Medical Plans Benefit Guide - Premera Blue Cross

Medical PlansBenefit GuideGroups with 51+ employees | 1.1.2015

Welcome to 2015Premera Blue CrossAlong with the great service and rich network access you have come to expect fromPremera, we are pleased to offer benefits tailored for the needs of large groups based inWashington, both local and those with employees nationwide.With our integrated product offerings, employers save money through enhanced plan performance and reducedadministrative burden. We provide flexibility to allow you to design just the right plan from our wide array ofproduct offerings.The wide range of plan options provides access to a network of doctors, hospitals, and pharmacies—statewide,nationwide, and beyond. Our plans also offer health support resources, including online tools that will help employeesand their dependents get and stay healthy, and discounts on products and services that help them take charge oftheir health.We recognize the need for a high value network alternative for our employer groups. So when considering networkoptions think about Heritage Prime, our value-based network that is designed to help keep overall costs down whileoffering cost savings to employers.And, while evaluating health plan options, think about Premera dental. The strength of our dental network and accessto nationwide contracted dental providers makes it easy for employees to find the right dentist for their needs, and ittranslates into even greater savings for in-network services.We know that choosing a health plan can be complex. We are committed to helping you through that—every step ofthe way.Thank you for considering Premera. We hope you will give us the opportunity to serve you.Sincerely,John CasperDirector, Western WA Mid-Market SalesTrevor MooreDirector, Eastern WA Sales and Marketing

Plan administration made easyWe’ve streamlined the administering of groupplans with easy-to-use online tools in theEnrollment Center:You can:• Manage Premera medical, dental, vision, andpharmacy benefits• Manage COBRA enrollment*• Manage open enrollment– Choose your dates– Applications process automatically• Manage life events and personal informationchanges for employees• Approve changes made by employees• Generate reportsIf you choose to enable employee self-service,employees can engage in the enrollment process whileyou maintain full control as the administrator.Enable the employee self-service function theemployee can:• Compare benefit options• Estimate out-of-pocket costs• Enroll in benefits• Manage life events and personal information changes• View educational material• Access Enrollment Center online 24/7 from a computerSupport for smarthealthcare decisionsPremera plans include consumer web-basedtools and health support programs. They helpemployees maintain good health and changeunhealthy behavior.Health support programs include:• Smoking cessation and substance abuse programs• Exclusive discounts on fitness club memberships,weight loss programs, and more• Personal health outreach program• Pregnancy and newborn support programPersonalized service and onlinetools include:• Find a Doctor tool• Health assessments• Treatment cost estimator• 24-Hour NurseLine• Order prescriptions online and have them deliveredby mail• Virtual care visits with a doctor by phone or onlineanytime, anywhere—even if in-persion care ismiles away.4

Provider network builtfor value and qualityPremera Blue Cross offers a comprehensivenetwork. The Premera network of doctors,dentists, hospitals, and other healthcareproviders is designed to offer ready accessto safe, effective, high-quality care ataffordable prices.Our strong relationships with ourprovider partners help maximizehealthcare dollars by:• Focusing on quality and cost-effective care• Helping control rising medical costs• Providing resources for improved healthcareHealthcare coverage wherever you goWhen outside of Washington, employees take theirhealthcare benefits with them—across the country andaround the world. The BlueCard Program gives themaccess to doctors and hospitals almost everywhereand the peace of mind that they’ll be able to find thehealthcare provider they need. They’ll have access tocare across the United States. Outside of the U.S.,they’ll have access to doctors and hospitals in nearly200 countries and territories around the world throughthe BlueCard Worldwide ® Program.One-call resolution:our customer service standardOur customer and claims service representativesare trained to answer questions in just one call.Through a rigorous education, servicerepresentatives are prepared to:• Ask the right questions• Address issues about health plan coverage• Give personalized attention and listen towhat members have to sayPlus they engage in ongoing coaching and developmentto ensure they stay on top of the changes to our healthplans and the healthcare industry.When you call customer service, you can expect expertguidance, help navigating available resources,and the information needed to resolve a problem.Members can use the Find a Doctor tool atpremera.com to see if their favorite provider is inour network, or to find a new one.5

Plan descriptionsYour ChoiceYour Choice offers a familiar PPO plan with coverage fora wide range of medical services. Employers can selectfrom a range of deductible options, with copays formany services.New split copay options available with lower copaysfor non-specialist office visits and a higher copaywhen a member sees a specialist.Specified preventive screenings and servicescovered in fullUnlimited coverage for many professional andnaturopathic servicesUnlimited inpatient and outpatient facility careMembers can save money by using an in-networkprovider. Non-network providers are still covered butat a higher cost to the member.Your FocusYour Focus offers an EPO plan with coverage for a widerange of medical services. It encourages the use ofpreventive care benefits.Benefits are provided only when members usein-network providers, which means you save onhealth plan costs by leveraging the Premera network.Employers can select from a range of deductibleoptions, with copays for many services.Unlimited inpatient and outpatient facility careUnlimited coverage for many professional andnaturopathic services12, 24, or unlimited visits covered for acupunctureand for spinal and other manipulationsOut-of-network care not covered except for medicalemergencies or as required by lawSpecified preventive screenings and servicescovered in full6

Your FutureThe HSA-qualified Your Future plan is designed to becombined with an employee-owned, tax-advantagedHealth Savings Account.Employers can choosebetween an aggregate or embedded deductible.Specified preventive screenings and servicescovered in fullUnlimited coverage for many professional andnaturopathic servicesMost other covered services, including prescriptiondrugs, subject to the plan’s deductible andcoinsuranceCertain generic preventive drugs covered in fullYour WorldFor a wide range of medical services,Your World plans offer access to any licensedor certified provider with the same level of deductibleand coinsurance benefit coverage.In-network providers accept our allowable charge aspayment in full, saving members money. Employerscan choose from a range of deductible options.Specified preventive screenings and servicescovered in fullUnlimited coverage for many professional andnaturopathic services, subject to deductibleand coinsuranceYour StartThe lower cost, “major med” style Your Start plancovers medical services and pharmacy. Employers canselect from seven aggregate or embedded deductibleoptions up to $6,600.To maintain employees’ medical benefits whilecontaining healthcare costs, Your Start can becombined with a Health Reimbursement Arrangement.Your Start plans are not HSA-qualified.Specified preventive screenings and servicescovered in fullUnlimited coverage for inpatient and outpatientfacility care and for many professional andnaturopathic servicesThree- or four-tier pharmacy plan included andtied to the medical plan deductible andout-of-pocket maximum77

