Who are you healthy for? Be there for the people you care about
Health plans for individuals and families 1/1/2016
WE’RE HERE FOR YOU EVERY STEP OF THE WAY For help choosing and enrolling in a plan
877-PREMERA (877-773-6372) shop.premera.com
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We have a plan to fit you and your family Premera Blue Cross has a health plan that’s right for you and your family, matched to your health needs, family size, stage of life, and financial situation. Our wide range of plans offers you the price, the choice of doctors, pharmacies, and hospitals, and the benefits you need so you can be there for the people and activities you care about. We’re here to walk you through the process of choosing and enrolling in a plan, making sure you understand all your options and what you’re getting. We can help you figure out if you’re eligible for help paying for your plan—a subsidy—and enroll you through Washington Healthplanfinder if you are. The whole process can be as simple as one phone conversation. But of course we’re also happy to give you all the time you need to make the right choice.
Welcome to Premera Blue Cross. For more than 80 years, Washington families have trusted Premera for their health coverage. Today, we cover more than 2 million people. We are dedicated to being there for you at every stage of your life, so you can be there for the people most important to you. We have plans for every need and budget, and we are ready to help you understand your options every step of the way. Thank you for considering Premera. We welcome the opportunity to be your health plan.
Jim Havens Vice President & General Manager Individual & Senior Markets
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1 STEP
Consider these factors when choosing a health plan Which doctors you can see The provider network
FIND A DOCTOR If you already have a doctor or go to certain pharmacies or hospitals, check to see if they are in the Heritage Signature provider network if you’re considering a PPO plan, or the Partner
The network includes doctors, pharmacies, hospitals, and other care providers. You’ll almost always pay less if you use providers that are in your plan’s network. Our PPO plans have the largest network—statewide, nationwide, and beyond. Our PersonalCare plans include five leading medical systems in King, Snohomish, and Pierce counties.
System for a PersonalCare plan. Then search for the provider by using the Find a Doctor tool on premera.com.
What you get for your money The benefits Our plans cover recommended preventive care services at no cost to you, plus office visits, urgent and emergency care, prescription drugs, lab tests, maternity and newborn care, hospitalization, mental health care, and more.
CHECK YOUR MEDICATION COVERAGE
For more detailed information about benefits, call 877-PREMERA or visit premera.com.
If you take prescription medications, check coverage at premera.com. Select Pharmacy, then click Rx Search. (See the plan summary for the name of the drug formulary (such as X1) to check prescription coverage for the appropriate plan.) Your share of the cost for prescriptions varies depending on whether the medication is a generic, brand-name, or specialty drug.
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ALTERNATIVE CARE
DIET AND NUTRITION PRODUCTS
SEATTLE FITNESS CLUB MEMBERSHIPS
In addition to the essential benefits, all Premera medical plans include discounts on other health options that you might like.
How much it costs you Monthly premiums and cost shares Premiums are due monthly, similar to your car or home insurance. When you see a doctor or get other medical care, you pay a share of the cost, and your health plan pays the rest. Your share includes deductibles, copays (a fixed charge), and coinsurance (a percentage of the cost). Another important cost to pay attention to is your out-of-pocket maximum—the most you’ll pay in a year for covered healthcare services.
YOU MAY BE ELIGIBLE FOR A SUBSIDY Depending on your household income, you may be eligible for a tax credit, also known as a subsidy, to help pay for your health coverage. In Washington, as many as half of the individuals enrolling in health plans
For more details about these terms, see page 17. Premera plans are available at different levels—bronze, silver, and gold— so you can pick the one that meets your needs. These levels refer only to the costs of the plans, not the quality. In most cases, they cover the same benefits.
are eligible for subsidies. We can help you find out if you qualify for a subsidy and apply through Washington Healthplanfinder. Call 877-PREMERA.
Plan generally covers this percentage of your healthcare costs Monthly premiums
GOLD PLANS
SILVER PLANS
BRONZE PLANS
80%
70%
60%
REMEMBER Higher
Medium
Lower
The plan with the lowest monthly premium may not always be the
Your share of costs for medical care (deductible, copay, coinsurance)
lowest-cost choice for you. Which plan
Lower
Medium
Higher
is best for you depends on whether you expect to need a lot of medical services during the year, or whether you are in
Out-of-pocket maximum
Lower
Medium
Higher
May need care sometimes
Are healthy and expect to need little care
excellent health and need coverage just in case something happens.
Good fit if you...
Expect to need care frequently
3
2 STEP
Choose the Premera plan that’s right for you
FOR MORE INFORMATION For help selecting a plan and enrolling, call 877-PREMERA or visit shop.premera.com.
Premera offers several different plans, available at different cost levels–bronze, silver and gold. You can see details for each plan on premera.com. Before you choose, decide which type of plan is best for you: • Most common are preferred provider organization (PPO) plans— available statewide, except in Clark County. • New for 2016 are PersonalCare plans, available in King, Snohomish, and Pierce counties.
There are two main differences between PPO plans and PersonalCare plans:
WASHINGTON
VIRTUAL CARE Most of our plans offer access to virtual care, so you can consult with
PREFERRED PROVIDER ORGANIZATION
PERSONALCARE PLANS
a doctor anytime by phone or online
National Network
King, Snohomish, Pierce Counties
PPO plans have a large state and nationwide network of providers. You can seek care from any of these providers without referrals.
PersonalCare plans coordinate seamless local support through your selected primary care doctor, and within a PersonalCare Partner System.
video—usually for the same cost as an in-person office visit. All of our plans include access to the free 24-Hour NurseLine for advice anytime day or night.
With both PPO and PersonalCare plans, you can choose from a wide variety of primary care providers, ob/gyn’s, pediatricians, nurse practitioners, and physician’s assistants. With PPO plans, you can also choose a naturopath as your doctor.
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Preferred Provider Organization (PPO) plans PPOs are the most common type of plan. They give you the greatest choice and flexibility of doctors and other providers, both locally and when you travel. If you see providers in the network, you’ll pay less—but you can also see out-of-network providers and we’ll still pay part of the cost. And you don’t need referrals to see specialists. YOU CHOOSE
PPO plans include access to the national and worldwide Blue Cross Blue Shield BlueCard™ network of providers at in-network costs to you. You can find the same quality of care you expect from Premera just about anywhere.
PPO plans come in two different designs. You’ll see these terms in the plan names: Preferred Plans
Health Savings Account (HSA) Plans
Most gold and silver level plans include two visits to your primary care doctor at no cost to you. And after that you’ll have unlimited primary care office visits for only a copay, with no deductible. In addition, when you select a primary care doctor, your office visit copays will be lower. (Exception: HSA plans, which don’t use copays.)
