2019 health plan guide - premera blue crosswellness tools and resources: employees who feel better...

2019 Health plan guide

FOR BUSINESSES WITH 1–50 EMPLOYEES

ABOUT PREMERA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Why businesses choose Premera . . . . . . . . . . . . . . . . . 5

WE’RE IN YOUR CORNER . . . . . . . . . . . . . . . . . . . . . 6

Medical plan support programs . . . . . . . . . . . . . . . . . . . 6

Premera Wellness Program . . . . . . . . . . . . . . . . . . . . . . 7

MEDICAL PLANS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Plus Bronze plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Plus Silver plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Plus Gold plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Plus HSA Qualified Bronze plans . . . . . . . . . . . . . . . . . 20

Plus HSA Qualified Silver plans . . . . . . . . . . . . . . . . . . 22

Plus HSA Qualified Gold plans . . . . . . . . . . . . . . . . . . . 24

Select HSA Qualified Bronze 5250 . . . . . . . . . . . . . . . . 25

Select Silver 3000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

Select Gold 1500 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

DENTAL PLANS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Adult Core Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Adult Dental Optima™ . . . . . . . . . . . . . . . . . . . . . . . . . . .32

Adult Dental Optima™ Voluntary . . . . . . . . . . . . . . . . . 33

Optional orthodontic coverage . . . . . . . . . . . . . . . . . . . 34

VISION PLANS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Premera’s adult vision plans . . . . . . . . . . . . . . . . . . . . . 36

Table of contents

Included in this guide are your 2019 plan options for:

MEDICAL | PHARMACY | DENTAL | VISION

We care for our customersThe customer is at the center of all we do—that’s why we offer plans that help you keep control of your expenses while giving your employees access to quality and affordable care.

4

Network strength provides choice and savings

• We offer an extensive provider network built for quality and value.

• Our provider network offers broad access to doctors and hospitals not only in Alaska, but also across the country.

Well-rounded benefits package

• We make it easy for you to attract and retain the best talent with appealing benefits packages that support the whole health of your employees.

• Choose from a range of plans to find the right balance that best fits the needs and budget for both your business and your employees.

Tools and programs for employees

• Our built-in support programs encourage your employees to engage in their healthcare, leading to healthier, happier employees.

• Online tools and apps help your employees find doctors, compare costs of services and medications, access pharmacy information, and review claims.

Administrative ease and support

• Integrate dental and pharmacy with your medical plans and simplify your work by dealing with only one health plan for all your healthcare administration.

• Effortlessly manage your health plans and pay bills online with our secure employer dashboard.

• Get ready-to-share resources that makes understanding benefits simple for you and your employees with the Employee Communications resource center. Log in to your secure employer website to get access.

Why businesses choose Premera

5

As a not-for-profit serving Alaska for over 65 years, we’re committed to having a positive impact in our communities. Through corporate giving, volunteering, and community engagement, we promote new partnerships and solutions to help make healthcare work better for the communities where we live and work.

Virtual care: Video or phone consultations with a Teladoc®* physician are available to your employees any time for a low copay.

24-Hour NurseLine: Free, confidential health advice from a registered nurse, available to your employees 24/7.

Alaska Medical Transportation Benefits: Premera plans include two types of medical transportation benefits to support your employees traveling to get the care they need. Travel is available for serious medical conditions that cannot be treated locally and for certain approved services for elective, non-emergent surgeries.

Wellness tools and resources: Employees who feel better do better. That’s why we offer tools and resources for employers and their employees through the Alaska Wellness Academy.

Low-cost fitness center memberships: Your employees get access to 9,000 fitness centers nationwide for only $25 a month (plus a $25 enrollment fee and applicable taxes).

CareCompass360®: This whole-person approach to health offers support services tailored to the unique needs of your employees who qualify.

Pregnancy and newborn support: Premera’s BestBeginnings Maternity program supports healthy babies and parents with personalized tools and encourages early discovery of high-risk pregnancies. Our program also helps reduce costs associated with high-risk pregnancies or newborns who end up in neonatal intensive care.

Preventive health: Preventive health services are part of every Premera plan. Our secure member website provides your employees with details about what is covered and suggested preventive routine exams, vaccinations, and screenings.

Mobile apps and online tools: Apps and digital tools give your employees more control when it comes to managing their healthcare. They can easily search for doctors, compare costs of services, track medications, review claims, and more.

Premera Pulse: Your employees can stay connected to their health plan benefits by simply activating their Premera Pulse account. With Premera Pulse they’ll receive proactive care notifications that help them take advantage of their health plan benefits and stay on top of recommended care. They can search for high-value doctors nearby, instantly book appointments with select primary care doctors, get timely alerts about their medication lists, and more.

We’re in your corner

All medical plans include these great support programs

*Teladoc is an independent company that provides virtual medical care services on behalf of Premera Blue Cross Blue Shield of Alaska.

6

Every Premera medical plan includes a Wellness Program to support you and your employees. We offer tools and resources that equip you with information to create a culture of well-being within your workplace.

Premera Wellness Program benefits for employers:

• Alaska Wellness Academy gives you tools and resources that equip you with information to create a culture of well-being within your workplace.

• Ready-to-share employee communications that help you deliver wellness tips and information to your employees.

Premera Wellness Program benefits for employees:

Employees get access to an employee assistance program that offers help with mental health, stress, grief and loss, illness or trauma, relationship conflicts, financial guidance, life adjustments, and more through:

• 3 confidential, face-to-face, counseling sessions per issue, free of charge.