Value PPOThe Value PPO plan offers coverage for a wide range ofmedical services. Many preventive services are coveredin full. Employers can select deductible options, withcopays for many services.Unlimited coverage for inpatient and outpatientfacility care and for many professional andnaturopathic services12 or unlimited visits covered for acupunctureand for spinal and other manipulationsPharmacy benefits includedPremera Value plans offer affordable coverage at theminimum value required to comply with the AffordableCare Act’s Employer Shared Responsibility requirement.Value HSAThe HSA-qualified Value HSA plan is designedto be combined with an employee-owned,tax-advantaged Health Savings Account.Employers can choose between aggregate andembedded deductible.Specified preventive services covered in fullUnlimited coverage for many professional andnaturopathic servicesPharmacy benefits includedCertain generic preventive drugs covered in fullPremera Value plans offer affordable coverage at theminimum value required to comply with the AffordableCare Act’s Employer Shared Responsibility requirement.8

YOUR CHOICE PLANSYour Choice offers a familiar PPO plan with coverage for a wide range of medical services.Employers can select from a range of deductible options, and new split copay options with lowercopays for non-specialist office visits and a higher copay when a member sees a specialist.Cost-share amounts represent members’ costs. Not all plan option combinations are offered.See your sales representative for clarification.COST-SHARE OPTIONS IN-NETWORK OUT-OF-NETWORKIndividual Deductible PCY$0 $100 $200 $250 $300 $500 $750$1,000 $1,500 $2,000 $2,500$3,000 $4,000 $5,000 $6350 $6,600Shared with in-network$200 $300 $400 $500 $600 $750 $1,000 $1,500$2,000 $3,000 $4,000 $5,000 $6,000 $8,000$10,000 $12,700 $13,200 $15,000 $19,050 $19,800Family Deductible PCY2x Individual 3x IndividualCoinsurance 0% 10% 20% 30% 50% 30% 40% 50%Individual Out-of-Pocket Maximum PCY(Includes deductible, coinsurance & copay)Family Out-of-Pocket Maximum PCY(Includes deductible, coinsurance & copay)Fourth Quarter Deductible Carryover$1,000 $1,100 $1,200 $1,250 $1,300 $1,500$1,750 $2,000 $2,100 $2,200 $2,250 $2,300$2,500 $2,750 $3,000 $3,500 $4,000$4,500 $5,000 $6,000 $6350 $6,600Shared with in-network$2,000 $2,200 $2,300 $2,400 $2,500 $2,600$3,000 $3,500 $3,750 $4,000 $4,200 $4,400$4,500 $4,600 $5,000 $5,500 $6,000 $7,000$8,000 $9,000 $10,000 $12,000 $12,700 $13,200$15,000 $16,000 $18,000 $19,050 $19,800 Unlimited2x Individual 3x IndividualIncluded ExcludedOffice Visit (OV) Cost ShareInpatient Cost ShareSplit Copay options:$25 non-specialist/$40 specialist and$30 non-specialist/$45 specialistIn-network deductible & coinsuranceCopay: $10, $15, $20, $25, $30, $35In-network deductible & coinsurance$250 per admit—unlimited days$250 per day up to 5 days per admit$100 per day—unlimited daysOut-of-network deductible & coinsuranceANNUAL PLAN MAXIMUMUnlimitedNote: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross.PCY = Per Calendar YearIn-Network Out-of-Pocket Maximum must not exceed the federally mandated maximum of $6,600 for an individual or $13,200 for a family.10

Benefits apply after calendar-year deductible is met, unless otherwise noted.PCY = Per Calendar YearCOVERED SERVICES BENEFIT LIMITS IN-NETWORK OUT-OF-NETWORKPreventive Care & Counseling VisitPreventive ScreeningsImmunizations (Seasonal immunizationsreceived at a pharmacy paid as in-network)Out-of-networkcoinsuranceUnlimited 1 Covered in full 2 Not coveredNot coveredProfessional Office Visit (Including urgent care)Other Outpatient Professional ServicesInpatient Professional ServicesUnlimitedOffice visit cost shareIn-network coinsuranceOut-of-networkcoinsuranceManipulations 3 (Spinal & other)Acupuncture 3Naturopathic Services12 visits PCY 24 visits PCY UnlimitedUnlimitedOffice visit cost shareOut-of-networkcoinsuranceMammography (Non-preventive)Outpatient Diagnostic Imaging& Laboratory ServicesUnlimitedIn-network coinsuranceIn-network coinsurance(deductible waived)Covered in full 2Out-of-networkcoinsuranceEmergency Room Care(Copay waived if direct admit to inpatient facility)Ambulance Transportation (Air & ground)UnlimitedAir: Unlimited; Ground: UnlimitedIn-network coinsuranceIn-network coinsurance PLUSCopay of: $50 $75$100 $150 $200 $300$50 copayIn-network coinsuranceIn-network coinsurance(deductible waived)Same as in-networkInpatient Facility CareOutpatient Facility CareSkilled Nursing FacilityUnlimited60 days PCY 90 days PCY120 days PCY 180 days PCYInpatient cost shareIn-network coinsuranceInpatient cost shareOut-of-networkcoinsuranceMaternity Care(Prenatal, delivery & postnatal care)Unlimited for: Subscriber,spouse/domestic partner & dependentssubscriber & spouse/domestic partner onlyIn-network coinsuranceOut-of-networkcoinsuranceMental Health Care 3UnlimitedChemical Dependency Treatment 3Rehabilitation(Including: Cardiac/pulmonary rehab, chronic pain &physical, occupational, speech & massage therapy)Unlimited15 visits/30 days PCY45 visits/30 days PCY60 visits/60 days PCYOutpatient: Office visit cost shareInpatient: Inpatient cost shareSupplies, Equipment, Prosthetics & OrthoticsTemporomandibular Joint Disorders (TMJ)Unlimited, except $300 max PCY for footorthotics that are not diabetes-relatedUnlimitedIn-network coinsuranceOutpatient: Office visit cost shareInpatient: Inpatient cost shareOut-of-networkcoinsuranceHome Health Agency Services 130 visits PCY Unlimited In-network coinsuranceHospice CareOutpatient: Unlimited(within 6 month lifetime max)Respite: 240 hours(within 6 month lifetime max)Inpatient: 10 days 30 daysUnlimited (within 6 month lifetime max)Outpatient & respite:In-network coinsuranceInpatient: Inpatient cost shareTransplants (Organ & bone marrow)Unlimited, except for $7,500travel & lodging limit per transplantOutpatient: Office visit cost shareInpatient: Inpatient Cost ShareCovered when approvedNote: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross.1A list of preventive screenings and other preventive services is available on premera.com in the Miscellaneous Forms page of the producer and employer websites.2Not subject to copay, deductible, or coinsurance.3With the split copay option, this benefit is subject to the non-specialist copay.This is only a brief summary of the major benefits provided by our plans. This is not a contract.For information and details regarding general exclusions and limitations, please refer to page 23.11

