  • Medicare members, including those with Medicare Advantage, can get free tests through a Medicare-contracted pharmacy.

For information about how to accurately complete a self-test, visit the Centers for Disease Control and Prevention.

Get reimbursed

If you do pay for a COVID test, you can get reimbursed for the cost by submitting a claim form.

  • Download and print the claim form
  • Fill out the form
  • Follow the directions and send the completed claim form to the address on the form.

Additional information on submitting a claim form for reimbursement:

  • You may submit a claim for up to eight individual tests per covered family member every 30 days.
  • Reimbursement is limited to $12 maximum per test (which may include tax, shipping, and handling).
  • Tests must be used by members who have COVID symptoms or who have had direct exposure. They may not be used for the purpose of attending school, work, travel, or events.
  • Tests purchased out-of-pocket at in-network pharmacies and submitted for reimbursement are limited to $12 maximum per test.
  • The test must be approved, or granted Emergency Use Authorization (EUA), by the Food & Drug Administration (FDA). Check the EUA lists for approved Molecular Molecular and Antigen home test kits. Search “OTC” to limit results to eligible tests.
  • A member cannot be paid twice for a single test. If you use your FSA/HRA/HSA account debit card to purchase a test, it cannot be submitted to the plan for reimbursement. Go to a testing site

Go to a testing site