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Medical Plans Benefit GuideEmployers with 1-50 employees | 1.1.2016

b

Provider network built for value and quality ............................................2

Wellness rewards ...................................................................................3

Medical Travel Support and Air or Surface Transportation ......................4

Support for smart healthcare decisions ..................................................4

Easy-to-use online and mobile tools .......................................................5

Customer service experience .................................................................5

Premera health plans ..............................................................................6

The 10 essential benefits your plan covers .............................................6

Choose from a range of plans .................................................................7

Plan summaries ......................................................................................8

Optional benefits ..................................................................................21

Definitions ............................................................................................22

General exclusions and limitations ........................................................25

1

Welcome to 2016 Premera Blue Cross Blue Shield of Alaska Along with the great service and rich network access you have come to expect from Premera, we are pleased to offer benefits tailored for the needs of groups based in Alaska.

Robust provider network*Did you know that Premera boasts the largest provider network in Alaska? Remember that, depending on the Premera medical plan you purchase, your employees have access to over 3,000 providers and 20 hospitals all across Alaska. Together with the Blue Cross Blue Shield system, our extended network includes more than 6,900 hospitals and 1,014,000 physicians across the country — the largest contracted nationwide network available in the United States — delivering the broadest access and lowest total cost of care available in all markets. (See page 2.)

Wellness rewardsWe spend most of our time at work. What better place to encourage people to make healthy lifestyle choices? By offering robust rewards to employers and employees for participating in wellness programs, we aim to help employers inspire employees to engage in a wellness program based on the latest research to make the greatest impact to their health and well-being

Ask your Premera representative for more information about the embedded wellness rewards program. (See page 3.)

Medical Travel SupportAlso known as medical tourism, our Medical Travel Support is a voluntary program that gives members broader access to quality care at lower cost for certain approved procedures outside of Alaska within the Blues national network. The benefit covers travel costs for the member and a companion, up to the IRS guidelines. Talk to your producer or your Premera sales professional for more information. (See page 4.)

Cost transparency toolsAs soon as they choose a plan, your employees receive instant access to free, easy-to-use online and mobile tools that help them understand and track their medical spending and prescriptions, estimate costs, and review claim status. (See page 5.)

Thank you for considering Premera for your employer-sponsored benefits.

* Consortium Health Plans, Inc. Network Compare Key Findings as of June 5, 2015. Available at www.chpmarketquest.com.

2

Robust provider networkProvider network built for value and quality

The Premera network of doctors, hospitals, and other healthcare providers is designed to offer ready access to safe, effective, high-quality care at affordable prices.

Our strong relationships with our provider partners help maximize healthcare dollars by:

Focusing on quality and cost-effective care

Helping control rising medical costs

Providing resources for improved healthcare

Premera also offers an excellent national network of preferred providers for members to access when outside Alaska.

Members can use the Find a Doctor tool at premera.com to see if their favorite provider is in our network, or to find a new one.

Members choose from two network options

Balance Plus plans offer employees savings on health plan costs and give the highest benefit level to employees when they use preferred providers and hospitals.

Nonpreferred and nonparticipating or out-of-network facilities and providers are also covered, but at a lower benefit level.*

Balance Select plans give employees the same benefit whether their doctor is in the Premera network or not:

Employees have the flexibility to see the doctor of their choice and receive the highest benefit levels.*

When an employee needs care in a hospital setting, they will get the highest benefit levels at preferred facilities.

Non-preferred and nonparticipating or out-of-network facilities are also covered, but at a lower benefit level.*

Healthcare coverage wherever you go

National PPO accessWhen outside of Alaska, employees can access doctors and hospitals in the BlueCard network around the world. In the U.S., the BlueCard Program gives them peace of mind that they’ll be

able to find the healthcare provider they need anywhere in the lower 48. Outside of the U.S., the BlueCard Worldwide Program gives them access to hospitals in nearly 200 countries and territories around the world.

