Premera Blue Cross Preferred Silver 4500 – PPO
94% cost sharing reduction [Popular Plan]
Network type: PPO
Coverage tier: Silver
Primary care visit: $10 copay
Specialist visit: $40 copay
Urgent care visit: $40 copay
Description
This plan has 94% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | PPO |
| Deductible | $400 per person $400 per person |
| Out-of-pocket max | $650 per person $1,300 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $10 copay |
| Specialist visit | $40 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $40 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 | $40 copay after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 30% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | $40 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 | $40 copay |
| Psychiatric hospital stay | 30% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.premera.com/documents/045640_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 |