These are qualified high-deductible PPO plans paired with a health savings account. These plans allow you to set up accounts to save and invest your money for future healthcare. They also have certain tax advantages. These plans generally have lower premiums, but you usually pay your share upfront.
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PersonalCare Plans (King, Snohomish, and Pierce counties) These plans, new for 2016, offer you affordable and coordinated healthcare from an integrated, local community of leading providers, called PersonalCare Partner Systems.
YOU AND YOUR DOCTOR PARTNER SYSTEM
Choices for care
Costs
When you choose your plan, you also choose one of our partner systems and a primary care doctor in that system, for a central point of care. Each member of your family can choose a different partner system and a different doctor, and you are free to change your system or doctor at almost any time.
Monthly premiums for these plans are lower than PPO plans with similar benefits. And for most services you pay only a fixed copay, so your outof-pocket costs are more predictable.
PERSONALCARE PARTNER SYSTEM
These plans help keep healthcare affordable because our partner systems provide and coordinate all of your care. In addition, they are paid based on the quality of the care, the care experience they provide and whether they improve your health.
Referrals and out-of-area coverage If you need to see a specialist, your primary care doctor will refer you to one in your partner system, or in our statewide Heritage Signature network if needed. These plans include coverage outside your partner system in cases of emergency. If you need non-emergent care while traveling in Washington, your doctor can make a referral in our statewide Heritage Signature network.
SERVICE AREA
EvergreenHealth Partners
East King County and southeast Snohomish County
MultiCare Connected Care
Pierce County and south King County
Northwest Physicians Network
Pierce County and south King County
UW Medicine Accountable Care Network
King County, south Snohomish County, north Pierce County
Virginia Mason Medical Center
King County and south Snohomish County
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3 STEP
Consider dental coverage Get high-quality dental coverage at a great value from the same company you already trust for your medical coverage.
Adult Dental Coverage
WHY DENTAL HEALTH IS IMPORTANT
Our Adult Dental Plan gives you coverage for a wide range of preventive and diagnostic, basic, and major dental services. It’s easy and seamless to add this coverage when you enroll in a medical plan, or any time during the year.
Dental and oral health can offer
With all your medical and dental coverage from one company, you get the convenience of one monthly premium bill, one ID card, and one Customer Service number. You can access all your coverage documents and claims records from one website and one mobile app.
clues about your overall health, and problems in your mouth can affect the rest of your body. For details about dental coverage, visit premera.com, click Shop for Plans, and select Dental Plans.
Pediatric Dental Coverage If your medical plan will cover dependents 18 or younger, federal law requires you to purchase a pediatric dental plan, either from Premera or another company, at the same time. This coverage is not required if you don’t cover any children. The Premera Individual Pediatric Dental Plan provides: • Coverage for most preventive and diagnostic, basic, and major dental services • Access to a network of dentists throughout Washington • No waiting period for dental services—your child can see a dentist immediately after the effective date of your plan
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4 STEP
Let us help you enroll now
WHAT YOU’LL NEED BEFORE YOU CALL When you call, be sure you have names, birth dates, and Social
We want to help you choose the right plan for yourself and your family, with the coverage you need at a price that fits your budget. We can help you find out whether you qualify for a subsidy to help pay for your health plan. Take this last important step so you can be there for the people you care about.
Security numbers for all family members you want to enroll, and household income to determine if you qualify for a subsidy.
Contact us today.
For detailed information about coverage and costs and help enrolling: Call 877-PREMERA (877-773-6372) 8 a.m. – 5 p.m. Pacific time Monday–Friday
Visit shop.premera.com
Call or visit your producer
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PREFERRED GOLD 1000 Washington plan for individuals & families Beginning January 1, 2016
PREFERRED GOLD 1000 Heritage Signature provider network Annual Deductible
Per Calendar Year (PCY) Family = 2x individual (in-network)
Coinsurance
Out-of-Pocket Maximum
Non-Heritage Signature provider network
$1,000
2x individual deductible
Amount you pay after your deductible is met
20%
50%
Includes deductible, coinsurance, and copays Family = 2x individual (in-network)
$4,500
Unlimited
Deductible, then 20%
Deductible, then 50%
10 Essential Benefits Covered Services
1 Ambulatory Patient Services Office Visits
Outpatient services Designated PCP office visit
$10 copay, first 2 PCP visits covered in full
Deductible, then 50%
Non-designated PCP & specialist office visit
$30 copay
Deductible, then 50%
Urgent care
$30 copay
Deductible, then 50%
Virtual care
$10 copay
Not covered
Spinal manipulation: 10 visits PCY; Acupuncture: 12 visits PCY
$10 copay
Deductible, then 50%
$200 copay, then deductible, then 20%
Same as in-network
Ambulance
Deductible, then 20%
Same as in-network
Inpatient services
Deductible, then 20%
Deductible, then 50%
Organ and tissue transplants, inpatient
Deductible, then 20%
Not covered
4 Maternity & Newborn Care
Prenatal and postnatal care
Deductible, then 20%
Deductible, then 50%
5 Mental Health & Substance
Office visit
$30 copay
Deductible, then 50%
Deductible, then 20%
Deductible, then 50%
Deductible waived, then 20%
Deductible, then 50%
$10 copay
Not covered
$30 copay
Not covered
Deductible, then 20%
Not covered
2 Emergency Services
3 Hospitalization
Use Disorder Services, including Behavioral Health Treatment
Emergency care (copay waived if directly admitted to an inpatient facility)
Inpatient hospital: mental/behavioral health Outpatient services
6 Prescription Drugs
Generic Retail/Specialty: 30-day supply Brand Mail Order: 90-day supply (copay x3) Specialty Drug formulary
7 Rehabilitative & Habilitative Services & Devices
8 Laboratory Services
9 Preventive/Wellness Services
10 Pediatric Vision Under 19 years of age
X3
Inpatient rehabilitation: 30 days PCY
Deductible, then 20%
Deductible, then 50%
Physical, speech, occupational, massage therapy: 25 visits combined PCY
Deductible, then 20%
Deductible, then 50%
Durable medical equipment
Deductible, then 20%
Deductible, then 50%
Includes x-ray, pathology, imaging/diagnostic, ultrasound
Deductible waived, then 20%
Deductible, then 50%
Major imaging including MRI, CT, PET (prior authorization required for certain services)
Deductible, then 20%
Deductible, then 50%
Screenings
Covered in full
Deductible, then 50%
Exams and immunizations
Covered in full
Not covered
$30 copay
Same as in-network
Covered in full
Same as in-network
Eye exam: 1 PCY Eyewear: 1 pair of glasses PCY (frames & lenses); 12-month supply of contacts PCY, in lieu of glasses (frames & lenses)
Premera Blue Cross does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment & benefit determinations.