Blue Distinction Total CareA comprehensive solution for multi-state employers, this program integrates local value-based care programs from Blue Plans across the country. Programs are custom designed to meet local market needs while also meeting national standards in four impact-driven categories:

Value-based reimbursement

Accountability across the care continuum

Patient-centered quality care

Provider empowerment

Members who reside in geographic areas served by Blue Distinction Total Care are automatically assigned to these patient-centered, value-based programs.

* Balance billing may still apply if a provider is not contracted with Premera Blue Cross Blue Shield of Alaska. For more information about providers, visit premera.com and use the Find a Doctor tool.

3

Built-in rewards for wellness activitiesThe built-in wellness rewards program is a simple way to encourage your workforce to engage in wellness activities.

Your employees get access to tools designed to help them maintain and improve their health. Our wellness rewards program rewards both employers and employees. All program participation data sharing and reports are HIPAA-compliant.

Wellness tools

The wellness reward program offers:

Biometric screenings by using physician fax forms, home test kits, retail options, or at employer-sponsored on-site events

Health assessments when members log in to use the Premera online wellness tools

Rewards for employers

Employers can earn a premium discount based on employee participation. Ask your Premera representative how to get your group involved in a wellness rewards program.

Rewards for employees

Employees earn a generous reward card if they participate in a biometric screening and take a health assessment within a designated time frame.

4

Health support programs included in all plans:

Virtual care gives covered members immediate and convenient access to care from a physician via phone call, online video, or other online media to treat certain ailments such as cold and flu symptoms, ear infections, and bronchitis.

24-Hour NurseLine offers free, confidential health advice from a registered nurse by phone any time day or night.

CareCompass360° is a whole-person approach to health support that meets members’ needs wherever they land on the care continuum—whether they’re healthy or navigating complex conditions. Members receive easily accessible, appropriate health support services tailored to their health needs.

Maternity and newborn support program promotes healthier mothers and babies and reduces costs associated with high-risk pregnancies and newborns that end up in neonatal intensive care units.

Exclusive member discounts on fitness club memberships, weight loss programs, and many other health products and services not covered by their health plan.

Medical Travel SupportPremera’s Medical Travel Support benefit reimburses members for approved travel expenses when they travel for qualified medical procedures at pre-approved medical facilities in and outside of Alaska. Approved travel expenses are covered up to IRS guidelines for both the member and a travel companion.

Because the price of medical care may be lower outside Alaska, the member’s share of the medical costs may also be lower. Customer Service can also assist in medical records transfers if needed.

Air or Surface TransportationBeginning in 2016, all group plans will include a standard Air or Surface Transportation benefit of three round trips. Transportation to the nearest in-network location equipped to provide treatment is available for:

A life-endangering illness or injury

A required surgery that cannot be performed locally

An existing condition that cannot be treated locally

When transportation is for a child under the age of 18, the benefit also covers a parent or guardian to accompany the child.

4

Support for smart network decisionsPremera health support programs help your employees maintain good health and change unhealthy behavior.

5

Easy-to-use online and mobile toolsThese tools make it simple for administrators and your employees to manage money, care, and wellness.

Tools for plan administrators

We streamlined the experience of administering group plans with easy-to-use online tools.

You can view helpful information such as:

Administrator’s Quick Reference Guide

Employer contract and member benefit booklet

Medical and dental invoices

You can add and make changes to employee enrollment information, including ordering identification cards. You can also contribute and monitor allocations to health reimbursement accounts (HRAs) and health savings accounts (HSAs).

Online tools for members

Members register and log in at premera.com to use tools securely:

Find and compare providers, including qualifications and user reviews with Find a Doctor.

Enter different coverage options to see how choices affect costs before deciding on a health plan with the Treatment Cost Estimator.

Review status of medical, prescription drug, and dental claims.

Manage and monitor consumer-driven health plans (HSA and HRA) spending and saving amounts, including reviewing account balances.

Access pharmacy information and order prescriptions

Award-winning mobile apps

Premera app — Find nearby doctors and clinics, look up benefits, and check claims.

ExpressScripts pharmacy app — Track medications, order prescriptions, and find a pharmacy.

ConnectYourCare app — Check spending and account balances on health savings accounts (HSA).

Wellness apps — Track activities, participate in fun fitness challenges, and get healthier.

