<aside> 💡 Looking for a in-network provider? Premera has a search tool to find covered Medical and Vision Providers
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| MEDICAL | 2024 Plan F – Low Deductible | 2024 Plan H – High Deductible |
|---|---|---|
| Plan Design | Premera PPO | High Deductible/HSA |
| Deductible Individual | $100 | $2,000 |
| Deductible Family | $200 | $4,000 |
| Max Out of Pocket Individual | $1,100 | $3,425 |
| Max Out of Pocket Family | $2,200 | $6,850 |
| Co-insurance/Patient Responsibility | 10% (Preferred) / 50% (OON) | 20% (Preferred) / 50% (OON) |
| ER Coverage | 90% after $100 | 80% after deductible |
| Rx 30 Day (Gen/Brand/Specialty) | $5/$25/$50 | 80% after deductible |
| Doctor Office & Preventative Care | ||
| Outpatient Diagnostic X-ray/Lab | 100% (Preferred) / 50% (OON) | 80% (Preferred) / 50% (OON) |
| Preventative Care Visit | 100% | 100% |
| Well-Baby/Child Care | 100% | 100% |
| Vision Benefits | Benefit | Frequency |
|---|---|---|
| Eye Exam | (18 & Under): Exam – $10 Copay | |
| (19+): Exam – Covered in full | 12 months (PCY) | |
| Hardware | (18 & Under): One pair of glasses/frames or contacts – covered in full | |
| (19+): Covered at 100% up to $300 | ||
| 12 months (PCY) | ||
| Contact Specific Info | • Instead of glasses, 1 pair of non-disposable contacts or a 12- month disposable supply | 12 months (PCY) |
| Additional Info | • No charge for contact lenses or glasses required for certain medical conditions. | |
| • No charge for low-vision devices, high power glasses when medically necessary |
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