(844) 967-1917
Premera Blue Cross Blue Shield of Alaska

Premera Blue Cross Preferred Silver 4500

Plan Overview

Combined Medical and Drug Deductible
  • Individual: $4,500.00
  • Family: $9,000
  • Per Person: $4,500
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $7,700.00
  • Family: $15,400
  • Per Person: $7,700

Office Visit

Primary Doctor
  • CoPay: $30.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: The first 2 visits to a designated primary care provider (PCP) are covered in full. Subsequent visits are subject to the PCP copay.
Specialist
  • CoPay: $60.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: $60.00
  • 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: $25.00
  • 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: Not Applicable
  • CoInsurance: 10.00%
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Visit(s) per 6 Months
Routine Dental Checkups for Adults
  • CoPay: Not Applicable
  • CoInsurance: 10.00%
  • Covered: Covered
  • Limit Quantity: 2
  • Limit Unit : Exam(s) per Year
  • Benefit Explanation: Routine Exam - 2 PCY and Cleanings- 2 PCY; Routine X-rays (bitewing) - 1 PCY; Annual maximum of $750 PCY
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