Premera Blue Cross Preferred Silver 4500 - 38344AK1060002 Health Insurance Plan

Premera Blue Cross Blue Shield of Alaska health insurance plan with the Plan ID 38344AK1060002. The plan is called Premera Blue Cross Preferred Silver 4500.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.01% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 29.99% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 38344AK1060002
Health Insurance Plan Year 2025
State Alaska
Health Insurance Issuer Premera Blue Cross Blue Shield of Alaska
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 38344AK1060002-01
Provider Network(s) LEGACYANDDENTALSELECT
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT).

Providers Alaska All US States
All 6610 68032
PCP 682 8534
Allergy 1 11
OB/GYN 18 274
Dentists 228 2212
Available Variants of the Health Plan

Standard On Exchange Plan - 38344AK1060002-01

Open to Indians below 300% FPL - 38344AK1060002-02

Open to Indians above 300% FPL - 38344AK1060002-03

73% AV Silver Plan - 38344AK1060002-04

87% AV Silver Plan - 38344AK1060002-05

94% AV Silver Plan - 38344AK1060002-06

Last Plan Update Date Thu, 10 Oct 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of Premera Blue Cross Preferred Silver 4500 Health Insurance Plan, 38344AK1060002-01

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Accidental Dental
YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Acupuncture

Limit: 12.0 Visit(s) per Year

Services must be medically necessary to relieve pain, induce surgical anesthesia, or to treat a covered illness, injury or condition.

YES

Tier 1: $30.00

Tier 2: $30.00

60.00% Coinsurance after deductible
Allergy Testing
YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child

Limit: 4.0 Procedure(s) per Year

YES

20.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Chemotherapy
YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Chiropractic Care

Limit: 12.0 Visit(s) per Year

YES

Tier 1: $30.00

Tier 2: $30.00

60.00% Coinsurance after deductible
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Dental Check-Up for Children

Limit: 1.0 Visit(s) per 6 Months

YES

10.00%

30.00% Coinsurance after deductible
Diabetes Education
YES

Tier 1: No Charge

Tier 2: No Charge

No Charge
Dialysis
YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Durable Medical Equipment
YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Emergency Room Services
YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Emergency Transportation/Ambulance

Air and Ground transpiration benefit is limited to medical emergency. Ambulance services is separate benefit, covers both medical emergency transport and non-emergent transport.

YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Under age 19; 1 pair of frames and lenses PCY includes polycarbonate lenses and scratch resistent coating; 12 month supply of contacts in lieu of glasses; Over age 19 Not Covered

YES

No Charge

No Charge
Gender Affirming Care
NO
Generic Drugs

Limit: 90.0 Item(s) per Month

Up to 90 day supply Retail (copay times 3); 90 day supply for Mail order. This tier contains only Preferred Generic Drugs

YES

$25.00

$25.00
Habilitation Services

Limit: 45.0 Visit(s) per Year

Habilitative services is only covered in the context of autism spectrum disorders services, including ABA, counseling and treatment programs necessary to develop, maintain, or restore the functioning of an individual.

YES

Tier 1: $60.00 Copay after deductible

Tier 2: $60.00 Copay after deductible

60.00% Coinsurance after deductible
Hearing Aids
NO
Home Health Care Services

Limit: 130.0 Visit(s) per Year

130 visits per applies to home visits of a home health care provider or one or more: registered nurse; a licensed practical nurse; a licensed physical therapist or occupational therapist; a certified respiratory therapist; a speech therapist certified by the American Speech, Language, and Hearing Association; a home health aide directly supervised by one of the above providers; and a person with a master's degree in social work.

YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Hospice Services

Limit: 6.0 Months per Lifetime

Inpatient hospice care up to a maximum of 10 days. Respite care, up to a maximum of 240 hours, to relieve anyone who lives with and cares for the terminally ill member.

YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)
YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Infertility Treatment
NO
Infusion Therapy
YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child

Limit: 1.0 Procedure(s) per 3 Years

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services

The cost sharing that displays applies to outpatient office visits only. All other outpatient services (Outpatient Facility Fee, Laborartory Outpatient and Professional Services, etc.) may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

YES

Tier 1: $60.00

Tier 2: $60.00

60.00% Coinsurance after deductible
Non-Preferred Brand Drugs

Limit: 90.0 Item(s) per Month

Up to 90 day supply Retail (copay times 3); 90 day supply for Mail order. This tier contains only non-preferred drugs.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Nutritional Counseling
YES

Tier 1: No Charge

Tier 2: No Charge

60.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)

Covered only when the provider is licensed to practice where the care is provided, is providing a service within the scope of that license, is providing a service or supply for which benefits are specified in this plan, and when benefits would be payable if the services were provided by a physician.

YES

Tier 1: $30.00

Tier 2: $30.00

60.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Outpatient Rehabilitation Services

Limit: 45.0 Visit(s) per Year

A 'visit' is a session of treatment for each type of therapy. Each type of therapy combined accrues toward the above visit maximum. Multiple therapy sessions on the same day will be counted as 1 visit, unless provided by different health care providers.

YES

Tier 1: $60.00 Copay after deductible

Tier 2: $60.00 Copay after deductible

60.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Preferred Brand Drugs

Limit: 90.0 Item(s) per Month

Up to 90 day supply Retail (copay times 3); 90 day supply for Mail order.

YES

$60.00

$60.00
Premera-Designated Centers of Excellence Program
YES

Tier 1: No Charge

Tier 2: No Charge

60.00% Coinsurance after deductible
Prenatal and Postnatal Care
YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
YES

Tier 1: No Charge

Tier 2: No Charge

No Charge, 60.00% Coinsurance after deductible
Primary Care Visit to Treat an Injury or Illness

The first two visits to a designated care provider (PCP) are subject to a $1 copay. Subsequent visits are subject to the PCP copay.

YES

Tier 1: $30.00

Tier 2: $30.00

60.00% Coinsurance after deductible
Private-Duty Nursing
NO
Prosthetic Devices

Benefit limited to initial purchase of prosthetic; does not cover replacement unless the existing device can't be repaired, or replacement is prescribed by a physician because of a change in your physical condition.

YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Radiation
YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Reconstructive Surgery

Breast reconstruction allowed.

YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 45.0 Visit(s) per Year

Visit limit for physical, speech, and occupational therapy services combined.

YES

Tier 1: $60.00 Copay after deductible

Tier 2: $60.00 Copay after deductible

60.00% Coinsurance after deductible
Rehabilitative Speech Therapy

Limit: 45.0 Visit(s) per Year

Visit limit for physical, speech, and occupational therapy services combined.

YES

Tier 1: $60.00 Copay after deductible

Tier 2: $60.00 Copay after deductible

60.00% Coinsurance after deductible
Routine Dental Services (Adult)

Limit: 2.0 Exam(s) per Year

Routine Exam - 2 PCY and Cleanings- 2 PCY; Routine X-rays (bitewing) - 1 PCY; Annual Maximum of $750 PCY

YES

10.00%

30.00% Coinsurance after deductible
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

Under age 19, 1 PCY; Over age 19 Not covered

YES

$30.00

$30.00
Routine Foot Care

Routine foot care when the member is a diabetic.

YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Skilled Nursing Facility

Limit: 60.0 Days per Year

YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Specialist Visit
YES

Tier 1: $60.00

Tier 2: $60.00

60.00% Coinsurance after deductible
Specialty Drugs

Limit: 30.0 Item(s) per Month

30 day supply Retail and Mail

YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
YES

Tier 1: $60.00

Tier 2: $60.00

60.00% Coinsurance after deductible
Transplant

Limit: 75000.0 Dollars per Lifetime

Quantitative limit on Donor costs only. The types of solid organ transplants and bone marrow/stem cell reinfusion procedures that currently meet the plan's criteria for coverage are: Heart, Heart/double lung, single lung, Double lung, Liver, Kidney, Pancreas, Pancreas with kidney, Bone marrow (autologous and allogenic), Stem cell (autologous and allogeneic).

YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 30.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities
YES

Tier 1: $60.00

Tier 2: $60.00

60.00% Coinsurance after deductible
Weight Loss Programs
NO
Well Baby Visits and Care
YES

Tier 1: No Charge

Tier 2: No Charge

60.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible

Premera Blue Cross Preferred Silver 4500 Health Insurance Plan Variant 38344AK1060002-01 Attributes

Plan Attribute Value
Begin Primary Care Cost-Sharing After Number Of Visits 2
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2025
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Silver On Exchange Plan
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Diabetes
EHB Percent of Total Premium 0.9937
First Tier Utilization 95%
Formulary ID AKF002
Formulary URL URL
HIOS Product ID 38344AK106
Import Date 2024-10-10 01:01:49
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer Actuarial Value 70.01%
Issuer ID 38344
Issuer Marketplace Marketing Name Premera Blue Cross Blue Shield of Alaska
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Silver
Multiple In Network Tiers Yes
National Network No
Network ID AKN002
Out of Country Coverage Yes
Out of Country Coverage Description Benefits for covered services received from providers located outside the United States, Puerto Rico and the U.S. Virgin Islands are provided at the highest level of benefits available under this plan.
Out of Service Area Coverage Yes
Out of Service Area Coverage Description If you're outside Alaska and Washington (the service area), covered services received from any provider licensed to provide the service will be paid the out of network benefit level (except emergencies).
Plan Brochure URL
Plan Effective Date 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 38344AK1060002-01
Plan Marketing Name Premera Blue Cross Preferred Silver 4500
Plan Type PPO
Plan Variant Marketing Name Premera Blue Cross Preferred Silver 4500
QHP/Non QHP On the Exchange
SBC Scenario, Having a Baby, Coinsurance $2,400
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $4,500
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,800
SBC Scenario, Having Diabetes, Deductible $200
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $300
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,300
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 5%
Service Area ID AKS001
Source Name HIOS
Plan ID 38344AK1060002
State Code AK
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 30.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $13500 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $4500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $4,500
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 40.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group $13500 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $4500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $4,500
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $13500 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $13,500
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $16200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8100 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,100
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $16200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $8100 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $8,100
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual Not Applicable
Unique Plan Design Yes
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Premera Blue Cross Preferred Silver 4500 Health Insurance Plan, 38344AK1060002

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Premera Blue Cross Preferred Silver 4500, 38344AK1060002 Health Insurance Plan, 38344AK1060002

  • Does Premera Blue Cross Preferred Silver 4500 Health Insurance Plan, 38344AK1060002 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (38344AK1060002) Health Insurance Plan, Variant (38344AK1060002-01) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes

    Does (38344AK1060002) Health Insurance Plan, Variant (38344AK1060002-01) have Out Of Country Coverage?

    Yes. Details: Benefits for covered services received from providers located outside the United States, Puerto Rico and the U.S. Virgin Islands are provided at the highest level of benefits available under this plan.

    Does (38344AK1060002) Health Insurance Plan, Variant (38344AK1060002-01) have Out of Service Area Coverage?

    Yes. Details: If you're outside Alaska and Washington (the service area), covered services received from any provider licensed to provide the service will be paid the out of network benefit level (except emergencies).

    Does (38344AK1060002) Health Insurance Plan, Variant (38344AK1060002-01) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes

    Does Premera Blue Cross Preferred Silver 4500 Health Insurance Plan, Variant (38344AK1060002-01) offer Disease Management Programs for Asthma?

    Yes, the Premera Blue Cross Preferred Silver 4500 Health Insurance Plan Variant 38344AK1060002-01 offers Disease Management Program for Asthma.

    Does Premera Blue Cross Preferred Silver 4500 Health Insurance Plan, Variant (38344AK1060002-01) offer Disease Management Programs for Heart disease?

    Yes, the Premera Blue Cross Preferred Silver 4500 Health Insurance Plan Variant 38344AK1060002-01 offers Disease Management Program for Heart disease.

    Does Premera Blue Cross Preferred Silver 4500 Health Insurance Plan, Variant (38344AK1060002-01) offer Disease Management Programs for Diabetes?

    Yes, the Premera Blue Cross Preferred Silver 4500 Health Insurance Plan Variant 38344AK1060002-01 offers Disease Management Program for Diabetes.

 

Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API