Asuris Northwest Health
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All supported filed details, including known conditions and limits. This is not the entire insurance contract. Unknown does not mean $0 or not covered.
This PPO covers participating and nonparticipating providers without specialist referrals. Nonparticipating care generally has higher cost sharing and may leave you responsible for charges above the plan’s allowed amount.
Asuris · Preferred · Issuer 69364. Confirm current provider participation and exact coverage in the plan documents.
| Benefit | Asuris EmployeeSelect Gold 1500 Preferred |
|---|---|
Medical deductibleNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 individual: $1,500 In-network tier 1 family: $1,500 per person | $3,000 per group In-network tier 1 coinsurance: 20.00% Out-of-network individual: $5,000 Out-of-network family: $5,000 per person | $10,000 per group Combined in/out-of-network individual: $6,500 Combined in/out-of-network family: $6,500 per person | $13,000 per group |
Prescription drug deductibleNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 individual: $0 In-network tier 1 family: $0 per person | $0 per group In-network tier 1 coinsurance: 50.00% Out-of-network individual: Not Applicable Out-of-network family: per person not applicable | per group not applicable Combined in/out-of-network individual: Not Applicable Combined in/out-of-network family: per person not applicable | per group not applicable |
| Benefit | Asuris EmployeeSelect Gold 1500 Preferred |
|---|---|
Maximum Out of Pocket for Medical and Drug Benefits (Total)Notes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 individual: $9,000 In-network tier 1 family: $9,000 per person | $18,000 per group Out-of-network individual: $12,000 Out-of-network family: $12,000 per person | $24,000 per group Combined in/out-of-network individual: $21,000 Combined in/out-of-network family: $21,000 per person | $42,000 per group |
| Benefit | Asuris EmployeeSelect Gold 1500 Preferred |
|---|---|
Combined medical and drug deductibleNotes & sourceWhether covered medical and prescription costs count toward the same deductible. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
Combined medical and drug spending limitNotes & sourceWhether covered medical and prescription costs count toward the same out-of-pocket limit. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Yes |
Specialty drug coinsurance capNotes & sourceA filed cap on the member’s percentage-based specialty drug cost, if supplied. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Hospital copay day limitNotes & sourceThe maximum number of hospital days charged a daily copay under the filed rule. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Unknown |
Primary care visits before cost sharingNotes & sourceThe filed number of primary care visits before member charges begin. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Primary care copays before other chargesNotes & sourceThe filed number of copay visits before a deductible or coinsurance rule begins. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Unknown |
| Benefit | Asuris EmployeeSelect Gold 1500 Preferred |
|---|---|
Primary Care Visit to Treat an Injury or IllnessNotes & sourceA visit with a primary care clinician for an illness or injury. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Benefit details: Virtual Care - Store and Forward & Virtual Care - Telehealth Visit $10 Copay found on the Schedule of Benefits Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Specialist VisitNotes & sourceA visit with a clinician who focuses on a particular condition or area of medicine. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $60.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Other Practitioner Office Visit (Nurse, Physician Assistant)Notes & sourceAn office visit with a nurse practitioner, physician assistant, or another listed clinician. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Benefit details: Virtual Care - Store and Forward & Virtual Care - Telehealth Visit $10 Copay found on the Schedule of Benefits Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Preventive Care/Screening/ImmunizationNotes & sourceServices intended to prevent illness or detect health problems early. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: No Charge In-network tier 1 coinsurance: No Charge Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Well Baby Visits and CareNotes & sourceRoutine visits to check a baby’s health and development. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: No Charge In-network tier 1 coinsurance: No Charge Coverage: Covered Benefit details: Human donor milk must be covered as it is covered by the state base benchmark plan. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | Asuris EmployeeSelect Gold 1500 Preferred |
|---|---|
Imaging (CT/PET Scans, MRIs)Notes & sourceAdvanced scans used to examine the inside of the body. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Laboratory Outpatient and Professional ServicesNotes & sourceLaboratory testing without inpatient admission. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coverage: Covered Benefit details: Supporting benefit crosswalk (SERFF submitted 2026-10-12): 20% Coinsurance, Deductible waived. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
X-rays and Diagnostic ImagingNotes & sourceX-rays and other listed images used to help diagnose a health problem. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Allergy TestingNotes & sourceTests used to identify substances that trigger allergic reactions. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Not an essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | Asuris EmployeeSelect Gold 1500 Preferred |