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PREFERRED SILVER 3000 Washington plan for individuals & families Beginning January 1, 2016
PREFERRED SILVER 3000 Heritage Signature provider network Annual Deductible
Per Calendar Year (PCY) Family = 2x individual (in-network)
Coinsurance
Out-of-Pocket Maximum
Non-Heritage Signature provider network
$3,000
2x individual deductible
Amount you pay after your deductible is met
20%
50%
Includes deductible, coinsurance, and copays Family = 2x individual (in-network)
$6,850
Unlimited
Deductible, then 20%
Deductible, then 50%
10 Essential Benefits Covered Services
1 Ambulatory Patient Services Office Visits
2 Emergency Services
Outpatient services Designated PCP office visit
$15 copay, first 2 PCP visits covered in full
Deductible, then 50%
Non-designated PCP & specialist office visit
$50 copay
Deductible, then 50%
Urgent care
$50 copay
Deductible, then 50%
Virtual care
$15 copay
Not covered
Spinal manipulation: 10 visits PCY; Acupuncture: 12 visits PCY
$15 copay
Deductible, then 50%
$250 copay, then deductible, then 20%
Same as in-network
Emergency care (copay waived if directly admitted to an inpatient facility) Ambulance
Deductible, then 20%
Same as in-network
Inpatient services
Deductible, then 20%
Deductible, then 50%
Organ and tissue transplants, inpatient
Deductible, then 20%
Not covered
4 Maternity & Newborn Care
Prenatal and postnatal care
Deductible, then 20%
Deductible, then 50%
5 Mental Health & Substance
Office visit
$50 copay
Deductible, then 50%
Deductible, then 20%
Deductible, then 50%
Deductible waived, then 20%
Deductible, then 50%
$20
Not covered
$55 copay
Not covered
Deductible, then 20%
Not covered
3 Hospitalization
Use Disorder Services, including Behavioral Health Treatment
Inpatient hospital: mental/behavioral health Outpatient services
6 Prescription Drugs
Generic Retail/Specialty: 30-day supply Brand Mail Order: 90-day supply (copay x3) Specialty Drug formulary
7 Rehabilitative & Habilitative Services & Devices
8 Laboratory Services
9 Preventive/Wellness Services
10 Pediatric Vision Under 19 years of age
X3
Inpatient rehabilitation: 30 days PCY
Deductible, then 20%
Deductible, then 50%
Physical, speech, occupational, massage therapy: 25 visits combined PCY
Deductible, then 20%
Deductible, then 50%
Durable medical equipment
Deductible, then 20%
Deductible, then 50%
Includes x-ray, pathology, imaging/diagnostic, ultrasound
Deductible waived, then 20%
Deductible, then 50%
Major imaging including MRI, CT, PET (prior authorization required for certain services)
Deductible, then 20%
Deductible, then 50%
Screenings
Covered in full
Deductible, then 50%
Exams and immunizations
Covered in full
Not covered
$45 copay
Same as in-network
Covered in full
Same as in-network
Eye exam: 1 PCY Eyewear: 1 pair of glasses PCY (frames & lenses); 12-month supply of contacts PCY, in lieu of glasses (frames & lenses)
Premera Blue Cross does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment & benefit determinations.
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PREFERRED BRONZE 6350 Washington plan for individuals & families Beginning January 1, 2016
PREFERRED BRONZE 6350 Heritage Signature provider network Annual Deductible
Per Calendar Year (PCY) Family = 2x individual (in-network)
Coinsurance
Out-of-Pocket Maximum
Non-Heritage Signature provider network
$6,350
2x individual deductible
Amount you pay after your deductible is met
20%
50%
Includes deductible, coinsurance, and copays Family = 2x individual (in-network)
$6,850
Unlimited
Deductible, then 20%
Deductible, then 50%
$20 copay
Deductible, then 50%
Non-designated PCP & specialist office visit
Deductible, then 20%
Deductible, then 50%
Urgent care
Deductible, then 20%
Deductible, then 50%
Virtual care
$20 copay
Not covered
Spinal manipulation: 10 visits PCY; Acupuncture: 12 visits PCY
$20 copay
Deductible, then 50%
$250 copay, then deductible, then 20%
Same as in-network
10 Essential Benefits Covered Services
1 Ambulatory Patient Services Office Visits
2 Emergency Services
Outpatient services Designated PCP office visit
Emergency care (copay waived if directly admitted to an inpatient facility) Ambulance
Deductible, then 20%
Same as in-network
Inpatient services
Deductible, then 20%
Deductible, then 50%
Organ and tissue transplants, inpatient
Deductible, then 20%
Not covered
4 Maternity & Newborn Care
Prenatal and postnatal care
Deductible, then 20%
Deductible, then 50%
5 Mental Health & Substance
Office visit
Deductible, then 20%
Deductible, then 50%
Inpatient hospital: mental/behavioral health
Deductible, then 20%
Deductible, then 50%
Outpatient services
Deductible, then 20%
Deductible, then 50%
Deductible, then 20%
Not covered
Deductible, then 20%
Not covered
Deductible, then 20%
Not covered
3 Hospitalization
Use Disorder Services, including Behavioral Health Treatment
6 Prescription Drugs
Generic Retail/Specialty: 30-day supply Brand Mail Order: 90-day supply Specialty Drug formulary
7 Rehabilitative & Habilitative Services & Devices
8 Laboratory Services
9 Preventive/Wellness Services
10 Pediatric Vision Under 19 years of age
X1
Inpatient rehabilitation: 30 days PCY
Deductible, then 20%
Deductible, then 50%
Physical, speech, occupational, massage therapy: 25 visits combined PCY
Deductible, then 20%
Deductible, then 50%
Durable medical equipment
Deductible, then 20%
Deductible, then 50%
Includes x-ray, pathology, imaging/diagnostic, ultrasound
Deductible, then 20%
Deductible, then 50%
Major imaging including MRI, CT, PET (prior authorization required for certain services)
Deductible, then 20%
Deductible, then 50%
Screenings
Covered in full
Deductible, then 50%
Exams and immunizations
Covered in full
Not covered
$30 copay
Same as in-network
Covered in full
Same as in-network
Eye exam: 1 PCY Eyewear: 1 pair of glasses PCY (frames & lenses); 12-month supply of contacts PCY, in lieu of glasses (frames & lenses)
Premera Blue Cross does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment & benefit determinations.
