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Medical Plans Benefit GuideEmployers with 1-50 employees | 1.1.2016
b
Provider network built for value and quality ............................................2
Wellness rewards ...................................................................................3
Medical Travel Support and Air or Surface Transportation ......................4
Support for smart healthcare decisions ..................................................4
Easy-to-use online and mobile tools .......................................................5
Customer service experience .................................................................5
Premera health plans ..............................................................................6
The 10 essential benefits your plan covers .............................................6
Choose from a range of plans .................................................................7
Plan summaries ......................................................................................8
Optional benefits ..................................................................................21
Definitions ............................................................................................22
General exclusions and limitations ........................................................25
1
Welcome to 2016 Premera Blue Cross Blue Shield of Alaska Along with the great service and rich network access you have come to expect from Premera, we are pleased to offer benefits tailored for the needs of groups based in Alaska.
Robust provider network*Did you know that Premera boasts the largest provider network in Alaska? Remember that, depending on the Premera medical plan you purchase, your employees have access to over 3,000 providers and 20 hospitals all across Alaska. Together with the Blue Cross Blue Shield system, our extended network includes more than 6,900 hospitals and 1,014,000 physicians across the country — the largest contracted nationwide network available in the United States — delivering the broadest access and lowest total cost of care available in all markets. (See page 2.)
Wellness rewardsWe spend most of our time at work. What better place to encourage people to make healthy lifestyle choices? By offering robust rewards to employers and employees for participating in wellness programs, we aim to help employers inspire employees to engage in a wellness program based on the latest research to make the greatest impact to their health and well-being
Ask your Premera representative for more information about the embedded wellness rewards program. (See page 3.)
Medical Travel SupportAlso known as medical tourism, our Medical Travel Support is a voluntary program that gives members broader access to quality care at lower cost for certain approved procedures outside of Alaska within the Blues national network. The benefit covers travel costs for the member and a companion, up to the IRS guidelines. Talk to your producer or your Premera sales professional for more information. (See page 4.)
Cost transparency toolsAs soon as they choose a plan, your employees receive instant access to free, easy-to-use online and mobile tools that help them understand and track their medical spending and prescriptions, estimate costs, and review claim status. (See page 5.)
Thank you for considering Premera for your employer-sponsored benefits.
* Consortium Health Plans, Inc. Network Compare Key Findings as of June 5, 2015. Available at www.chpmarketquest.com.
2
Robust provider networkProvider network built for value and quality
The Premera network of doctors, hospitals, and other healthcare providers is designed to offer ready access to safe, effective, high-quality care at affordable prices.
Our strong relationships with our provider partners help maximize healthcare dollars by:
Focusing on quality and cost-effective care
Helping control rising medical costs
Providing resources for improved healthcare
Premera also offers an excellent national network of preferred providers for members to access when outside Alaska.
Members can use the Find a Doctor tool at premera.com to see if their favorite provider is in our network, or to find a new one.
Members choose from two network options
Balance Plus plans offer employees savings on health plan costs and give the highest benefit level to employees when they use preferred providers and hospitals.
Nonpreferred and nonparticipating or out-of-network facilities and providers are also covered, but at a lower benefit level.*
Balance Select plans give employees the same benefit whether their doctor is in the Premera network or not:
Employees have the flexibility to see the doctor of their choice and receive the highest benefit levels.*
When an employee needs care in a hospital setting, they will get the highest benefit levels at preferred facilities.
Non-preferred and nonparticipating or out-of-network facilities are also covered, but at a lower benefit level.*
Healthcare coverage wherever you go
National PPO accessWhen outside of Alaska, employees can access doctors and hospitals in the BlueCard network around the world. In the U.S., the BlueCard Program gives them peace of mind that they’ll be
able to find the healthcare provider they need anywhere in the lower 48. Outside of the U.S., the BlueCard Worldwide Program gives them access to hospitals in nearly 200 countries and territories around the world.
Blue Distinction Total CareA comprehensive solution for multi-state employers, this program integrates local value-based care programs from Blue Plans across the country. Programs are custom designed to meet local market needs while also meeting national standards in four impact-driven categories:
Value-based reimbursement
Accountability across the care continuum
Patient-centered quality care
Provider empowerment
Members who reside in geographic areas served by Blue Distinction Total Care are automatically assigned to these patient-centered, value-based programs.
* Balance billing may still apply if a provider is not contracted with Premera Blue Cross Blue Shield of Alaska. For more information about providers, visit premera.com and use the Find a Doctor tool.
3
Built-in rewards for wellness activitiesThe built-in wellness rewards program is a simple way to encourage your workforce to engage in wellness activities.
Your employees get access to tools designed to help them maintain and improve their health. Our wellness rewards program rewards both employers and employees. All program participation data sharing and reports are HIPAA-compliant.
Wellness tools
The wellness reward program offers:
Biometric screenings by using physician fax forms, home test kits, retail options, or at employer-sponsored on-site events
Health assessments when members log in to use the Premera online wellness tools
Rewards for employers
Employers can earn a premium discount based on employee participation. Ask your Premera representative how to get your group involved in a wellness rewards program.
Rewards for employees
Employees earn a generous reward card if they participate in a biometric screening and take a health assessment within a designated time frame.
4
Health support programs included in all plans:
Virtual care gives covered members immediate and convenient access to care from a physician via phone call, online video, or other online media to treat certain ailments such as cold and flu symptoms, ear infections, and bronchitis.
24-Hour NurseLine offers free, confidential health advice from a registered nurse by phone any time day or night.
CareCompass360° is a whole-person approach to health support that meets members’ needs wherever they land on the care continuum—whether they’re healthy or navigating complex conditions. Members receive easily accessible, appropriate health support services tailored to their health needs.
Maternity and newborn support program promotes healthier mothers and babies and reduces costs associated with high-risk pregnancies and newborns that end up in neonatal intensive care units.
Exclusive member discounts on fitness club memberships, weight loss programs, and many other health products and services not covered by their health plan.
Medical Travel SupportPremera’s Medical Travel Support benefit reimburses members for approved travel expenses when they travel for qualified medical procedures at pre-approved medical facilities in and outside of Alaska. Approved travel expenses are covered up to IRS guidelines for both the member and a travel companion.
Because the price of medical care may be lower outside Alaska, the member’s share of the medical costs may also be lower. Customer Service can also assist in medical records transfers if needed.
Air or Surface TransportationBeginning in 2016, all group plans will include a standard Air or Surface Transportation benefit of three round trips. Transportation to the nearest in-network location equipped to provide treatment is available for:
A life-endangering illness or injury
A required surgery that cannot be performed locally
An existing condition that cannot be treated locally
When transportation is for a child under the age of 18, the benefit also covers a parent or guardian to accompany the child.
4
Support for smart network decisionsPremera health support programs help your employees maintain good health and change unhealthy behavior.
5
Easy-to-use online and mobile toolsThese tools make it simple for administrators and your employees to manage money, care, and wellness.
Tools for plan administrators
We streamlined the experience of administering group plans with easy-to-use online tools.
You can view helpful information such as:
Administrator’s Quick Reference Guide
Employer contract and member benefit booklet
Medical and dental invoices
You can add and make changes to employee enrollment information, including ordering identification cards. You can also contribute and monitor allocations to health reimbursement accounts (HRAs) and health savings accounts (HSAs).
Online tools for members
Members register and log in at premera.com to use tools securely:
Find and compare providers, including qualifications and user reviews with Find a Doctor.
Enter different coverage options to see how choices affect costs before deciding on a health plan with the Treatment Cost Estimator.
Review status of medical, prescription drug, and dental claims.
Manage and monitor consumer-driven health plans (HSA and HRA) spending and saving amounts, including reviewing account balances.
Access pharmacy information and order prescriptions
Award-winning mobile apps
Premera app — Find nearby doctors and clinics, look up benefits, and check claims.
ExpressScripts pharmacy app — Track medications, order prescriptions, and find a pharmacy.
ConnectYourCare app — Check spending and account balances on health savings accounts (HSA).
Wellness apps — Track activities, participate in fun fitness challenges, and get healthier.