YOUR FOCUS PLANSYour Focus offers an EPO plan with coverage for a wide range of medical services.It encourages the use of preventive care benefits.Cost-share amounts represent members’ costs. Not all plan option combinations are offered.See your sales representative for clarification.COST-SHARE OPTIONS IN-NETWORK OUT-OF-NETWORKIndividual Deductible PCYFamily Deductible PCY$0 $100 $200 $250 $300 $500 $750 $1,000$1,500 $2,000 $2,500 $5,000 $6350 $6,6002x Individual 3x IndividualNot coveredCoinsurance 0% 10% 20% 30% Not coveredIndividual Out-of-Pocket Maximum PCY(Includes deductible, coinsurance & copay)Family Out-of-Pocket Maximum PCY(Includes deductible, coinsurance & copay)Fourth Quarter Deductible CarryoverOffice Visit (OV) Cost ShareInpatient Cost ShareANNUAL PLAN MAXIMUM$1,000 $1,100 $1,200 $1,250 $1,300 $1,500 $1,750$2,000 $2,100 $2,200 $2,250 $2,300 $2,500 $2,750$3,000 $3,500 $4,000 $4,500 $5,000 $6350 $6,600In-network deductible & coinsuranceCopay of: $10 $15 $20 $25 $30 $35In-network deductible & coinsurance$250 per admit—unlimited days$250 per day up to 5 days per admit$100 per day—unlimited days2x Individual 3x IndividualIncluded ExcludedUnlimitedNot coveredNot coveredNote: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross.PCY = Per Calendar Year.In-Network Out-of-Pocket Maximum must not exceed the federally mandated maximum of $6,600 for an individual or $13,200 for a family.12

Benefits apply after calendar-year deductible is met, unless otherwise noted.PCY = Per Calendar YearCOVERED SERVICES BENEFIT LIMITS IN-NETWORK OUT-OF-NETWORKPreventive Care & Counseling VisitPreventive ScreeningsImmunizations (Seasonal immunizationsreceived at a pharmacy paid as in-network)Unlimited 1 Covered in full 2 Not coveredProfessional Office Visit (Including urgent care)Office visit cost shareOther Outpatient Professional ServicesInpatient Professional ServicesUnlimitedIn-network coinsuranceNot coveredManipulations (Spinal & other)Acupuncture12 visits PCY24 visits PCY UnlimitedOffice visit cost shareNot coveredNaturopathic ServicesUnlimitedMammography (Non-preventive)Outpatient Diagnostic Imaging &Laboratory ServicesUnlimitedIn-network coinsuranceIn-network coinsurance(deductible waived)Covered in full 2Not coveredEmergency Care(Copay waived if direct admit to inpatient facility)Ambulance Transportation (Air & ground)UnlimitedAir: Unlimited; Ground: UnlimitedIn-network coinsuranceIn-network coinsurance PLUSCopay of: $50 $75$100 $150 $200 $300$50 copayIn-network coinsuranceIn-network coinsurance(deductible waived)Same as in-networkInpatient Facility CareOutpatient Facility CareUnlimitedInpatient cost shareIn-network coinsuranceNot coveredSkilled Nursing Facility60 days PCY 90 days PCY120 days PCY 180 days PCYInpatient cost shareMaternity Care (Prenatal, delivery & postnatal care)Unlimited for: Subscriber,spouse/domestic partner& dependents subscriber,spouse/domestic partner onlyIn-network coinsuranceNot coveredMental Health CareUnlimitedChemical Dependency TreatmentRehabilitation(Including: Cardiac/pulmonary rehab, chronic pain &physical, occupational, speech & massage therapy)Unlimited15 visits/ 30 days PCY45 visits/ 30 days PCY60 visits/ 60 days PCYOutpatient: Office visit cost shareInpatient: Inpatient cost shareSupplies, Equipment, Prosthetics & OrthoticsUnlimited, except $300 max PCY for footorthotics that are not diabetes-relatedIn-network coinsuranceTemporomandibular Joint Disorders (TMJ)UnlimitedOutpatient: Office visit cost shareInpatient: Inpatient cost shareNot coveredHome Health Agency Services 130 visits PCY Unlimited In-network coinsuranceHospice CareTransplants (Organ & bone marrow)Outpatient: Unlimited(within 6 month lifetime max)Respite: 240 hours(within 6 month lifetime max)Inpatient: 10 days 30 daysUnlimited (within 6 month lifetime max)Unlimited, except for $7,500travel & lodging limit per transplantOutpatient & respite:In-network coinsuranceInpatient: Inpatient cost shareOutpatient: Office visit cost shareInpatient: Inpatient cost shareNote: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross.1A list of preventive screenings and other preventive services is available on premera.com in the Miscellaneous Forms page of the producer and employer websites.2Not subject to copay, deductible, or coinsurance.This is only a brief summary of the major benefits provided by our plans. This is not a contract.For information and details regarding general exclusions and limitations, please refer to page 23.13

YOUR FUTURE PLANSThe HSA-qualified Your Future plan is designed to be combined with an employee-owned,tax-advantaged Health Savings Account. Employers can choose between an aggregateor embedded deductible.DEDUCTIBLE OPTIONSAggregate DeductibleEmbedded DeductibleThe aggregate deductible amount is different when a subscriber enrolls alone or with dependents. Whendependents are enrolled, the full amount of the aggregate deductible must be met before benefits can begin forany covered family member.An embedded deductible works like a traditional PPO health plan deductible. Benefits begin for a single familymember after the individual deductible for that member has been met or after the family deductible is met—whichever comes first.Cost-share amounts represent members’ costs. Not all plan option combinations are offered.See your sales representative for clarification.COST-SHARE OPTIONS IN-NETWORK OUT-OF-NETWORKAggregateEmbeddedIndividual Deductible/Family PCY$1,500/ $1,700/ $2,000/ $2,500/ $5,000/ $6,050/ $6,450/ $2,700/ $6,050/ $6,450/ See footnote in$3,000 1 $3,400 1 $4,000 2 $5,000 1 $10,000 2 $12,100 2 $12,900 2 $5,400 1 $12,100 2 $12,900 2 in-network for optionsIndividual/Family Out-of-Pocket Maximum PCY(Includes deductible & coinsurance)$4.000/$8,000$4,200/$8,400$2,000/$4,000$5,000/$10,000$5,000/$10,000$6,050/$12,100$6,450/$12,900$5,100/$10,200$6,050/$12,100$6,450/$12,900UnlimitedCoinsurance (Member’s percentage of costs,after deductible, based on allowable charges)20% 0% 20% 0% 20% 0% 50%Fourth Quarter Deductible Carryover Excluded ExcludedOffice Visit (OV) Cost Share In-network deductible & coinsurance Deductible / 50%Inpatient Cost Share In-network deductible & coinsurance Deductible / 50%ANNUAL PLAN MAXIMUMUnlimitedNote: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross.1Out-of-Network Deductible can be either shared with In-Network or 2x the In-Network Deductible.2Out-of-Network Deductible is 2x the In-Network Deductible.PCY = Per Calendar YearIn-Network Out-of-Pocket Maximum must not exceed the federally mandated maximum of $6,600 for an individual or $13,200 for a family.14