• Unlimited access to lifestyle guidance resources with online support and direct access to a guidance consult by phone, online, or through a mobile app.

• Online health tools to set goals, track health information, access health reports, and create personalized wellness plans.

Premera Wellness Program

7

Providernetwork

We believe in working closely with doctors and hospitals to deliver great care for the customer together. That’s why our provider network is more than just a collection of contracts–it gives members access to quality care, good experiences, and services at a fair price.

8

National and worldwide network coverage with BlueCard®

Our large nationwide provider network includes over 1,000,000 providers and 6,900 hospitals. When you choose a Premera Blue Cross Blue Shield of Alaska health plan, it offers specific levels of healthcare benefits wherever your employees live or travel, across the country and worldwide.

Contact your producer or Premera representative for more details and to find out what level of BlueCard healthcare benefits are included in your Premera health plan.

Our broadest provider network offers access to over 4,000 preferred providers and 21 preferred hospitals across Alaska.

Heritage network

9

Medical plans

Premera offers a wide range of bronze, silver, and gold plans. All of these plans offer broad access to doctors and hospitals through the Heritage network as well as pediatric vision and pediatric dental at no additional cost. You can also pair any Premera medical plan with one of our adult dental and/or adult vision plans—allowing you to offer your employees a well-rounded benefits package all in one place.

10

With Premera medical plans, you can help your employees find the right balance between their budget and their healthcare needs.Plus vs. Select plans: Plus plans offer the flexibility of medical plans at all levels. Select plans offer a choice between gold and silver—or just bronze.

PPO plans: All of the medical plans outlined in this guide are preferred provider organization (PPO) plans. PPO plans work with a network of participating providers to deliver quality care at lower costs.

HSA-qualified plans: Health savings account (HSA)–qualified plans offer valuable benefits for covered services and are qualified to work in combination with an employee-owned, tax-advantaged HSA. The plans offer the option for ConnectYourCare (an independent company that administers HSA accounts for Premera customers at a federally insured bank).

Here’s one way your employees can save:When you choose a Plus or Select PPO medical plan your employees may get some office visits covered in full as well as lower copays if they designate an in-network primary care provider (PCP). These office visits are in addition to a no-cost visit for preventive services. Speak with your producer for complete details.

PLUS PPO SELECT PPO PLUS HSA SELECT HSA

PLAN TYPE

PPO plan X X X X

HSA-qualified with the option of ConnectYourCare X X

NETWORK

Heritage X X X X

LEVELS

Gold X X X

Silver X X X

Bronze X X X

DENTAL

Pediatric X X X X

Adult OPTIONAL BENEFIT ENHANCEMENT

VISION

Pediatric X X X X

Adult OPTIONAL BENEFIT ENHANCEMENT

Check out Premera’s adult dental plans on the following pages.

Together, Premera’s medical and dental plans encourage healthy habits and better outcomes, provide a robust network of providers, and make it easy and simple so you can take great care of your employees.

11

Plus Bronze 5500Medical plan for 1–50 employees starting January 1, 2019The deductible applies whenever there is a coinsurance listed, unless otherwise noted. PLUS BRONZE 5500

IN-NETWORK NON-PREFERRED NON-PARTICIPATING

Individual deductible Per calendar year = PCY Family = 2x individual deductible (in-network only) $5,500 2x individual deductible

Coinsurance Amount you pay after your deductible is met 30% 40% 60%

Out-of-pocket maximum Includes deductible, coinsurance, pharmacy, and copays Family = 2x individual out-of-pocket maximum $7,900 $45,000

Office visits Designated primary care provider (PCP) office visit $55 Deductible, then 40% Deductible, then 60%

Non-designated PCP or specialist office visit $110Network Heritage Out-of-network

10 ESSENTIAL BENEFITS | COVERED SERVICES1 Ambulatory

patient services Outpatient services Deductible, then 30%Deductible, then 40% Deductible, then 60%

Office visits Spinal manipulation (12 visits PCY); Acupuncture (12 visits PCY) $55

2 Emergency services Emergency care Copay waived if directly admitted to inpatient facility $250 copay, then in-network deductible and coinsurance

Ambulance transportation (air and ground)$25 copay,

then deductible andin-network coinsurance

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

Ground – Same as in-network

3 Hospitalization Inpatient

Deductible, then 30%

Deductible, then 40% Deductible, then 60%Hospice: 10 days inpatient Respite care: 240 hours lifetime maximum

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

Not covered

4 Maternity and newborn care Prenatal, delivery, postnatal care Deductible, then 30% Deductible, then 40% Deductible, then 60%

5 Mental health and substance use disorder services, including behavioral health treatment

Office visit $110

Deductible, then 40% Deductible, then 60%Inpatient hospital: mental and behavioral health

Deductible, then 30%Outpatient services

6 Rehabilitative and habilitative services and devices

Inpatient rehabilitation: 30 days PCY Inpatient habilitation: 30 days PCY Deductible, then 30%

Deductible, then 40% Deductible, then 60%Therapy Physical, speech, occupational, massage therapy:

45 visits PCY Deductible, then $110

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

Durable medical equipmentSkilled nursing facility: 60 days PCY Deductible, then 30%

7 Laboratory services Includes x-ray, pathology, imaging/diagnostic, MRI, CT, PET (pre-approval required for certain services) Deductible, then 30% Deductible, then 40% Deductible, then 60%