Customer service experience

All Premera customer service representatives are fully trained to provide excellent service to members. Our representatives are especially knowledgeable about the unique needs of Alaska, such as:

Alaska’s logistical challenges

Alaskan culture

Our customer service standard is first call resolution.

6

Premera health plans

INSURANCE PLANS

MONTHLY PREMIUM

IN-NETWORK DEDUCTIBLE

INSURANCE PAYS

Bronze Plans $ $$$ $Silver Plans $$ $$ $$Gold Plans $$$ $ $$$

Premera offers a wide range of Bronze, Silver, and Gold plans. Each plan covers the 10 essential benefits as required by the Affordable Care Act (ACA)

7 Rehabilitative and habilitative services and devices — to help gain or regain mental and physical skills in case of injury, disability, or chronic condition. Includes inpatient rehabilitation; physical, speech, and occupational therapy; durable medical equipment; or skilled nursing.

8 Laboratory services — covers lab tests, X-ray services, and pathology, and imaging and diagnostics such as MRI, CT scan, and PET scan.

9 Preventive/Wellness services and chronic disease management — includes mammograms, colonoscopies, vaccines, and more. Covered in full if you use in-network providers for care such as routine physicals, screening, and immunizations. Care management programs and services seek to coordinate care for a variety of chronic conditions, such as diabetes and asthma.

Pediatric services — Kids are covered for vision care (eye exam, lenses, and eyewear).

1 Ambulatory patient services — such as office visits to your in-network primary care doctor or specialists.

2 Emergency services — for issues that could lead to death or disability if you do not treat them.

3 Hospitalization — covers room and board, tests, drugs, and care from doctors and nurses while admitted; includes organ and tissue transplants, and hospice and respite care.

4 Maternity and newborn care — covers prenatal and postnatal care, delivery and inpatient maternity services, plus newborn child care.

5 Mental health and substance use disorder services, including behavioral health treatment — covers inpatient hospital and outpatient mental and behavioral health.

6 Prescription drugs — covers retail, mail order, and specialty drugs.

10

7

9

8

10

1

4

2

3

5

6

The 10 essential benefits your plan covers:

These essential benefits focus on prevention

and primary care to help people stay healthy.

They also aim to manage chronic medical

conditions before these conditions become

more complex.

7

INSURANCE PLANS

MONTHLY PREMIUM

IN-NETWORK DEDUCTIBLE

INSURANCE PAYS

Bronze Plans $ $$$ $Silver Plans $$ $$ $$Gold Plans $$$ $ $$$

Choose from a range of plansHelp your employees find the right balance between their budget and their healthcare needs.

Balance PCP

These innovative plans offer a combination of upfront, first-dollar benefits, and standard coverage for other services. The difference is that a lower copay applies when a member designates and gets care from a primary care provider (PCP).

Balance PPO

Our preferred provider plans offer a combination of upfront, first-dollar benefits, and standard coverage for other services.

Balance HSA

The Balance HSA plans offer valuable benefits for covered services and are qualified to work in combination with an employee-owned, tax-advantaged health savings account (HSA).

Balance HRA

The Balance HRA plan offers valuable benefits for covered services and works in combination with an employer-owned, health reimbursement arrangement (HRA). The employer contributes half of the pre-defined deductible amount in the HRA, and employees are reimbursed from the HRA after they meet the first half of the plans deductible.

8

A full list of services is available on premera.com/ak/member

In-network Non-participating

30% 60%

Office VisitsFirst 6 visits PCY $30/deductible

waived, otherwise deductible, then coinsurance

Deductible, then 30%

Network Heritage Plus

1 Deductible, then 30%

$30

2

3 Hospitalization

4

5 Office visit

Inpatient hospital: mental/behavioral health

6

Therapy

Laboratory Services

8

9

10 Prescription Drugs Retail up to 90-day supply (3x 30 day supply cost)

Mail Order 90-day supply; 3x retail supply cost

Specialty Rx 30-day supply

Drug Formulary X4

Additional benefits embedded within the medical planHearing

Out-of-Pocket

Rehabilitative and habiltative benefits have the same number of visits, but are counted separately