|---|---|
Urgent Care Centers or FacilitiesNotes & sourceCare at an urgent care center for problems that need prompt attention. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $60.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Emergency Room ServicesNotes & sourceEvaluation and treatment of a medical emergency in an emergency department. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $300.00 Copay after deductible In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Benefit details: Supporting benefit crosswalk (SERFF submitted 2026-10-12): After $300 Copayment and In-Network Deductible, 20% Coinsurance. Copayment does not accrue toward the deductible. Out-of-network copay: $300.00 Copay after deductible Out-of-network coinsurance: 20.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Emergency Transportation/AmbulanceNotes & sourceAmbulance or other listed transportation for an emergency. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 20.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | Asuris EmployeeSelect Gold 1500 Preferred |
|---|---|
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Notes & sourceThe charge for using an outpatient facility, separate from a clinician’s professional fee. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Benefit details: Care provided at an in-network Ambulatory Surgery Center may be covered at a lower cost share, see Schedule of Benefits for lower cost share amount for you plan. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Outpatient Surgery Physician/Surgical ServicesNotes & sourceThe surgeon’s or other clinician’s services for surgery without inpatient admission. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Inpatient Hospital Services (e.g., Hospital Stay)Notes & sourceHospital facility services after admission as an inpatient. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Inpatient Physician and Surgical ServicesNotes & sourceClinicians’ professional services during an inpatient hospital stay. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Cosmetic SurgeryNotes & sourceSurgery mainly intended to change appearance. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Benefit details: Covers cosmetic surgery when medically necessary. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
TransplantNotes & sourceMedical care involving transplantation of an organ or tissue. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Reconstructive SurgeryNotes & sourceSurgery to restore function or repair a body part affected by injury, illness, or a birth condition. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Benefit details: Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | Asuris EmployeeSelect Gold 1500 Preferred |
|---|---|
Mental/Behavioral Health Outpatient ServicesNotes & sourceMental or behavioral health care without inpatient admission. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Benefit details: Virtual Care - Store and Forward & Virtual Care - Telehealth Visit $10 Copay found on the Schedule of Benefits. Outpatient office/psychotherapy visits - Copayment, Deductible waived. Other outpatient services - Coinsurance after Deductible Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Mental/Behavioral Health Inpatient ServicesNotes & sourceMental or behavioral health treatment during an inpatient stay. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Substance Abuse Disorder Outpatient ServicesNotes & sourceTreatment for substance use disorders without inpatient admission. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Benefit details: Virtual Care - Store and Forward & Virtual Care - Telehealth Visit $10 Copay found on the Schedule of Benefits. Outpatient office/psychotherapy visits - Copayment, Deductible waived. Other outpatient services - Coinsurance after Deductible Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Substance Abuse Disorder Inpatient ServicesNotes & sourceTreatment for substance use disorders during an inpatient stay. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | Asuris EmployeeSelect Gold 1500 Preferred |
|---|---|
Generic DrugsNotes & sourceMedicines classified by the plan as generic drugs. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $15.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 90 Limit unit: Days per Month Benefit details: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. For prescription contraceptive drugs coverage includes a twelve-month refill of contraceptive drugs obtained at one time by the enrollee, unless the enrollee requests a smaller supply or the prescribing provider instructs that the enrollee must receive a smaller supply. Insulin limit: $35 for a 30 day supply and $105 for a 90 day. Benefit details: Supporting benefit crosswalk (SERFF submitted 2026-10-12): $15 Copayment, Deductible waived for each Preferred Generic Medication. Copayment does not accrue toward the deductible: $35 Copayment, Deductible waived, for each Generic Medication. Copayment does not accrue toward the deductible: Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Preferred Brand DrugsNotes & sourceBrand-name medicines placed in the plan’s preferred drug category. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $50.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 90 Limit unit: Days per Month Benefit details: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. For prescription contraceptive drugs coverage includes a twelve-month refill of contraceptive drugs obtained at one time by the enrollee, unless the enrollee requests a smaller supply or the prescribing provider instructs that the enrollee must receive a smaller supply. Insulin limit: $35 for a 30 day supply and $105 for a 90 day. Benefit details: Supporting benefit crosswalk (SERFF submitted 2026-10-12): $50 Copayment, Deductible waived, for each Preferred Brand-Name Medication. Copayment does not accrue toward the deductible: Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Non-Preferred Brand DrugsNotes & sourceBrand-name medicines outside the plan’s preferred drug category. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 50.00% Coverage: Covered Service limit: Yes Limit amount: 90 Limit unit: Days per Month Benefit details: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. For prescription contraceptive drugs coverage includes a twelve-month refill of contraceptive drugs obtained at one time by the enrollee, unless the enrollee requests a smaller supply or the prescribing provider instructs that the enrollee must receive a smaller supply. Insulin limit: $35 for a 30 day supply and $105 for a 90 day. Benefit details: Supporting benefit crosswalk (SERFF submitted 2026-10-12): 50% Coinsurance, Deductible waived, for each Brand-Name Medication. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Specialty DrugsNotes & sourceMedicines placed in the plan’s specialty category, often requiring special handling or monitoring. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Days per Month Benefit details: First fill allowed at a retail pharmacy. Additional fills must be provided at a specialty pharmacy. Coverage is limited to a 30-day supply for specialty and self-administrable cancer chemotherapy medications from a specialty pharmacy per fill or refill. Benefit details: Supporting benefit crosswalk (SERFF submitted 2026-10-12): 20% Coinsurance, Deductible waived, for each Preferred Specialty Medication; 50% Coinsurance, Deductible waived, for each Specialty Medication. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Supply limits and coverage conditionsNotes & sourceRetail, mail-order and specialty prescription terms, with the source drug tiers and exceptions retained. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Generic Drugs; Preferred Brand Drugs · Benefit details: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. For prescription contraceptive drugs coverage includes a twelve-month refill of contraceptive drugs obtained at one time by the enrollee, unless the enrollee requests a smaller supply or the prescribing provider instructs that the enrollee must receive a smaller supply. Insulin limit: $35 for a 30 day supply and $105 for a 90 day. Non-Preferred Brand Drugs · Benefit details: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. For prescription contraceptive drugs coverage includes a twelve-month refill of contraceptive drugs obtained at one time by the enrollee, unless the enrollee requests a smaller supply or the prescribing provider instructs that the enrollee must receive a smaller supply. Insulin limit: $35 for a 30 day supply and $105 for a 90 day. Specialty Drugs · Benefit details: First fill allowed at a retail pharmacy. Additional fills must be provided at a specialty pharmacy. Coverage is limited to a 30-day supply for specialty and self-administrable cancer chemotherapy medications from a specialty pharmacy per fill or refill. |
Formulary tier 1Notes & sourceFiled formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Drug category: Preferred Generic Three-month in-network mail order: Yes |
Formulary tier 2Notes & sourceFiled formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Drug category: Generic Three-month in-network mail order: Yes |
Formulary tier 3Notes & sourceFiled formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Drug category: Preferred Brand Three-month in-network mail order: Yes |
Formulary tier 4Notes & sourceFiled formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Drug category: Brand Three-month in-network mail order: Yes |
Formulary tier 5Notes & sourceFiled formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Drug category: Preferred Generic, Preferred Brand, Specialty Drugs Three-month in-network mail order: No |
Formulary tier 6Notes & sourceFiled formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Drug category: Generic, Brand, Specialty Drugs Three-month in-network mail order: No |
Formulary tier 7Notes & sourceFiled formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Drug category: Medical Service Drugs Three-month in-network mail order: No |
| Benefit | Asuris EmployeeSelect Gold 1500 Preferred |
|---|---|
Prenatal and Postnatal CareNotes & sourceCare during pregnancy and after childbirth. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Delivery and All Inpatient Services for Maternity CareNotes & sourceCare for childbirth and related inpatient services. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Abortion for Which Public Funding is ProhibitedNotes & sourceThe filing’s category for abortion services that cannot receive public funding. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: No Charge In-network tier 1 coinsurance: No Charge Coverage: Covered Benefit details: Coverage includes termination of pregnancy for all members. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | Asuris EmployeeSelect Gold 1500 Preferred |
|---|---|
Hospice ServicesNotes & sourceCare focused on comfort and support near the end of life. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 14 Limit unit: Days per Lifetime Benefit details: Limit applies to respite care only Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Home Health Care ServicesNotes & sourceMedical care delivered at home under a care plan. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 130 Limit unit: Visit(s) per Year Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Skilled Nursing FacilityNotes & sourceCare in a facility providing skilled nursing or rehabilitation. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 60 Limit unit: Days per Year Benefit details: Coverage is limited to 60-inpatient days/year. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Outpatient Rehabilitation ServicesNotes & sourceTherapy to help restore abilities after illness or injury without inpatient admission. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $35.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 25 Limit unit: Visit(s) per Year Benefit details: Limit combined with Occupational, Physical, and Speech therapy. Visit limit does not apply to Mental Health/Substance Abuse. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Habilitation ServicesNotes & sourceTherapy to help develop or maintain skills needed for daily activities. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $35.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Days per Year Benefit details: Coverage for habilitative services is limited to 30-inpatient days/year. Coverage for habilitative services is limited to 25-outpatient visits/year. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Rehabilitative Speech TherapyNotes & sourceTherapy to restore speech, communication, or swallowing abilities. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $35.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Days per Year Benefit details: Coverage is limited to 30-inpatient days/year and 25-outpatient visits/year. Rehabilitative Speech Therapy and Rehabilitative Occupational and Rehabilitative Physical Therapy combine for 25 visits for Rehabilitative Services and 25 visits for Habilitative Services. Visit limit does not apply to Mental Health/Substance Abuse. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Rehabilitative Occupational and Rehabilitative Physical TherapyNotes & sourceTherapy to restore movement or the ability to carry out everyday tasks. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $35.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Days per Year Benefit details: Coverage is limited to 30-inpatient days/year and 25-outpatient visits/year. Rehabilitative Speech Therapy and Rehabilitative Occupational and Rehabilitative Physical Therapy combine for 25 visits for Rehabilitative Services and 25 visits for Habilitative Services. Visit limit does not apply to Mental Health/Substance Abuse. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Infusion TherapyNotes & sourceTreatment that delivers medicine or fluids through a needle or catheter. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Benefit details: Covered under applicable benefit (such as office visit). Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Durable Medical EquipmentNotes & sourceMedical equipment for repeated use, such as a wheelchair or home oxygen equipment. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | Asuris EmployeeSelect Gold 1500 Preferred |
|---|---|
Infertility TreatmentNotes & sourceMedical services to evaluate or treat difficulty becoming pregnant. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Exclusions: Only evaluations to determine if and why a covered member is infertile and artificial insemination are covered. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Chiropractic CareNotes & sourceCare provided by a chiropractor, including listed spinal or joint treatments. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 10 Limit unit: Visit(s) per Year Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Hearing AidsNotes & sourceDevices that help improve hearing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: No Charge Coverage: Covered Service limit: Yes Limit amount: 1 Limit unit: Item(s) per 3 Years Benefit details: Coverage is limited to one hearing aid per ear every 3 years. Cochlear Implants for children are also covered. Out-of-network copay: Not Applicable Out-of-network coinsurance: No Charge Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Routine Foot CareNotes & sourceRegular foot care, such as listed nail or callus services. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
AcupunctureNotes & sourceTreatment using thin needles placed at specific points on the body. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
DialysisNotes & sourceTreatment that filters the blood when the kidneys cannot do so adequately. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
ChemotherapyNotes & sourceDrug treatment used for cancer and certain other conditions. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Benefit details: Covered under the base benchmark plan. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
RadiationNotes & sourceTreatment using targeted radiation, commonly for cancer. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Benefit details: Covered under the base benchmark plan; covered under applicable benefit (such as office visit). Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Diabetes EducationNotes & sourceInstruction to help a person manage diabetes. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: No Charge In-network tier 1 coinsurance: No Charge Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Prosthetic DevicesNotes & sourceDevices that replace a missing body part. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Temporomandibular joint (TMJ) treatmentNotes & sourceTreatment for problems affecting the jaw joint and nearby muscles. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Nutritional CounselingNotes & sourceProfessional guidance on food choices and nutrition. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Diabetes Care ManagementNotes & sourceCoordinated support for managing diabetes and its treatment. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Inherited Metabolic Disorder - PKUNotes & sourceCare for phenylketonuria, an inherited condition affecting how the body processes part of dietary protein. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Gender Affirming CareNotes & sourceHealth services that support a person’s gender identity. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Benefit details: Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Hearing examsNotes & sourceAssessments of hearing; consult the filed benefit for limits and member costs. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: No Charge Coverage: Covered Benefit details: Coverage is limited to an initial assessment and one annual hearing exam. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Bariatric SurgeryNotes & sourceListed in the source exclusion summary. Check its exceptions and the issued contract for the exact terms. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Source statement: Bariatric Surgery is listed in the source exclusions; review the qualifications. Source exclusion context: The 2027 sample SBC generally excludes bariatric surgery; cosmetic surgery except congenital anomalies; adult dental care; infertility treatment; long-term care; non-emergency care outside the U.S.; private-duty nursing; routine adult eye care; and weight-loss programs. The sample booklet preserves specified artificial-insemination services and infertility diagnostic procedures under Other Professional Services. This is a partial list with exceptions; consult the issued contract for full terms. |
| Benefit | Asuris EmployeeSelect Gold 1500 Preferred |
|---|---|
Routine Eye Exam for ChildrenNotes & sourceRegular vision exams for children. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: No Charge In-network tier 1 coinsurance: No Charge Coverage: Covered Service limit: Yes Limit amount: 1 Limit unit: Exam(s) per Year Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes |
Eye Glasses for ChildrenNotes & sourcePrescription eyeglasses for children. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: No Charge In-network tier 1 coinsurance: No Charge Coverage: Covered Service limit: Yes Limit amount: 1 Limit unit: Item(s) per Year Benefit details: Coverage is limited to one frame and one pair (two lenses)/ calendar year or contacts (in lieu of glasses). Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes |
Dental Check-Up for ChildrenNotes & sourceRoutine dental exams for children. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: No Charge In-network tier 1 coinsurance: No Charge Coverage: Covered Service limit: Yes Limit amount: 2 Limit unit: Visit(s) per Year Out-of-network copay: No Charge Out-of-network coinsurance: No Charge Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes |
Basic Dental Care - ChildNotes & sourceDental services classified as basic care for children, such as listed fillings. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coverage: Covered Service limit: Yes Limit amount: 2 Limit unit: Exam(s) per Year Out-of-network copay: Not Applicable Out-of-network coinsurance: 20.00% Essential health benefit: Yes Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes |
Orthodontia - ChildNotes & sourceTreatment to align children’s teeth or jaws, such as braces. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 50.00% Coverage: Covered Benefit details: Medically necessary orthodontia must be covered. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes |
Major Dental Care - ChildNotes & sourceDental services classified as major care for children. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 50.00% Coverage: Covered Benefit details: Quantitative limits apply; see essential health benefits base benchmark plan. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes |
Dental AnesthesiaNotes & sourceAnesthesia used during dental treatment. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | Asuris EmployeeSelect Gold 1500 Preferred |
|---|---|
Provider networkNotes & sourceThe insurer’s name for the network linked to this plan. Check the current provider directory to confirm a doctor or hospital participates. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Preferred |
Specialist referralNotes & sourceWhether the plan generally requires a referral before seeing a specialist. Check the listed exceptions. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
Referral detailsNotes & sourceThe insurer’s explanation of when specialist referrals are needed. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | The 2027 Asuris sample booklet says referrals are not required before using covered benefits. Some covered services require preauthorization by contracted providers. Medical-necessity and network rules still apply; consult the issued booklet for service-specific requirements. |
Provider tiersNotes & sourceWhether in-network providers are grouped into tiers with different member costs. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
National networkNotes & sourceWhether the filing lists a national provider network; this does not confirm any particular provider participates. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Yes |
Care outside the countryNotes & sourceWhether the filing lists coverage outside the country; restrictions may apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Yes |
International care detailsNotes & sourceThe insurer’s explanation of coverage and restrictions outside the country. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed. |
Care outside the service areaNotes & sourceWhether the filing lists coverage away from the plan’s normal service area. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Yes |