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PERSONALCARE GOLD 750 Washington plan for individuals & families Beginning January 1, 2016 PersonalCare Plans are a new way for you to receive more coordinated care and coverage in King, Pierce and Snohomish counties. Each member chooses their own PersonalCare Partner system and personal doctor (PCP) in that system who gives, or refers you for the care you need. Note that the plans cover only emergency services outside your Partner system.
PERSONALCARE GOLD 750 PersonalCare Partner System
Annual Deductible
Per Calendar Year (PCY) Family = 2x individual (in-network only)
Coinsurance
Amount you pay after your deductible is met
20% coinsurance
Out-of-Pocket Maximum
Includes deductible, coinsurance, and copays Family = 2x individual (in-network only)
$4,500
$750
10 Essential Benefits Covered Services
1 Ambulatory Patient Services Office Visits
2 Emergency Services
3 Hospitalization
4 Maternity & Newborn Care
Outpatient services
$15 copay
Specialist office visit
$40 copay
Urgent care
$40 copay
Virtual care
$15 copay
Spinal manipulation: 10 visits PCY; Acupuncture: 12 visits PCY
$15 copay
Emergency care (copay waived if directly admitted to an inpatient facility)
$200 copay
Ambulance
$200 copay
Inpatient services
$500 copay per day (maximum of 3 copays per admission), then deductible
Organ and tissue transplants, inpatient
$500 copay per day (maximum of 3 copays per admission), then deductible
Prenatal and postnatal care Inpatient delivery and services
5 Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment
Office visit Inpatient hospital: mental/behavioral health Outpatient services
6 Prescription Drugs
Generic Retail/Specialty: 30-day supply Preferred brand Mail Order: 90-day supply Non-preferred brand (copay x3) Specialty Drug formulary
7 Rehabilitative & Habilitative Services & Devices
Inpatient rehabilitation: 30 days PCY Physical, speech, occupational, massage therapy: 25 visits combined PCY Durable medical equipment
8 Laboratory Services
9 Preventive/Wellness Services
10 Pediatric Vision Under 19 years of age
Deductible, then 20%
Designated PCP office visit
$15 copay $500 copay per day (maximum of 3 copays per admission), then deductible $40 copay $500 copay per day (maximum of 3 copays per admission), then deductible Deductible, then 20% $10 $40 $80 $100 X4 $500 copay per day (maximum of 3 copays per admission), then deductible $40 copay
Deductible, then 20%
Includes x-ray, pathology, imaging/diagnostic, ultrasound
$50 copay
Major imaging including MRI, CT, PET (prior authorization required for certain services)
$250 copay
Screenings
Covered in full
Exams and immunizations
Covered in full
Eye exam: 1 PCY Eyewear: 1 pair of glasses PCY (frames & lenses); 12-month supply of contacts PCY, in lieu of glasses (frames & lenses)
$30 copay Covered in full
Premera Blue Cross does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment & benefit determinations.
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PERSONALCARE SILVER 2500 Washington plan for individuals & families Beginning January 1, 2016 PersonalCare Plans are a new way for you to receive more coordinated care and coverage in King, Pierce and Snohomish counties. Each member chooses their own PersonalCare Partner system and personal doctor (PCP) in that system who gives, or refers you for the care you need. Note that the plans cover only emergency services outside your Partner system.
PERSONALCARE SILVER 2500 PersonalCare Partner System
Annual Deductible
Per Calendar Year (PCY) Family = 2x individual (in-network only)
Coinsurance
Amount you pay after your deductible is met
20% coinsurance
Out-of-Pocket Maximum
Includes deductible, coinsurance, and copays Family = 2x individual (in-network only)
$6,850
$2,500
10 Essential Benefits Covered Services
1 Ambulatory Patient Services Office Visits
2 Emergency Services
Outpatient services
$20 copay
Specialist office visit
$45 copay
Urgent care
$45 copay
Virtual care
$20 copay
Spinal manipulation: 10 visits PCY; Acupuncture: 12 visits PCY
$20 copay
Emergency care (copay waived if directly admitted to an inpatient facility) Ambulance
3 Hospitalization
4 Maternity & Newborn Care
Use Disorder Services, including Behavioral Health Treatment
Organ and tissue transplants, inpatient
$600 copay per day (maximum of 4 copays per admission), then deductible
Prenatal and postnatal care
Office visit Inpatient hospital: mental/behavioral health Outpatient services
Generic Retail/Specialty: 30-day supply Preferred brand Mail Order: 90-day supply Non-preferred brand (copay x3) Specialty Drug formulary
Services & Devices
Inpatient rehabilitation: 30 days PCY Physical, speech, occupational, massage therapy: 25 visits combined PCY Durable medical equipment
8 Laboratory Services
9 Preventive/Wellness Services
10 Pediatric Vision Under 19 years of age
$250 copay $600 copay per day (maximum of 4 copays per admission), then deductible
6 Prescription Drugs
7 Rehabilitative & Habilitative
$250 copay, then deductible
Inpatient services
Inpatient delivery and services
5 Mental Health & Substance
Deductible, then 20%
Designated PCP office visit
$20 copay $600 copay per day (maximum of 4 copays per admission), then deductible $45 copay $600 copay per day (maximum of 4 copays per admission), then deductible Deductible, then 20% $15 $50 $100 Deductible, then $150 X4 $600 copay per day (maximum of 4 copays per admission), then deductible $45 copay
Deductible, then 20%
Includes x-ray, pathology, imaging/diagnostic, ultrasound
$100 copay
Major imaging including MRI, CT, PET (prior authorization required for certain services)
$500 copay, then deductible
Screenings
Covered in full
Exams and immunizations
Covered in full
Eye exam: 1 PCY Eyewear: 1 pair of glasses PCY (frames & lenses); 12-month supply of contacts PCY, in lieu of glasses (frames & lenses)
$30 copay Covered in full
Premera Blue Cross does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment & benefit determinations.
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PERSONALCARE BRONZE 4500 Washington plan for individuals & families Beginning January 1, 2016 PersonalCare Plans are a new way for you to receive more coordinated care and coverage in King, Pierce and Snohomish counties. Each member chooses their own PersonalCare Partner system and personal doctor (PCP) in that system who gives, or refers you for the care you need. Note that the plans cover only emergency services outside your Partner system.