10 Essential Benefits Covered Services

Office visits

Designated PCP office visit

Per Calendar Year = PCYFamily = 2x individual deductible (in-network only)

Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment

Rehabilitative & Habilitative Services & Devices

Maternity & Newborn Care

Ambulatory Patient Services Outpatient services

Emergency Services

Outpatient services


Non-preferred

$6,850

$5,500 / $6,350 2x individual deductible

Unlimited

Individual Deductible

Coinsurance Amount you pay after your deductible is met

Family = 2x Ind. out-of-pocket-max (in-network only)

BALANCE PLUS BRONZE PCP

Balance Plus Bronze PCPAlaska plans for group 1-50Beginning January 1, 2016The deductible applies whenever there is a coinsurance listed, unless otherwise noted.

Not covered


Durable medical equipment

Skilled nursing facility: 60 days PCY

Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services) Deductible, then 30%

Physical, speech, occupational, massage therapy: 45 visits PCY

Inpatient rehabilitation: 30 days PCYInpatient habilitation: 30 days PCY


Spinal manipulation (12 visits PCY);Acupuncture (12 visits PCY)

Prenatal, delivery, postnatal care

Emergent: Same as in-networkNon-emergent: Air – Ded, then 40% / Ded, then 60%;

Ground – Same as in-network


Inpatient

Organ and tissue transplants, inpatient unlimited, except $75,000 donor coverage limit and $7,500 travel and lodging per transplant

Ambulance transportation (air & ground)

Emergency careCopay waived if directly admitted to inpatient facility

Hospice: 10 days inpatientRespite care: 240 hours lifetime

Deductible, then 40% Deductible, then 60%


$200 Copay, then in-network deductible & coinsurance

$25 copay, then deductible & in-network coinsurance

7

Orthodontia (medically necessary only)

Exams and immunizations

Eye exam: 1 PCY

Screenings

Dental: preventive/basic/major

Pediatric Services,including Vision CareUnder 19 years of age

40%

Non-designated PCP or specialist office visit


Out-of-network

Includes deductible, coinsurance, and copays




4-Tier: Generic/Brand/Non-Preferred Brand/Specialty

$35 /Deductible, then 50% /Deductible, then 50% /Deductible, then 30%

Retail: Same as in-networkMail order & specialty: not covered

Preventive/Wellness Services & Chronic Disease Management Deductible, then 60%

Eyewear: One pair of glasses PCY (frames & lenses); or 12-month supply of contacts PCY, in lieu of glasses (frames & lenses)

Deductible waived, then 10%

Covered in full

Not covered

Not covered

Covered in full Deductible, then 40%

Covered in fullHearing aids and hardware: $1,000/3 calendar years

Hearing exam: 1 per 2 calendar years Deductible waived, then 20%


9



30% 60%

Office Visits$25 copay

First 2 PCP visits covered in full

$45



$25

2

3 Hospitalization

4

5 Office visit $45

Inpatient hospital: mental/behavioral health Deductible, then 30%


6

Therapy



8

9




Drug Formulary X4



Hearing exam: 1 per 2 calendar years $45


$15 /$50 /

$150 /Deductible, then 30%


Not covered




Out-of-network







Inpatient





$200 Copay, then in-network deductible & coinsuranceEmergency Services

Not covered


Deductible, then $45



$45

Covered in full








Not covered







7



Eye exam: 1 PCY

Screenings


Laboratory Services Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services)


Non-preferred

$6,850

$2,000 2x individual deductible

Unlimited

BALANCE PLUS SILVER PCP

Balance Plus Silver PCP

The deductible applies whenever there is a coinsurance listed, unless otherwise noted.

Includes deductible, coinsurance, and copaysOut-of-Pocket Maximum


40%


Alaska plans for group 1-50Beginning January 1, 2016


Office visits





Outpatient services





10



20% 60%



$30 / $40



$10

2

3 Hospitalization

4

5 Office visit $30 / $40



6

Therapy



8

9


Mail Order 90-day supply; 3x retail


Drug Formulary X4



500 - $20 / $40 / Deductible waived, then 50% /

Deductible, then 20%1000 - $10 / $40 /

Deductible waived, then 50% /Deductible waived, then 20%




500 - Deductible, then $30 1000 - Deductible, then $40


Outpatient services



$30 / $40

Covered in full



Hearing exam: 1 per 2 calendar years $30 / $40

Not covered

Not covered


Out-of-network















Inpatient


Emergency careCopay waived if direct admitted to inpatient facility








Not covered

7



Eye exam: 1 PCY

Screenings



Preventive/Wellness Services & Chronic Disease Management





Non-preferred

$5,000

$500 / $1,000 2x individual deductible

Unlimited

BALANCE PLUS GOLD PCP

Balance Plus Gold PCP



40%

Alaska plans for group 1-50Beginning January 1, 2016The deductible applies whenever there is a coinsurance listed, unless otherwise noted.




Outpatient services


Ambulatory Patient Services


Office visits


Emergency Services

11



Individual: $4,500 / $5,250 Family: $9,000 /$10,500

30% 60%

Office Visits Cost share Deductible, then 30%


1

2

3 Hospitalization

4

5 Office visit


6

Therapy

Laboratory Services

8

9

10 Prescription Drugs Retail up to 90-day supply

Mail Order 90-day supply


Drug Formulary X1


Deductible, then 20%Hearing aids and hardware: $1,000/3 calendar years

Hearing exam: 1 per 2 calendar years


Out-of-network




Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services)






Deductible, then 30%Retail: Same as in-network

Mail order & specialty: not covered




Covered in full

Not covered

Not covered




Eye exam: 1 PCY

Screenings



7



Emergency care















Inpatient



Not covered


Non-preferred

Unlimited



Family = 2x individual (embedded)

BALANCE PLUS BRONZE HSA

Balance Plus Bronze HSA


2x individual deductible

40%

Individual: $6,450Family: $12,900



Office visits

Per Calendar Year = PCYFamily = 2x individual (embedded)




Emergency Services

Outpatient services



12




30% 60%

Individual: $4,400

Family: $8,800

Office Visits Deductible, then 30%


1

2

3 Hospitalization

4

5 Office visit


6

Therapy

Laboratory Services

8

9




Drug Formulary X1











Out-of-network



Not covered





Prenatal, delivery, postnatal careMaternity & Newborn Care

7



Outpatient services






Emergency Services

Non-preferred


Unlimited

BALANCE PLUS SILVER HSA

Balance Plus Silver HSA



40%



Office visits

Cost share










Covered in full

Not covered

Not covered




Eye exam: 1 PCY

Screenings

Deductible, then 20%Hearing aids and hardware: $1,000/3 calendar years



Outpatient services


Inpatient



Emergency Care


Deductible, then 40%Deductible, then 30%




13



Required Employer Contribution Family = 2x employer contribution $1,500

20% 60%



$45



$15

2

3 Hospitalization

4

5 Office visit $45



6

Therapy



8

9




Drug Formulary X4




Outpatient services




Office visits


Emergency Services

Non-preferred

$6,850


Unlimited

BALANCE PLUS GOLD PCP

Balance Plus Gold HRA



40%


2x individual



Not covered

7



Eye exam: 1 PCY

Screenings


















Inpatient





Out-of-network












Not covered

Not covered


$15 /$50 /

Deductible waived, then 50% /Deductible, then 30%






Outpatient services



$45

Covered in full


14



Pharmacy Deductible Family = 2x individual pharmacy deductible $1,700

60%

Office Visits

Network


$35

2

3 Hospitalization

4

5 Office visit


6

Therapy

Laboratory Services

8

9




Drug Formulary X4


Balance Plus Bronze PCP 5000/1700 Rx


$25 /Rx Deductible, then 50% /Rx Deductible, then 50% /Rx Deductible, then 50%





Covered in full

Not covered

40%



Out-of-network



Hearing exam: 1 per 2 calendar years Deductible waived, then 20%


Not covered





Eye exam: 1 PCY

Screenings







Inpatient



7


Outpatient services





Not covered




Prenatal, delivery, postnatal care Deductible, then 60%



Deductible, then 40%Deductible, then 30%




Unlimited




BALANCE PLUS BRONZE PCPThe deductible applies whenever there is a coinsurance listed, unless otherwise noted.

