Premera Blue Cross Preferred Gold 1500

38344AK1060001
Gold
PPO

Premera Blue Cross Preferred Gold 1500 is a Gold PPO plan by Premera Blue Cross Blue Shield of Alaska.

IMPORTANT: You are viewing the 2024 version of Premera Blue Cross Preferred Gold 1500 38344AK1060001. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Premera Blue Cross Preferred Gold 1500 is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Premera Blue Cross Preferred Gold 1500 38344AK1060001.
Insurer: Premera Blue Cross Blue Shield of Alaska
Network Type: PPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 38344AK1060001

Cost-Sharing Overview

Premera Blue Cross Preferred Gold 1500 offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Premera Blue Cross Preferred Gold 1500?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Premera Blue Cross Preferred Gold 1500 offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Diabetes
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Premera Blue Cross Preferred Gold 1500 covers when you are out of the service area or out of the country.

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 available under the plan.
Out of Service Area Coverage: Yes
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).
National Network: No

Additional Benefits and Cost-Sharing

Premera Blue Cross Preferred Gold 1500 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$30.00 Not ApplicableNot Applicable 60.00% Coinsurance after deductible The first two visis to a designated primary care provider (PCP) are covered in full. Subesquent visits are subject to the PCP copay.
Specialist Visit
Covered
$60.00 Not ApplicableNot Applicable 60.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 Not ApplicableNot Applicable 60.00% Coinsurance after deductible 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.
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible
Hospice Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible6.0 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.
Routine Dental Services (Adult)
Covered
Not Applicable 10.00%Not Applicable 30.00% Coinsurance after deductible2.0 Exam(s) per Year Routine Exam – 2 PCY and Cleanings- 2 PCY; Routine X-rays (bitewing) – 1 PCY; Annual Maximum of $750 PCY
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$60.00 Not ApplicableNot Applicable 60.00% Coinsurance after deductible
Home Health Care Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible130.0 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.
Emergency Room Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 30.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 30.00% Coinsurance after deductible Air and Ground transpiration benefit is limited to medical emergency. Ambulance services is separate benefit, covers both medical emergency transport and non-emergent transport.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible60.0 Days per Year
Prenatal and Postnatal Care
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
Covered
$60.00 Not ApplicableNot Applicable 60.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
Covered
$60.00 Not ApplicableNot Applicable 60.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible
Generic Drugs
Covered
$15.00 Not Applicable$15.00 Not Applicable90.0 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
Preferred Brand Drugs
Covered
$45.00 Not Applicable$45.00 Not Applicable90.0 Item(s) per Month Up to 90 day supply Retail (copay times 3; 90 day supply for Mail order
Non-Preferred Brand Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible90.0 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
Specialty Drugs
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible30.0 Item(s) per Month 30 day supply Retail and Mail
Outpatient Rehabilitation Services
Covered
$60.00 Copay after deductible Not ApplicableNot Applicable 60.00% Coinsurance after deductible45.0 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.
Habilitation Services
Covered
$60.00 Copay after deductible Not ApplicableNot Applicable 60.00% Coinsurance after deductible45.0 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.
Chiropractic Care
Covered
$30.00 Not ApplicableNot Applicable 60.00% Coinsurance after deductible12.0 Visit(s) per Year
Durable Medical Equipment
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
Covered
No Charge No ChargeNot Applicable 60.00% Coinsurance after deductible
Routine Foot Care
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible Routine foot care when the member is a diabetic.
Acupuncture
Covered
$30.00 Not ApplicableNot Applicable 60.00% Coinsurance after deductible12.0 Visit(s) per Year Services must be medically necessary to relieve pain, induce surgical anesthesia, or to treat a covered illness, injury or condition.
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
$30.00 Not Applicable$30.00 Not Applicable1.0 Exam(s) per Year Under age 19, 1 PCY; Over age 19 Not covered
Eye Glasses for Children
Covered
No Charge No ChargeNo Charge No Charge1.0 Item(s) per Year Under age 19; 1 pair of frames and lenses PCY includes polycarbonate lenses and scratch resistent coating; 12 month supply of contacts in lieu of glasses; Over age 19 Not Covered
Dental Check-Up for Children
Covered
Not Applicable 10.00%Not Applicable 30.00% Coinsurance after deductible1.0 Visit(s) per 6 Months
Rehabilitative Speech Therapy
Covered
$60.00 Copay after deductible Not ApplicableNot Applicable 60.00% Coinsurance after deductible45.0 Visit(s) per Year Visit limit for physical, speech, and occupational therapy services combined.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$60.00 Copay after deductible Not ApplicableNot Applicable 60.00% Coinsurance after deductible45.0 Visit(s) per Year Visit limit for physical, speech, and occupational therapy services combined.
Well Baby Visits and Care
Covered
No Charge No ChargeNot Applicable 60.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible
Basic Dental Care – Child
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible4.0 Procedure(s) per Year
Orthodontia – Child
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Major Dental Care – Child
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible1.0 Procedure(s) per 3 Years
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible
Transplant
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%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).
Accidental Dental
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible
Dialysis
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible
Allergy Testing
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible
Chemotherapy
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible
Radiation
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible
Diabetes Education
Covered
No Charge No ChargeNo Charge No Charge
Prosthetic Devices
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible 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.
Infusion Therapy
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
Not Covered
Nutritional Counseling
Covered
No Charge No ChargeNot Applicable 60.00% Coinsurance after deductible
Reconstructive Surgery
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible Breast reconstruction allowed.
Gender Affirming Care
Not Covered
Premera-Designated Centers of Excellence Program
Covered
Not Applicable No ChargeNot Applicable 60.00% Coinsurance after deductible

Free Preventive Services

There is no copayment or coinsurance for any of the following Premera Blue Cross Preferred Gold 1500 preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Premera Blue Cross Preferred Gold 1500 including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Premera Blue Cross Preferred Gold 1500?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Table of Contents