Customer service experience
All Premera customer service representatives are fully trained to provide excellent service to members. Our representatives are especially knowledgeable about the unique needs of Alaska, such as:
Alaska’s logistical challenges
Alaskan culture
Our customer service standard is first call resolution.
6
Premera health plans
INSURANCE PLANS
MONTHLY PREMIUM
IN-NETWORK DEDUCTIBLE
INSURANCE PAYS
Bronze Plans $ $$$ $Silver Plans $$ $$ $$Gold Plans $$$ $ $$$
Premera offers a wide range of Bronze, Silver, and Gold plans. Each plan covers the 10 essential benefits as required by the Affordable Care Act (ACA)
7 Rehabilitative and habilitative services and devices — to help gain or regain mental and physical skills in case of injury, disability, or chronic condition. Includes inpatient rehabilitation; physical, speech, and occupational therapy; durable medical equipment; or skilled nursing.
8 Laboratory services — covers lab tests, X-ray services, and pathology, and imaging and diagnostics such as MRI, CT scan, and PET scan.
9 Preventive/Wellness services and chronic disease management — includes mammograms, colonoscopies, vaccines, and more. Covered in full if you use in-network providers for care such as routine physicals, screening, and immunizations. Care management programs and services seek to coordinate care for a variety of chronic conditions, such as diabetes and asthma.
Pediatric services — Kids are covered for vision care (eye exam, lenses, and eyewear).
1 Ambulatory patient services — such as office visits to your in-network primary care doctor or specialists.
2 Emergency services — for issues that could lead to death or disability if you do not treat them.
3 Hospitalization — covers room and board, tests, drugs, and care from doctors and nurses while admitted; includes organ and tissue transplants, and hospice and respite care.
4 Maternity and newborn care — covers prenatal and postnatal care, delivery and inpatient maternity services, plus newborn child care.
5 Mental health and substance use disorder services, including behavioral health treatment — covers inpatient hospital and outpatient mental and behavioral health.
6 Prescription drugs — covers retail, mail order, and specialty drugs.
10
7
9
8
10
1
4
2
3
5
6
The 10 essential benefits your plan covers:
These essential benefits focus on prevention
and primary care to help people stay healthy.
They also aim to manage chronic medical
conditions before these conditions become
more complex.
7
INSURANCE PLANS
MONTHLY PREMIUM
IN-NETWORK DEDUCTIBLE
INSURANCE PAYS
Bronze Plans $ $$$ $Silver Plans $$ $$ $$Gold Plans $$$ $ $$$
Choose from a range of plansHelp your employees find the right balance between their budget and their healthcare needs.
Balance PCP
These innovative plans offer a combination of upfront, first-dollar benefits, and standard coverage for other services. The difference is that a lower copay applies when a member designates and gets care from a primary care provider (PCP).
Balance PPO
Our preferred provider plans offer a combination of upfront, first-dollar benefits, and standard coverage for other services.
Balance HSA
The Balance HSA plans offer valuable benefits for covered services and are qualified to work in combination with an employee-owned, tax-advantaged health savings account (HSA).
Balance HRA
The Balance HRA plan offers valuable benefits for covered services and works in combination with an employer-owned, health reimbursement arrangement (HRA). The employer contributes half of the pre-defined deductible amount in the HRA, and employees are reimbursed from the HRA after they meet the first half of the plans deductible.
8
A full list of services is available on premera.com/ak/member
In-network Non-participating
30% 60%
Office VisitsFirst 6 visits PCY $30/deductible
waived, otherwise deductible, then coinsurance
Deductible, then 30%
Network Heritage Plus
1 Deductible, then 30%
$30
2
3 Hospitalization
4
5 Office visit
Inpatient hospital: mental/behavioral health
6
Therapy
Laboratory Services
8
9
10 Prescription Drugs Retail up to 90-day supply (3x 30 day supply cost)
Mail Order 90-day supply; 3x retail supply cost
Specialty Rx 30-day supply
Drug Formulary X4
Additional benefits embedded within the medical planHearing
Out-of-Pocket
Rehabilitative and habiltative benefits have the same number of visits, but are counted separately
10 Essential Benefits Covered Services
Office visits
Designated PCP office visit
Per Calendar Year = PCYFamily = 2x individual deductible (in-network only)
Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment
Rehabilitative & Habilitative Services & Devices
Maternity & Newborn Care
Ambulatory Patient Services Outpatient services
Emergency Services
Outpatient services
Deductible, then 30%
Non-preferred
$6,850
$5,500 / $6,350 2x individual deductible
Unlimited
Individual Deductible
Coinsurance Amount you pay after your deductible is met
Family = 2x Ind. out-of-pocket-max (in-network only)
BALANCE PLUS BRONZE PCP
Balance Plus Bronze PCPAlaska plans for group 1-50Beginning January 1, 2016The deductible applies whenever there is a coinsurance listed, unless otherwise noted.
Not covered
Deductible, then 30%
Durable medical equipment
Skilled nursing facility: 60 days PCY
Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services) Deductible, then 30%
Physical, speech, occupational, massage therapy: 45 visits PCY
Inpatient rehabilitation: 30 days PCYInpatient habilitation: 30 days PCY
Deductible, then 30%
Spinal manipulation (12 visits PCY);Acupuncture (12 visits PCY)
Prenatal, delivery, postnatal care
Emergent: Same as in-networkNon-emergent: Air – Ded, then 40% / Ded, then 60%;
Ground – Same as in-network
Deductible, then 30%
Inpatient
Organ and tissue transplants, inpatient unlimited, except $75,000 donor coverage limit and $7,500 travel and lodging per transplant
Ambulance transportation (air & ground)
Emergency careCopay waived if directly admitted to inpatient facility
Hospice: 10 days inpatientRespite care: 240 hours lifetime
Deductible, then 40% Deductible, then 60%
Deductible, then 40% Deductible, then 60%
$200 Copay, then in-network deductible & coinsurance
$25 copay, then deductible & in-network coinsurance
7
Orthodontia (medically necessary only)
Exams and immunizations
Eye exam: 1 PCY
Screenings
Dental: preventive/basic/major
Pediatric Services,including Vision CareUnder 19 years of age
40%
Non-designated PCP or specialist office visit
Deductible, then 40% Deductible, then 60%
Out-of-network
Includes deductible, coinsurance, and copays
Deductible, then 40% Deductible, then 60%
Deductible, then 40% Deductible, then 60%
Deductible, then 40% Deductible, then 60%
4-Tier: Generic/Brand/Non-Preferred Brand/Specialty
$35 /Deductible, then 50% /Deductible, then 50% /Deductible, then 30%
Retail: Same as in-networkMail order & specialty: not covered
Preventive/Wellness Services & Chronic Disease Management Deductible, then 60%
Eyewear: One pair of glasses PCY (frames & lenses); or 12-month supply of contacts PCY, in lieu of glasses (frames & lenses)
Deductible waived, then 10%
Covered in full
Not covered
Not covered
Covered in full Deductible, then 40%
Covered in fullHearing aids and hardware: $1,000/3 calendar years
Hearing exam: 1 per 2 calendar years Deductible waived, then 20%
Deductible, then 40% Deductible, then 60%
9
A full list of services is available on premera.com/ak/member
In-network Non-participating
30% 60%
Office Visits$25 copay
First 2 PCP visits covered in full
$45
Network Heritage Plus
1 Deductible, then 30%
$25
2
3 Hospitalization
4
5 Office visit $45
Inpatient hospital: mental/behavioral health Deductible, then 30%
Deductible, then 30%
6
Therapy
Deductible, then 30%
Deductible, then 30%
8
9
10 Prescription Drugs Retail up to 90-day supply (3x 30 day supply cost)
Mail Order 90-day supply; 3x retail supply cost
Specialty Rx 30-day supply
Drug Formulary X4
Additional benefits embedded within the medical planHearing
Covered in fullHearing aids and hardware: $1,000/3 calendar years
Hearing exam: 1 per 2 calendar years $45
4-Tier: Generic/Brand/Non-Preferred Brand/Specialty
$15 /$50 /
$150 /Deductible, then 30%
Retail: Same as in-networkMail order & specialty: not covered
Not covered
Covered in full Deductible, then 40%
Non-designated PCP or specialist office visit
Deductible, then 40% Deductible, then 60%
Out-of-network
Deductible, then 40% Deductible, then 60%
Spinal manipulation (12 visits PCY);Acupuncture (12 visits PCY)
Prenatal, delivery, postnatal care
Emergent: Same as in-networkNon-emergent: Air – Ded, then 40% / Ded, then 60%;
Ground – Same as in-network
Deductible, then 30%
Inpatient
Organ and tissue transplants, inpatient unlimited, except $75,000 donor coverage limit and $7,500 travel and lodging per transplant
$25 copay, then deductible & in-network coinsurance
Emergency careCopay waived if directly admitted to inpatient facility
Hospice: 10 days inpatientRespite care: 240 hours lifetime
$200 Copay, then in-network deductible & coinsuranceEmergency Services
Not covered
Deductible, then 30%
Deductible, then $45
Preventive/Wellness Services & Chronic Disease Management Deductible, then 60%
Eyewear: One pair of glasses PCY (frames & lenses); or 12-month supply of contacts PCY, in lieu of glasses (frames & lenses)
$45
Covered in full
Deductible, then 30%
Durable medical equipment
Skilled nursing facility: 60 days PCY
Deductible, then 30%
Ambulance transportation (air & ground)
Deductible, then 40% Deductible, then 60%
Deductible, then 40% Deductible, then 60%
Not covered
Physical, speech, occupational, massage therapy: 45 visits PCY
Inpatient rehabilitation: 30 days PCYInpatient habilitation: 30 days PCY
Deductible, then 60%
Deductible, then 40% Deductible, then 60%
Deductible, then 40% Deductible, then 60%
Deductible, then 40%
7
Orthodontia (medically necessary only)
Exams and immunizations
Eye exam: 1 PCY
Screenings
Dental: preventive/basic/major
Laboratory Services Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services)
Pediatric Services,including Vision CareUnder 19 years of age
Non-preferred
$6,850
$2,000 2x individual deductible
Unlimited
BALANCE PLUS SILVER PCP
Balance Plus Silver PCP
The deductible applies whenever there is a coinsurance listed, unless otherwise noted.