Shared with in-network pharmacy deductible

Out-of-Pocket





Emergency Services Emergency careCopay waived if direct admitted to inpatient facility


Non-preferred

30%

$6,850

First 6 visits PCY $35/deductible waived, otherwise deductible, then

coinsurance


Heritage Plus



Office visits





15



Pharmacy Deductible Family = 2x individual pharmacy deductible $1,500

30% 60%



$40



$20

2

3 Hospitalization

4

5 Office visit $40



6

Therapy



8

9




Drug Formulary X4


Balance Plus Silver PCP 3000/1500 Rx




Office visits





Outpatient services







Non-preferred

$6,850


Unlimited







BALANCE PLUS SILVER PCPThe deductible applies whenever there is a coinsurance listed, unless otherwise noted.



40%


7



Eye exam: 1 PCY

Screenings





Not covered




$200 Copay, then in-network deductible & coinsuranceEmergency Services

Not covered





$40

Covered in full










Not covered




Non-designated PCP or specialist office visit40% 60%

Out-of-network







Inpatient


16



Pharmacy Deductible Family = 2x individual pharmacy deductible $500

20% 60%



$35



$10

2

3 Hospitalization

4

5 Office visit $35



6

Therapy



8

9




Drug Formulary X4


Balance Plus Gold PCP 1500/500 Rx








Outpatient services



$35

Covered in full




Not covered

Not covered


Out-of-network















Inpatient










Not covered

7



Eye exam: 1 PCY

Screenings










40%

Non-preferred

$4,000


Unlimited





BALANCE PLUS GOLD PCPThe deductible applies whenever there is a coinsurance listed, unless otherwise noted.


Outpatient services




Office visits


Emergency Services

17



30%

Office Visits $35

Network Heritage Select


Office visit cost share

2

3 Hospitalization

4

5 Office visit Office visit cost share



6

Therapy



8

9




Drug Formulary X4


Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network











Emergency Services

Not covered





Office visits

Cost share



Family = 2x Ind. Out-of-pocket-max (in-network only)


Non-preferred

$6,850

$2,000 / $3,000 2x individual deductible

Unlimited

BALANCE SELECT SILVER PPO

Balance Select Silver PPO



Hospital: 40% Hospital: 60%All other facilities & professional: Same as in-network


7



Eye exam: 1 PCY

Screenings




Laboratory Services


Outpatient services


Inpatient










Same as in-network


$25$50

$100Deductible, then 30%





Covered in full

Not covered

Not covered

Covered in full

Out-of-network







Hearing exam: 1 per 2 calendar years Office visit cost share

18



20%

Office Visits $25 / $30 / $30




2

3 Hospitalization

4

5 Office visit Office visit cost share



6

Therapy



8

9




Drug Formulary X4



Hearing exam: 1 per 2 calendar years Office visit cost share

Same as in-network



Out-of-network





Emergent: Same as in-networkNon-emergent: Air – Ded, then 40% /Ded, then 60%;



Office visits

Cost share


500 - $10 / $40 / $80 / Deductible, then 20%

1000, 1500 - $10 / $25 / $45 / Deductible, then 20%





Covered in full

Not covered

Not covered

Covered in full


Inpatient








7



Eye exam: 1 PCY

Screenings




Laboratory Services

Non-preferred

$5,000 / $5,000 / $4,500

$500 / $1,000 / $1,500 2x individual deductible

Unlimited

BALANCE SELECT GOLD PPO

Balance Select Gold PPO









Emergency Services Emergency careCopay waived if directly admitted to inpatient facility


Not covered











500 - Deductible, then $25 1000/1500 - Deductible, then $30

Outpatient services


19



30%



1

2

3 Hospitalization

4

5 Office visit


6

Therapy

Laboratory Services

8

9



Specialty Rx 30-day supplyDrug Formulary X1


Hearing aids and hardware: $1,000/3 calendar years





Inpatient











Covered in full

Not coveredNot covered

Covered in full



Eye exam: 1 PCY

Screenings Hospital: Ded, then 40% Hospital: Ded, then 60%All other facilities & professional: Same as in-network


Emergency Care



7

Emergency Services



Not covered








Cost share


Non-preferred


Individual: $4,500 / $5,250 Family: $9,000 / $10,500

Unlimited

BALANCE SELECT BRONZE HSA

Balance Select Bronze HSA






Office visits




Same as in-network


Out-of-network



Outpatient services










Outpatient services


20 A full list of services is available on premera.com/ak/member




Hospitalization

Office visit


Inpatient rehabilitation: 30 days PCY

Dental: preventative/basic/major

Prescription Drugs Retail up to 90-day supply


Hearing


Not covered

Office visits


Emergency Services

Outpatient services


30%

PCYFamily = 2x individual (embedded)

Out-of-Pocket Maximum






Non-preferred




Unlimited


Coinsurance Amount you pay after your deductible is metHospital: 40% Hospital: 60%

All other facilities & professional: Same as in-network


Covered in full

Covered in full


Balance Select Silver HSAAlaska plans for groups 1-50Beginning January 1, 2016

The deductible applies whenever there is a coinsurance listed, unless otherwise noted.

PCY = per calendar year



Inpatient

Laboratory Services


Includes x-ray, pathology, imaging/diagnostic, CT, PET, MRI (Prior Authorization required for certain services )

Outpatient services


BALANCE SELECT SILVER HSA

Same as in-networkCost share


Pediatric Services, including Vision & Oral CareUnder 19 years of age




Eye exam: 1 PCY


ScreeningsExams and immunizations

2

1

6




Spinal Manipulation (12 visits PCY); Acupuncture (12 visits PCY)


Hospice 10 days inpatientRespite care: 240 hours lifetime

Organ and tissue transplants, inpatient unlimited, except $75,000 donor and $7,500 travel and lodging per transplant


Emergency Care

Physical, speech, occupational, massage therapy:45 visits PCY




Hearing exam: 1 per 2 calendar yearsHearing aids and hardware: $1,000/3 calendar years

Out-of-network

Additional benefits embedded within the medical plan

Drug Formulary X1

Retail: Same as in-network;Mail order & specialty: not covered





Rehabilitative & HabilitativeServices & DevicesTherapy

Rehabilitative and habilitative benefits have the same number of visits, but are counted separately


Not covered



Not covered

8

9

10

4

3

7

5

21

Optional benefitsPremera Adult Vision Plan

These optional vision benefits include exams and eyewear. Vision exam and eyewear are covered up to a maximum benefit of $350 per calendar year per member.

Exam—One per calendar year with $25 copayment

Eyewear

One pair of lenses for eyeglasses per calendar year per member

One pair of frames up to $90 every two calendar years per member

Contact lenses up to $170 per calendar year per member

Life and disability

Employers can offer an integrated benefits program to help reduce disability and healthcare costs, improve health, and increase workforce productivity. Through our partner, USAble Life, groups will find flexible products, high-quality customer service, and fast, reliable claims service.

Several package options are available for employers with 1 – 50 employees.

Employers with 10 or more enrolled employees can choose from the following products:

Group life insurance

Group term life — Provides benefits to a beneficiary in the event of an employee’s death

Accidental death and dismemberment (AD&D)— Provides benefits in the event that a death or dismemberment is caused by an accident

Dependent life — Provides benefits to the employee in the event of a dependent’s death

Supplemental life and AD&D — Provides additional coverage options for your employees

Disability coverage

Short-term disability coverage: Protects a portion of employees’ income in the event of a disability

Long-term disability coverage: Provides employees and their families the income needed to help meet financial commitments and give them financial stability

Dental coverage

It’s no secret—good dental health affects your employees’ overall health. Premera’s dental plans help both kids and adults maintain healthy teeth.

Plus, they have access to a nationwide network of more than 120,000 dentists for dental care. See our DentalBlue benefit guide for information about our full line of dental plans.

NOTE: The Balance Kids Dental plan meets the federal requirements for providing pediatric dental plans.