PERSONALCARE BRONZE 4500 PersonalCare Partner System
Annual Deductible
Per Calendar Year (PCY) Family = 2x individual (in-network only)
Coinsurance
Amount you pay after your deductible is met
25% coinsurance
Out-of-Pocket Maximum
Includes deductible, coinsurance, and copays Family = 2x individual (in-network only)
$6,850
$4,500 Medical
$1,000 Prescription
10 Essential Benefits Covered Services
1 Ambulatory Patient Services Office Visits
2 Emergency Services
Outpatient services Designated PCP office visit
4 Maternity & Newborn Care
$50 copay, then deductible
Urgent care
$50 copay, then deductible
Virtual care
$30 copay
Spinal manipulation: 10 visits PCY; Acupuncture: 12 visits PCY
$30 copay
Emergency care (copay waived if directly admitted to an inpatient facility)
Use Disorder Services, including Behavioral Health Treatment
Organ and tissue transplants, inpatient
$700 copay per day (maximum of 5 copays per admission), then deductible
Prenatal and postnatal care
Office visit Inpatient hospital: mental/behavioral health Outpatient services
Generic Retail/Specialty: 30-day supply Preferred brand Mail Order: 90-day supply Non-preferred brand (copay x3) Specialty Drug formulary
Services & Devices
Inpatient rehabilitation: 30 days PCY Physical, speech, occupational, massage therapy: 25 visits combined PCY Durable medical equipment
8 Laboratory Services
9 Preventive/Wellness Services
10 Pediatric Vision Under 19 years of age
$250 copay $700 copay per day (maximum of 5 copays per admission), then deductible
6 Prescription Drugs
7 Rehabilitative & Habilitative
$250 copay, then deductible
Inpatient services
Inpatient delivery and services
5 Mental Health & Substance
$30 copay
Specialist office visit
Ambulance
3 Hospitalization
Deductible, then 25%
$30 copay $700 copay per day (maximum of 5 copays per admission), then deductible $50 copay, then deductible $700 copay per day (maximum of 5 copays per admission), then deductible Deductible, then 25% $25 copay, no prescription deductible Prescription deductible, then $65 copay Prescription deductible, then $150 copay Prescription deductible, then $250 copay X4 $700 copay per day (maximum of 5 copays per admission), then deductible $50 copay, then deductible
Deductible, then 25%
Includes x-ray, pathology, imaging/diagnostic, ultrasound
$100 copay, then deductible
Major imaging including MRI, CT, PET (prior authorization required for certain services)
$750 copay, then deductible
Screenings
Covered in full
Exams and immunizations
Covered in full
Eye exam: 1 PCY Eyewear: 1 pair of glasses PCY (frames & lenses); 12-month supply of contacts PCY, in lieu of glasses (frames & lenses)
$30 copay Covered in full
Premera Blue Cross does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment & benefit determinations.
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PREFERRED SILVER 3000 HSA Washington plan for individuals & families Beginning January 1, 2016
PREFERRED SILVER 3000 HSA Heritage Signature provider network Annual Deductible
Per Calendar Year (PCY) Family = 2x individual
Coinsurance
Out-of-Pocket Maximum
Non-Heritage Signature provider network
$3,000
2x Individual deductible
Amount you pay after your deductible is met
20%
50%
Includes deductible, coinsurance, and copays Family = 2x individual (in-network)
$4,100
Unlimited
Outpatient services
Deductible, then 20%
Deductible, then 50%
PCP office visit
Deductible, then 20%
Deductible, then 50%
Non-designated PCP & specialist office visit
Deductible, then 20%
Deductible, then 50%
Urgent care
Deductible, then 20%
Deductible, then 50%
Virtual care
Deductible, then 20%
Deductible, then 50%
Spinal manipulation: 10 visits PCY; Acupuncture: 12 visits PCY
Deductible, then 20%
Deductible, then 50%
Emergency care
Deductible, then 20%
Same as in-network
Ambulance
Deductible, then 20%
Same as in-network
Inpatient services
Deductible, then 20%
Deductible, then 50%
Organ and tissue transplants, inpatient
Deductible, then 20%
Not covered
4 Maternity & Newborn Care
Prenatal and postnatal care
Deductible, then 20%
Deductible, then 50%
5 Mental Health & Substance
Office visit
Deductible, then 20%
Deductible, then 50%
Inpatient hospital: mental/behavioral health
Deductible, then 20%
Deductible, then 50%
Outpatient services
Deductible, then 20%
Deductible, then 50%
Deductible, then 20%
Not covered
Deductible, then 20%
Not covered
Deductible, then 20%
Not covered
10 Essential Benefits Covered Services
1 Ambulatory Patient Services Office Visits
2 Emergency Services
3 Hospitalization
Use Disorder Services, including Behavioral Health Treatment
6 Prescription Drugs
Generic Retail/Specialty: 30-day supply Brand Mail Order: 90-day supply Specialty Drug formulary
7 Rehabilitative & Habilitative Services & Devices
8 Laboratory Services
9 Preventive/Wellness Services
10 Pediatric Vision Under 19 years of age
X1
Inpatient rehabilitation: 30 days PCY
Deductible, then 20%
Deductible, then 50%
Physical, speech, occupational, massage therapy: 25 visits combined PCY
Deductible, then 20%
Deductible, then 50%
Durable medical equipment
Deductible, then 20%
Deductible, then 50%
Includes x-ray, pathology, imaging/diagnostic, ultrasound
Deductible, then 20%
Deductible, then 50%
Major imaging including MRI, CT, PET (prior authorization required for certain services)
Deductible, then 20%
Deductible, then 50%
Screenings
Covered in full
Deductible, then 50%
Exams and immunizations
Covered in full
Not covered
Deductible waived, then 20%
Same as in-network
Covered in full
Same as in-network
Eye exam: 1 PCY Eyewear: 1 pair of glasses PCY (frames & lenses); 12-month supply of contacts PCY, in lieu of glasses (frames & lenses)
Premera Blue Cross does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment & benefit determinations.
