Premera Blue Cross Preferred Bronze 5800 HSA – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$5,800 per person $5,800 per person
Out-of-pocket max	$7,300 per person $14,600 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	35% coinsurance after deductible
Specialist visit	35% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	35% coinsurance after deductible
Emergency room	35% coinsurance after deductible
Ambulance	35% coinsurance after deductible
Hospital stay (facility)	35% coinsurance after deductible
Hospital stay (physician)	35% coinsurance after deductible
Outpatient procedure (facility)	35% coinsurance after deductible
Outpatient procedure (physician)	35% coinsurance after deductible
Physical rehabilitation	35% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	35% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	35% coinsurance after deductible
Brand	35% coinsurance after deductible
Non-preferred Brand	35% coinsurance after deductible
Specialty	40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	35% coinsurance after deductible
Imaging (CT/PET/MRI)	35% coinsurance after deductible
Blood work	35% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	35% coinsurance after deductible
Psychiatric hospital stay	35% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.premera.com/documents/045646_2024.pdf
Drug and medication plan formulary	https://www.Premera.com/documents/052164_2024.pdf
Search doctor list	https://premera.sapphirecareselect.com/?ci=premeraak&network_id=46