Premera Blue Cross Blue Shield of Alaska

Premera Blue Cross Alaska One Gold

Plan Overview

Combined Medical and Drug Deductible
  • Individual: $1,500.00
  • Family: $3,000
  • Per Person: $1,500
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $6,300.00
  • Family: $12,600
  • Per Person: $6,300

Office Visit

Primary Doctor
  • CoPay: $30.00
  • CoInsurance: Not Applicable
  • Covered: Covered
Specialist
  • CoPay: $60.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: $45.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 90
  • Limit Unit : Item(s) per Month
  • Benefit Explanation: Up to 90 day supply Retail (copay times 3); 90 day supply for Mail order.
Non Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
  • Limit Quantity: 90
  • Limit Unit : Item(s) per Month
  • Benefit Explanation: Up to 90 day supply Retail (copay times 3); 90 day supply for Mail order. This tier contains all non-preferred drugs.
Generic Drugs
  • CoPay: $15.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 90
  • Limit Unit : Item(s) per Month
  • Benefit Explanation: Up to 90 day supply Retail (copay times 3); 90 day supply for Mail order. This tier contains only Preferred Generic drugs.
Specialty Drugs
  • CoPay: Not Applicable
  • CoInsurance: 40.00% Coinsurance after deductible
  • Covered: Covered
  • Limit Quantity: 30
  • Limit Unit : Item(s) per Month
  • Benefit Explanation: 30 day supply Retail and Mail

Inpatient Coverage

Hospital Services
  • CoPay: Not Applicable
  • CoInsurance: 30.00% Coinsurance after deductible
  • Covered: Covered
Inpatient Services
  • CoPay: Not Applicable
  • CoInsurance: 30.00% Coinsurance after deductible
  • Covered: Covered

Emergency and Urgent Care

Emergency Room
  • CoPay: Not Applicable
  • CoInsurance: 30.00% Coinsurance after deductible
  • Covered: Covered
Urgent Care Facility
  • CoPay: $60.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Maternity

Labor and Delivery Hospital Stay
  • CoPay: Not Applicable
  • CoInsurance: 30.00% Coinsurance after deductible
  • Covered: Covered
Pre and Postnatal Office Visit
  • CoPay: Not Applicable
  • CoInsurance: 30.00% Coinsurance after deductible
  • Covered: Covered

Vision

Routine Eye Exams For Children
  • CoPay: $30.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Exam(s) per Year
  • Benefit Explanation: Under age 19, 1 PCY; Over age 19 Not Covered

Major Dental Care

Routine Dental Checkups for Children
  • CoPay: $0.00
  • CoInsurance: 0.00%
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Visit(s) per 6 Months
Routine Dental Checkups for Adults
  • CoPay: Not Applicable
  • CoInsurance: 10.00%
  • Covered: Not Covered
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We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN38344AK1080001ACA1

© 2024 HealthMarkets Insurance Agency. All rights reserved.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN38344AK1080001ACA1

© 2024 HealthMarkets Insurance Agency. All rights reserved.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN38344AK1080001ACA1