Premera Blue Cross

Premera Blue Cross Preferred Silver EPO 4500

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $4,500 Family: $9,000 Per Person: $4,500
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: In network: You pay $25. See Additional Benefits for an exception. Out of network: Benefit not covered
Specialist	Standard: In network: You pay $60 Out of network: Benefit not covered

Prescription Drug Information

Preferred Brand Drugs	Standard: In network: You pay up to the deductible / 30% of the cost of care after you meet your deductible Out of network: Benefit not covered
Non Preferred Brand Drugs	Standard: In network: You pay up to the deductible / 50% of the cost of care after you meet your deductible Out of network: Benefit not covered
Generic Drugs	Standard: In network: You pay $20 Out of network: Benefit not covered
Specialty Drugs	Standard: In network: You pay up to the deductible / 50% of the cost of care after you meet your deductible Out of network: Benefit not covered

Inpatient Coverage

Hospital Services	Standard: In network: You pay up to the deductible / 30% of the cost of care after you meet your deductible Out of network: Benefit not covered
Inpatient Services	Standard: In network: You pay up to the deductible / 30% of the cost of care after you meet your deductible Out of network: Benefit not covered

Emergency and Urgent Care

Emergency Room

Standard: In network: You pay up to the deductible / 30% of the cost of care after you meet your deductible Out of network: You pay up to the deductible / 30% of the cost of care after you meet your deductible