15
PREFERRED BRONZE 5250 HSA Washington plan for individuals & families Beginning January 1, 2016
PREFERRED BRONZE 5250 HSA Heritage Signature provider network Annual Deductible
Per Calendar Year (PCY) Family = 2x individual
Coinsurance
Out-of-Pocket Maximum
Non-Heritage Signature provider network
$5,250
2x individual
Amount you pay after your deductible is met
20%
50%
Includes deductible, coinsurance, and copays Family = 2x individual (in-network)
$6,100
Unlimited
Outpatient services
Deductible, then 20%
Deductible, then 50%
PCP office visit
Deductible, then 20%
Deductible, then 50%
Non-designated PCP & specialist office visit
Deductible, then 20%
Deductible, then 50%
Urgent care
Deductible, then 20%
Deductible, then 50%
Virtual care
Deductible, then 20%
Not covered
Spinal manipulation: 10 visits PCY; Acupuncture: 12 visits PCY
Deductible, then 20%
Deductible, then 50%
Emergency care
Deductible, then 20%
Same as in-network
Ambulance
Deductible, then 20%
Same as in-network
Inpatient services
Deductible, then 20%
Deductible, then 50%
10 Essential Benefits Covered Services
1 Ambulatory Patient Services Office Visits
2 Emergency Services
3 Hospitalization
Organ and tissue transplants, inpatient
Deductible, then 20%
Not covered
4 Maternity & Newborn Care
Prenatal and postnatal care
Deductible, then 20%
Deductible, then 50%
5 Mental Health & Substance
Office visit
Deductible, then 20%
Deductible, then 50%
Inpatient hospital: mental/behavioral health
Deductible, then 20%
Deductible, then 50%
Outpatient services
Deductible, then 20%
Deductible, then 50%
Deductible, then 20%
Not covered
Deductible, then 20%
Not covered
Deductible, then 20%
Not covered
Use Disorder Services, including Behavioral Health Treatment
6 Prescription Drugs
Generic Retail/Specialty: 30-day supply Brand Mail Order: 90-day supply Specialty Drug formulary
7 Rehabilitative & Habilitative Services & Devices
8 Laboratory Services
9 Preventive/Wellness Services
10 Pediatric Vision Under 19 years of age
X1
Inpatient rehabilitation: 30 days PCY
Deductible, then 20%
Deductible, then 50%
Physical, speech, occupational, massage therapy: 25 visits combined PCY
Deductible, then 20%
Deductible, then 50%
Durable medical equipment
Deductible, then 20%
Deductible, then 50%
Includes x-ray, pathology, imaging/diagnostic, ultrasound
Deductible, then 20%
Deductible, then 50%
Major imaging including MRI, CT, PET (prior authorization required for certain services)
Deductible, then 20%
Deductible, then 50%
Screenings
Covered in full
Deductible, then 50%
Exams and immunizations
Covered in full
Not covered
Deductible waived, then 20%
Same as in-network
Covered in full
Same as in-network
Eye exam: 1 PCY Eyewear: 1 pair of glasses PCY (frames & lenses); 12-month supply of contacts PCY, in lieu of glasses (frames & lenses)
Premera Blue Cross does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment & benefit determinations.
16
Exclusions and Limitations Benefits are not provided for treatment, surgery, services, drugs, or supplies for any of the following: Cosmetic surgery or reconstructive surgery (except as specifically provided) Experimental or investigative services
Orthognathic surgery (except when repairing a dependent child’s congenital abnormality)
Infertility
Service in excess of specified benefit maximums
Obesity/morbid obesity, including surgery, drugs, foods, and exercise programs
Services payable by other types of insurance coverage
Services received when you are not covered by this program Sexual dysfunction Sterilization reversal For a list of services and procedures that require approval for coverage from your plan before you receive them (prior authorization), visit premera.com.
Definitions of Healthcare Coverage Terms Allowed Amount — When providers have a contract with us, the amount your health plan has agreed to pay healthcare providers for services or supplies. You’ll be responsible only for any applicable cost sharing, including deductibles, copays, coinsurance, charges in excess of the stated benefit maximums and charges for services and supplies not covered under this plan. In-network providers cannot bill you for charges over the allowed amount. Coinsurance — Your share of the cost for a service. If your plan’s coinsurance is 20%, you pay 20% of the allowed amount and your plan pays the other 80% of the allowed amount. Copay — A flat fee you pay for a specific service, such as an office visit, at the time you receive service.
Covered In Full — Services for which your plan pays the total cost, at 100% of the allowed amount. You do not pay deductibles, coinsurance or copays for these services.
In-Network — Doctors, dentists, hospitals, and other healthcare providers that are contracted to provide services and supplies at negotiated amounts called allowed amounts.
Deductible — The amount of money you pay every year for covered services before the plan pays for certain benefits.
Out-of-Pocket Maximum — The maximum amount of money you will pay for covered services in a calendar year. After you’ve paid this amount, your plan pays 100% of the allowed amount for services received from in-network providers.
Formulary — A list of drugs covered by a health plan. Not all generic, brandname and specialty drugs are included in every formulary. Health Savings Account (HSA) — A savings account through a bank that is available to individuals who are enrolled in a qualified high-deductible health plan. The funds contributed to the account, as well as interest and investment earnings, aren’t subject to federal income tax when used for qualified medical expenses.
This is only a summary of the major benefits provided by our plans. This is not a contract. Please see premera.com/SBC for the Summary of Benefits and Coverage and Glossary. On our website, you can also find a Supplemental Guide with information about privacy policies, provider organization, key utilization management procedures, and pharmaceutical management procedures.
17
Premera Blue Cross health plans include tools to help you manage your health and your plan: • Cost and quality tool. Estimate costs for services from various providers and view ratings and reviews from other customers. • Spending activity report. Track your claims and the status of your deductible, among other things.
• Find a Doctor. Research providers and check which networks include them at premera.com or via Premera Mobile. • Premera Mobile. Download the free app for on-the-go access to locate doctors, show proof of coverage, manage benefits, claims, and prescriptions — and more.
