Asuris EmployeeSelect Platinum 250 Preferred

Asuris Northwest Health

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Annual in-network deductible: $250
Metal level: Platinum
Plan type: PPO
HSA-compatible plan: No (most common)

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Plan benefits

All supported filed details, including known conditions and limits. This is not the entire insurance contract. Unknown does not mean $0 or not covered.

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132 benefit rows

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.

Notes & source

Asuris · Preferred · Issuer 69364. Confirm current provider participation and exact coverage in the plan documents.

Annual deductibles: Asuris EmployeeSelect Platinum 250 Preferred
Benefit	Asuris EmployeeSelect Platinum 250 Preferred
Medical deductible Notes & source 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 individual: $250 In-network tier 1 family: $250 per person \| $500 per group In-network tier 1 coinsurance: 10.00% Out-of-network individual: $3,000 Out-of-network family: $3,000 per person \| $6,000 per group Combined in/out-of-network individual: $3,250 Combined in/out-of-network family: $3,250 per person \| $6,500 per group
Prescription drug deductible Notes & source 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 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

Annual out-of-pocket limits: Asuris EmployeeSelect Platinum 250 Preferred
Benefit	Asuris EmployeeSelect Platinum 250 Preferred
Maximum Out of Pocket for Medical and Drug Benefits (Total) Notes & source 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 individual: $5,000 In-network tier 1 family: $5,000 per person \| $10,000 per group Out-of-network individual: $10,000 Out-of-network family: $10,000 per person \| $20,000 per group Combined in/out-of-network individual: $15,000 Combined in/out-of-network family: $15,000 per person \| $30,000 per group

How costs are shared: Asuris EmployeeSelect Platinum 250 Preferred
Benefit	Asuris EmployeeSelect Platinum 250 Preferred
Combined medical and drug deductible Notes & source Whether 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 limit Notes & source Whether 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 cap Notes & source A 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 limit Notes & source The 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 sharing Notes & source The 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 charges Notes & source The 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

Office and routine care: Asuris EmployeeSelect Platinum 250 Preferred
Benefit	Asuris EmployeeSelect Platinum 250 Preferred
Primary Care Visit to Treat an Injury or Illness Notes & source A 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: $20.00 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 Visit Notes & source A 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: $45.00 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 & source An 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: $20.00 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/Immunization Notes & source Services 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 Care Notes & source Routine 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

Tests and imaging: Asuris EmployeeSelect Platinum 250 Preferred
Benefit	Asuris EmployeeSelect Platinum 250 Preferred
Imaging (CT/PET Scans, MRIs) Notes & source Advanced 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: 10.00% 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 Services Notes & source Laboratory 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: 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
X-rays and Diagnostic Imaging Notes & source X-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: 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
Allergy Testing Notes & source Tests 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: 10.00% 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

Urgent and emergency care: Asuris EmployeeSelect Platinum 250 Preferred
Benefit	Asuris EmployeeSelect Platinum 250 Preferred
Urgent Care Centers or Facilities Notes & source Care 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: $45.00 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 Services Notes & source Evaluation 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: $250.00 Copay after deductible In-network tier 1 coinsurance: 10.00% Coinsurance after deductible Coverage: Covered Benefit details: Supporting benefit crosswalk (SERFF submitted 2026-10-12): After $250 Copayment and In-Network Deductible, 10% Coinsurance. Copayment does not accrue toward the deductible. Out-of-network copay: $250.00 Copay after deductible Out-of-network coinsurance: 10.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No
Emergency Transportation/Ambulance Notes & source Ambulance 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: 10.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 10.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No

Hospital and surgery: Asuris EmployeeSelect Platinum 250 Preferred
Benefit	Asuris EmployeeSelect Platinum 250 Preferred
Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Notes & source The 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: 10.00% 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 Services Notes & source The 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: 10.00% 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 & source Hospital 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: 10.00% 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 Services Notes & source Clinicians’ 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: 10.00% 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 Surgery Notes & source Surgery 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: 10.00% 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
Transplant Notes & source Medical 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: 10.00% 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 Surgery Notes & source Surgery 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: 10.00% 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

Mental health and substance use: Asuris EmployeeSelect Platinum 250 Preferred
Benefit	Asuris EmployeeSelect Platinum 250 Preferred
Mental/Behavioral Health Outpatient Services Notes & source Mental 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: $20.00 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 Services Notes & source Mental 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: 10.00% 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 Services Notes & source Treatment 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: $20.00 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 Services Notes & source Treatment 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: 10.00% 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

Prescription drugs: Asuris EmployeeSelect Platinum 250 Preferred
Benefit	Asuris EmployeeSelect Platinum 250 Preferred
Generic Drugs Notes & source Medicines 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: $8.00 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): $8 Copayment, Deductible waived for each Preferred Generic Medication. Copayment does not accrue toward the deductible: $30 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 Drugs Notes & source Brand-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: $40.00 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): $40 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 Drugs Notes & source Brand-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 Non-Preferred Brand Drug 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 Drugs Notes & source Medicines 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 conditions Notes & source Retail, 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 1 Notes & source Filed 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 2 Notes & source Filed 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 3 Notes & source Filed 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 4 Notes & source Filed 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 5 Notes & source Filed 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 6 Notes & source Filed 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 7 Notes & source Filed 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

Pregnancy and childbirth: Asuris EmployeeSelect Platinum 250 Preferred
Benefit	Asuris EmployeeSelect Platinum 250 Preferred
Prenatal and Postnatal Care Notes & source Care 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: 10.00% 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 Care Notes & source Care 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: 10.00% 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 Prohibited Notes & source The 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

