for employers with 1—50 employees complete … · • our qualified high-deductible plans are...

Complete guide to health benefit plansFOR EMPLOYERS WITH 1—50 EMPLOYEES

Taking great care of our customers is important to us

That’s why we offer a range of plans that support the health of your employees with a focus on quality, cost, and ease.

Here’s why businesses with 50 or fewer employees trust Premera Blue Cross as their health plan:

• We’re in your corner: As the largest and oldest health plan in Washington, we believe in being there for you and your employees every step of the way.

• We provide access to quality care: With a Premera medical or dental plan, you and your employees get access to care in a large provider network.

• We give you a wide range of options: Whether you want to offer comprehensive coverage—or just the core essentials— you can choose the level of coverage that works best for your business needs.

• We make it easy and simple: Our secure employer website makes it easy to manage your health plan with self-service tools. We also offer a simple system for implementing and administering flexible spending, dependent care, and health savings accounts. If you offer both a medical and a dental plan from Premera, you get a one-stop-shopping experience for managing your benefits.

• �We�help�your�benefits�package�look�appealing: Job seekers look for well-rounded benefit packages from employers. You’ll be able to attract and retain the best talent by offering benefits that are important to your employees.

• We encourage healthier, happier employees: If your employees get the care they need, they’ll be better prepared to meet the needs of your business.

Medical plans

You can get a range of Premera medical plans that offer preventive and primary care benefits to help your employees and their families stay healthy and manage chronic conditions.

• We have two basic types of plans: Choice plans are paired with our largest network of providers, called Heritage. Balance plans are paired with the Heritage Signature network.

• Our qualified high-deductible plans are meant to be paired with an employee-owned, tax-advantaged health savings account (HSA) that allows employees to save their healthcare dollars for when they need them, even in retirement. Groups have the option to use ConnectYourCare and UMB for their HSA bank accounts at no additional cost.

• All plans are available in three metallic levels: gold, silver, and bronze. Levels do not refer to quality. Instead, they indicate the level paid for monthly premiums, deductibles, and out-of-pocket costs.

• All our medical plans come with embedded pediatric dental coverage for qualified dependents age 18 or younger. Children covered under a pediatric dental plan can get care as soon as coverage starts.

• All our plans include an embedded Wellness Program that provides employers with quarterly resources and rewards eligible employees for completing a health assessment.

• All our non-qualified high-deductible health plans have lower copays when an employee and their dependents designate and get care from a primary care provider (PCP). All health plans also cover preventive services without requiring copayments or deductibles first.