8 Preventive/wellness services and chronic disease management

ScreeningsExams and vaccinations Covered in full Deductible, then 40% Deductible, then 60%

9 Pediatric services, including vision care under age 19

Eye exam: 1 PCY $25Eyewear: one pair of glasses PCY (frames and lenses); or 12-month supply of contacts PCY, in lieu of glasses (frames and lenses)

Covered in full

Dental: pediatric dental class I (cleanings, exams, and x-rays) Deductible waived, covered in full Deductible waived, then 10%

Pediatric dental class II (fillings, non-surgical periodontal services, and extractions)

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

Pediatric dental class III (crowns, root canals, and medically necessary orthodontia) Deductible, then 50% Deductible, then 50%

10 Prescription drugs Retail up to 90-day supply (3x 30-day supply cost) $25 / Ded $85 / Ded $175

Retail and specialty: Same as in-network

Mail Order: Not covered

Tier 1: Preferred genericTier 2: Preferred brandTier 3: Non-preferred generic and brandTier 4: Speciality

Mail order 90-day supply; 3x retail supply cost $75/ Ded $255/ Ded $525

Specialty Rx 30-day supplyDed 40%

Drug formulary M4ADDITIONAL BENEFIT EMBEDDED WITHIN THE MEDICAL PLAN

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

Hearing aids and hardware: $3,000 every 3 calendar years

Teladoc A full list of services is available on premera.com/ak/member $20 Not covered

12

Plus Bronze 6350Medical plan for 1–50 employees starting January 1, 2019 The deductible applies whenever there is a coinsurance listed, unless otherwise noted. PLUS BRONZE 6350




Out-of-pocket maximum Includes deductible, coinsurance, pharmacy, and copays Family = 2x Individual out-of-pocket maximum $7,900 $45,000

Office visits Designated primary care provider (PCP) office visit $55Deductible, then 40% Deductible, then 60%

Non-designated PCP or specialist office visit $110

Network Heritage Out-of-network

10 ESSENTIAL BENEFITS COVERED SERVICES1 Ambulatory

patient servicesOutpatient services Deductible, then 30%

Deductible, then 40% Deductible, then 60%Office visits Spinal manipulation (12 visits PCY);

Acupuncture (12 visits PCY) $55










Not covered



Office visit $110

Deductible, then 40% Deductible, then 60%Inpatient hospital: mental and behavioral healthDeductible, then 30%

Outpatient services











Eye exam: 1 PCY $25Eyewear: One pair of glasses PCY (frames and lenses); or 12-month supply of contacts PCY, in lieu of glasses (frames and lenses)

Covered in full

Dental: Pediatric dental class I (cleanings, exams, and x-rays) Deductible waived, covered in full

Deductible waived, then 10%




10 Prescription drugs Retail up to 90-day supply (3x 30-day supply cost)Mail Order 90-day supply; 3x retail supply costSpecialty Rx 30-day supplyDrug Formulary M4

$25/Ded, $85/Ded, $175

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

$75/Ded, $255/Ded, $525Tier 1: Preferred genericTier 2: Preferred brandTier 3: Non-preferred generic and brandTier 4: Speciality


ADDITIONAL BENEFITS EMBEDDED WITHIN THE MEDICAL PLANHearing Hearing exam: 1 per 2 calendar years

Hearing aids and hardware: $3,000 every 3 calendar years Deductible waived, then 20%


13

Plus Bronze 7900Medical plan for 1–50 employees starting January 1, 2019The deductible applies whenever there is a coinsurance listed, unless otherwise noted. PLUS BRONZE 7900




Out-of-pocket maximum Includes deductible, coinsurance, pharmacy, and copays Family = 2x individual out-of-pocket maximum $7,900 $45,000

Office visits Cost share Deductible, then 0% Deductible, then 40% Deductible, then 60%


10 ESSENTIAL BENEFITS | COVERED SERVICES 1 Ambulartory patient

services office visits

Outpatient servicesDeductible, then 0% Deductible, then 40% Deductible, then 60%Spinal manipulation (12 visits PCY);

Acupuncture (12 visits PCY)


Ambulance transporation (air and ground)$25 copay, then

deductible and in-network coinsurance

Emergent: Same as in-network Non-emergent: Air - Ded, then 40%/ Ded, then 60%

Ground - Same as in-network


Deductible, then 0%



Not covered



Office visit

Deductible, then 0% Deductible, then 40% Deductible, then 60%Inpatient hospital: mental and behavioral health

Outpatient services

6 Rehabilitation and habilitative services and devices Therapy Rehabilitation and habilitative therapy benefits have the same numberof visits, but are counted seperately

Inpatient rehabilitation: 30 days PCY Inpatient habilitation: 30 days PCY

Deductible, then 0% Deductible, then 40% Deductible, then 60%

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

Durable medical equipment Skilled nursing facility: 60 days PCY

7 Laboratory services Includes x-ray, pathology, imaging/diagnostics, MRI, CT, PET (pre-approval required for certain services) Deductible, then 0% Deductible, then 40% Deductible, then 60%


Screenings, exams and vaccinations Covered in full Deductible, then 40% Deductible, then 60%


Eye exam: 1 PCY $25

Eyewear: one pair of glasses PCY (frames and lenses); or 12-month supply of contracts PCY, in lieu of glasses (frames and lenses)

Covered in full

Dental: pediatric dental class I (cleanings, exams, and x-rays)

Deductible waived, covered in full Deductible waived, then 10%




10 Prescription drugs Tier 1: Preferred genericTier 2: Preferred brandTier 3: Non-preferred generic and brandTier 4: Speciality

Retail: up to 90-day supply (3x 30-day supply cost)Mail order 90-day supply; 3x retailSpecialty Rx 30-day supplyDrug formulary M1

Deductible, then 0% Retail and specialty: Same as in-network Mail order: not covered

ADDITIONAL BENEFIT EMBEDDED WITHIN THE MEDICAL PLANHearing Hearing exam: 1 per 2 calendar years

Hearing aids and hardware: $3,000 every 3 calendar years

Deductible waived, then 20%

Teladoc $20 Not covered

14

Plus Silver 2000Medical plan for 1–50 employees starting January 1, 2019The deductible applies whenever there is a coinsurance listed, unless otherwise noted. PLUS SILVER 2000




Out-of-pocket maximum Includes deductible, coinsurance, pharmacy, and copaysFamily = 2x individual out-of-pocket maximum $7,900 $45,000

Office visits Designated primary care provider (PCP) office visit$35 copay

First 2 PCP visits covered in full Deductible, then 40% Deductible, then 60%







2 Emergency services Emergency care $250 copay, then in-network deductible and coinsurance









Not covered



Office visit $75


Outpatient services












Covered in full





10 Prescription drugs Retail up to 90-day supply (3x 30 day supply cost)Mail order 90-day supply; 3x retailSpecialty Rx 30-day supplyDrug formulary M4

$25/$65/$150



$75/$195/$450





15

Plus Silver 2500Medical plan for 1–50 employees starting January 1, 2019The deductible applies whenever there is a coinsurance listed, unless otherwise noted. PLUS SILVER 2500




Out-of-pocket maximum

Includes deductible, coinsurance, pharmacy, and copaysFamily = 2x individual out-of-pocket maximum $7,900 $45,000









2 Emergency services Emergency careCopay waived if directly admitted to inpatient facility $250 copay, then in-network deductible and coinsurance









Not covered



Office visit $75


Outpatient services












Covered in full





10 Prescription drugs Retail up to 90-day supply (3x 30-day supply cost)Mail order 90-day supply; 3x retailSpecialty Rx 30-day supplyDrug formulary M4

$25/$65/$150



$75/$195/$450





16

Plus Silver 3000/4000Medical plan for 1–50 employees starting January 1, 2019The deductible applies whenever there is a coinsurance listed, unless otherwise noted. PLUS SILVER 3000/4000


Individual deductible Per calendar year = PCY Family = 2x individual deductible (in-network only) $3,000/$4,000 2x individual deductible




















Not covered



Office visit $75


Outpatient services











Eye exam: 1 PCY $25Eyewear: One pair of glasses PCY (frames and lenses); or 12-month supply of contacts PCY, in lieu of glasses (frames and lenses)

Covered in full






$25/$65/$150



$75/$195/$450





17

Plus Gold 500Medical plan for 1–50 employees starting January 1, 2019The deductible applies whenever there is a coinsurance listed, unless otherwise noted. PLUS GOLD 500

IN-NETWORK NON-PREFERRED NONPARTICIPATING

Individual deductible Per calendar year = PCY Family = 2x individual deductible (in-network only) $500 2x individual deductible

Coinsurance Amount you pay after your deductible is met 20% 40% 60%Out-of-pocket maximum

Includes deductible, coinsurance, pharmacy, and copaysFamily = 2x individual out-of-pocket maximum $6,000 $45,000







Deductible, then 40% Deductible, then 60%Office visits

Spinal manipulation (12 visits PCY); Acupuncture (12 visits PCY) $25










Not covered



Office visit $50


Outpatient services












Covered in full





10 Prescription drugs Tier 1: Preferred generic Tier 2: Preferred brand Tier 3: Non-preferred generic and brand Tier 4: Speciality

Retail up to 90-day supply (3x 30-day supply cost)Mail order 90-day supply; 3x retailSpecialty Rx 30-day supplyDrug formulary M4

$20/$40/$100

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

$60/$120/$300





18

Plus Gold 1000/1500Medical plan for 1–50 employees starting January 1, 2019The deductible applies whenever there is a coinsurance listed, unless otherwise noted. PLUS GOLD 1000/1500


Individual deductible Per calendar year = PCY Family = 2x individual deductible (in-network only) $1,000/$1,500 2x individual deductible









Deductible, then 40% Deductible, then 60%Office Visits Spinal manipulation (12 visits PCY);


2 Emergency services Emergency careCopay waived if directly admitted to inpatient facility $250 Copay, then in-network deductible and coinsurance









Not covered



Office visit $50


Outpatient services

6Rehabilitative and habilitative services and devices







8Preventive/wellness services and chronic disease management



Eye exam: 1 PCY $25

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

Covered in full






$10/$40/$100



$30/$120/$300





19

Plus HSA Qualified Bronze 5250(Embedded deductible)Medical plan for 1–50 employees starting January 1, 2019The deductible applies whenever there is a coinsurance listed, unless otherwise noted. PLUS HSA QUALIFIED BRONZE 5250 (EMBEDDED)


Individual deductible Per calendar year = PCY Family = 2x individual deductible (in-network only) Individual $5,250 2x individual deductible


Out-of-pocket maximum Includes deductible, coinsurance, pharmacy, and copaysFamily = 2x individual out-of-pocket maximum Individual $6,550 $45,000




patient servicesOutpatient services

Deductible, then 30% Deductible, then 40% Deductible, then 60%Office visits Spinal manipulation (12 visits PCY);