Outside-area care detailsNotes & sourceThe insurer’s explanation of care covered away from the normal service area. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States |
| Benefit | Asuris EmployeeSelect Gold 1500 Preferred |
|---|---|
HSA-compatible planNotes & sourceWhether the filing identifies the plan as HSA-compatible; your personal ability to contribute also depends on other rules. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
Filed employer account contributionNotes & sourceWhether the plan filing includes an employer HSA or HRA contribution; it does not describe your employer’s actual contribution. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
Filed contribution amountNotes & sourceThe employer account contribution amount included in the filing, if supplied. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
HSA in source plan nameNotes & sourceSource name evidence only; this does not establish personal HSA eligibility. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
| Benefit | Asuris EmployeeSelect Gold 1500 Preferred |
|---|---|
Wellness programNotes & sourceWhether the filing lists a program intended to support healthy habits. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
Condition support programsNotes & sourcePrograms listed to help members manage ongoing health conditions. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Case management for serious illness or injury with potential continuing major or complex care needs. Licensed health-care professionals provide information, support and guidance, coordinate with treating professionals, and may propose alternative benefits. See the 2027 sample booklet and contact Asuris for applicable services. |
Plan designNotes & sourceThe plan design description supplied by the insurer. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Unknown |
Unique plan designNotes & sourceWhether the insurer marked the benefit design as distinct in its filing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Yes |
Plan exclusionsNotes & sourceServices or situations the insurer lists as excluded from coverage. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | The 2027 sample SBC generally excludes bariatric surgery; cosmetic surgery except congenital anomalies; adult dental care; infertility treatment; long-term care; non-emergency care outside the U.S.; private-duty nursing; routine adult eye care; and weight-loss programs. The sample booklet preserves specified artificial-insemination services and infertility diagnostic procedures under Other Professional Services. This is a partial list with exceptions; consult the issued contract for full terms. Possible source conflict: the selected filing describes overseas benefits as the same as U.S. benefits with BlueCross BlueShield Global access, while the 2027 Asuris SBC excludes non-emergency care outside the U.S. The booklet does not verify the filed BlueCard access description. Confirm international and outside-area coverage with Asuris. |
Pregnancy noticeNotes & sourceWhether the filing indicates a pregnancy-related notice requirement. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
Adult dental waiting periodNotes & sourceWhether the filing lists a wait before adult dental benefits begin. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Waiting period lengthNotes & sourceHow long the filed waiting period lasts, if supplied. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Child-only coverageNotes & sourceHow the filing describes coverage offered for children without an enrolled adult. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Allows Adult and Child-Only |
| Benefit | Asuris EmployeeSelect Gold 1500 Preferred |
|---|---|
Having a baby exampleNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Example deductible: $1,500 Example copays: $10 Example coinsurance: $2,100 Example uncovered costs: $60 |
Managing diabetes exampleNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Example deductible: $800 Example copays: $800 Example coinsurance: $20 Example uncovered costs: $200 |
Simple fracture exampleNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Example deductible: $1,500 Example copays: $600 Example coinsurance: $60 Example uncovered costs: $0 |
| Benefit | Asuris EmployeeSelect Gold 1500 Preferred |
|---|---|
Calculated actuarial valueNotes & sourceAn estimate of the share of covered costs the plan pays for a standard population, not your expected spending. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | 0.826007448866909 |
Insurer actuarial valueNotes & sourceThe insurer’s estimate of the plan’s share of covered costs for a standard population. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | 80.90% |
Tier 1 filing assumptionNotes & sourceThe use of tier 1 providers assumed in the filing, not a prediction of your care. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | 100% |
Tier 2 filing assumptionNotes & sourceThe use of tier 2 providers assumed in the filing, not a prediction of your care. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Unknown |
Essential benefit premium shareNotes & sourceThe filed portion of the premium allocated to essential health benefits. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Children’s dental allocationNotes & sourceThe filed allocation for children’s dental benefits. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Composite premium availableNotes & sourceWhether the filing offers a shared premium rate instead of separate age-based rates. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
Rate descriptionNotes & sourceWhether the insurer labels its filed rate as guaranteed or estimated. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
