Premera Blue Cross Preferred Silver 4500 – PPO

73% cost sharing reduction [Popular Plan]
Network type: PPO
Coverage tier: Silver
Primary care visit: $15 copay
Specialist visit: $55 copay
Urgent care visit: $55 copay

SKU: 38344AK106000204 Category:

Description

This plan has 73% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type PPO
Deductible $4,350 per person $4,350 per person
Out-of-pocket max $7,200 per person $14,400 per family
Metal tier Silver

Visit Copay

Primary care visit $15 copay
Specialist visit $55 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $55 copay
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 $55 copay after deductible

Maternitowny and Pregnancy

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

Pharmacy, Drugs, and Medication

Generic $18 copay
Brand $60 copay
Non-preferred Brand 50% 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 $55 copay
Psychiatric hospital stay 30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://www.premera.com/documents/045638_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