PPO PLANS

BALANCE PPO PLANS Heritage Signature Network

CHOICE PPO PLANS Heritage Network

BALANCE 500 GOLD

BALANCE 1000 GOLD

BALANCE 1500 GOLD

BALANCE 2000 SILVER

BALANCE 3000 SILVER

CHOICE 750 GOLD

CHOICE 1000 GOLD

CHOICE 1500 GOLD

CHOICE 2500 SILVER

CHOICE 5500 BRONZE

Deductible Family = 2x Individual

$500 $1,000 $1,500 $2,000 $3,000 $750 $1,000 $1,500 $2,500 $5,500

Out-of-pocket Maximum Family = 2x Individual

$7,350 $5,600 $4,500 $7,350 $6,850 $5,500 $5,600 $4,500 $7,350 $7,150

Emergency Room

$150 copay, Deductible/Coinsurance










Office�Visit

PCP1

designated = 2 CIF2,

then $10 Specialist/

non- designated PCP = $35

PCP designated =

2 CIF, then $10

Specialist/ non-

designated PCP = $40

PCP designated =

2 CIF, then $10

Specialist/ non-


PCP designated =

2 CIF, then $30

Specialist/ non-


PCP designated =

2 CIF, then $20

Specialist/ non-


PCP designated =

2 CIF, then $10

Specialist/ non-


PCP designated =

2 CIF, then $10

Specialist/ non-


PCP designated =

2 CIF, then $10

Specialist/ non-


PCP designated =

2 CIF, then $20

Specialist/ non-


PCP designated =

$30 Specialist/

non- designated PCP = D$50

Basic Imaging and Lab Services

Deductible/Coinsurance

Waive deductible,

then coinsurance

Waive deductible,

then coinsurance




Waive deductible,

then coinsurance

Waive deductible,

then coinsurance



Retail Rx 30-day supply cost Mail Order Copay = 3x retail

$15/$40/ $80/D***25%

$15/$40/ $80/25%

$15/$40/ $80/25%

$30/$65/ $125/D30%

$1,500 Rx Deductible $25/D25%/D25%/D25%

$15/$40/ $80/D25%

$15/$40/ $80/25%

$15/$40/ $80/25%

$25/$65/ $100/D25%

$1,000 Rx Deductible $25/D50%/D50%/D50%

HSA QUALIFIED PLANS

BALANCE HSA QUALIFIED PLANSHeritage Signature Network / Integrated Banking Optional

CHOICE HSA QUALIFIED PLANS Heritage Network / Integrated Banking Optional

BALANCE HSA QUALIFIED

1500 GOLD

BALANCE HSA QUALIFIED

3000 SILVER

BALANCE HSA QUALIFIED 6000 BRONZE

CHOICE HSA QUALIFIED

1500 GOLD


3000 SILVER

CHOICE HSA QUALIFIED 6000 BRONZE


$1,500 (Aggregate)

$3,000 (Embedded)

$6,000 (Embedded)

$1,500 (Aggregate)

$3,000 (Embedded)

$6,000 (Embedded)


$3,000 (Aggregate)

$4,800 (Embedded)

$6,350 (Embedded)

$3,000 (Aggregate)

$4,800 (Embedded)

$6,350 (Embedded)

Emergency Room







Office�Visit Deductible/Coinsurance













Retail Rx 30-day supply cost Mail Order 3x retail







Medical plan snapshot

MEDICAL + FAMILY DENTAL PLANS

BALANCE MEDICAL + FAMILY DENTAL PLANS Heritage Signature Network / Dental Choice Network

CHOICE MEDICAL + FAMILY DENTAL PLANSHeritage Network / Dental Choice Network

BALANCE 500 GOLD +

FAMILY DENTAL

BALANCE 1000 GOLD +

FAMILY DENTAL

BALANCE 2000 SILVER +

FAMILY DENTAL

CHOICE 750 GOLD +

FAMILY DENTAL

CHOICE 1000 GOLD +

FAMILY DENTAL

CHOICE 2500 SILVER +

FAMILY DENTAL


3000 SILVER + FAMILY DENTAL


$500 $1,000 $2,000 $750 $1,000 $2,500 $3,000 (Embedded)


$7,350 $5,600 $7,350 $5,500 $5,600 $7,350 $4,800 (Embedded)

Emergency Room








Office�Visit

PCP designated = 2 CIF, then $10

Specialist/ non-designated

PCP = $35



PCP = $40



PCP = $55



PCP = $35



PCP = $40



PCP = $45




Waive deductible, then coinsurance



Waive deductible, then coinsurance



Retail Rx 30-day supply cost Mail Order Copay = 3x retail

$15/$40/ $80/D325%

$15/$40/ $80/25%

$30/$65/ $125/D30%

$15/$40/ $80/D25%

$15/$40/ $80/25%

$25/$65/ $100/D25%


ADULT VISION

OPTIONAL BENEFIT RIDER

Vision Exam In and out of network $25 (1 exam PCY4)

Vision Hardware Limit In and out of network $150 PCY

1PCP = Primary care provider2CIF = Covered in full3D = Deductible4PCY = Per calendar year

Medical plans with Family Dental

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

PCY = Per Calendar Year

ADULT DENTAL BENEFITS AS PART OF FAMILY DENTAL 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 30%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 / emergency exams 1 PCY shared limit

Dental deductible, then 20%

Dental deductible, then 40%

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

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

Dental deductible, then 50%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. Metallic medical plans that include Family Dental cannot be paired with Adult Dental Optima or Adult Dental Optima Voluntary plans.

Seven of our medical plans have Family Dental benefits built in. By bundling pediatric and adult dental benefits with medical coverage, employees get well-rounded health coverage for their whole family.

Here�are�the�additional�benefits�of� Family Dental:

• Employees get core dental benefits at a lower cost.

• When your employees have a medical plan and a dental plan from Premera, they get one easy experience: one ID card, one customer service number, one website, and one secure account for managing their healthcare.

