Benefit Summary
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Plan NameLow Cost Plan - Prime
DescriptionAll Employees
CarrierPremera Blue Cross
Policy Type Medical 2-Tier In-Network
Effective Dates4/1/2022 to 4/1/2023
Benefit Attributes - All EmployeesIn-Network Tier 1In-Network Tier 2
Emergency Services
Emergency Room
General Plan Information
Annual Out-of-Pocket Limit/Family
Annual Out-of-Pocket Limit/Individual
Coinsurance
Office Visit/Exam
Annual Deductible/Family
Outpatient Specialist Visit
Annual Deductible/Individual
Deductible Included in Out-of-Pocket Limits
Inpatient Hospital Services
Outpatient Facility Charges
Diagnostic X-Ray and Lab Tests
Inpatient Hospitalization
Mail Order
Brand (Formulary/Preferred)
Generic
Number of Days Supply for Mail Order
Preferred Specialty
Preferred Generic
Non-preferred Specialty
Brand (Non-Formulary/Non-preferred)
Maternity Care
Pregnancy and Maternity Care (Pre-Natal Care)
Mental Health Benefits
Inpatient Care
Outpatient Care
Other Services and Supplies
Chiropractic Services
Outpatient Rehabilitative Therapy Services
Physical
Speech
Occupational
Outpatient Services
Pediatric Vision
Immunizations
Diagnostic X-Ray and Lab Tests
Well-Child Care
Pediatric Dental
Adult Periodic Exams with Preventive Tests
Prescription Drug Benefits
Brand (Formulary/Preferred)
Generic
Brand (Non-Formulary/Non-preferred)
Number of Days Supply
Preferred Specialty
Preferred Generic
Non-preferred Specialty
Injectables
Prescription Drug Deductible
Substance Abuse
Outpatient Services
Inpatient Hospitalization
Urgent Care
Urgent Care Facility