|
The chart below provides highlights of medical coverage for the Trooper Chapter, Airport Police and Fire Officers Chapter, Fairbanks Police Department, Fairbanks Fire Department and Juneau Police Department members as of July 1, 2009. Refer to your Benefit Booklet for details, general limitations and exclusions.
|
Plan Features |
Heritage Providers |
Non Heritage Providers |
|
How the plan works |
For Heritage Providers, the plan pays 90% of allowable charges after you meet the annual deductible. |
You may choose to receive care from any licensed provider in Alaska or Washington.
For non Heritage providers, the plan pays 60% of allowable charges after you meet the annual deductible. |
|
Annual deductible |
Individual: $250
Family: $750 |
| Professional Visit Copay |
For each office visit or visit in your home by a Heritage physician you pay a $25 copay per visit. After your copay, benefits subject to the copay are provided at 100% of allowable charges and aren't subject to your annual deductible. Please note that the professional visit copay does not apply to services from non Heritage physicians. Professional visits by non Heritage physicians will be paid at 60% subject to the annual deductible. |
|
Annual out-of- pocket maximum |
When the amount you pay toward your annual deductible and your 10% of allowable charges reaches $1,250, the plan will pay 100% of allowable charges for most services for the remainder of the year. Professional visit copays and the 40% you pay for services from Non Heritage Providers do not count toward the out-of-pocket maximum. Some benefits are not subject to the out-of-pocket maximum. |
|
Lifetime maximum benefit per person |
$2,000,000 |
| Care management |
A voluntary service that coordinates care with your program benefits and helps you and your physician consider effective alternatives to hospitalization and other high cost care. |
| BlueCard Program |
A national program available to enrollees who receive care outside of Alaska and Washington. If you see a Provider who has contracted with the local Blue Cross and/or Blue Shield Licensee in the are you are receiving care, your cost for services may be less. |
| Covered services |
Plan Pays (% of allowable charges) |
| Ambulance |
90% after deductible |
90% after deductible |
| Chemical dependency treatment |
90% up to $16,380 per 24 consecutive-month period; $32,750 lifetime maximum benefit (this applies to the $2 million lifetime benefit) |
60% up to $16,380 per 24 consecutive-month period; $32,750 lifetime maximum benefit (this applies to the $2 million lifetime benefit) |
Diabetes health education
(outpatient only) |
100%; not subject to deductible or coinsurance |
100%; not subject to deductible or coinsurance |
| Emergency room |
90% after you pay a $100 emergency room copay (copay waived if admitted or if emergency room care is for treatment of an accidental injury within two days of injury) |
60% after you pay a $100 emergency room copay (copay waived if admitted or if emergency room care is for treatment of an accidental injury within two days of injury). Covered services received by a Non Heritage Provider are provided at the Heritage Provider benefit level if medical emergency or accidental injury |
| Home health care |
90% after deductible for home health provider and agency services; up to 130 visits per calendar year |
60% after deductible for home health provider and agency services; up to 130 visits per calendar year |
Home medical equipment
(includes respiratory equipment/medical supplies) |
90% after deductible up to $5,000 per calendar year |
60% after deductible up to $5,000 per calendar year |
| Hospice |
90% after deductible, not to exceed 6 months |
60% after deductible, not to exceed 6 months |
| Hospital visit |
Inpatient: 90% after deductible for semiprivate room
Outpatient: 90% after deductible |
Inpatient: 60% after deductible for semiprivate room
Outpatient: 60% after deductible |
Immunizations
(outpatient only) |
100%; not subject to deductible or coinsurance. Seasonal immunizations received at pharmacies will also be covered including flu shots, flu mist and pneumonia immunizations. |
100%; not subject to deductible or coinsurance. Seasonal immunizations received at pharmacies will also be covered including flu shots, flu mist and pneumonia immunizations. |
| Mental health care |
Inpatient: 90% after
deductible
Outpatient: 100% after $25 copay; maximum of 20 visits per person each calendar year |
Inpatient: 60% after deductible
Outpatient: 60% after deductible; maximum of 20 visits per person each calendar year |
Physician visits
(Does not include mental health care, rehabilitation, or neurodevelopmental therapy) |
100% after $25 copay; not subject to deductible or coinsurance |
60% after deductible |
Preventive care
(Routine physicals, lab and X-ray, screenings) |
100% after $25 copay; not subject to deductible or coinsurance |
60% after deductible |
Rehabilitative care
(includes physical, occupational and speech therapy) |
Inpatient: 90% after deductible, up to 60 days per calendar year
Outpatient: 100% after $25 copay in office setting. Otherwise 90% after deductible. |
Inpatient: 60% after deductible, up to 60 days per calendar year
Outpatient: 60% after deductible |
| Round-trip air transportation |
Maximum of 3 round trip transports per calendar year; see Benefit Booklet for details and limitations |
| Skilled nursing facility |
90% after deductible for semiprivate room, up to 60 days per calendar year |
60% after deductible for semiprivate room, up to 60 days per calendar year |
Surgical Services
|
90% after deductible |
60% after deductible |
| Transplants |
90% up to $250,000 lifetime maximum for all covered organ, bone marrow, and stem cell transplants combined |
N/A |
| Well-baby care |
100% after $25 copay; not subject to deductible or coinsurance |
60% after deductible |
| X-rays and lab tests |
90% after deductible |
60% after deductible |
The allowable charge for Heritage Providers is the fee that the provider has agreed to accept as payment in full for medically necessary covered services. The agreed upon amount is determined by agreements between Premera Blue Cross Blue Shield of Alaska and the providers.
The allowable charge for non Heritage providers is based on the average cost of the service or supply in the geographical area it is provided. The allowable charge will be no less than the 80th percentile charge for the geographic area.
You are responsible for any applicable deductibles, copayments, coinsurance, charges in excess of stated benefit maximums, charges for services and supplies not covered under this plan, and charges by non-Heritage providers above the allowable amount.
Contact Information
Premera Blue Cross Blue Shield of Alaska
P.O. Box 91059
Seattle, WA 98111-9159
Local and toll free: 1-800-508-4722
Hearing-impaired TTY:1-800-842-5357
Premera Blue Cross Blue Shield of Alaska: https://www.premera.com
|