In addition, all medical plans include:

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

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

• BestBeginnings Maternity and newborn support: Our BestBeginnings app supports healthy babies and moms with personalized tools, and it encourages early discovery of high-risk pregnancies. Our newborn program helps reduce costs associated with high-risk pregnancies or newborns who end up in neonatal intensive care.

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

• Mobile apps: Apps for finding doctors and tracking costs and medications make it easy to manage care.

• Online tools: Digital tools help customers compare costs of services, access pharmacy information, and review claims.

• Local customer service: Trained customer service professionals are ready to help answer questions.

• �Low-cost�fitness�center�memberships: Access to 9,000 fitness centers nationwide is available for only $25 a month (plus $25 enrollment fee and applicable taxes).

Adult dental plansFOR AGES 19 AND OLDER

Premera also offers two separate dental plans: Adult Dental Optima and Adult Dental Optima Voluntary. Employers can pair these with their medical plan to provide adult dental coverage for a broader range of services.

• Dental services, such as cleanings, routine exams, and bitewing x-rays are covered in full.

• Customers can visit any dentist, but their costs will be less for in-network services and care. For 2018, Premera is offering a lower-cost alternative to employers whose employees live in areas with a high concentration of in-network providers and most likely will not frequently use the out-of-network benefits.

Dental plan snapshot

DENTAL BENEFITS FAMILY DENTAL ADULT OPTIMA ADULT OPTIMA VOLUNTARY

Cost to employer $ (included in medical plan) $$ $0

Member’s out-of-pocket cost Member coinsurance is less when seeing an in-network dentist

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

but balance billing may apply

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

but balance billing may apply

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. 1For groups with 26 or more enrolled employees 2Employer contributes 0%–49% of premium. Minimum enrollment is 5 or 30% of eligible employees (whichever is greater).

With every dental plan, Premera provides:

• Access to the broad Choice network: Dental customers get one of the largest networks of dentists in the state of Washington.

• Plans that emphasize prevention: Premera dental customers do not pay a deductible for regular dental visits, and most plans cover preventive services in full.

• Online tools that make things easy: Find in-network care with our dental provider directory, and see how much dental services will cost with our Dental Cost Estimator. Your employees can even email a licensed dentist with questions about their oral health.

• Dental expertise: We’ve been taking care of dental customers for more than 30 years.

Adult Dental Optima

With Adult Dental Optima, employers can offer their employees comprehensive coverage and flexibility to choose their dentist.

Key�benefits

• Employers can choose to have routine diagnostic and preventive services not count toward the annual maximum.

• Employees can choose any licensed or certified provider from our broad network. When they use an in-network provider, they won’t be billed for costs beyond the allowable amount.

• There is no waiting period for any service.

• Diagnostic and preventive services (such as routine exams and bitewing x-rays) are covered at 100 percent.

• All plans provide benefits for periodontal maintenance. Employees can get up to four visits per year to help manage gum disease.

• Includes expanded coverage for basic services such as fillings and simple extractions. Also covers a broader range of major services such as dentures, bridges, implants, and oral surgery.

DIAGNOSTIC AND PREVENTIVE COST SHARES IN- AND OUT-OF-NETWORK

Cleanings limited to 2 PCY

0%Emergency exams unlimited

Routine oral exams limited to 2 PCY

Bitewing x-rays 1 set (up to 4) PCY

BASIC

Emergency palliative treatment

20%

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

Fillings limited to once per tooth surface every 24 consecutive months

Full-mouth debridement limited to once every 3 calendar years

Routine x-rays complete series or panoramic x-ray once per 36 consecutive months, but not both

Simple extractions

Periodontal maintenance limited to 4 visits per calendar year

Periodontal surgery limited to once per quadrant every 3 calendar years

Periodontal scaling limited to once per quadrant every 2 calendar years

MAJOR

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

50%

Repair and recementing of crowns, inlays, bridgework, and dentures

Oral surgery

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

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

Surgical extractions

Note: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross.*Plan options depend on if your group is renewing or starting a new plan. They also depend on your group size. Discuss your options with your producer.

**Reimbursement up to the 90th percentile of billed charges in the geographic area. Ask your producer for more details.1Annual deductible waived for diagnostic and preventive services.2Maximum allowance waived for diagnostic and preventive services.