Premera Blue Cross is an independent licensee of the Blue Cross Blue Shield Association 005914 (11-2015)
For help choosing and enrolling in a plan
877-PREMERA (877-773-6372) shop.premera.com
Discrimination is Against the Law Premera Blue Cross complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Premera does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Premera: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages If you need these services, contact the Civil Rights Coordinator. If you believe that Premera has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator - Complaints and Appeals PO Box 91102, Seattle, WA 98111 Toll free 855-332-4535, Fax 425-918-5592, TTY 800-842-5357 Email
[email protected] You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW, Room 509F, HHH Building Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Getting Help in Other Languages This Notice has Important Information. This notice may have important information about your application or coverage through Premera Blue Cross. There may be key dates in this notice. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Call 800-722-1471 (TTY: 800-842-5357). አማሪኛ (Amharic): ይህ ማስታወቂያ አስፈላጊ መረጃ ይዟል። ይህ ማስታወቂያ ስለ ማመልከቻዎ ወይም የ Premera Blue Cross ሽፋን አስፈላጊ መረጃ ሊኖረው ይችላል። በዚህ ማስታወቂያ ውስጥ ቁልፍ ቀኖች ሊኖሩ ይችላሉ። የጤናን ሽፋንዎን ለመጠበቅና በአከፋፈል እርዳታ ለማግኘት በተውሰኑ የጊዜ ገደቦች እርምጃ መውሰድ ይገባዎት ይሆናል። ይህን መረጃ እንዲያገኙ እና ያለምንም ክፍያ በቋንቋዎ እርዳታ እንዲያገኙ መብት አለዎት።በስልክ ቁጥር 800-722-1471 (TTY: 800-842-5357) ይደውሉ።
( العربيةArabic): قد يحوي ھذا اإلشعار معلومات مھمة بخصوص طلبك أو.يحوي ھذا اإلشعار معلومات ھامة قد تكون ھناك تواريخ مھمة.Premera Blue Cross التغطية التي تريد الحصول عليھا من خالل وقد تحتاج التخاذ إجراء في تواريخ معينة للحفاظ على تغطيتك الصحية أو للمساعدة.في ھذا اإلشعار اتصل. يحق لك الحصول على ھذه المعلومات والمساعدة بلغتك دون تكبد أية تكلفة.في دفع التكاليف 800-722-1471 (TTY: 800-842-5357)بـ 中文 (Chinese): 本通知有重要的訊息。本通知可能有關於您透過 Premera Blue Cross 提交的 申請或保險的重要訊息。本通知內可能有重要日期。您可能需要在截止日期 之前採取行動，以保留您的健康保險或者費用補貼。您有權利免費以您的母 語得到本訊息和幫助。請撥電話 800-722-1471 (TTY: 800-842-5357)。
037338 (07-2016)
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한국어 (Korean): 본 통지서에는 중요한 정보가 들어 있습니다. 즉 이 통지서는 귀하의 신청에 관하여 그리고 Premera Blue Cross 를 통한 커버리지에 관한 정보를 포함하고 있을 수 있습니다. 본 통지서에는 핵심이 되는 날짜들이 있을 수 있습니다. 귀하는 귀하의 건강 커버리지를 계속 유지하거나 비용을 절감하기 위해서 일정한 마감일까지 조치를 취해야 할 필요가 있을 수 있습니다. 귀하는 이러한 정보와 도움을 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 800-722-1471 (TTY: 800-842-5357) 로 전화하십시오.
Pусский (Russian): Настоящее уведомление содержит важную информацию. Это уведомление может содержать важную информацию о вашем заявлении или страховом покрытии через Premera Blue Cross. В настоящем уведомлении могут быть указаны ключевые даты. Вам, возможно, потребуется принять меры к определенным предельным срокам для сохранения страхового покрытия или помощи с расходами. Вы имеете право на бесплатное получение этой информации и помощь на вашем языке. Звоните по телефону 800-722-1471 (TTY: 800-842-5357).
ລາວ (Lao): ແຈ້ ງການນ້ີ ມີຂ້ໍ ມູ ນສໍາຄັ ນ. ແຈ້ ງການນ້ີ ອາດຈະມີຂ້ໍ ມູ ນສໍາຄັ ນກ່ ຽວກັ ບຄໍາຮ້ ອງສະ ໝັ ກ ຫື ຼ ຄວາມຄຸ້ ມຄອງປະກັ ນໄພຂອງທ່ ານຜ່ ານ Premera Blue Cross. ອາດຈະມີ ວັ ນທີສໍາຄັ ນໃນແຈ້ ງການນີ້. ທ່ ານອາດຈະຈໍາເປັນຕ້ ອງດໍາເນີນການຕາມກໍານົ ດ ເວລາສະເພາະເພື່ອຮັ ກສາຄວາມຄຸ້ ມຄອງປະກັ ນສຸ ຂະພາບ ຫື ຼ ຄວາມຊ່ ວຍເຫື ຼ ອເລື່ອງ ຄ່ າໃຊ້ ຈ່ າຍຂອງທ່ ານໄວ້ . ທ່ ານມີສິດໄດ້ ຮັ ບຂ້ໍ ມູ ນນ້ີ ແລະ ຄວາມຊ່ ວຍເຫື ຼ ອເປັນພາສາ ຂອງທ່ ານໂດຍບໍ່ເສຍຄ່ າ. ໃຫ້ ໂທຫາ 800-722-1471 (TTY: 800-842-5357). ភាសាែខម រ (Khmer): េសចកត ីជូនដំណឹងេនះមានព័ត៌មានយា៉ងសំខាន់។ េសចកត ីជូនដំណឹងេនះរបែហល ជាមានព័ត៌មានយា៉ងសំខាន់អំពីទរមង់ែបបបទ ឬការរា៉ប់រងរបស់អនកតាមរយៈ Premera Blue Cross ។ របែហលជាមាន កាលបរ ិេចឆ ទសំខាន់េនៅកនុងេសចកត ីជូន ដំណឹងេនះ។ អន ករបែហលជារតូវការបេញច ញសមតថ ភាព ដល់កំណត់ៃថង ជាក់ចបាស់ នានា េដើមបីនឹងរកសាទុកការធានារា៉ប់រងសុខភាពរបស់អនក ឬរបាក់ជំនួយេចញៃថល ។ អន កមានសិទធិទទួ លព័ត៌មានេនះ និងជំនួយេនៅកនុងភាសារបស់អនកេដាយមិនអស លុយេឡើយ។ សូ មទូ រស័ពទ 800-722-1471 (TTY: 800-842-5357)។ ਪੰ ਜਾਬੀ (Punjabi): ਇਸ ਨੋਿਟਸ ਿਵਚ ਖਾਸ ਜਾਣਕਾਰੀ ਹੈ. ਇਸ ਨੋਿਟਸ ਿਵਚ Premera Blue Cross ਵਲ ਤੁਹਾਡੀ ਕਵਰੇਜ ਅਤੇ ਅਰਜੀ ਬਾਰੇ ਮਹੱ ਤਵਪੂਰਨ ਜਾਣਕਾਰੀ ਹੋ ਸਕਦੀ ਹੈ . ਇਸ ਨੋਿਜਸ ਜਵਚ ਖਾਸ ਤਾਰੀਖਾ ਹੋ ਸਕਦੀਆਂ ਹਨ. ਜੇਕਰ ਤੁਸੀ ਜਸਹਤ ਕਵਰੇਜ ਿਰੱ ਖਣੀ ਹੋਵੇ ਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵੱ ਚ ਮਦਦ ਦੇ ਇਛੁੱ ਕ ਹੋ ਤਾਂ ਤੁਹਾਨੂੰ ਅੰ ਤਮ ਤਾਰੀਖ਼ ਤ ਪਿਹਲਾਂ ਕੁੱ ਝ ਖਾਸ ਕਦਮ ਚੁੱ ਕਣ ਦੀ ਲੋ ੜ ਹੋ ਸਕਦੀ ਹੈ ,ਤੁਹਾਨੂੰ ਮੁਫ਼ਤ ਿਵੱ ਚ ਤੇ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵੱ ਚ ਜਾਣਕਾਰੀ ਅਤੇ ਮਦਦ ਪ੍ਰਾਪਤ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹੈ ,ਕਾਲ 800-722-1471 (TTY: 800-842-5357).
