Premera Blue Cross Standard Gold - 38344AK1100001 Health Insurance Plan
Premera Blue Cross Blue Shield of Alaska health insurance plan with the Plan ID 38344AK1100001. The plan is called Premera Blue Cross Standard Gold.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.06% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.94% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 38344AK1100001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Alaska | ||||||||||||||||||
| Health Insurance Issuer | Premera Blue Cross Blue Shield of Alaska | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 38344AK1100001-03 | ||||||||||||||||||
| Provider Network(s) | LEGACYANDDENTALSELECT | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | Standard On Exchange Plan - 38344AK1100001-01 |
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| Last Plan Update Date | Thu, 10 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Premera Blue Cross Standard Gold Health Insurance Plan, 38344AK1100001-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Accidental Dental
|
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Acupuncture
Limit: 12.0 Visit(s) per Year Services must be medically necessary to relieve pain, induce surgical anesthesia, or to treat a covered illness, injury or condition. |
YES | $30.00 |
60.00% Coinsurance after deductible |
| Allergy Testing
|
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
Limit: 4.0 Procedure(s) per Year |
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Chemotherapy
|
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Chiropractic Care
Limit: 12.0 Visit(s) per Year |
YES | $30.00 |
60.00% Coinsurance after deductible |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months |
YES | No Charge |
30.00% Coinsurance after deductible |
| Diabetes Education
|
YES | No Charge |
No Charge |
| Dialysis
|
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Durable Medical Equipment
|
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Emergency Room Services
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Air and Ground transpiration benefit is limited to medical emergency. Ambulance services is separate benefit, covers both medical emergency transport and non-emergent transport. |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Under age 19; 1 pair of frames and lenses PCY includes polycarbonate lenses and scratch resistant coating; 12 month supply of contacts in lieu of glasses; over age 19 Not Covered. |
YES | No Charge |
No Charge |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Limit: 90.0 Item(s) per Month Up to 90 day supply Retail (copay times 3); 90 day supply for Mail Order. This tier contains only Preferred Generic Drugs. |
YES | $15.00 |
$15.00 |
| Habilitation Services
Limit: 45.0 Visit(s) per Year Habilitative services is only covered in the context of autism spectrum disorders services, including ABA, counseling and treatment programs necessary to develop, maintain, or restore the functioning of an individual. |
YES | $30.00 |
60.00% Coinsurance after deductible |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 130.0 Visit(s) per Year 130 visits per applies to home visits of a home health care provider or one or more: registered nurse; a licensed practical nurse; a licensed physical therapist or occupational therapist; a certified respiratory therapist; a speech therapist certified by the American Speech, Language, and Hearing Association; a home health aide directly supervised by one of the above providers; and a person with a master's degree in social work. |
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Hospice Services
Limit: 6.0 Months per Lifetime Inpatient hospice care up to a maximum of 10 days. Respite care, up to a maximum of 240 hours, to relieve anyone who lives with and cares for the terminally ill member. |
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
Limit: 1.0 Procedure(s) per 3 Years |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
The cost sharing that displays applies to outpatient office visits only. All other outpatient services (Outpatient Facility Fee, Laborartory Outpatient and Professional Services, etc.) may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
YES | $30.00 |
60.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
Limit: 90.0 Item(s) per Month Up to 90 day supply Retail (copay times 3); 90 day supply for Mail Order. This tier contains only non-preferred drugs. |
YES | $60.00 |
$60.00 |
| Nutritional Counseling
|
YES | No Charge |
60.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Unlimited if Medically Necessary Only |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered only when the provider is licensed to practice where the care is provided, is providing a service within the scope of that license, is providing a service or supply for which benefits are specified in this plan, and when benefits would be payable if the services were provided by a physician. |
YES | $30.00 |
60.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
Limit: 45.0 Visit(s) per Year A 'visit' is a session of treatment for each type of therapy. Each type of therapy combined accrues toward the above visit maximum. Multiple therapy sessions on the same day will be counted as 1 visit, unless provided by different health care providers. |
YES | $30.00 |
60.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Preferred Brand Drugs
Limit: 90.0 Item(s) per Month Up to 90 day supply Retail (copay times 3); 90 day supply for Mail Order. |
YES | $30.00 |
$30.00 |
| Premera-Designated Centers of Excellence
|
YES | No Charge |
60.00% Coinsurance after deductible |
| Prenatal and Postnatal Care
|
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