2 Emergency services Emergency care Deductible, then 30%

Ambulance transportation (air and ground) Deductible, then 30%Emergent: Same as in-network

Non-emergent: Air – Ded, then 40% / Ded, then 60%;Ground – Same as in-network





Not covered



Office visitInpatient hospital: mental and behavioral healthOutpatient services




Deductible, then 30% Deductible, then 40% Deductible, then 60%Therapy Physical, speech, occupational, massage therapy:

45 visits PCY


Durable medical equipmentSkilled nursing facility: 60 days PCY




9Pediatric services, including vision care under age 19

Eye exam: 1 PCY $25


Covered in full


Pediatric dental class II (fillings, non-surgical periodontal services, and extractions) Deductible, then 30% Deductible, then 50%


10 Prescription drugsTier 1: Preferred genericTier 2: Preferred brandTier 3: Non-preferred generic and brandTier 4: Speciality




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

Teladoc A full list of services is available on premera.com/ak/member Deductible, then 30% Not covered

20

Plus HSA Qualified Bronze 6000(Embedded deductible)Medical plan for 1–50 employees starting January 1, 2019The deductible applies whenever there is a coinsurance listed, unless otherwise noted. PLUS HSA QUALIFED BRONZE 6000 (EMBEDDED)


Individual deductible Per calendar year = PCY Family = 2x individual deductible (in-network only) Individual: $6,000 2x individual deductible

Coinsurance Amount you pay after your deductible is met 30% 40% 60%Out-of-pocket maximum

Includes deductible, coinsurance, pharmacy, and copays Family = 2x individual out-of-pocket maximum Individual: $6,650 $45,000



10 ESSENTIAL BENEFITS | COVERED SERVICES

1 Ambulartory patient services Office visits

Outpatient servicesSpinal manipulation (12 visits PCY); Acupuncture (12 visits PCY)


2 Emergency services Emergency care. Copay waived if directly admitted to inpatient facility Deductible, then 30%

Ambulance transporation (air and ground) Deductible, then 30%Emergent: Same as in-network

Non-emergent: Air - Ded, then 40%/ Ded, then 60% Ground - Same as in-network





Not covered





6 Rehabilitation and habilitative services and devices

Therapy Rehabilitation and habilitative benefits have the same number of visits, but are counted seperately


Deductible, then 30% Deductible, then 40% Deductible, then 60%Physical, speech, occupational, massage therapy: 45 visits PCY

Durable medical equipment Skilled nursing facility: 60 days PCY

7 Laboratory services Includes x-ray, pathology, imaging/diagnostics, MRI, CT, PET (pre-approval required for certain services) Deductible, then 30% Deductible, then 40% Deductible, then 60%

8 Preventive/wellness services and chronic-disease management

Screenings Exams and vaccinations Deductible, then 30% Deductible, then 40% Deductible, then 60%


Eye exam: 1 PCY $25

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

Covered in full




10 Prescription drugs Tier 1: Preferred genericTier 2: Preferred brandTier 3: Non-preferred generic and brandTier 4: Speciality

Retail: up to 90-day supply (3x 30-day supply cost)Mail order 90-day supply; 3x retailSpecialty Rx 30-day supplyDrug formulary M1


ADDITIONAL BENEFIT EMBEDDED WITHIN THE MEDICAL PLANHearing Hearing exam: 1 per 2 calendar years


Teladoc Deductible, then 30% Not covered

21

Plus HSA Qualified Silver 2700(Embedded deductible)Medical plan for 1–50 employees starting January 1, 2019The deductible applies whenever there is a coinsurance listed, unless otherwise noted. PLUS HSA QUALIFIED SILVER 2700 (EMBEDDED)








1 Ambulatory patient services Outpatient services

Deductible, then 25% Deductible, then 40% Deductible, then 60%Office visits Spinal manipulation (12 visits PCY);









Not covered


5

Mental health and substance use disorder services, including behavioral health treatment






45 visits PCY








Covered in full











22

Plus HSA Qualified Silver 3500(Embedded deductible)Medical plan for 1–50 employees starting January 1, 2019The deductible applies whenever there is a coinsurance listed, unless otherwise noted. PLUS HSA QUALIFIED SILVER 3500 (EMBEDDED)








patient servicesOutpatient services

Deductible, then 20% Deductible, then 40% Deductible, then 60%Office Visits Spinal manipulation (12 visits PCY);









Not covered


5







45 visits PCY







Eye exam: 1 PCY $25


Covered in full











23

Plus HSA Qualified Gold 1500(Aggregate deductible)Medical plan for 1–50 employees starting January 1, 2019The deductible applies whenever there is a coinsurance listed, unless otherwise noted. PLUS HSA QUALIFIED GOLD 1500 (AGGREGATE)


Individual deductible Per calendar year = PCY Family = 2x individual deductible (aggregate ) Individual: $1,500 2x individual deductible


Out-of-pocket maximum Includes deductible, coinsurance, pharmacy, and copaysFamily = 2x individual out-of-pocket maximum (aggregate) Individual: $3,000 $45,000




patient services Outpatient servicesDeductible, then 20% Deductible, then 40% Deductible, then 60%