Benefits apply after calendar-year deductible is met, unless otherwise noted.PCY = Per Calendar YearCOVERED SERVICES BENEFIT LIMITS IN-NETWORK OUT-OF-NETWORKPreventive Care & Counseling VisitNot coveredPreventive Screenings Unlimited 1 Covered in full 2 50%Immunizations (Seasonal immunizationsreceived at a pharmacy paid as In-network)Professional Office Visit (Including urgent care)Other Outpatient Professional ServicesInpatient Professional ServicesNot coveredUnlimited In-network coinsurance 50%Manipulations (Spinal & other) 12 visits PCY UnlimitedAcupuncture12 visits PCYIn-network coinsurance 50%Naturopathic ServicesUnlimitedMammography (Non-preventive)Outpatient Diagnostic Imaging &Laboratory ServicesUnlimited In-network coinsurance 50%Emergency CareAmbulance Transportation (Air & ground)Inpatient Facility CareOutpatient Facility CareSkilled Nursing FacilityMaternity Care (Prenatal, delivery & postnatal care)Mental Health CareUnlimitedUnlimited60 days PCYUnlimited for: Subscriber,spouse/domestic partner only subscriber,spouse/domestic partner & dependentsUnlimitedIn-network coinsuranceIn-network coinsurance 50%In-network coinsurance 50%Chemical Dependency TreatmentRehabilitation(Including: Cardiac/pulmonary rehab, chronic pain &physical, occupational, speech & massage therapy)Supplies, Equipment, Prosthetics & OrthoticsTemporomandibular Joint Disorders (TMJ)Unlimited15 visits PCY/30 days PCY45 visits PCY/30 days PCY60 visits PCY/60 days PCYUnlimited, except $300 max PCY for footorthotics that are not diabetes-relatedUnlimitedIn-network coinsurance 50%Home Health Agency ServicesHospice CareTransplants (Organ & bone marrow)Certain Generic Preventive DrugsRetail & Mail Order 3Retail Pharmacy (Subject to medical deductible)Mail Order Pharmacy (Subject to medical deductible)130 visits PCYOutpatient: Unlimited (within 6 mo. lifetime max)Respite: 240 hours (within 6 mo. lifetime max)Inpatient: 10 days (within 6 mo. lifetime max)Unlimited, except for $7,500travel & lodging limit per transplant90-day supply, exceptSpecialty Rx: 30-day supplyCovered when approvedCovered in full 2In-network coinsuranceIn-network coinsuranceNote: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross.1A list of preventive screenings and other preventive services is available on premera.com in the Miscellaneous Forms page of the producer and employer websites.2Not subject to copay, deductible, or coinsurance.3Buy-up options available, contact your sales representative.This is only a brief summary of the major benefits provided by our plans. This is not a contract. For information and details regarding general exclusions and limitations,please refer to page 23. Please see our Personal Funding Accounts brochure for more details on Health Savings Accounts.15

YOUR START PLANSThe lower cost, “major med” style Your Start plan covers medical services and pharmacy.Employers can select from seven aggregate or embedded deductible options up to $6,600.DEDUCTIBLE OPTIONSAggregate DeductibleEmbedded DeductibleThe aggregate deductible amount is different when a subscriber enrolls alone or with dependents. Whendependents are enrolled, the full amount of the aggregate deductible must be met before benefits canbegin for any covered family member.An embedded deductible works like a traditional PPO health plan deductible. Benefits begin for a singlefamily member after the individual deductible for that member has been met or after the family deductibleis met—whichever comes first.Cost-share amounts represent members’ costs. Not all plan option combinations are offered.See your sales representative for clarification.COST-SHARE OPTIONS IN-NETWORK OUT-OF-NETWORKIndividual Deductible PCYFamily Deductible PCY$1,500 $2,500 $3,500 $5,000 $6,000 $6,350 $6,600(Aggregate or embedded)Aggregate: 2x Individual;Embedded: 2x Individual, 3x Individual2x in-network,3x in-networkCoinsurance 0% 10% 20% 30% 50% 30% 40% 50%Individual Out-of-Pocket Maximum PCY(Includes deductible, coinsurance, and copays)$3,000 $4,000$5,000 $6,000, $6,350 $6,600UnlimitedFamily Out-of-Pocket Maximum PCY(Includes deductible, coinsurance, and copays)Aggregate: 2x Individual;Embedded: 2x Individual, 3x IndividualOffice Visit (OV) Cost ShareInpatient Cost ShareIn-network deductible & coinsuranceOut-of-network deductible & coinsuranceANNUAL PLAN MAXIMUMUnlimitedNote: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross.PCY = Per Calendar YearIn-Network Out-of-Pocket Maximum must not exceed the federally mandated maximum of $6,600 for an individual or $13,200 for a family.16

Benefits apply after calendar-year deductible is met, unless otherwise noted.PCY = Per Calendar YearCOVERED SERVICES BENEFIT LIMITS IN-NETWORK OUT-OF-NETWORKPreventive Care & Counseling VisitPreventive ScreeningsImmunizations (Seasonal immunizationsreceived at a pharmacy paid as in-network)Out-of-networkcoinsuranceUnlimited 1 Covered in full 2 Not coveredNot coveredProfessional Office Visit (Including urgent care)Other Outpatient Professional ServicesInpatient Professional ServicesUnlimitedOffice visit cost shareIn-network coinsuranceOut-of-networkcoinsuranceManipulations (Spinal & other)AcupunctureNaturopathic Services12 visits PCY 24 visits PCY UnlimitedUnlimitedOffice visit cost shareOut-of-networkcoinsuranceMammography (Non-preventive)Outpatient Diagnostic Imaging &Laboratory ServicesUnlimitedIn-network coinsuranceIn-network coinsurance(deductible waived)Covered in full 2Out-of-networkcoinsuranceEmergency Care(Copay waived if direct admit to inpatient facility)Ambulance Transportation (Air & ground)UnlimitedAir: Unlimited; Ground: UnlimitedIn-network coinsuranceIn-network coinsurance;In-network coinsurance(deductible waived)Same as in-networkInpatient Facility CareOutpatient Facility CareSkilled Nursing FacilityUnlimited60 days PCY 90 days PCY120 days PCY 180 days PCYInpatient cost shareIn-network coinsuranceInpatient cost shareOut-of-networkcoinsuranceMaternity Care (Prenatal, delivery & postnatal care)Unlimited for: Subscriber, spouse/domestic partner &dependents subscriber,spouse/domestic partner onlyIn-network coinsuranceOut-of-networkcoinsuranceMental Health CareUnlimitedChemical Dependency TreatmentRehabilitation(Including: Cardiac/pulmonary rehab, chronic pain &physical, occupational, speech & massage therapy)Unlimited15 visits / 30 days PCY45 visits / 30 days PCY60 visits / 60 days PCYOutpatient: Office visit cost shareInpatient: Inpatient cost shareSupplies, Equipment, Prosthetics & OrthoticsTemporomandibular Joint Disorders (TMJ)Unlimited, except $300 max PCY for footorthotics that are not diabetes-relatedUnlimitedIn-network coinsuranceOutpatient: Office visit cost shareInpatient: Inpatient cost shareOut-of-networkcoinsuranceHome Health Agency Services 130 visits PCY Unlimited In-network coinsuranceHospice CareOutpatient: Unlimited(within 6 month lifetime max)Respite: 240 hours(within 6 month lifetime max)Inpatient: 10 days 30 daysUnlimited (within 6 month lifetime max)Outpatient & respite:In-network coinsuranceInpatient: Inpatient cost shareTransplants (Organ & bone marrow)Unlimited, except for$7,500 travel & lodginglimit per transplantOutpatient: Office visit cost shareInpatient: Inpatient cost shareNot coveredRetail Pharmacy(Subject to medical deductible)Mail Order Pharmacy(Subject to medical deductible)Retail: 30-day supplyMail Order: 90-day supplySpecialty Rx: 30-day supply throughpreferred specialty pharmacies3-Tier: $15 3 / In-network medical coins./50% with preferred B3 drug list4-Tier: $15 3 /In-network medical coins./50%/30% with preferred B4 drug list3-Tier: $38 3 / In-network medical coins./50% with preferred B3 drug list4-Tier: $38 3 /In-network medical coins./50%/30% with preferred B4 drug listNote: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross.1A list of preventive screenings and other preventive services is available on premera.com in the Miscellaneous Forms page of the producer and employer websites.2Not subject to copay, deductible, or coinsurance.Not covered3Deductible waived on Tier 1 generic drugs.This is only a brief summary of the major benefits provided by our plans. This is not a contract. For information and details regarding general exclusions and limitations,please refer to page 23. Please see our Personal Funding Accounts brochure for more details on Health Reimbursement Arrangements.17

YOUR WORLD PLANSFor a wide range of medical services,Your World plans offer access to any licensedor certified provider with the same level of deductible and coinsurance benefit coverage.Cost-share amounts represent members’ costs. Not all plan option combinations are offered.See your sales representative for clarification.COST-SHARE OPTIONSIndividual Deductible PCYFamily Deductible PCYANY PROVIDER$0 $100 $200 $250 $300 $500 $750 $1,000 $1,500$2,000 $2,500 $3,000 $4,000 $5,000 $6,350 $6,6002x Individual3x IndividualCoinsurance 0% 10% 20% 30% 50%Individual Out-of-Pocket Maximum PCY(Includes deductible, coinsurance, and copays)Family Out-of-Pocket Maximum PCY(Includes deductible,coinsurance, and copays)Fourth Quarter Deductible CarryoverOffice Visit (OV) Cost ShareInpatient Cost ShareANNUAL PLAN MAXIMUM$1,000 $1,100 $1,200 $1,250 $1,300 $1,500 $1,750$2,000 $2,100 $2,200 $2,250 $2,300 $2,500 $2,750$3,000 $3,500 $4,000 $4,500 $5,000 $6,000 $6,350 $6,6002x Individual3x IndividualIncludedExcludedDeductible & coinsuranceUnlimitedNote: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross.PCY = Per Calendar YearIn-Network Out-of-Pocket Maximum must not exceed the federally mandated maximum of $6,600 for an individual or $13,200 for a family.18

Benefits apply after calendar-year deductible is met, unless otherwise noted.PCY = Per Calendar YearCOVERED SERVICES BENEFIT LIMITS COST SHARESPreventive Care & Counseling VisitPreventive ScreeningsImmunizations (Seasonal immunizationsreceived at a pharmacy paid as in-network)Unlimited 1 Covered in full 2Professional Office Visit (Including urgent care)Other Outpatient Professional ServicesInpatient Professional ServicesManipulations (Spinal & other)AcupunctureNaturopathic ServicesMammography (Non-preventive)Outpatient Diagnostic Imaging& Laboratory ServicesEmergency Room Care(Copay waived if direct admit to inpatient facility)Ambulance Transportation (Air & ground)Inpatient Facility CareOutpatient Facility CareSkilled Nursing FacilityMaternity Care (Prenatal, delivery & postnatal care)Mental Health CareUnlimited12 visits PCY 24 visits PCY UnlimitedUnlimitedUnlimitedUnlimitedAir: Unlimited; Ground: UnlimitedUnlimited60 days PCY 90 days PCY120 days PCY 180 days PCYUnlimited for: Subscriber,spouse/domestic partner & dependentssubscriber & spouse/domestic partner onlyUnlimitedCoinsuranceCoinsuranceCoinsuranceCoinsurance (deductible waived)Covered in full 2CoinsuranceCoinsurance PLUS copay of:$50 $75 $100 $150 $200 $300CoinsuranceCoinsurance (deductible waived)CoinsuranceCoinsuranceChemical Dependency TreatmentRehabilitation(Including: Cardiac/pulmonary rehab, chronic pain &physical, occupational, speech & massage therapy)Supplies, Equipment, Prosthetics & OrthoticsTemporomandibular Joint Disorders (TMJ)Unlimited15 visits/30 days PCY45 visits/30 days PCY60 visits/60 days PCYUnlimited, except $300 max PCY for footorthotics that are not diabetes-relatedUnlimitedCoinsuranceHome Health Agency ServicesHospice CareTransplants (Organ & bone marrow)130 visits PCY UnlimitedOutpatient: Unlimited (within 6 month lifetime max)Respite: 240 hours (within 6 month lifetime max)Inpatient: 10 days, 30 days,Unlimited (within 6 month lifetime max)Unlimited, except for $7,500travel & lodging limit per transplantNote: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross.1A list of preventive screenings and other preventive services is available on premera.com in the Miscellaneous Forms page of the producer and employer websites.2Not subject to copay, deductible, or coinsurance.This is only a brief summary of the major benefits provided by our plans. This is not a contract.For information and details regarding general exclusions and limitations, please refer to page 23.19

