Premera Blue Cross Standard Silver
Premera Blue Cross Blue Shield of Alaska
Plan overview
Medical deductible
Individual: $6000
Family: $12000
Per Person: $6000
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $8900
Family: $17800
Per Person: $8900
Office visit
Primary Doctor
CoPay: $40.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Specialist
CoPay: $80.00
CoInsurance: Not Applicable
Covered: Covered
Prescription drug information
Preferred brand drugs
CoPay: $40.00
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: $80.00 Copay after deductible
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 non-preferred drugs.
Generic drugs
CoPay: $20.00
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: $350.00 Copay after deductible
CoInsurance: Not Applicable
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: 40.00% Coinsurance after deductible
Covered: Covered
Inpatient services
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Emergency and urgent care
Emergency room
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Urgent care facility
CoPay: $60.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Maternity
Labor and delivery hospital stay
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal office visit
CoPay: Not Applicable
CoInsurance: 40.00% 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: No Charge
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 1
Limit Unit: Visit(s) per 6 Months
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).