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








Not covered


5







45 visits PCY






9

Pediatric services, including vision care under age 19

Eye exam: 1 PCY $25


Covered in full










24

Select HSA Qualified Bronze 5250(Embedded deductible)Medical plan for 1–50 employees starting January 1, 2019The deductible applies whenever there is a coinsurance listed, unless otherwise noted. SELECT HSA QUALIFIED BRONZE (EMBEDDED)



Coinsurance Amount you pay after your deductible is met 30% Hospital: 40% Hospital: 60%

All other facilities and professional: Same as in-network


Office visits Cost share Deductible, then 30% Same as in-network



1 Ambulatory patient services

Outpatient servicesDeductible, then 30%

Hospital: Deductible, then 40%


Office visits Spinal manipulation (12 visits PCY); Acupuncture (12 visits PCY) All other facilities and professional: Same as in-network






Hospital:Deductible, then 40%


Hospice: 10 days inpatient Respite care: 240 hours lifetime maximum All other facilities and professional: Same as in-network


Not covered

4 Maternity and newborn care Prenatal, delivery, postnatal care Deductible, then 30%




5



Deductible, then 30%Deductible, then 40% Deductible, then 60%







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




7 Laboratory services Includes x-ray, pathology, imaging/diagnostic, MRI, CT, PET (pre-approval required for certain services) Deductible, then 30%





ScreeningsExams and vaccinations Covered in full

Deductible, then 40% Deductible, then 60%



Eye exam: 1 PCY $25

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

Covered in full

Dental: Pediatric dental class I (cleanings, exams, and x-rays) Deductible waived, covered in full Deductible waived, then 10%









25

Select Silver 3000Medical plan for 1–50 employees starting January 1, 2019The deductible applies whenever there is a coinsurance listed, unless otherwise noted. SELECT SILVER 3000



Coinsurance Amount you pay after your deductible is met 30% Hospital: 40% Hospital: 60%



Office visits Cost share $75 Same as in-network



1 Ambulatory patient services Outpatient services Deductible, then 30% Hospital:

Deductible, then 40%Hospital:


Office visits Spinal manipulation (12 visits PCY); Acupuncture (12 visits PCY) Office visit cost share All other facilities and professional: Same as in-network


Ambulance transportation (air and ground)$25 copay, then










Not covered

4 Maternity and newborn care Prenatal, delivery, postnatal care Deductible, then 30%




5


Office visit Office visit cost share Hospital: Deductible, then 40%


Inpatient hospital: mental and behavioral health Deductible, then 30% All other facilities and professional: Same as in-network

6

Rehabilitative and habilitative services and devices

Therapy

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



Hospital: Deductible, then 60%Physical, speech, occupational, massage therapy:


Durable medical equipmentDeductible, then 30%

Skilled nursing facility: 60 days PCY All other facilities and professional: Same as in-network










Eye exam: 1 PCY $25


Covered in full






$25/$65/Ded, 50%



$75/$195/ Ded, 50%





26

Select Gold 1500Medical plan for 1–50 employees starting January 1, 2019The deductible applies whenever there is a coinsurance listed, unless otherwise noted. SELECT GOLD 1500



Coinsurance Amount you pay after your deductible is met 20% Hospital: 40% Hospital: 60%All other facilities and professional: Same as in-network


Office visits Cost share $50 Same as in-network



patient services Outpatient services Deductible, then 20% Hospital: Deductible, then 40%


Office visits Spinal manipulation (12 visits PCY); Acupuncture (12 visits PCY) Office visit cost share All other facilities and professional: Same as in-network


Ambulance transportation (air and ground)$25 copay, then










Not covered

4Maternity and newborn care Prenatal, delivery, postnatal care Deductible, then 20%




5


Office visit Office visit cost shareDeductible, then 40% Deductible, then 60%

Inpatient hospital: mental and behavioral healthDeductible, then 20%

Outpatient services All other facilities and professional: Same as in-network





Therapy Physical, speech, occupational, massage therapy: 45 visits PCY Deductible, then $50


Durable medical equipmentSkilled nursing facility: 60 days PCY Deductible, then 20% All other facilities and professional: Same as in-network











Covered in full






$10/$40/Ded, 50%



$30/$120/Ded, 50%





27

Dental plans

Good oral health is pivotal to your employee’s overall health. Here’s why : Regular preventive oral health visits assist with early detection and management of diseases. When you offer your employees both dental and medical benefits from Premera, you help encourage healthy habits.

28

Pediatric dental benefits are already included in Premera medical plansYour employees will receive pediatric dental coverage because it’s already embedded in their Premera medical plan. This allows you to provide your employees coverage for essential dental treatments for anyone age 18 or younger.

This embedded benefit includes a range of services from routine dental cleanings and x-rays to root canals and extractions. In addition, this coverage offers:

• The ability to visit any dentist*

• No waiting period

Because pediatric dental just isn’t enough, Premera offers options for adult dental benefitsTo complement the embedded pediatric dental coverage your employees get with their medical plans, we offer adult (anyone age 19 or older) dental options as a great way to provide ample value to your employees’ medical plan.

*Different in-network and out-of-network deductibles and coinsurance apply based on service. Speak to your producer for more details.

29

DENTAL BENEFITS ADULT CORE DENTAL ADULT DENTAL OPTIMA ADULT DENTAL OPTIMA VOLUNTARY

Cost to employer $ $$ $0

Member’s out-of-pocket cost

Member coinsurance is higher when seeing an out-of-network dentist

Member coinsurance is the same for in-network and out-of-network

dentists

Member coinsurance is the same for in-network and out-of-network

dentists

Expanded benefits for Major dental services (such as dentures, bridges, implants, oral and periodontal surgery)

Not covered Covered Covered (implants not included)

Orthodontia1 No option Optional No option

Employee-funded plan2 No No Yes

Note: For a summary of plan benefits and limitations, see plan details to follow. 1 For groups with 26 or more enrolled employees 2 Employer contributes 0%–49% of premium. Minimum enrollment is 2 or 30% of eligible employees (whichever is greater).