VALUE PPO PLANSThe Value PPO plan offers coverage for a wide range of medical services. Many preventiveservices are covered in full. Employers can select deductible options, with copays formany services.COST-SHARE OPTIONS IN-NETWORK OUT-OF-NETWORKIndividual Deductible PCY $3,500 $4,000 $5,500 $6,350 2x in-network deductibleFamily Deductible PCY2x IndividualCoinsurance 20% 0% 50%Individual Out-of-Pocket Maximum PCY(Includes deductible, coinsurance & copay)Family Out-of-Pocket Maximum PCY(Includes deductible, coinsurance & copay)$6,3502x IndividualUnlimitedFourth Quarter Deductible CarryoverExcludedOffice Visit (OV) Cost Share In-network deductible & coinsurance $45Inpatient Cost ShareIn-network deductible & coinsuranceOut-of-networkdeductible & coinsuranceANNUAL PLAN MAXIMUMUnlimitedPRESCRIPTION DRUGS IN-NETWORK OUT-OF-NETWORKRetail Pharmacy(Subject to medical deductible)Mail Order Pharmacy(Subject to medical deductible)$15/50%/50% $15/50%/50% $25*/50%/50%$45/50%/50% $45/50%/50% $75*/50%/50%In-networkdeductible &coinsuranceNot coveredBENEFIT LIMITSRetail: 30-day supply Mail order: 90-day supplySpecialty Rx: 30-day supply through specialty pharmacies 1*Deductible waived on Tier 1 generic drug1 Specialty Rx subject to medical deductible & coinsuranceIn-Network Out-of-Pocket Maximum must not exceed the federally mandated maximum of $6,600 for an individual or $13,200 for a family.20

COVERED SERVICES BENEFIT LIMITS IN-NETWORK OUT-OF-NETWORKPreventive Care & Counseling VisitPreventive ScreeningsImmunizations (Seasonal immunizationsreceived at a pharmacy paid as in-network)Out-of-network coinsuranceUnlimited 1 Covered in full 2 Not coveredNot coveredProfessional Office Visit (Including urgent care)Office visit cost shareOther Outpatient Professional ServicesInpatient Professional ServicesUnlimitedIn-network coinsuranceOut-of-network coinsuranceManipulations (Spinal & other)12 visits PCY or unlimitedAcupuncture12 visits PCYOffice visit cost shareOut-of-network coinsuranceNaturopathic ServicesUnlimitedMammography (Non-preventive)Outpatient Diagnostic Imaging& Laboratory ServicesUnlimited In-network coinsurance Out-of-network coinsuranceEmergency Room Care(Copay waived if direct admit to inpatient facility)Unlimited$250 then subject to deductible, then coinsuranceAmbulance Transportation (Air & ground) In-network coinsurance Same as in-networkInpatient Facility CareOutpatient Facility CareUnlimitedInpatient cost share/in-network coinsuranceSkilled Nursing Facility 60 day PCY Inpatient cost shareOut-of-network coinsuranceMaternity (Prenatal, delivery & postnatal care for thesubscriber and any female dependent)Unlimited In-network coinsurance Out-of-network coinsuranceMental Health & Chemical Dependency TreatmentUnlimitedRehabilitation(Including: Cardiac/pulmonary rehab, chronic pain &physical, occupational, speech & massage therapy)15 visits/30 days PCYOutpatient: Office visit cost shareInpatient: Inpatient cost shareOut-of-network coinsuranceSupplies, Equipment, Prosthetics and OrthoticsUnlimited, except $300 max PCYfor foot orthotics that are notdiabetes-relatedIn-network coinsuranceTemporomandibular Joint Disorders (TMJ)UnlimitedOutpatient: Office visit cost shareInpatient: Inpatient cost shareHome Health Agency Services 130 visits PCY In-network coinsuranceOut-of-network coinsuranceHospice CareOutpatient: Unlimited(within 6 month lifetime max)Respite: 240 hours(within 6 month lifetime max)Inpatient: 10 days30 days unlimited(within 6 month lifetime max)Outpatient & respite:In-network coinsuranceInpatient: Inpatient cost shareTransplants (Organ & bone marrow)Unlimited, except for$7,500 travel& lodginglimit per transplantOutpatient: Office visit cost shareInpatient: Inpatient cost shareCovered when approvedNote: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross.1A list of preventive screenings and other preventive services is available on premera.com in the Miscellaneous Forms page of the producer and employer websites.2Not subject to copay, deductible, or coinsurance.This is only a brief summary of the major benefits provided by our plans. This is not a contract.For information and details regarding general exclusions and limitations, please refer to page 23.21

VALUE HSA PLANSThe HSA-qualified Value HSA plan is designed to be combined with an employee-owned,tax-advantaged Health Savings Account. Employers can choose between aggregate andembedded deductible.DEDUCTIBLE OPTIONSAggregate DeductibleEmbedded DeductibleThe aggregate deductible amount is different when a subscriber enrolls alone or with dependents. Whendependents are enrolled, the full amount of the aggregate deductible must be met before benefits can beginfor any covered family member.An embedded deductible works like a traditional PPO health plan deductible. Benefits begin for a single familymember after the individual deductible for that member has been met or after the family deductible is met—whichever comes first.COST-SHARE OPTIONS IN-NETWORK OUT-OF-NETWORKIndividual/Family Deductible PCY $3,850 / $7,700 $5,250 / $10,500 2x In-network deductibleCoinsurance 20% 50%Individual/Family Out-of-Pocket Maximum PCY(Includes deductible & coinsurance)Fourth Quarter Deductible Carryover$6,350 / $12,700 UnlimitedExcludedOffice Visit (OV) Cost ShareInpatient Cost ShareANNUAL PLAN MAXIMUMIn-network deductible & coinsuranceUnlimitedOut-of-network deductible& coinsurancePRESCRIPTION DRUGS IN-NETWORK OUT-OF-NETWORKCertain Generic Preventive Drugs Retail & Mail OrderRetail Pharmacy (Subject to medical deductible)Mail Order Pharmacy (Subject to medical deductible)BENEFIT LIMITSCovered in fullIn-network deductible & coinsuranceRetail: 30-day supply Mail order: 90-day supplySpecialty Rx: 30-day supply through specialty pharmaciesNot covered22

