Medical
Medical coverage offers healthcare protection for you and your family. You may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.
Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums– the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
Premera CDHP + HSA
Plan Information
Plan Name: Premera CDHP + HSA
Policy Number: 4002747
Effective Date: 01/01/2025
Provider Network: Premera
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$1,650/$3,300
Out-of-Pocket Max (Individual/Family)
$3,300/$6,600
Preventive Care
Plan pays 100%
Emergency Room
Plan pays 80% after deductible
Office Visit
Plan pays 80% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay after deductible
Preferred Brand
$30 copay after deductible
Non-Preferred Brand
$30% after deductible
Specialty
$50 copay after deductible
Mail-Order Rx (Up to 90-Day Supply)
Generic
2x retail copay
Preferred Brand
2x retail copay
Non-Preferred Brand
2x retail copay
Specialty
2x retail copay
Out-of-Network
Deductible (Individual/Family)
$3,300/$6,600
Out-of-Pocket Max (Individual/Family)
$6,600/$13,200
Preventive Care
Plan pays 60% after deductible
Emergency Room
Plan pays 80% after deductible
Office Visit
Plan pays 80% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
Plan pays 60% after deductible
Preferred Brand
Plan pays 60% after deductible
Non-Preferred Brand
Plan pays 60% after deductible
Specialty
Plan pays 60% after deductible
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Contact Information
Premera CDHP + HRA
Plan Information
Plan Name: Premera CDHP + HRA
Policy Number: 4002747
Effective Date: 01/01/2025
Provider Network: Premera
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$2,000/$4,000
Out-of-Pocket Max (Individual/Family)
$3,300/$6,600
Preventive Care
Plan pays 100%
Emergency Room
Plan pays 80% after deductible
Office Visit
Plan pays 80% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay after deductible
Preferred Brand
$30 copay after deductible
Non-Preferred Brand
30% after deductible
Specialty
$50 copay after deductible
Mail-Order Rx (Up to 90-Day Supply)
Generic
2x retail copay
Preferred Brand
2x retail copay
Non-Preferred Brand
2x retail copay
Specialty
2x retail copay
Out-of-Network
Deductible (Individual/Family)
$4,000/$8,000
Out-of-Pocket Max (Individual/Family)
$6,600/$13,200
Preventive Care
Plan pays 60% after deductible
Emergency Room
Plan pays 80% after deductible
Office Visit
Plan pays 60% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
Plan pays 60% after deductible
Preferred Brand
Plan pays 60% after deductible
Non-Preferred Brand
Plan pays 60% after deductible
Specialty
Plan pays 60% after deductible
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Contact Information
Premera High Deductible Basic
Plan Information
Plan Name: Premera High Deductible Basic
Policy Number: 4002747
Effective Date: 01/01/2025
Provider Network: Premera
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$5,000/$10,000
Out-of-Pocket Max (Individual/Family)
$6,000/$12,000
Preventive Care
Plan pays 100%
Emergency Room
Plan pays 80% after deductible
Office Visit
Plan pays 70% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay after deductible
Preferred Brand
$30 copay after deductible
Non-Preferred Brand
30% after deductible
Specialty
$50 copay after deductible
Mail-Order Rx (Up to 90-Day Supply)
Generic
2x retail copay
Preferred Brand
2x retail copay
Non-Preferred Brand
2x retail copay
Specialty
2x retail copay
Out-of-Network
Deductible (Individual/Family)
$5,000/$10,000
Out-of-Pocket Max (Individual/Family)
$6,000/$12,000
Preventive Care
Plan pays 50% after deductible
Emergency Room
Plan pays 80% after deductible
Office Visit
Plan pays 50% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
Plan pays 60% after deductible
Preferred Brand
Plan pays 60% after deductible
Non-Preferred Brand
Plan pays 60% after deductible
Specialty
Plan pays 60% after deductible
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered