Plan Name |
Benefit |
2021 |
2022 |
Premera Blue Cross Plus HSA Qualified Bronze 6900
|
In-Network Deductible
|
$6,900
|
$5,950
|
Out-of-Network Deductible
|
$13,800
|
$11,900
|
In-Network Coinsurance
|
0%
|
50%
|
Out-of-Network Participating Coinsurance
|
40%
|
50%
|
Pharmacy
|
Deductible, then 0% Coinsurance
|
Deductible, then 50% Coinsurance
|
HSA Generic Preventive Drug List
|
PV1
|
PV Core
|
Premera Blue Cross Plus Platinum 250
|
Mail Order Copays (Tiers 1/2/3)
|
$30/$120/$300
|
$25/$100/$250
|
Premera Blue Cross Plus Platinum 500
|
Mail Order Copays (Tiers 1/2/3)
|
$30/$120/$300
|
$25/$100/$250
|
Premera Blue Cross Plus Gold 500
|
Mail Order Copays (Tiers 1/2/3)
|
$60/$150/$300
|
$50/$125/$250
|
Premera Blue Cross Plus Gold 1000
|
Mail Order Copays (Tiers 1/2/3)
|
$30/$120/$300
|
$25/$100/$250
|
Premera Blue Cross Plus Gold 1500
|
Mail Order Copays (Tiers 1/2/3)
|
$30/$120/$300
|
$25/$100/$250
|
Premera Blue Cross Plus Gold 2000
|
Mail Order Copays (Tiers 1/2/3)
|
$60/$150/$375
|
$50/$125/$312.50
|
Premera Blue Cross Plus Silver 2000
|
Mail Order Copays (Tiers 1/2/3)
|
$75/$195/$450
|
$62.50/$175/$375
|
Premera Blue Cross Plus Silver 2500
|
Mail Order Copays (Tiers 1/2/3)
|
$75/$195/$450
|
$62.50/$175/$375
|
Premera Blue Cross Plus Silver 3000
|
Mail Order Copays (Tiers 1/2/3)
|
$75/$195/$450
|
$62.50/$175/$375
|
Premera Blue Cross Plus Silver 4000
|
Mail Order Copays (Tiers 1/2/3)
|
$75/$195/$450
|
$62.50/$175/$375
|
Premera Blue Cross Plus Bronze 5500
|
Mail Order Copays (Tiers 1/2/3)
|
$75/Ded, $255/Ded, $525
|
$62.50/Ded, $212.50/Ded, $437.50
|
Premera Blue Cross Plus Bronze 6350
|
Mail Order Copays (Tiers 1/2/3)
|
$75/Ded, $255/Ded, $525
|
$62.50/Ded, $212.50/Ded, $437.50
|
Premera Blue Cross Plus Bronze 8150
|
In Network Ambulance Transportation (air and ground)
|
$25 copay, then in network deductible and coinsurance
|
In network deductible and coinsurance
|
Out of Network Ambulance Transportation (emergent air and ground)
|
$25 copay, then in network deductible and coinsurance
|
In network deductible and coinsurance
|
In Network Emergency Room Cost Share
|
$250 copay, then in network deductible and coinsurance
|
In network deductible and coinsurance
|
Out of Network Emergency Room Cost Share
|
$250 copay, then in network deductible and coinsurance
|
In network deductible and coinsurance
|
Mail Order Copays (Tier 1)
|
$75
|
$62.50
|
Premera Blue Cross Plus Bronze 8550
|
Mail Order Copays (Tier 1)
|
$90
|
$75
|
Premera Blue Cross Plus HSA Qualified Gold 1500
|
HSA Generic Preventive Drug List
|
PV1
|
PV Core
|
Premera Blue Cross Plus HSA Qualified Silver 2800
|
HSA Generic Preventive Drug List
|
PV1
|
PV Core
|
Premera Blue Cross Plus HS A Qualified Silver 3500
|
HSA Generic Preventive Drug List
|
PV1
|
PV Core
|
Premera Blue Cross Plus HSA Qualified Bronze 5950
|
HSA Generic Preventive Drug List
|
PV1
|
PV Core
|
Out of network Participating Coinsurance
|
40% coinsurance
|
50% coinsurance
|