COVERED SERVICES BENEFIT LIMITS IN-NETWORK OUT-OF-NETWORKPreventive Care & Counseling VisitPreventive ScreeningsImmunizations (Seasonal immunizationsreceived at a pharmacy paid as in-network)Out-of-network coinsuranceUnlimited 1 Covered in full 2 Not coveredNot coveredProfessional Office Visit (Including urgent care)Other Outpatient Professional ServicesInpatient Professional ServicesManipulations (Spinal & other)Unlimited In-network coinsurance Out-of-network coinsurance12 visits PCY or unlimitedAcupuncture12 visits PCYIn-network coinsuranceOut-of-network coinsuranceNaturopathic ServicesUnlimitedMammography (Non-preventive)Outpatient Diagnostic Imaging& Laboratory ServicesUnlimited In-network coinsurance Out-of-network coinsuranceEmergency Room CareIn-network coinsuranceUnlimitedAmbulance Transportation (Air & ground) In-network coinsurance Same as in-networkInpatient Facility CareOutpatient Facility CareUnlimitedIn-network coinsuranceOut-of-network coinsuranceSkilled Nursing Facility60 day PCYMaternity (Prenatal, delivery & postnatal care) Unlimited In-network coinsurance Out-of-network coinsuranceMental Health & Chemical Dependency TreatmentUnlimitedRehabilitation(Including: Cardiac/pulmonary rehab, chronic pain &physical, occupational, speech & massage therapy)15 visits/30 days PCYIn-network coinsuranceOut-of-network coinsuranceSupplies, Equipment, Prosthetics and OrthoticsUnlimited, except $300 max PCYfor foot orthotics that are notdiabetes-relatedTemporomandibular Joint Disorders (TMJ)UnlimitedHome Health Agency Services130 visits PCYOut-of-network coinsuranceHospice CareOutpatient: Unlimited(within 6 month lifetime max)Respite: 240 hours(within 6 month lifetime max)Inpatient: 10 days30 days unlimited(within 6 month lifetime max)In-network coinsuranceTransplants (Organ & bone marrow)Unlimited, except for$7,500 travel& lodginglimit per transplantCovered when approvedNote: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross.1A list of preventive screenings and other preventive services is available on premera.com in the Miscellaneous Forms page of the producer and employer websites.2Not subject to copay, deductible, or coinsurance.This is only a brief summary of the major benefits provided by our plans. This is not a contract.For information and details regarding general exclusions and limitations, please refer to page 23.23

Prescriptiondrug coverageOur prescription drug optionshelp reduce costs, not choice.Cost-saving incentives encourage the use of generic orpreferred brand-name drugs, with even greater savingsif members use the mail order service.All medical plans are required to include a prescriptiondrug plan. The options listed on this page are availablefor all plans except Your Start, HSA and Value Plans.Your Future and Value HSA plans include prescriptiondrug coverage and feature first-dollar preventive drugcoverage on certain generic cardiovascular and oraldiabetic medications. Please see the HSA and Valueplan summary pages for more details.[ ]MORE DETAILSFor details about prescription drug coverage,see the Pharmacy section on premera.comor ask your Premera representative.4-TIER PLAN DESIGNSTier 1 Tier 2 Tier 3 Tier 4Generic drugs Preferred brand-name drugs Non-preferred brand-name drugs Specialty drugs 1Lowest copay / coinsurance Second lowest copay / coinsurance Highest coinsurance Highest cost / 30% coinsurance3-TIER PLAN DESIGNSTier 1 Tier 2 Tier 3Generic drugs Preferred brand-name drugs Non-preferred brand-name drugsLower copay / coinsurance Higher copay / coinsurance Highest copay / coinsurance2-TIER PLAN DESIGNSTier 1 Tier 2Generic drugsLower copay / coinsuranceBrand-name drugsHigher copay / coinsurance1Specialty drugs are used for treating complex or rare conditions such as rheumatoid arthritis, hepatitis C, or multiple sclerosis.Coverage requires that these prescriptions be filled through our Specialty Pharmacy Program, which uses pharmacists dedicated to supporting specialty drugs and those who require them.24

COST SHARE OPTIONS4-TIER – PREFERRED B4 DRUG LIST APPLIESConfigurable Copay PlansRetail Pharmacy Up to 30-day supply per Rx $10 / $30 / 40% / 30% $15 / 35% / 50% / 30% $20 / $50 / 50% / 30%Mail Service Up to 90-day supply per Rx $25 / $75 / 40% / 30% $37.50 / 35% / 50% / 30% $50 / $125 / 50% / 30%Rx Individual Deductible 2 PCY(Separate from medical plan deductible)None, $150, $300, $500Rx Family Deductible 2 PCY None, same as medical 3Individual Out-of-Pocket Maximum PCYAccrues to the medical out-of-pocketCOST SHARE OPTIONS3-TIER – PREFERRED B3 DRUG LIST APPLIESStandardCopay PlansConfigurable Copay PlansConfigurableCoinsurance PlansRetail PharmacyUp to 30-day supply per Rx$10/$25/$45$10/$30/$50$5/$15/$30$10/$20/$40$15/$15/ $10/ 25%/$25/$40 1 $30/$50 1 30%/45% 1 40%/45% 1Mail ServiceUp to 90-day supply per Rx$25/$62/ $112$25/$75/$125$10/$30/$60$12/$37/$75$20/$40/ $80$25/$50/ $100$30/$50/$80$37/$62/$100$30/$60/$100$37/$75/$125$25/25%/40%20%/35%/40%Rx Individual Deductible 2 PCY(Separate from medical plan deductible)None $300 None, $150, $300, $500None, $150,$300, $500Rx Family Deductible 2 PCYIndividual Out-of-Pocket Maximum PCYNoneNone, sameas medical 3 None, same as None, samemedical3 as medical 3Accrues to the medical out-of-pocketCOST SHARE OPTIONS2-TIER – PREFERRED A2 DRUG LIST APPLIESStandard Coinsurance PlanConfigurable Copay PlansRetail Pharmacy Up to 30-day supply per Rx $10 / 50% $10 / $30 $15 / $35Mail Service Up to 90-day supply per Rx $25 / 45% $20 / $60 / $25 / $75 $30 / $70 / $37 / $87Rx Individual Deductible 2 PCY(Separate from medical plan deductible)$500 None / $150 / $300Rx Family Deductible 2 PCY None, same as medical 3Individual Out-of-Pocket Maximum PCYAccrues to the medical out-of-pocket1A buy-up option is available with this plan to extend certain generic preventive drugs to be covered in full. Ask your sales representative for more details.2Deductible waived for generics.3 Family deductible is separate from medical deductible; value uses same multiplier as medical deductible.4 Out-of-pocket (OOP) maximum is in-network only; unlimited for out-of-network.PCY = Per Calendar YearThis is only a brief summary of the major benefits provided by our plans. This is not a contract.For information and details regarding general exclusions and limitations, please refer to page 23.25