Includes deductible, coinsurance, and copaysOut-of-Pocket Maximum
Per Calendar Year = PCYFamily = 2x individual deductible (in-network only)
40%
Rehabilitative and habiltative benefits have the same number of visits, but are counted separately
Alaska plans for group 1-50Beginning January 1, 2016
10 Essential Benefits Covered Services
Office visits
Designated PCP office visit
Individual Deductible
Coinsurance Amount you pay after your deductible is met
Family = 2x Ind. out-of-pocket-max (in-network only)
Outpatient services
Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment
Rehabilitative & Habilitative Services & Devices
Maternity & Newborn Care
Ambulatory Patient Services Outpatient services
10
A full list of services is available on premera.com/ak/member
In-network Non-participating
20% 60%
Office Visits$10 copay
First 2 PCP visits covered in full
$30 / $40
Network Heritage Plus
1 Deductible, then 20%
$10
2
3 Hospitalization
4
5 Office visit $30 / $40
Inpatient hospital: mental/behavioral health Deductible, then 20%
Deductible, then 20%
6
Therapy
Deductible, then 20%
Deductible, then 20%
8
9
10 Prescription Drugs Retail up to 90-day supply (3x 30 day supply cost)
Mail Order 90-day supply; 3x retail
Specialty Rx 30-day supply
Drug Formulary X4
Additional benefits embedded within the medical planHearing
4-Tier: Generic/Brand/Non-Preferred Brand/Specialty
500 - $20 / $40 / Deductible waived, then 50% /
Deductible, then 20%1000 - $10 / $40 /
Deductible waived, then 50% /Deductible waived, then 20%
Retail: Same as in-networkMail order & specialty: not covered
$25 copay, then deductible & in-network coinsurance
Deductible, then 20%
500 - Deductible, then $30 1000 - Deductible, then $40
Ambulance transportation (air & ground)
Outpatient services
Deductible, then 60%
Eyewear: One pair of glasses PCY (frames & lenses); or 12-month supply of contacts PCY, in lieu of glasses (frames & lenses)
$30 / $40
Covered in full
Covered in full Deductible, then 40%
Covered in fullHearing aids and hardware: $1,000/3 calendar years
Hearing exam: 1 per 2 calendar years $30 / $40
Not covered
Not covered
Deductible, then 40% Deductible, then 60%
Out-of-network
Deductible, then 40% Deductible, then 60%
Emergent: Same as in-networkNon-emergent: Air – Ded, then 40% / Ded, then 60%;
Ground – Same as in-network
$200 Copay, then in-network deductible & coinsurance
Deductible, then 40%
Deductible, then 20%
Deductible, then 20%
Deductible, then 60%
Deductible, then 40% Deductible, then 60%
Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment
Rehabilitative & Habilitative Services & Devices
Non-designated PCP or specialist office visit
Spinal manipulation (12 visits PCY);Acupuncture (12 visits PCY)
Prenatal, delivery, postnatal care
Inpatient
Organ and tissue transplants, inpatient unlimited, except $75,000 donor coverage limit and $7,500 travel and lodging per transplant
Emergency careCopay waived if direct admitted to inpatient facility
Hospice: 10 days inpatientRespite care: 240 hours lifetime
Deductible, then 40% Deductible, then 60%
Deductible, then 40% Deductible, then 60%
Rehabilitative and habiltative benefits have the same number of visits, but are counted separately
Durable medical equipment
Skilled nursing facility: 60 days PCY
Deductible, then 40% Deductible, then 60%
Not covered
7
Orthodontia (medically necessary only)
Exams and immunizations
Eye exam: 1 PCY
Screenings
Dental: preventive/basic/major
Laboratory Services Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services)
Preventive/Wellness Services & Chronic Disease Management
Pediatric Services,including Vision CareUnder 19 years of age
Deductible, then 20%
Physical, speech, occupational, massage therapy: 45 visits PCY
Inpatient rehabilitation: 30 days PCYInpatient habilitation: 30 days PCY
Non-preferred
$5,000
$500 / $1,000 2x individual deductible
Unlimited
BALANCE PLUS GOLD PCP
Balance Plus Gold PCP
Includes deductible, coinsurance, and copaysOut-of-Pocket Maximum
Per Calendar Year = PCYFamily = 2x individual deductible (in-network only)
40%
Alaska plans for group 1-50Beginning January 1, 2016The deductible applies whenever there is a coinsurance listed, unless otherwise noted.