ADULT DENTAL OPTIMA COVERED SERVICES*

ADULT DENTAL OPTIMA 1000 1500 2000 VOLUNTARY 1000

1000 ENHANCED

1500 ENHANCED

2000 ENHANCED

1500 ENHANCED+

Annual Deductible1 PCY $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150

Maximum allowance per person PCY $1,000 $1,500 $2,000 $1,000 $1,000 $1,500 $2,000 $1,5002

Out of network Reimbursement Washington out-of-network reduced fee schedule Reimbursed up to the 90th percentile**

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


With Adult Optima Voluntary, employers with as few as five employees can offer dental coverage at little or no cost.

Key�benefits

• Employers can choose any licensed or certified provider from our broad network. 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 bitewing x-rays are covered at 100 percent to help employees and their families keep their smiles healthy. And that supports overall health.

• Plan provides benefits for periodontal maintenance. Employees can get up to four visits per year to help manage gum disease.

• Employers can choose to fund up to 50 percent of employees’ premiums—helping them save money while offering valued dental coverage to their employees.

• Includes expanded coverage for basic services such as fillings and simple extractions. Also covers a broader range of major services such as dentures, bridges, and oral surgery.

Adult Dental Optima Voluntary

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


ADULT DENTAL OPTIMA VOLUNTARY COVERED SERVICES (for groups 5–50) DEDUCTIBLE / MAXIMUM ALLOWANCE

Annual deductible PCYIndividual $50

Family $150

Maximum allowance per person, PCY $1,000

DIAGNOSTIC AND PREVENTIVE1 COST SHARES IN- AND OUT-OF-NETWORK

Cleanings limited to 2 PCY

0%Routine oral exams limited to 2 PCY

Bitewing x-rays 1 set (up to 4) PCY

BASIC

Emergency exams (unlimited)

Emergency palliative treatment

30%

Fillings limited to once per tooth surface every 24 consecutive months

Full-mouth debridement limited to once every 3 calendar years

Periodontal maintenance limited to 4 visits per calendar year

Periodontal scaling once per quadrant every 2 calendar years

Routine x-rays complete series or panoramic x-ray once per 36 consecutive months, but not both

Simple extractions

MAJOR2

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

50%

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

Periodontal surgery limited to once per quadrant every 3 calendar years

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

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

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

Oral surgery

Surgical extractions

Note: 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. 2A 12-month waiting period for major services applies to customers who have not had continuous comparable dental coverage under the group’s prior dental plan.

OPTIONAL BENEFITS ADULT DENTAL OPTIMA

ORTHODONTIA1

Diagnostic services and active / retention treatment including appliances50%2 up to lifetime maximum

Monthly�orthodontic�adjustments�including retention treatment

Lifetime maximum per person $1,500

Age limit No age limit

TMJ DENTAL SERVICES3

TMJ exams and x-rays; occlusal guards; and TMJ surgical procedures, manipulations under anesthesia Deductible and coinsurance apply

Annual�benefit�maximum $1,000

Lifetime maximum per person $5,0001 For groups with 26 or more enrolled employees 2 Benefits provided at 50% of allowable charges; not subject to deductible. 3 Balance billing may apply if a provider is not contracting with Premera Blue Cross.

Employers can choose to offer additional dental coverage to customize their benefits package.

PARTICIPATION AND CONTRIBUTION REQUIREMENTS FOR ADULT DENTAL PLANS

FUNDING TYPE / GROUP SIZE EMPLOYER CONTRIBUTION PARTICIPATION REQUIREMENTS

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

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

Voluntary plans 5–50 0%–49% of premium Minimum of 5 employees or 30% of eligible employees, whichever is greater

NOTE: Adult Dental Optima and Adult Dental Optima Voluntary plans cannot be paired with metallic medical plans that include Family Dental.

Depending on the funding type and group size, there are different requirements for the Adult Dental Optima plans. Employers must also meet the participation requirements in order to offer the plan.

More options

learn more

Visit premera.com/smallgroup.

Talk with your producer or general agency partner.

017038 (09-2017)

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 producer.

for employers with 1—50 employees complete … · • our qualified high-deductible plans are...

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