Optional benefitsPackaged prescription drug, dental, vision,and hearing coverage is easier to managefor employees, employers, and producers:One account teamOne ID cardOne billOne websiteVision and HearingFor vision coverage, employers can choose exam only or exam plus hardware. Our group plans embed visioncoverage with medical coverage and adult vision coverage (19 or older) also includes pediatric coverage (18 oryounger). See the grid below for pediatric benefits in embedded plans. When a group offers vision coverage as aseparate option, benefits for members younger than 19 are the same as benefits for adults.For details about dental coverage, see the Premera DentalBlue benefit guide.BENEFIT LIMITSCOVERAGE OPTIONSYour ChoiceYour FocusYour Future,Value HSAYour Start,Your WorldValue PPOVisionAdultExam onlyExam & eyewear1 Routine exam, 1PCY1 Routine exam PCY;Hardware: $150 PCY;$150 every 2consecutive CY; $300PCY; $300 every 2consecutive CYCovered in Full or Deductible/Coinsurance or Flat copayExam: Covered in Full or Deductible/Coinsurance or Flat copayHardware: Covered in fullCovered in Fullor Deductible/Coinsurance or$25 copayExam: Covered inFull or Deductible/Coinsurance or$25 copayHardware:Covered in fullCovered in Fullor Deductible/CoinsuranceExam: Covered inFull or Deductible/CoinsuranceHardware: Coveredin fullOption 6350 - $45or Covered in FullAll Others:Deductible/Coinsurance orCovered in FullOption 6350 - $45or Covered in FullAll Others:Deductible/Coinsurance orCovered in FullVisionPediatric Exam only 1 Routine exam PCYOffice visitcost shareDeductible waived,then coinsuranceor Deductible/CoinsuranceOffice VisitCost ShareDeductible waived,then coinsuranceOffice VisitCost ShareExam & eyewear1 Routine exam PCY;Hardware: 1 pair ofglasses PCY (frames& lenses); 12-monthsupply of contactsPCY, in lieu of glasses(frames & lenses)Exam: Office VisitCost share orWaive Deductible,then coinsuranceEyeware: Coveredin fullExam: Deductiblewaived, thencoinsuranceor Deductible/CoinsuranceEyeware: Coveredin FullExam: Office VisitCost shareEyeware:Deductible, then0%Exam: Deductiblewaived, thencoinsuranceEyeware: Coveredin FullExam: Option6350 - Office VisitCost share; AllOther - WaivedDeductible, thenCoinsuranceEyeware: Coverin FullHearingExam onlyExam and Hearingaids & hardware1 Exam PCY or1 Exam every 2 CY1 Exam PCY or1 Exam every 2 CY;Hardware:$1,000 every 3 CY or$3,000 every 3 CYCovered in Full orDeductible/Coinsurance or Flat copayExam: Covered in Full orDeductible/Coinsurance or Flat copayHardware: Covered in fullNot CoveredDeductible/Coinsurance orCovered in FullExam: Deductible/Coinsurance orCovered in FullHardware:Covered in fullOption 6350 - $45or Covered in FullAll Others:Deductible/Coinsurance orCovered in FullOption 6350 - $45or Covered in FullAll Others:Deductible/Coinsurance orCovered in FullThis is only a brief summary of the major benefits provided by our plans. This is not a contract.For information and details regarding general exclusions and limitations, please refer to page 23.26

General exclusions & limitationsBenefit plans typically have exclusions and limitations—what the plans limit or do not cover.The following are general exclusions and limitations for Premera Blue Cross benefit plans.*What is limited or not coveredBenefits are not provided for treatment, surgery,services, drugs or supplies for any of the following:• Any disease, ailment, or condition listed as notcovered in the contract• Caffeine dependence• Complications of non-covered services• Conditions arising from acts of war, or service inthe military• Conditions arising from the member’s commissionof a felony or act of terrorism• Convenience items (i.e., guest meals and services,television, telephone charges)• Cosmetic or reconstructive surgery (except asspecifically provided) and supplies• Dental services (except as specifically provided)• Unless benefit option is selected, a dependentchild’s pregnancy is not covered, except fortreatment of complications• Dietary and food supplements (except medical foods)• Experimental or investigative services• Hair loss/cranial prosthesis (wig)• Infertility treatment (except as specifically provided)• Over-the-counter or non-prescription drugs,except as required by law• Private duty nursing• Services in excess of specified benefit maximumsand/or allowable charges• Services payable by other types of insurance such asmotor vehicle insurance or personal liability insurance• Services received when you are not covered bythis program• Sexual dysfunction• Vision therapy, eye exercise, and vision surgeries toimprove the refractive character of the cornea (LASIK)• Vocational counseling, vocational rehabilitation,and recreational therapy• Work-related conditions for which you are eligiblefor benefits from other sourcesPrior authorizationCertain medical services and prescriptions require priorauthorization (approval from the health plan) before themember gets them. Contact your Premera representativefor more information.More informationA supplemental guide that shares information aboutprivacy policies, provider organization, key utilizationmanagement procedures, and pharmaceuticalmanagement procedures is available on our website.*For a complete list of the exclusions and limitations, please see the plan contract or visit premera.com.Please contact your Premera Blue Cross representative for more information.27

premera.comWestern Washington7001 220th St. SWMountlake Terrace, WA 98043800.722.5561Eastern Washington3900 East SpragueSpokane, WA 99202800.722.5561017044 (10-2014)