Premera Blue Cross Preferred Silver EPO 4500 – EPO
Network type: EPO
Coverage tier: Silver
Primary care visit: first 2 visit(s) $0 then $25 copay
Specialist visit: $65 copay
Urgent care visit: $65 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $4,500 per person $4,500 per person |
| Out-of-pocket max | $6,950 per person $13,900 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | first 2 visit(s) $0 then $25 copay |
| Specialist visit | $65 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $65 copay |
| Emergency room | 30% after deductible |
| Ambulance | 30% after deductible |
| Hospital stay (facility) | 30% after deductible |
| Hospital stay (physician) | 30% after deductible |
| Outpatient procedure (facility) | 30% after deductible |
| Outpatient procedure (physician) | 30% after deductible |
| Physical rehabilitation | $40 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 30% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $25 copay |
| Brand | 30% after deductible |
| Non-preferred Brand | 50% after deductible |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 30% after deductible |
| Imaging (CT/PET/MRI) | 30% after deductible |
| Blood work | 30% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $65 copay |
| Psychiatric hospital stay | 30% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/YRL3DdEvm9BT8GR1BAGnusSd.pdf |
| Drug and medication plan formulary | https://www.premera.com/documents/062278_2024.pdf |