( فارسیFarsi): اين اعالميه ممکن است حاوی اطالعات مھم درباره فرم. اين اعالميه حاوی اطالعات مھم ميباشد به تاريخ ھای مھم در. باشدPremera Blue Cross تقاضا و يا پوشش بيمه ای شما از طريق شما ممکن است برای حقظ پوشش بيمه تان يا کمک در پرداخت ھزينه. اين اعالميه توجه نماييد شما حق. به تاريخ ھای مشخصی برای انجام کارھای خاصی احتياج داشته باشيد،ھای درمانی تان برای کسب.اين را داريد که اين اطالعات و کمک را به زبان خود به طور رايگان دريافت نماييد ( تماس800-842-5357 تماس باشمارهTTY )کاربران800-722-1471 اطالعات با شماره .برقرار نماييد Polskie (Polish): To ogłoszenie może zawierać ważne informacje. To ogłoszenie może zawierać ważne informacje odnośnie Państwa wniosku lub zakresu świadczeń poprzez Premera Blue Cross. Prosimy zwrócic uwagę na kluczowe daty, które mogą być zawarte w tym ogłoszeniu aby nie przekroczyć terminów w przypadku utrzymania polisy ubezpieczeniowej lub pomocy związanej z kosztami. Macie Państwo prawo do bezpłatnej informacji we własnym języku. Zadzwońcie pod 800-722-1471 (TTY: 800-842-5357). Português (Portuguese): Este aviso contém informações importantes. Este aviso poderá conter informações importantes a respeito de sua aplicação ou cobertura por meio do Premera Blue Cross. Poderão existir datas importantes neste aviso. Talvez seja necessário que você tome providências dentro de determinados prazos para manter sua cobertura de saúde ou ajuda de custos. Você tem o direito de obter esta informação e ajuda em seu idioma e sem custos. Ligue para 800-722-1471 (TTY: 800-842-5357).
Fa’asamoa (Samoan): Atonu ua iai i lenei fa’asilasilaga ni fa’amatalaga e sili ona taua e tatau ona e malamalama i ai. O lenei fa’asilasilaga o se fesoasoani e fa’amatala atili i ai i le tulaga o le polokalame, Premera Blue Cross, ua e tau fia maua atu i ai. Fa’amolemole, ia e iloilo fa’alelei i aso fa’apitoa olo’o iai i lenei fa’asilasilaga taua. Masalo o le’a iai ni feau e tatau ona e faia ao le’i aulia le aso ua ta’ua i lenei fa’asilasilaga ina ia e iai pea ma maua fesoasoani mai ai i le polokalame a le Malo olo’o e iai i ai. Olo’o iai iate oe le aia tatau e maua atu i lenei fa’asilasilaga ma lenei fa’matalaga i legagana e te malamalama i ai aunoa ma se togiga tupe. Vili atu i le telefoni 800-722-1471 (TTY: 800-842-5357). Español (Spanish): Este Aviso contiene información importante. Es posible que este aviso contenga información importante acerca de su solicitud o cobertura a través de Premera Blue Cross. Es posible que haya fechas clave en este aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura médica o ayuda con los costos. Usted tiene derecho a recibir esta información y ayuda en su idioma sin costo alguno. Llame al 800-722-1471 (TTY: 800-842-5357). Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na walang gastos. May karapatan ka na makakuha ng ganitong impormasyon at tulong sa iyong wika ng walang gastos. Tumawag sa 800-722-1471 (TTY: 800-842-5357).
ไทย (Thai): ประกาศนี ้มีข้อมูลสําคัญ ประกาศนี ้อาจมีข้อมูลที่สําคัญเกี่ยวกับการการสมัครหรื อขอบเขตประกัน สุขภาพของคุณผ่าน Premera Blue Cross และอาจมีกําหนดการในประกาศนี ้ คุณอาจจะต้ อง ดําเนินการภายในกําหนดระยะเวลาที่แน่นอนเพื่อจะรักษาการประกันสุขภาพของคุณหรื อการช่วยเหลือที่ มีค่าใช้ จ่าย คุณมีสิทธิที่จะได้ รับข้ อมูลและความช่วยเหลือนี ้ในภาษาของคุณโดยไม่มีค่าใช้ จ่าย โทร 800-722-1471 (TTY: 800-842-5357) Український (Ukrainian): Це повідомлення містить важливу інформацію. Це повідомлення може містити важливу інформацію про Ваше звернення щодо страхувального покриття через Premera Blue Cross. Зверніть увагу на ключові дати, які можуть бути вказані у цьому повідомленні. Існує імовірність того, що Вам треба буде здійснити певні кроки у конкретні кінцеві строки для того, щоб зберегти Ваше медичне страхування або отримати фінансову допомогу. У Вас є право на отримання цієї інформації та допомоги безкоштовно на Вашій рідній мові. Дзвоніть за номером телефону 800-722-1471 (TTY: 800-842-5357). Tiếng Việt (Vietnamese): Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông tin quan trọng về đơn xin tham gia hoặc hợp đồng bảo hiểm của quý vị qua chương trình Premera Blue Cross. Xin xem ngày quan trọng trong thông báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn để duy trì bảo hiểm sức khỏe hoặc được trợ giúp thêm về chi phí. Quý vị có quyền được biết thông tin này và được trợ giúp bằng ngôn ngữ của mình miễn phí. Xin gọi số 800-722-1471 (TTY: 800-842-5357).