| Benefit | Asuris EmployeeSelect Gold 1500 Preferred |
|---|---|
Plan IDNotes & sourceThe identifier used to distinguish this plan in the filing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | 69364WA0930021 |
Plan variation IDNotes & sourceIdentifies this plan’s specific version of benefits and cost sharing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | 69364WA0930021-00 |
Plan variation nameNotes & sourceThe insurer’s name for this version of the plan. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Asuris EmployeeSelect Gold 1500 Preferred |
Cost-sharing variationNotes & sourceThe filed category for this version of the plan’s member costs. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Standard Gold Off Exchange Plan |
Product IDNotes & sourceThe identifier for the product family this plan belongs to. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | 69364WA093 |
Network IDNotes & sourceIdentifies this plan’s provider network within this insurer’s filing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | WAN002 |
Service area IDNotes & sourceIdentifies the area where the insurer offers this plan. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | WAS002 |
Drug list IDNotes & sourceIdentifies the prescription drug list referenced by this plan. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | WAF009 |
Marketplace statusNotes & sourceWhether the filing describes the plan as offered through the health insurance marketplace. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Off the Exchange |
New or existing planNotes & sourceWhether the insurer filed this as a new or continuing plan. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Existing |
Child-only plan IDNotes & sourceIdentifies a related child-only plan when one is supplied. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Tribal cost-sharing variationNotes & sourceIdentifies a special cost-sharing variation, if one is listed. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Effective dateNotes & sourceThe start date listed for this plan in the filing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | 1/1/2027 |
Expiration dateNotes & sourceThe end date listed in the filing; a blank does not mean coverage continues indefinitely. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Unknown |
Plan nameNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Asuris EmployeeSelect Gold 1500 Preferred |
Legal issuerNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Asuris Northwest Health |
Plan typeNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | PPO |
| Benefit | Asuris EmployeeSelect Gold 1500 Preferred |
|---|---|
Virtual care optionsNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | 2027 sample booklet: telehealth (live remote visits) and store-and-forward services (asynchronous care) have an in-network cost share of $10 Copay, Deductible waived. Out-of-network cost share: 50% after the deductible, for covered services. Some providers may offer lower cost sharing; confirm the provider and service with Asuris. Separate facility fees use the Other Professional Services benefit. |
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2027 · Public plan ID 69364WA0930021 · Benefit variant 69364WA0930021-00
Original identity review: 2027 Asuris sample SBC. The enrolled coverage period is a placeholder; this is not an executed group contract. Possible source conflict: the selected filing describes overseas benefits as the same as U.S. benefits with BlueCross BlueShield Global access, while the 2027 Asuris SBC excludes non-emergency care outside the U.S. The booklet does not verify the filed BlueCard access description. Confirm international and outside-area coverage with Asuris. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.
Carrier source index; formats and available documents vary. 2027 Asuris sample SBC. The enrolled coverage period is a placeholder; this is not an executed group contract. Possible source conflict: the selected filing describes overseas benefits as the same as U.S. benefits with BlueCross BlueShield Global access, while the 2027 Asuris SBC excludes non-emergency care outside the U.S. The booklet does not verify the filed BlueCard access description. Confirm international and outside-area coverage with Asuris.
Original identity review: 2027 Asuris medical benefit summary, January 1–December 31, 2027. Read with the sample SBC and booklet; this is not the issued group contract. Possible source conflict: the selected filing describes overseas benefits as the same as U.S. benefits with BlueCross BlueShield Global access, while the 2027 Asuris SBC excludes non-emergency care outside the U.S. The booklet does not verify the filed BlueCard access description. Confirm international and outside-area coverage with Asuris. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.
Original identity review: 2027 Asuris sample benefit booklet with an exact-title benefit schedule. Group name, cover plan name, group number and enrolled effective date contain placeholders; confirm the issued contract and current provider participation. Possible source conflict: the selected filing describes overseas benefits as the same as U.S. benefits with BlueCross BlueShield Global access, while the 2027 Asuris SBC excludes non-emergency care outside the U.S. The booklet does not verify the filed BlueCard access description. Confirm international and outside-area coverage with Asuris. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.
Adams, Asotin, Benton, Chelan, Douglas, Ferry, Franklin, Garfield, Grant, Kittitas, Lincoln, Okanogan, Pend Oreille, Spokane, Stevens, Whitman. Availability still depends on the coverage start and employer eligibility.
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