Individual Deductible
Coinsurance Amount you pay after your deductible is met
Family = 2x Ind. out-of-pocket-max (in-network only)
Outpatient services
Maternity & Newborn Care
Ambulatory Patient Services
10 Essential Benefits Covered Services
Office visits
Designated PCP office visit
Emergency Services
11
A full list of services is available on premera.com/ak/member
In-network Non-participating
Individual: $4,500 / $5,250 Family: $9,000 /$10,500
30% 60%
Office Visits Cost share Deductible, then 30%
Network Heritage Plus
1
2
3 Hospitalization
4
5 Office visit
Inpatient hospital: mental/behavioral health
6
Therapy
Laboratory Services
8
9
10 Prescription Drugs Retail up to 90-day supply
Mail Order 90-day supply
Specialty Rx 30-day supply
Drug Formulary X1
Additional benefits embedded within the medical planHearing
Deductible, then 20%Hearing aids and hardware: $1,000/3 calendar years
Hearing exam: 1 per 2 calendar years
Deductible, then 40% Deductible, then 60%
Out-of-network
Deductible, then 30%
Durable medical equipment
Skilled nursing facility: 60 days PCY
Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services)
Deductible, then 30%
Deductible, then 30%
Physical, speech, occupational, massage therapy: 45 visits PCY
Deductible, then 40% Deductible, then 60%
Deductible, then 40%
Deductible, then 30%Retail: Same as in-network
Mail order & specialty: not covered
Preventive/Wellness Services & Chronic Disease Management Deductible, then 60%
Eyewear: One pair of glasses PCY (frames & lenses); or 12-month supply of contacts PCY, in lieu of glasses (frames & lenses)
Deductible waived, then 10%
Covered in full
Not covered
Not covered
Covered in full Deductible, then 40%
Orthodontia (medically necessary only)
Exams and immunizations
Eye exam: 1 PCY
Screenings
Deductible, then 60%
Deductible, then 40% Deductible, then 60%
7
Dental: preventive/basic/major
Pediatric Services,including Vision CareUnder 19 years of age
Emergency care
Hospice: 10 days inpatientRespite care: 240 hours lifetime
Rehabilitative and habiltative benefits have the same number of visits, but are counted separately
Rehabilitative & Habilitative Services & Devices
Inpatient rehabilitation: 30 days PCYInpatient habilitation: 30 days PCY
Deductible, then 40% Deductible, then 60%
Deductible, then 30%
Deductible, then 30%
Deductible, then 40%
Deductible, then 30%
Deductible, then 30%
Deductible, then 60%
Emergent: Same as in-networkNon-emergent: Air – Ded, then 40% / Ded, then 60%;
Ground – Same as in-network
Deductible, then 30%
Inpatient
Organ and tissue transplants, inpatient unlimited, except $75,000 donor coverage limit and $7,500 travel and lodging per transplant
Ambulance transportation (air & ground)
Not covered
Deductible, then 40% Deductible, then 60%
Non-preferred
Unlimited
Individual Deductible
Coinsurance Amount you pay after your deductible is met
Family = 2x individual (embedded)
BALANCE PLUS BRONZE HSA
Balance Plus Bronze HSA
Includes deductible, coinsurance, and copaysOut-of-Pocket Maximum
2x individual deductible
40%
Individual: $6,450Family: $12,900
Alaska plans for group 1-50Beginning January 1, 2016The deductible applies whenever there is a coinsurance listed, unless otherwise noted.
10 Essential Benefits Covered Services
Office visits
Per Calendar Year = PCYFamily = 2x individual (embedded)
Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment
Maternity & Newborn Care
Ambulatory Patient Services Outpatient services
Emergency Services
Outpatient services
Spinal manipulation (12 visits PCY);Acupuncture (12 visits PCY)
Prenatal, delivery, postnatal care
12
A full list of services is available on premera.com/ak/member
In-network Non-participating
Individual: $3,000Family: $6,000
30% 60%
Individual: $4,400
Family: $8,800
Office Visits Deductible, then 30%
Network Heritage Plus
1
2
3 Hospitalization
4
5 Office visit
Inpatient hospital: mental/behavioral health
6
Therapy
Laboratory Services
8
9
10 Prescription Drugs Retail up to 90-day supply
Mail Order 90-day supply
Specialty Rx 30-day supply
Drug Formulary X1
Additional benefits embedded within the medical planHearing
Spinal manipulation (12 visits PCY);Acupuncture (12 visits PCY)
Deductible, then 40% Deductible, then 60%
Deductible, then 30%
Deductible, then 40% Deductible, then 60%
Deductible, then 30%
Deductible, then 30%
Deductible, then 40% Deductible, then 60%
Deductible, then 40% Deductible, then 60%
Deductible, then 30%
Out-of-network
Emergent: Same as in-networkNon-emergent: Air – Ded, then 40% / Ded, then 60%;
Ground – Same as in-network
Not covered
Individual Deductible
Coinsurance Amount you pay after your deductible is met
Family = 2x individual (embedded)
Ambulatory Patient Services
Prenatal, delivery, postnatal careMaternity & Newborn Care
7
Deductible, then 60%
Rehabilitative and habiltative benefits have the same number of visits, but are counted separately
Outpatient services
Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment
Rehabilitative & Habilitative Services & Devices
Deductible, then 60%
Deductible, then 40% Deductible, then 60%
Inpatient rehabilitation: 30 days PCYInpatient habilitation: 30 days PCY
Emergency Services
Non-preferred
2x individual deductible
Unlimited
BALANCE PLUS SILVER HSA
Balance Plus Silver HSA
Includes deductible, coinsurance, and copaysOut-of-Pocket Maximum
Per Calendar Year = PCYFamily = 2x individual (embedded)
40%
Alaska plans for group 1-50Beginning January 1, 2016The deductible applies whenever there is a coinsurance listed, unless otherwise noted.
10 Essential Benefits Covered Services
Office visits
Cost share
Dental: preventive/basic/major
Pediatric Services,including Vision CareUnder 19 years of age
Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services) Deductible, then 30%
Physical, speech, occupational, massage therapy: 45 visits PCY
Deductible, then 30%Retail: Same as in-network
Mail order & specialty: not covered
Preventive/Wellness Services & Chronic Disease Management Deductible, then 60%
Eyewear: One pair of glasses PCY (frames & lenses); or 12-month supply of contacts PCY, in lieu of glasses (frames & lenses)
Deductible waived, then 10%
Covered in full
Not covered
Not covered
Covered in full Deductible, then 40%
Orthodontia (medically necessary only)
Exams and immunizations
Eye exam: 1 PCY
Screenings
Deductible, then 20%Hearing aids and hardware: $1,000/3 calendar years
Hearing exam: 1 per 2 calendar years
Deductible, then 30%
Outpatient services
Deductible, then 30%
Inpatient
Organ and tissue transplants, inpatient unlimited, except $75,000 donor coverage limit and $7,500 travel and lodging per transplant
Ambulance transportation (air & ground)
Emergency Care
Hospice: 10 days inpatientRespite care: 240 hours lifetime
Deductible, then 40%Deductible, then 30%
Durable medical equipment
Skilled nursing facility: 60 days PCY
Deductible, then 40%
13
A full list of services is available on premera.com/ak/member
In-network Non-participating
Required Employer Contribution Family = 2x employer contribution $1,500
20% 60%
Office Visits$15 copay
First 2 PCP visits covered in full
$45
Network Heritage Plus
1 Deductible, then 20%
$15
2
3 Hospitalization
4
5 Office visit $45
Inpatient hospital: mental/behavioral health Deductible, then 20%
Deductible, then 20%
6
Therapy
Deductible, then 20%
Deductible, then 20%
8
9
10 Prescription Drugs Retail up to 90-day supply (3x 30 day supply cost)
Mail Order 90-day supply; 3x retail
Specialty Rx 30-day supply
Drug Formulary X4
Additional benefits embedded within the medical planHearing
Coinsurance Amount you pay after your deductible is met
Family = 2x Ind. out-of-pocket-max (in-network only)
Outpatient services
Maternity & Newborn Care
Ambulatory Patient Services
10 Essential Benefits Covered Services
Office visits
Designated PCP office visit
Emergency Services
Non-preferred
$6,850
$3,000 2x individual deductible
Unlimited
BALANCE PLUS GOLD PCP
Balance Plus Gold HRA
Includes deductible, coinsurance, and copaysOut-of-Pocket Maximum
Per Calendar Year = PCYFamily = 2x individual deductible (in-network only)
40%
Alaska plans for group 1-50Beginning January 1, 2016The deductible applies whenever there is a coinsurance listed, unless otherwise noted.
2x individual
Individual Deductible
Deductible, then 40% Deductible, then 60%
Not covered
7
Orthodontia (medically necessary only)
Exams and immunizations
Eye exam: 1 PCY
Screenings
Dental: preventive/basic/major
Laboratory Services Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services)
Preventive/Wellness Services & Chronic Disease Management
Pediatric Services,including Vision CareUnder 19 years of age
Deductible, then 20%
Physical, speech, occupational, massage therapy: 45 visits PCY
Inpatient rehabilitation: 30 days PCYInpatient habilitation: 30 days PCY
Deductible, then 40% Deductible, then 60%
Deductible, then 40% Deductible, then 60%
Rehabilitative and habiltative benefits have the same number of visits, but are counted separately
Durable medical equipment
Skilled nursing facility: 60 days PCY
Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment
Rehabilitative & Habilitative Services & Devices
Non-designated PCP or specialist office visit
Spinal manipulation (12 visits PCY);Acupuncture (12 visits PCY)
Prenatal, delivery, postnatal care
Inpatient
Organ and tissue transplants, inpatient unlimited, except $75,000 donor coverage limit and $7,500 travel and lodging per transplant
Emergency careCopay waived if directly admitted to inpatient facility
Hospice: 10 days inpatientRespite care: 240 hours lifetime
Deductible, then 40% Deductible, then 60%
Out-of-network
Deductible, then 40% Deductible, then 60%
Emergent: Same as in-networkNon-emergent: Air – Ded, then 40% / Ded, then 60%;
Ground – Same as in-network
$200 Copay, then in-network deductible & coinsurance
Deductible, then 40%
Deductible, then 20%
Deductible, then 20%
Deductible, then 60%
Deductible, then 40% Deductible, then 60%
Covered in fullHearing aids and hardware: $1,000/3 calendar years
Hearing exam: 1 per 2 calendar years $45
Not covered
Not covered
4-Tier: Generic/Brand/Non-Preferred Brand/Specialty
$15 /$50 /
Deductible waived, then 50% /Deductible, then 30%
Retail: Same as in-networkMail order & specialty: not covered
$25 copay, then deductible & in-network coinsurance
Deductible, then 20%
Deductible, then $45
Ambulance transportation (air & ground)
Outpatient services
Deductible, then 60%
Eyewear: One pair of glasses PCY (frames & lenses); or 12-month supply of contacts PCY, in lieu of glasses (frames & lenses)
$45
Covered in full
Covered in full Deductible, then 40%
14
A full list of services is available on premera.com/ak/member
In-network Non-participating
Pharmacy Deductible Family = 2x individual pharmacy deductible $1,700
60%
Office Visits
Network
1 Deductible, then 30%
$35
2
3 Hospitalization
4
5 Office visit
Inpatient hospital: mental/behavioral health
6
Therapy
Laboratory Services
8
9
10 Prescription Drugs Retail up to 90-day supply (3x 30 day supply cost)
Mail Order 90-day supply; 3x retail supply cost
Specialty Rx 30-day supply
Drug Formulary X4
Additional benefits embedded within the medical planHearing
Balance Plus Bronze PCP 5000/1700 Rx
4-Tier: Generic/Brand/Non-Preferred Brand/Specialty
$25 /Rx Deductible, then 50% /Rx Deductible, then 50% /Rx Deductible, then 50%
Retail: Same as in-networkMail order & specialty: not covered
Preventive/Wellness Services & Chronic Disease Management Deductible, then 60%
Eyewear: One pair of glasses PCY (frames & lenses); or 12-month supply of contacts PCY, in lieu of glasses (frames & lenses)
Deductible waived, then 10%
Covered in full
Not covered
40%
Non-designated PCP or specialist office visit
Deductible, then 40% Deductible, then 60%
Out-of-network
Includes deductible, coinsurance, and copays
Covered in fullHearing aids and hardware: $1,000/3 calendar years
Hearing exam: 1 per 2 calendar years Deductible waived, then 20%
Deductible, then 40% Deductible, then 60%
Not covered
Covered in full Deductible, then 40%
Deductible, then 30%
Orthodontia (medically necessary only)
Exams and immunizations
Eye exam: 1 PCY
Screenings
Deductible, then 40% Deductible, then 60%
Deductible, then 40% Deductible, then 60%
$200 Copay, then in-network deductible & coinsurance
$25 copay, then deductible & in-network coinsurance
Emergent: Same as in-networkNon-emergent: Air – Ded, then 40% / Ded, then 60%;
Ground – Same as in-network
Inpatient
Organ and tissue transplants, inpatient unlimited, except $75,000 donor coverage limit and $7,500 travel and lodging per transplant
Ambulance transportation (air & ground)
7
Inpatient rehabilitation: 30 days PCYInpatient habilitation: 30 days PCY
Outpatient services
Dental: preventive/basic/major
Pediatric Services,including Vision CareUnder 19 years of age
Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services)
Physical, speech, occupational, massage therapy: 45 visits PCY
Not covered
Deductible, then 30%
Durable medical equipment
Skilled nursing facility: 60 days PCY
Prenatal, delivery, postnatal care Deductible, then 60%
Deductible, then 40% Deductible, then 60%
Deductible, then 40% Deductible, then 60%
Deductible, then 40%Deductible, then 30%
Deductible, then 30%
Deductible, then 30%
$5,000 2x individual deductible
Unlimited
Individual Deductible
Coinsurance Amount you pay after your deductible is met
Family = 2x Ind. out-of-pocket-max (in-network only)
BALANCE PLUS BRONZE PCPThe deductible applies whenever there is a coinsurance listed, unless otherwise noted.
Shared with in-network pharmacy deductible
Out-of-Pocket
Rehabilitative and habiltative benefits have the same number of visits, but are counted separately
Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment
Rehabilitative & Habilitative Services & Devices
Maternity & Newborn Care
Emergency Services Emergency careCopay waived if direct admitted to inpatient facility
Hospice: 10 days inpatientRespite care: 240 hours lifetime
Non-preferred
30%
$6,850
First 6 visits PCY $35/deductible waived, otherwise deductible, then
coinsurance
Deductible, then 30%
Heritage Plus
Alaska plans for group 1-50Beginning January 1, 2016
10 Essential Benefits Covered Services
Office visits
Designated PCP office visit
Per Calendar Year = PCYFamily = 2x individual deductible (in-network only)
Ambulatory Patient Services Outpatient services
Spinal manipulation (12 visits PCY);Acupuncture (12 visits PCY)
15
A full list of services is available on premera.com/ak/member
In-network Non-participating
Pharmacy Deductible Family = 2x individual pharmacy deductible $1,500
30% 60%
Office Visits$20 copay
First 2 PCP visits covered in full
$40
Network Heritage Plus
1 Deductible, then 30%
$20
2
3 Hospitalization
4
5 Office visit $40
Inpatient hospital: mental/behavioral health Deductible, then 30%
Deductible, then 30%
6
Therapy
Deductible, then 30%
Deductible, then 30%
8
9
10 Prescription Drugs Retail up to 90-day supply (3x 30 day supply cost)
Mail Order 90-day supply; 3x retail supply cost
Specialty Rx 30-day supply
Drug Formulary X4
Additional benefits embedded within the medical planHearing
Balance Plus Silver PCP 3000/1500 Rx
Rehabilitative and habiltative benefits have the same number of visits, but are counted separately
Alaska plans for group 1-50Beginning January 1, 2016
10 Essential Benefits Covered Services
Office visits
Designated PCP office visit
Individual Deductible
Coinsurance Amount you pay after your deductible is met
Family = 2x Ind. out-of-pocket-max (in-network only)
Outpatient services
Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment
Rehabilitative & Habilitative Services & Devices
Maternity & Newborn Care
Ambulatory Patient Services Outpatient services
Physical, speech, occupational, massage therapy: 45 visits PCY
Inpatient rehabilitation: 30 days PCYInpatient habilitation: 30 days PCY
Non-preferred
$6,850
$3,000 2x individual deductible
Unlimited
Deductible, then 40%
Deductible, then 60%
Organ and tissue transplants, inpatient unlimited, except $75,000 donor coverage limit and $7,500 travel and lodging per transplant
$25 copay, then deductible & in-network coinsurance
Emergency careCopay waived if directly admitted to inpatient facility
Hospice: 10 days inpatientRespite care: 240 hours lifetime
BALANCE PLUS SILVER PCPThe deductible applies whenever there is a coinsurance listed, unless otherwise noted.
