Premera Blue Cross Blue Shield of Alaska

Premera Blue Cross Preferred Bronze 5800 HSA

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $5,800.00 Family: $11,600 Per Person: $5,800
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,000.00 Family: $14,000 Per Person: $7,000

Office Visit

Primary Doctor	CoPay: Not Applicable CoInsurance: 35.00% Coinsurance after deductible Covered: Covered
Specialist	CoPay: Not Applicable CoInsurance: 35.00% Coinsurance after deductible Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 35.00% Coinsurance after deductible Covered: Covered Limit Quantity: 90 Limit Unit : Item(s) per Month Benefit Explanation: Up to 90 day supply Retail (copay times 3); 90 day supply for Mail order.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 35.00% Coinsurance after deductible Covered: Covered Limit Quantity: 90 Limit Unit : Item(s) per Month Benefit Explanation: Up to 90 day supply Retail (copay times 3); 90 day supply for Mail order. This tier contains all non-preferred drugs.
Generic Drugs	CoPay: Not Applicable CoInsurance: 35.00% Coinsurance after deductible Covered: Covered Limit Quantity: 90 Limit Unit : Item(s) per Month Benefit Explanation: Up to 90 day supply Retail (copay times 3); 90 day supply for Mail order. This tier contains only Preferred Generic drugs.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Limit Quantity: 30 Limit Unit : Item(s) per Month Benefit Explanation: 30 day supply Retail and Mail

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 35.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 35.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 35.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: Not Applicable CoInsurance: 35.00% Coinsurance after deductible Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 35.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 35.00% Coinsurance after deductible Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: Not Applicable
CoInsurance: 35.00%
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: Under age 19, 1 PCY; Over age 19 Not Covered

Major Dental Care

Routine Dental Checkups for Children	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered Limit Quantity: 1 Limit Unit : Visit(s) per 6 Months
Routine Dental Checkups for Adults	Covered: Not Covered

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