Premera Blue Cross Alaska One Bronze – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$6,350 per person $6,350 per person
Out-of-pocket max	$8,700 per person $17,400 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	$50 copay
Specialist visit	$100 copay after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$100 copay after deductible
Emergency room	30% coinsurance after deductible
Ambulance	30% coinsurance after deductible
Hospital stay (facility)	30% coinsurance after deductible
Hospital stay (physician)	30% coinsurance after deductible
Outpatient procedure (facility)	30% coinsurance after deductible
Outpatient procedure (physician)	30% coinsurance after deductible
Physical rehabilitation	30% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$30 copay
Brand	30% coinsurance after deductible
Non-preferred Brand	30% coinsurance after deductible
Specialty	40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	30% coinsurance after deductible
Imaging (CT/PET/MRI)	30% coinsurance after deductible
Blood work	30% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$75 copay
Psychiatric hospital stay	30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.premera.com/documents/055217_2024.pdf
Drug and medication plan formulary	https://www.Premera.com/documents/052166_2024.pdf
Search doctor list	https://premera.sapphirecareselect.com/?ci=premeraak&network_id=46