Includes deductible, coinsurance, and copaysOut-of-Pocket Maximum
Per Calendar Year = PCYFamily = 2x individual deductible (in-network only)
40%
Shared with in-network pharmacy deductible
7
Orthodontia (medically necessary only)
Exams and immunizations
Eye exam: 1 PCY
Screenings
Dental: preventive/basic/major
Laboratory Services Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services)
Pediatric Services,including Vision CareUnder 19 years of age
Deductible, then 60%
Not covered
Deductible, then 60%
Deductible, then 40% Deductible, then 60%
Deductible, then 40% Deductible, then 60%
$200 Copay, then in-network deductible & coinsuranceEmergency Services
Not covered
Deductible, then 30%
Deductible, then $40
Preventive/Wellness Services & Chronic Disease Management Deductible, then 60%
Eyewear: One pair of glasses PCY (frames & lenses); or 12-month supply of contacts PCY, in lieu of glasses (frames & lenses)
$40
Covered in full
Deductible, then 30%
Durable medical equipment
Skilled nursing facility: 60 days PCY
Deductible, then 30%
Ambulance transportation (air & ground)
Deductible, then 40%
4-Tier: Generic/Brand/Non-Preferred Brand/Specialty
$15 /Rx Deductible, then 30% /Rx Deductible, then 30% /Rx Deductible, then 30%
Retail: Same as in-networkMail order & specialty: not covered
Not covered
Covered in full Deductible, then 40%
Covered in fullHearing aids and hardware: $1,000/3 calendar years
Hearing exam: 1 per 2 calendar years $40
Non-designated PCP or specialist office visit40% 60%
Out-of-network
Deductible, then 40% Deductible, then 60%
Spinal manipulation (12 visits PCY);Acupuncture (12 visits PCY)
Prenatal, delivery, postnatal care
Emergent: Same as in-networkNon-emergent: Air – Ded, then 40% / Ded, then 60%;
Ground – Same as in-network
Deductible, then 30%
Inpatient
Deductible, then 40%
16
A full list of services is available on premera.com/ak/member
In-network Non-participating
Pharmacy Deductible Family = 2x individual pharmacy deductible $500
20% 60%
Office Visits$10 copay
First 2 PCP visits covered in full
$35
Network Heritage Plus
1 Deductible, then 20%
$10
2
3 Hospitalization
4
5 Office visit $35
Inpatient hospital: mental/behavioral health Deductible, then 20%
Deductible, then 20%
6
Therapy
Deductible, then 20%
Deductible, then 20%
8
9
10 Prescription Drugs Retail up to 90-day supply (3x 30 day supply cost)
Mail Order 90-day supply; 3x retail
Specialty Rx 30-day supply
Drug Formulary X4
Additional benefits embedded within the medical planHearing
Balance Plus Gold PCP 1500/500 Rx
4-Tier: Generic/Brand/Non-Preferred Brand/Specialty
$10 /Rx Deductible, then 20% /Rx Deductible, then 20% /Rx Deductible, then 20%
Retail: Same as in-networkMail order & specialty: not covered
$25 copay, then deductible & in-network coinsurance
Deductible, then 20%
Deductible, then $35
Ambulance transportation (air & ground)
Outpatient services
Deductible, then 60%
Eyewear: One pair of glasses PCY (frames & lenses); or 12-month supply of contacts PCY, in lieu of glasses (frames & lenses)
$35
Covered in full
Covered in full Deductible, then 40%
Covered in fullHearing aids and hardware: $1,000/3 calendar years
Hearing exam: 1 per 2 calendar years $35
Not covered
Not covered
Deductible, then 40% Deductible, then 60%
Out-of-network
Deductible, then 40% Deductible, then 60%
Emergent: Same as in-networkNon-emergent: Air – Ded, then 40% / Ded, then 60%;
Ground – Same as in-network
$200 Copay, then in-network deductible & coinsurance
Deductible, then 40%
Deductible, then 20%
Deductible, then 20%
Deductible, then 60%
Deductible, then 40% Deductible, then 60%
Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment
Rehabilitative & Habilitative Services & Devices
Non-designated PCP or specialist office visit
Spinal manipulation (12 visits PCY);Acupuncture (12 visits PCY)
Prenatal, delivery, postnatal care
Inpatient
Organ and tissue transplants, inpatient unlimited, except $75,000 donor coverage limit and $7,500 travel and lodging per transplant
Emergency careCopay waived if directly admitted to inpatient facility
Hospice: 10 days inpatientRespite care: 240 hours lifetime
Deductible, then 40% Deductible, then 60%
Deductible, then 40% Deductible, then 60%
Rehabilitative and habiltative benefits have the same number of visits, but are counted separately
Durable medical equipment
Skilled nursing facility: 60 days PCY
Deductible, then 40% Deductible, then 60%
Not covered
7
Orthodontia (medically necessary only)
Exams and immunizations
Eye exam: 1 PCY
Screenings
Dental: preventive/basic/major
Laboratory Services Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services)
Preventive/Wellness Services & Chronic Disease Management
Pediatric Services,including Vision CareUnder 19 years of age
Deductible, then 20%
Physical, speech, occupational, massage therapy: 45 visits PCY
Inpatient rehabilitation: 30 days PCYInpatient habilitation: 30 days PCY
Includes deductible, coinsurance, and copaysOut-of-Pocket Maximum
Per Calendar Year = PCYFamily = 2x individual deductible (in-network only)
40%
Non-preferred
$4,000
$1,500 2x individual deductible
Unlimited
Alaska plans for group 1-50Beginning January 1, 2016
Shared with in-network pharmacy deductible
Individual Deductible
Coinsurance Amount you pay after your deductible is met
BALANCE PLUS GOLD PCPThe deductible applies whenever there is a coinsurance listed, unless otherwise noted.
Family = 2x Ind. out-of-pocket-max (in-network only)
Outpatient services
Maternity & Newborn Care
Ambulatory Patient Services
10 Essential Benefits Covered Services
Office visits
Designated PCP office visit
Emergency Services
17
A full list of services is available on premera.com/ak/member
In-network Non-participating
30%
Office Visits $35
Network Heritage Select
1 Deductible, then 30%
Office visit cost share
2
3 Hospitalization
4
5 Office visit Office visit cost share
Inpatient hospital: mental/behavioral health Deductible, then 30%
Deductible, then 30%
6
Therapy
Deductible, then 30%
Deductible, then 30%
8
9
10 Prescription Drugs Retail up to 90-day supply (3x 30 day supply cost)
Mail Order 90-day supply; 3x retail supply cost
Specialty Rx 30-day supply
Drug Formulary X4
Additional benefits embedded within the medical planHearing
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Emergent: Same as in-networkNon-emergent: Air – Ded, then 40% / Ded, then 60%;
Ground – Same as in-network
$200 Copay, then in-network deductible & coinsurance
$25 copay, then deductible & in-network coinsurance
Deductible, then 30%
Deductible, then $35
Emergency Services
Not covered
Deductible, then 30%
Ambulance transportation (air & ground)
Emergency careCopay waived if directly admitted to inpatient facility
10 Essential Benefits Covered Services
Office visits
Cost share
Individual Deductible
Coinsurance Amount you pay after your deductible is met
Family = 2x Ind. Out-of-pocket-max (in-network only)
Ambulatory Patient Services Outpatient services
Non-preferred
$6,850
$2,000 / $3,000 2x individual deductible
Unlimited
BALANCE SELECT SILVER PPO
Balance Select Silver PPO
Includes deductible, coinsurance, and copaysOut-of-Pocket Maximum
Per Calendar Year = PCYFamily = 2x individual deductible (in-network only)
Hospital: 40% Hospital: 60%All other facilities & professional: Same as in-network
Alaska plans for group 1-50Beginning January 1, 2016The deductible applies whenever there is a coinsurance listed, unless otherwise noted.
7
Orthodontia (medically necessary only)
Exams and immunizations
Eye exam: 1 PCY
Screenings
Dental: preventive/basic/major
Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services)
Pediatric Services,including Vision CareUnder 19 years of age
Laboratory Services
Rehabilitative and habiltative benefits have the same number of visits, but are counted separately
Outpatient services
Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment
Inpatient
Organ and tissue transplants, inpatient unlimited, except $75,000 donor coverage limit and $7,500 travel and lodging per transplant
Prenatal, delivery, postnatal care
Rehabilitative & Habilitative Services & Devices
Maternity & Newborn Care
Durable medical equipment
Skilled nursing facility: 60 days PCY
Physical, speech, occupational, massage therapy: 45 visits PCY
Inpatient rehabilitation: 30 days PCYInpatient habilitation: 30 days PCY
Hospice: 10 days inpatientRespite care: 240 hours lifetime
Same as in-network
4-Tier: Generic/Brand/Non-Preferred Brand/Specialty
$25$50
$100Deductible, then 30%
Retail: Same as in-networkMail order & specialty: not covered
Preventive/Wellness Services & Chronic Disease Management
Eyewear: One pair of glasses PCY (frames & lenses); or 12-month supply of contacts PCY, in lieu of glasses (frames & lenses)
Office visit cost share
Covered in full
Not covered
Not covered
Covered in full
Out-of-network
Spinal manipulation (12 visits PCY);Acupuncture (12 visits PCY)
Deductible, then 30%
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Deductible, then 30%
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Covered in fullHearing aids and hardware: $1,000/3 calendar years
Hearing exam: 1 per 2 calendar years Office visit cost share
18
A full list of services is available on premera.com/ak/member
In-network Non-participating
20%
Office Visits $25 / $30 / $30
Network Heritage Select
1 Deductible, then 20%
Office visit cost share
2
3 Hospitalization
4
5 Office visit Office visit cost share
Inpatient hospital: mental/behavioral health Deductible, then 20%
Deductible, then 20%
6
Therapy
Deductible, then 20%
Deductible, then 20%
8
9
10 Prescription Drugs Retail up to 90-day supply (3x 30 day supply cost)
Mail Order 90-day supply; 3x retail supply cost
Specialty Rx 30-day supply
Drug Formulary X4
Additional benefits embedded within the medical planHearing
Covered in fullHearing aids and hardware: $1,000/3 calendar years
Hearing exam: 1 per 2 calendar years Office visit cost share
Same as in-network
$200 Copay, then in-network deductible & coinsurance
$25 copay, then deductible & in-network coinsurance
Out-of-network
Spinal manipulation (12 visits PCY);Acupuncture (12 visits PCY)
Prenatal, delivery, postnatal care
Durable medical equipment
Skilled nursing facility: 60 days PCY
Emergent: Same as in-networkNon-emergent: Air – Ded, then 40% /Ded, then 60%;
Ground – Same as in-network
10 Essential Benefits Covered Services
Office visits
Cost share
4-Tier: Generic/Brand/Non-Preferred Brand/Specialty
500 - $10 / $40 / $80 / Deductible, then 20%
1000, 1500 - $10 / $25 / $45 / Deductible, then 20%
Retail: Same as in-networkMail order & specialty: not covered
Preventive/Wellness Services & Chronic Disease Management
Eyewear: One pair of glasses PCY (frames & lenses); or 12-month supply of contacts PCY, in lieu of glasses (frames & lenses)
Office visit cost share
Covered in full
Not covered
Not covered
Covered in full
Deductible, then 20%
Inpatient
Organ and tissue transplants, inpatient unlimited, except $75,000 donor coverage limit and $7,500 travel and lodging per transplant
Ambulance transportation (air & ground)
Rehabilitative & Habilitative Services & Devices
Maternity & Newborn Care
Physical, speech, occupational, massage therapy: 45 visits PCY
Inpatient rehabilitation: 30 days PCYInpatient habilitation: 30 days PCY
Hospice: 10 days inpatientRespite care: 240 hours lifetime
7
Orthodontia (medically necessary only)
Exams and immunizations
Eye exam: 1 PCY
Screenings
Dental: preventive/basic/major
Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services)
Pediatric Services,including Vision CareUnder 19 years of age
Laboratory Services
Non-preferred
$5,000 / $5,000 / $4,500
$500 / $1,000 / $1,500 2x individual deductible
Unlimited
BALANCE SELECT GOLD PPO
Balance Select Gold PPO
Includes deductible, coinsurance, and copaysOut-of-Pocket Maximum
Per Calendar Year = PCYFamily = 2x individual deductible (in-network only)
Hospital: 40% Hospital: 60%All other facilities & professional: Same as in-network
Alaska plans for group 1-50Beginning January 1, 2016The deductible applies whenever there is a coinsurance listed, unless otherwise noted.
Individual Deductible
Coinsurance Amount you pay after your deductible is met
Family = 2x Ind. out-of-pocket-max (in-network only)
Ambulatory Patient Services Outpatient services
Emergency Services Emergency careCopay waived if directly admitted to inpatient facility
Rehabilitative and habiltative benefits have the same number of visits, but are counted separately
Not covered
Deductible, then 20%
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Deductible, then 20%
Deductible, then 20%
500 - Deductible, then $25 1000/1500 - Deductible, then $30
Outpatient services
Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment
19
A full list of services is available on premera.com/ak/member
In-network Non-participating
30%
Office Visits Deductible, then 30%
Network Heritage Select
1
2
3 Hospitalization
4
5 Office visit
Inpatient hospital: mental/behavioral health
6
Therapy
Laboratory Services
8
9
10 Prescription Drugs Retail up to 90-day supply
Mail Order 90-day supply
Specialty Rx 30-day supplyDrug Formulary X1
Additional benefits embedded within the medical planHearing
Hearing aids and hardware: $1,000/3 calendar years
Hearing exam: 1 per 2 calendar years
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Deductible, then 30%
Inpatient
Organ and tissue transplants, inpatient unlimited, except $75,000 donor coverage limit and $7,500 travel and lodging per transplant
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Deductible, then 20%
Deductible, then 30%Retail: Same as in-network
Mail order & specialty: not covered
Preventive/Wellness Services & Chronic Disease Management
Eyewear: One pair of glasses PCY (frames & lenses); or 12-month supply of contacts PCY, in lieu of glasses (frames & lenses)
Deductible waived, then 10%
Covered in full
Not coveredNot covered
Covered in full
Orthodontia (medically necessary only)
Exams and immunizations
Eye exam: 1 PCY
Screenings Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Dental: preventive/basic/major
Emergency Care
Hospice: 10 days inpatientRespite care: 240 hours lifetime
Hospital: 40% Hospital: 60%All other facilities & professional: Same as in-network
7
Emergency Services
Deductible, then 30%
Deductible, then 30%
Not covered
Deductible, then 30%
Prenatal, delivery, postnatal care
Emergent: Same as in-networkNon-emergent: Air – Ded, then 40% / Ded, then 60%;
Ground – Same as in-network
Rehabilitative & Habilitative Services & Devices
Ambulatory Patient Services
10 Essential Benefits Covered Services
Cost share
Pediatric Services,including Vision CareUnder 19 years of age
Non-preferred
Individual: $6,450Family: $12,900
Individual: $4,500 / $5,250 Family: $9,000 / $10,500
Unlimited
BALANCE SELECT BRONZE HSA
Balance Select Bronze HSA
Includes deductible, coinsurance, and copaysOut-of-Pocket Maximum
Per Calendar Year = PCYFamily = 2x individual (embedded)
2x individual deductible
Alaska plans for group 1-50Beginning January 1, 2016The deductible applies whenever there is a coinsurance listed, unless otherwise noted.
Ambulance transportation (air & ground)
Office visits
Individual Deductible
Coinsurance Amount you pay after your deductible is met
Family = 2x individual (embedded)
Same as in-network
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Out-of-network
Spinal manipulation (12 visits PCY);Acupuncture (12 visits PCY)
Deductible, then 30%
Outpatient services
Maternity & Newborn Care
Deductible, then 30%
Durable medical equipment
Skilled nursing facility: 60 days PCY
Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services) Deductible, then 30%
Physical, speech, occupational, massage therapy: 45 visits PCY
Inpatient rehabilitation: 30 days PCYInpatient habilitation: 30 days PCY
Deductible, then 30%
Rehabilitative and habiltative benefits have the same number of visits, but are counted separately
Outpatient services
Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment
20 A full list of services is available on premera.com/ak/member
In-network Non-participating
Office Visits Deductible, then 30%
Network Heritage Select
Hospitalization
Office visit
Inpatient hospital: mental/behavioral health
Inpatient rehabilitation: 30 days PCY
Dental: preventative/basic/major
Prescription Drugs Retail up to 90-day supply
Mail Order 90-day supply
Hearing
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Not covered
Office visits
Ambulatory Patient Services
Emergency Services
Outpatient services
Includes deductible, coinsurance, and copays
30%
PCYFamily = 2x individual (embedded)
Out-of-Pocket Maximum
Emergent: Same as in-networkNon-emergent: Air – Ded, then 40% / Ded, then 60%;
Ground – Same as in-network
Deductible, then 30%
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
10 Essential Benefits Covered Services
Non-preferred
Individual: $4,400Family: $8,800
Individual: $3,000Family: $6,000
2x individual deductible
Unlimited
Individual Deductible
Coinsurance Amount you pay after your deductible is metHospital: 40% Hospital: 60%
All other facilities & professional: Same as in-network
Family = 2x individual (embedded)
Covered in full
Covered in full
Deductible waived, then 10%
Balance Select Silver HSAAlaska plans for groups 1-50Beginning January 1, 2016
The deductible applies whenever there is a coinsurance listed, unless otherwise noted.