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This is only a summary of the major benefits provided by our plans. This is not a contract. Please see premera.com for the Summary of Benefits and Coverage and Glossary. On our website, you can also find a Supplemental Guide with information about privacy policies, provider organization, key utilization management procedures, and pharmaceutical management procedures.

DefinitionsAllowed amount* The negotiated amount for which a contracted provider agrees to provide

services or supplies.

Coinsurance Your employee’s share of the cost for a service. If the plan’s coinsurance is 20%, the employee pays 20% of the allowed amount and the plan benefit pays the other 80% of the allowed amount.

Copay A flat fee your employee pays for a specific service, such as an office visit, at the time they receive service.

Covered in full Services the plan pays for in full. Benefits provided at 100 percent of the allowed amount; not subject to deductible or coinsurance.

Deductible The amount of money your employee pays every year before the plan pays for certain services.

Embedded deductible There are two deductibles—one for the family and one for each member of the family. When an individual family member reaches his or her deductible, the member starts to receive benefit coverage. For other family members to receive benefit coverage, they must either reach their own deductible or the family deductible must be met. The family out-of-pocket maximum is also embedded.

* Note that if they see a non-contracted provider, your employee will be responsible for the difference between the allowed amount and the provider’s billed charges, in addition to the coinsurance and any applicable copay. The allowed amount for a non-contracted provider is determined by Premera as described in your forthcoming benefit book.

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This is only a summary of the major benefits provided by our plans. This is not a contract. Please see premera.com for the Summary of Benefits and Coverage and Glossary. On our website, you can also find a Supplemental Guide with information about privacy policies, provider organization, key utilization management procedures, and pharmaceutical management procedures.

Formulary A list of drugs the plan covers for specific uses. Not all generic, name-brand, and specialty drugs are included in the formulary. To find the formulary for your employee’s plan, go to premera.com and select Pharmacy.

In-network A group of doctors, dentists, hospitals, and other healthcare providers that contract with Premera to provide services and supplies at negotiated amounts called allowed amounts.

Out-of-pocket maximum A preset limit after which the plan pays 100 percent of the allowed amount for services received in-network. All in-network essential benefits apply to the out-of-pocket maximum.

Primary care provider (PCP) The provider who helps coordinate your employee’s care. They can choose a different primary care provider for each family member from: physicians and internists, physician assistants, and nurse practitioners; ob/gyns and women’s health specialists, pediatricians, and geriatric specialists; or naturopaths. To get a reduced office visit copay with the PCP plans, your employee must choose a provider contracted as part of the Premera network and inform us this is your designated PCP.

This is not a contract. Please see premera.com/SBC for the Summary of Benefits and Coverage and Glossary. On our website, you can also find a Supplemental Guide with information about privacy policies, provider organization, key utilization management procedures, and pharmaceutical management procedures.

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General exclusions Benefits are not provided for treatment, surgery, services, drugs, or supplies for any of the following:

Cosmetic surgery

Experimental or investigative services

Infertility

Obesity/morbid obesity, related surgery, drugs, and supplements obesity surgery, drugs, and supplements for weight loss or weight control

Orthognathic surgery

Services in excess of specified benefit maximums

Services payable by other types of insurance coverage

Services received when you are not covered by this program

Sexual dysfunction

Sterilization reversal

For a complete list of exclusions and limitations, visit premera.com and click the Member Services tab, then click Benefit Exclusions.

Prior authorization

Certain medical services and prescriptions require prior authorization (approval from the health plan). See your Premera representative for more information.

This is only a summary of the

major benefits provided by our

plans. This is not a contract.

Please see premera.com/SBC

for the Summary of Benefits

and Coverage and Glossary.

On our website, you can also

find a Supplemental Guide

with information about privacy

policies, provider organization,

key utilization management

procedures, and pharmaceutical

management procedures.

027474 (04-2016)

Premera Blue Cross Blue Shield of Alaska is an Independent Licensee of the Blue Cross Blue Shield Association

Contact information

Premera Blue Cross Blue Shield of Alaska 2550 Denali St., Suite 1404 Anchorage, AK 99503

888.669.2583

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