CHOOSE BETWEEN TWO ADULT DENTAL OPTIONS:

Adult Core Dental

Adult Core Dental can be paired with any medical plan to provide your employees core dental benefits at a lower cost.

Adult Dental Optima and Adult Dental Optima Voluntary

Adult Dental Optima and Adult Dental Optima Voluntary are separate dental plans. You can pair either of these with your medical plan to provide adult dental coverage and a broader range of services for your employees.

30

Benefits apply after dental calendar year deductible is met, unless otherwise noted. Dental deductible and coinsurance represent member’s cost share

PCY = Per Calendar Year

COVERED SERVICES IN-NETWORK OUT-OF-NETWORK

Individual dental deductible PCY $50

DIAGNOSTIC AND PREVENTIVE

Cleanings 2 PCY

Covered in full Dental deductible waived, then 10%

Routine oral exams 2 PCY

Routine x-rays full mouth: 1 every 60 months / bitewings: 2 PCY to maximum of 4

BASIC

Non-routine, problem-focused, or emergency exams 1 PCY shared limit

Dental deductible, then 30% Dental deductible, then 50%

Non-routine x-rays panoramic 1 every 60 months / periapical unlimited

Fillings once every 24 months

Periodontal maintenance 4 PCY

Periodontics, non-surgical services scaling / root planing 1 per quadrant every 24 months

Endodontics 1 per lifetime

Simple / surgical extractions

General anesthesia

MAJOR

Recementing / repair of crowns 1 every 24 months, 6 months after placement

Dental deductible, then 50% Dental deductible, then 50%Installation of crowns porcelain, ceramic, and metal only, once every 7 years

Build-ups crowns only, 1 every 7 years

ANNUAL DENTAL PLAN MAXIMUM $1,000 PCY

NOTE: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross.

Adult Core DentalWith Adult Core Dental, you can offer your adult employees and their adult dependents the core benefits they need to keep their smiles healthy.

Preventive services like cleanings, routine exams, and routine x-rays are covered in full to help them properly care for their overall health—with no waiting period.

In addition, they will have the freedom to choose any dental care provider, but will enjoy lower overall out-of-pocket costs when that provider is in network.

31

Adult Dental Optima™With Adult Dental Optima, you can offer your employees comprehensive coverage and flexibility to choose any dental care provider. They won’t be billed for costs beyond the allowable amount when they use a provider who is in network.

Diagnostic and preventive services such as routine exams, cleanings, and x-rays are 100 percent covered to help keep smiles healthy.

Additionally, all plans provide benefits for periodontal maintenance, which includes up to four visits per year to help manage gum disease, expanded coverage for basic services such as fillings and extractions, and a broader range of major services such as dentures, bridges, implants, and oral surgery.

Benefits apply after calendar year deductible is met, unless otherwise noted. Deductible and coinsurance represent member’s cost share


ADULT DENTAL OPTIMA 1000 1500

ADULT DENTAL OPTIMA 1500 ENHANCED2000 ENHANCED 2500 ENHANCED

COVERED SERVICES DEDUCTIBLE / MAXIMUM ALLOWANCE

For Groups 2–9

Annual deductible (the amount you pay before your plan starts to pay) PCY

Individual $50 $50

Family $150 $150

Maximum allowance (the most your plan will pay toward services) per person, PCY $1,000 | $1,500 $1,500

For Groups 10–50

Annual deductible (the amount you pay before your plan starts to pay) PCY

Individual $50 $50

Family $150 $150

Maximum allowance (the most your plan will pay toward services) per person, PCY $1,000 | $1,500 $1,500 | $2,000 | $2,500

DIAGNOSTIC AND PREVENTIVE1 COST SHARES IN- AND OUT-OF-NETWORKCleanings limited to 2 PCY

0%Emergency and non-routine exams limited to 1 PCY

Routine oral exams limited to 2 PCY

Routine x-rays complete series or panoramic x-ray once per 36 consecutive months, but not both. Bitewing x-rays 1 set (up to 4) PCY

BASICEmergency palliative treatment

20%

Fillings limited to once per tooth surface every 24 consecutive months

General anesthesia or intravenous sedation limited to covered dental procedures at a dental-care provider’s office when dentally necessary

Simple and surgical extractions

Periodontal maintenance limited to 4 treatments PCY

MAJOREndodontic (root canal) treatment limited to once per tooth every 2 calendar years

50%

20%Periodontal scaling limited to once per quadrant every 2 calendar years

Periodontal surgery limited to once per quadrant every 3 calendar years

Full-mouth debridement limited to once every 3 calendar years

Inlays, onlays, and crowns replacements limited to once per tooth every 5 years

50%Implants, dentures, partials, and fixed bridges replacements limited to once every 5 calendar years

Oral surgery

Recementing and repair of crowns, inlays, bridgework, and denturesNote: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross.1Annual deductible waived for diagnostic and preventive services.

32

Adult Dental Optima VoluntaryWith Adult Dental Optima Voluntary, you can offer valued dental coverage to your employees and help them save money by funding up to 50 percent of their premiums.