PCY = per calendar year
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment
Inpatient
Laboratory Services
Maternity & Newborn Care
Includes x-ray, pathology, imaging/diagnostic, CT, PET, MRI (Prior Authorization required for certain services )
Outpatient services
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
BALANCE SELECT SILVER HSA
Same as in-networkCost share
Deductible, then 30%
Pediatric Services, including Vision & Oral CareUnder 19 years of age
Preventive/Wellness Services & Chronic Disease Management
Eyewear: One pair of glasses PCY (frames & lenses); or 12-month supply of contacts PCY, in lieu of glasses (frames & lenses)
Specialty Rx 30-day supply
Eye exam: 1 PCY
Orthodontia (medically necessary only)
ScreeningsExams and immunizations
2
1
6
Deductible, then 30%
Deductible, then 30%
Deductible, then 30%
Spinal Manipulation (12 visits PCY); Acupuncture (12 visits PCY)
Prenatal, delivery, postnatal care
Hospice 10 days inpatientRespite care: 240 hours lifetime
Organ and tissue transplants, inpatient unlimited, except $75,000 donor and $7,500 travel and lodging per transplant
Ambulance transportation (air & ground)
Emergency Care
Physical, speech, occupational, massage therapy:45 visits PCY
Durable medical equipment
Skilled nursing facility: 60 days PCY
Deductible, then 30%
Hearing exam: 1 per 2 calendar yearsHearing aids and hardware: $1,000/3 calendar years
Out-of-network
Additional benefits embedded within the medical plan
Drug Formulary X1
Retail: Same as in-network;Mail order & specialty: not covered
Deductible, then 20%
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Deductible, then 30%
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Rehabilitative & HabilitativeServices & DevicesTherapy
Rehabilitative and habilitative benefits have the same number of visits, but are counted separately
Deductible, then 30%
Not covered
Deductible, then 30%
Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network
Not covered
8
9
10
4
3
7
5
21
Optional benefitsPremera Adult Vision Plan
These optional vision benefits include exams and eyewear. Vision exam and eyewear are covered up to a maximum benefit of $350 per calendar year per member.
Exam—One per calendar year with $25 copayment
Eyewear
One pair of lenses for eyeglasses per calendar year per member
One pair of frames up to $90 every two calendar years per member
Contact lenses up to $170 per calendar year per member
Life and disability
Employers can offer an integrated benefits program to help reduce disability and healthcare costs, improve health, and increase workforce productivity. Through our partner, USAble Life, groups will find flexible products, high-quality customer service, and fast, reliable claims service.
Several package options are available for employers with 1 – 50 employees.
Employers with 10 or more enrolled employees can choose from the following products:
Group life insurance
Group term life — Provides benefits to a beneficiary in the event of an employee’s death
Accidental death and dismemberment (AD&D)— Provides benefits in the event that a death or dismemberment is caused by an accident
Dependent life — Provides benefits to the employee in the event of a dependent’s death
Supplemental life and AD&D — Provides additional coverage options for your employees
Disability coverage
Short-term disability coverage: Protects a portion of employees’ income in the event of a disability
Long-term disability coverage: Provides employees and their families the income needed to help meet financial commitments and give them financial stability
Dental coverage
It’s no secret—good dental health affects your employees’ overall health. Premera’s dental plans help both kids and adults maintain healthy teeth.
Plus, they have access to a nationwide network of more than 120,000 dentists for dental care. See our DentalBlue benefit guide for information about our full line of dental plans.
NOTE: The Balance Kids Dental plan meets the federal requirements for providing pediatric dental plans.
22
This is only a summary of the major benefits provided by our plans. This is not a contract. Please see premera.com for the Summary of Benefits and Coverage and Glossary. On our website, you can also find a Supplemental Guide with information about privacy policies, provider organization, key utilization management procedures, and pharmaceutical management procedures.
DefinitionsAllowed amount* The negotiated amount for which a contracted provider agrees to provide
services or supplies.
Coinsurance Your employee’s share of the cost for a service. If the plan’s coinsurance is 20%, the employee pays 20% of the allowed amount and the plan benefit pays the other 80% of the allowed amount.
Copay A flat fee your employee pays for a specific service, such as an office visit, at the time they receive service.
Covered in full Services the plan pays for in full. Benefits provided at 100 percent of the allowed amount; not subject to deductible or coinsurance.
Deductible The amount of money your employee pays every year before the plan pays for certain services.
Embedded deductible There are two deductibles—one for the family and one for each member of the family. When an individual family member reaches his or her deductible, the member starts to receive benefit coverage. For other family members to receive benefit coverage, they must either reach their own deductible or the family deductible must be met. The family out-of-pocket maximum is also embedded.
* Note that if they see a non-contracted provider, your employee will be responsible for the difference between the allowed amount and the provider’s billed charges, in addition to the coinsurance and any applicable copay. The allowed amount for a non-contracted provider is determined by Premera as described in your forthcoming benefit book.
23
This is only a summary of the major benefits provided by our plans. This is not a contract. Please see premera.com for the Summary of Benefits and Coverage and Glossary. On our website, you can also find a Supplemental Guide with information about privacy policies, provider organization, key utilization management procedures, and pharmaceutical management procedures.
Formulary A list of drugs the plan covers for specific uses. Not all generic, name-brand, and specialty drugs are included in the formulary. To find the formulary for your employee’s plan, go to premera.com and select Pharmacy.
In-network A group of doctors, dentists, hospitals, and other healthcare providers that contract with Premera to provide services and supplies at negotiated amounts called allowed amounts.
Out-of-pocket maximum A preset limit after which the plan pays 100 percent of the allowed amount for services received in-network. All in-network essential benefits apply to the out-of-pocket maximum.
Primary care provider (PCP) The provider who helps coordinate your employee’s care. They can choose a different primary care provider for each family member from: physicians and internists, physician assistants, and nurse practitioners; ob/gyns and women’s health specialists, pediatricians, and geriatric specialists; or naturopaths. To get a reduced office visit copay with the PCP plans, your employee must choose a provider contracted as part of the Premera network and inform us this is your designated PCP.
This is not a contract. Please see premera.com/SBC for the Summary of Benefits and Coverage and Glossary. On our website, you can also find a Supplemental Guide with information about privacy policies, provider organization, key utilization management procedures, and pharmaceutical management procedures.
2424
25
General exclusions Benefits are not provided for treatment, surgery, services, drugs, or supplies for any of the following:
Cosmetic surgery
Experimental or investigative services
Infertility
Obesity/morbid obesity, related surgery, drugs, and supplements obesity surgery, drugs, and supplements for weight loss or weight control
Orthognathic surgery
Services in excess of specified benefit maximums
Services payable by other types of insurance coverage
Services received when you are not covered by this program
Sexual dysfunction
Sterilization reversal
For a complete list of exclusions and limitations, visit premera.com and click the Member Services tab, then click Benefit Exclusions.
Prior authorization
Certain medical services and prescriptions require prior authorization (approval from the health plan). See your Premera representative for more information.
This is only a summary of the
major benefits provided by our
plans. This is not a contract.
Please see premera.com/SBC
for the Summary of Benefits
and Coverage and Glossary.
On our website, you can also
find a Supplemental Guide
with information about privacy
policies, provider organization,
key utilization management
procedures, and pharmaceutical
management procedures.
027474 (04-2016)
Premera Blue Cross Blue Shield of Alaska is an Independent Licensee of the Blue Cross Blue Shield Association
Contact information
Premera Blue Cross Blue Shield of Alaska 2550 Denali St., Suite 1404 Anchorage, AK 99503
888.669.2583