60.00% Coinsurance after deductible |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 |
60.00% Coinsurance after deductible |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Benefit limited to initial purchase of prosthetic; does not cover replacement unless the existing device can't be repaired, or replacement is prescribed by a physician because of a change in your physical condition. |
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Radiation
|
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Reconstructive Surgery
Breast reconstruction allowed. |
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 45.0 Visit(s) per Year Visit limit for physical, speech, and occupational therapy services combined. |
YES | $30.00 |
60.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
Limit: 45.0 Visit(s) per Year Visit limit for physical, speech, and occupational therapy services combined. |
YES | $30.00 |
60.00% Coinsurance after deductible |
| Routine Dental Services (Adult)
Limit: 2.0 Exam(s) per Year Routine Exam - 2 PCY and Cleanings- 2 PCY; Routine X-rays (bitewing) - 1 PCY; Annual Maximum $750 |
YES | 10.00% |
30.00% Coinsurance after deductible |
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Under age 19, 1 PCY; Over age 19 Not Covered |
YES | $30.00 |
$30.00 |
| Routine Foot Care
Routine foot care when the member is a diabetic. |
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Skilled Nursing Facility
Limit: 60.0 Days per Year |
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Specialist Visit
|
YES | $60.00 |
60.00% Coinsurance after deductible |
| Specialty Drugs
Limit: 30.0 Item(s) per Month 30 day supply Retail and Mail |
YES | $250.00 |
$250.00 |
| Substance Abuse Disorder Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | $30.00 |
60.00% Coinsurance after deductible |
| Transplant
Limit: 75000.0 Dollars per Lifetime Quantitative limit on Donor costs only. The types of solid organ transplants and bone marrow/stem cell reinfusion procedures that currently meet the plan's criteria for coverage are: Heart, Heart/double lung, single lung, Double lung, Liver, Kidney, Pancreas, Pancreas with kidney, Bone marrow (autologous and allogenic), Stem cell (autologous and allogeneic). |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | $45.00 |
60.00% Coinsurance after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
60.00% Coinsurance after deductible |
| X-rays and Diagnostic Imaging
|
YES | 25.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Premera Blue Cross Standard Gold Health Insurance Plan Variant 38344AK1100001-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7806125763529309 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Design 1 |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes |
| EHB Percent of Total Premium | 0.9928 |
| First Tier Utilization | 100% |
| Formulary ID | AKF004 |
| Formulary URL | URL |
| HIOS Product ID | 38344AK110 |
| Import Date | 2024-10-10 01:01:49 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 38344 |
| Issuer Marketplace Marketing Name | Premera Blue Cross Blue Shield of Alaska |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | AKN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Benefits for covered services received from providers located outside the United States, Puerto Rico, and the U.S. Virgin Islands are provided at the highest level of benefits under the plan. |
| Out of Service Area Coverage | No |
| Out of Service Area Coverage Description | If you're outside Alaska and Washington (the service area), covered services received from any provider licensed to provide the service will be paid the out of network benefit level (except emergencies). |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 38344AK1100001-03 |
| Plan Marketing Name | Premera Blue Cross Standard Gold |
| Plan Type | PPO |
| Plan Variant Marketing Name | Premera Blue Cross Standard Gold |
| QHP/Non QHP | On the Exchange |
| SBC Scenario, Having a Baby, Coinsurance | $2,800 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,300 |
| SBC Scenario, Having Diabetes, Deductible | $200 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | AKS001 |
| Source Name | HIOS |
| Plan ID | 38344AK1100001 |
| State Code | AK |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $4500 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $4,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $15600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,800 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Premera Blue Cross Standard Gold Health Insurance Plan, 38344AK1100001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Premera Blue Cross Standard Gold, 38344AK1100001 Health Insurance Plan, 38344AK1100001
-
Does Premera Blue Cross Standard Gold Health Insurance Plan, 38344AK1100001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (38344AK1100001) Health Insurance Plan, Variant (38344AK1100001-03) offer Disease Management Programs?
Does (38344AK1100001) Health Insurance Plan, Variant (38344AK1100001-03) have Out Of Country Coverage?
Does (38344AK1100001) Health Insurance Plan, Variant (38344AK1100001-03) have Out of Service Area Coverage?
Does (38344AK1100001) Health Insurance Plan, Variant (38344AK1100001-03) offer Disease Management Programs?
Does Premera Blue Cross Standard Gold Health Insurance Plan, Variant (38344AK1100001-03) offer Disease Management Programs for Asthma?
Does Premera Blue Cross Standard Gold Health Insurance Plan, Variant (38344AK1100001-03) offer Disease Management Programs for Heart disease?
Does Premera Blue Cross Standard Gold Health Insurance Plan, Variant (38344AK1100001-03) offer Disease Management Programs for Diabetes?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API