Employees can choose any licensed or certified dental care provider for their care. When they use an in-network provider, they’ll get the dental care they need and won’t be billed for costs beyond the allowable amount.

Diagnostic and preventive services such as routine exams, cleanings, and x-rays are 100 percent covered to help keep their smiles healthy.

Additionally, all plans provide benefits for periodontal maintenance, including up to four visits per year to help manage gum disease, as well as basic and major services such as fillings, extractions, crowns, inlays, and dentures.

Benefits apply after calendar year deductible is met, unless otherwise noted. Deductible and coinsurance represent member’s cost share


COVERED SERVICES DEDUCTIBLE / MAXIMUM ALLOWANCE

For Groups 2–50Annual deductible PCY

Individual $50

Family $150

Maximum allowance per person, PCY $1,000

COST SHARES IN- AND OUT-OF-NETWORK

DIAGNOSTIC AND PREVENTIVE1

Cleanings limited to 2 PCY

0%Routine oral exams limited to 2 PCY

Routine x-rays complete series or panoramic x-ray once per 36 consecutive months, but not both. Bitewing x-rays 1 set (up to 4) PCY

BASIC

Emergency and non-routine exams limited to 1 PCY

20%

Emergency palliative treatment

Fillings limited to once per tooth surface every 24 consecutive months

Periodontal maintenance limited to 4 visits PCY

General anesthesia or intravenous sedation limited to covered dental procedures at a dental-care provider’s office when dentally necessary

Simple and surgical extractions

MAJOR2

Dentures, partials, and fixed bridges replacements limited to once every 5 calendar years

50%

Endodontic (root canal) treatment limited to once per tooth every 2 calendar years

Full-mouth debridement limited to once every 3 calendar years

Inlays, onlays, and crowns replacements limited to once per tooth every 5 years

Oral surgery

Periodontal scaling once per quadrant every 2 calendar years

Periodontal surgery once per quadrant every 3 calendar years

Recementing and repair of crowns, inlays, bridgework, and dentures

Note: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross Blue Shield of Alaska. 1 Annual deductible waived for diagnostic and preventive services. 2A 12-month waiting period applies to members who have not had continuous comparable dental coverage under the group’s prior dental plan.

33

Optional orthodontic coverage

You can choose to offer additional dental coverage to customize your benefits package.

ADULT DENTAL OPTIMA

ORTHODONTIA1

Diagnostic services and active / retention treatment including appliances 50%1 up to lifetime maximumMonthly orthodontic adjustments including retention treatment

Lifetime maximum per person $1,500

Age limit No age limit

1 Benefits provided at 50% of allowable charges; not subject to deductible or coinsurance. Available only with 26 or more enrolled employees.

Participation and contribution requirements for adult dental plans

Depending on the funding type and group size, there are different options for how much you can choose to contribute to premiums. You must also meet the participation requirements in order to offer the plan.

FUNDING TYPE / GROUP SIZE EMPLOYER CONTRIBUTION PARTICIPATION REQUIREMENTS

Non-voluntary plans 2–4 employees 50%–100% of premium 100% participation

Non-voluntary plans 5–50 employees 50%–100% of premium Minimum of 5 employees or 50% of eligible employees, whichever is greater

Voluntary plan 2–50 employees 0%–49% of premium Minimum of 2 employees or 30% of eligible employees, whichever is greater

34

Vision plans

Routine eye and hearing exams can lead to earlier diagnosis of chronic diseases. Choose the level of vision and hearing coverage that works best for your business and your employees.

35

DENTAL BENEFITS CORE VISION MANDATED OFFERING VISION

Exam Covered in full up to $125 per calendar year 1 visit per calendar year, $25 copay

Eyewear $150 every 2 consecutive calendar years

1 pair of lenses, per calendar year; 1 pair of frames every 2 consecutive calendar years ($90 retail max);

contacts $170 retail max; $350 annual maximum, shared with vision exam

Choose from two adult (anyone age 19 or older) vision plan options:

Offering vision benefits along with medical and dental is easier to manage for both your business and your employees.

In fact, routine eye exams can lead to earlier diagnosis of chronic diseases.

Plus, offering all of your employees’ benefits with Premera means you get the ease of dealing with just one health plan. Your employees and their covered dependents enjoy the simplicity of one card, one customer service phone number, and one website.

36

What our customers say

@premera THANK YOU SO MUCH for helping me get my question answered. Jennifer in Alaska just gave me the info I needed.The gentleman I spoke with was knowledgeable and helpful. Could not have been handled more professionally.Whato remove such a financial hardship. One of the best customer experiences I’ve had over the phone.It’s awesome that they’re actually paying attention, it’s good to know this is a way to reach them. Got the call this morning—issue resolved!We couldn’t have asked for a better person to help us through all we’ve been through with my wife’s strokes.Shout-out to @premera Customer Service rep Carrie in Spokane WA for helping me w/my insurance. #insurance #premera #bestcustomerserviceI felt so helpless, but now I feel like I have help.I have faith that Adrian will have the issue resolved today. He promised me a card and the numbers I need

This brochure is not a contract. It is only a summary of the major benefits provided by these plans. For full coverage provisions, including a description of waiting periods, limitations, and exclusions, please contact your Premera representative or producer.

Find out

Visit premera.com/ak/employer.

Talk with your Premera representative or producer.

027474 (10-04-2018)

2019 health plan guide - premera blue crosswellness tools and resources: employees who feel better...

Documents