Therapy and recovery: Asuris EmployeeSelect Platinum 250 Preferred
Benefit	Asuris EmployeeSelect Platinum 250 Preferred
Hospice Services Notes & source Care 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: 10.00% 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 Services Notes & source Medical 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: 10.00% 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 Facility Notes & source Care 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: 10.00% 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 Services Notes & source Therapy 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: $30.00 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 Services Notes & source Therapy 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: $30.00 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 Therapy Notes & source Therapy 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: $30.00 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 Therapy Notes & source Therapy 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: $30.00 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 Therapy Notes & source Treatment 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: 10.00% 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 Equipment Notes & source Medical 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: 10.00% 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

Other services: Asuris EmployeeSelect Platinum 250 Preferred
Benefit	Asuris EmployeeSelect Platinum 250 Preferred
Infertility Treatment Notes & source Medical 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: 10.00% 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 Care Notes & source Care 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: $20.00 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 Aids Notes & source Devices 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 Care Notes & source Regular 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: 10.00% 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
Acupuncture Notes & source Treatment 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: $20.00 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
Dialysis Notes & source Treatment 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: 10.00% 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
Chemotherapy Notes & source Drug 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: 10.00% 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
Radiation Notes & source Treatment 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: 10.00% 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 Education Notes & source Instruction 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 Devices Notes & source Devices 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: 10.00% 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) treatment Notes & source Treatment 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: 10.00% 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 Counseling Notes & source Professional 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: 10.00% 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 Management Notes & source Coordinated 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: 10.00% 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 - PKU Notes & source Care 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: 10.00% 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 Care Notes & source Health 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: 10.00% 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 exams Notes & source Assessments 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 Surgery Notes & source Listed 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.

Dental and vision: Asuris EmployeeSelect Platinum 250 Preferred
Benefit	Asuris EmployeeSelect Platinum 250 Preferred
Routine Eye Exam for Children Notes & source Regular 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 Children Notes & source Prescription 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 Children Notes & source Routine 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 - Child Notes & source Dental 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 - Child Notes & source Treatment 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 - Child Notes & source Dental 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 Anesthesia Notes & source Anesthesia 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: 10.00% 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

Network and access: Asuris EmployeeSelect Platinum 250 Preferred
Benefit	Asuris EmployeeSelect Platinum 250 Preferred
Provider network Notes & source The 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 referral Notes & source Whether 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 details Notes & source The 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 tiers Notes & source Whether 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 network Notes & source Whether 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 country Notes & source Whether 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 details Notes & source The 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 area Notes & source Whether 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 details Notes & source The 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

Health accounts: Asuris EmployeeSelect Platinum 250 Preferred
Benefit	Asuris EmployeeSelect Platinum 250 Preferred
HSA-compatible plan Notes & source Whether 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 contribution Notes & source Whether 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 amount Notes & source The 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 name Notes & source Source 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

Plan features and exclusions: Asuris EmployeeSelect Platinum 250 Preferred
Benefit	Asuris EmployeeSelect Platinum 250 Preferred
Wellness program Notes & source Whether 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 programs Notes & source Programs 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 design Notes & source The 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 design Notes & source Whether 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 exclusions Notes & source Services 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 notice Notes & source Whether 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 period Notes & source Whether 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 length Notes & source How 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 coverage Notes & source How 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

Standardized coverage examples: Asuris EmployeeSelect Platinum 250 Preferred
Benefit	Asuris EmployeeSelect Platinum 250 Preferred
Having a baby example Notes & source 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Example deductible: $250 Example copays: $10 Example coinsurance: $1,100 Example uncovered costs: $60
Managing diabetes example Notes & source 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Example deductible: $250 Example copays: $700 Example coinsurance: $50 Example uncovered costs: $200
Simple fracture example Notes & source 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Example deductible: $250 Example copays: $500 Example coinsurance: $100 Example uncovered costs: $0

Filing assumptions: Asuris EmployeeSelect Platinum 250 Preferred
Benefit	Asuris EmployeeSelect Platinum 250 Preferred
Calculated actuarial value Notes & source An 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.	0.916840544971556
Insurer actuarial value Notes & source The 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.	91.05%
Tier 1 filing assumption Notes & source The 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 assumption Notes & source The 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 share Notes & source The 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 allocation Notes & source The 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 available Notes & source Whether 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 description Notes & source Whether 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

Plan identifiers and filing context: Asuris EmployeeSelect Platinum 250 Preferred
Benefit	Asuris EmployeeSelect Platinum 250 Preferred
Plan ID Notes & source The 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.	69364WA0930003
Plan variation ID Notes & source Identifies 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.	69364WA0930003-00
Plan variation name Notes & source The 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 Platinum 250 Preferred
Cost-sharing variation Notes & source The 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 Platinum Off Exchange Plan
Product ID Notes & source The 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 ID Notes & source Identifies 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 ID Notes & source Identifies 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 ID Notes & source Identifies 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.	WAF005
Marketplace status Notes & source Whether 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 plan Notes & source Whether 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 ID Notes & source Identifies 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 variation Notes & source Identifies 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 date Notes & source The 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 date Notes & source The 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 name Notes & source 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Asuris EmployeeSelect Platinum 250 Preferred
Legal issuer Notes & source 2027 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 type Notes & source 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	PPO

Carrier virtual care: Asuris EmployeeSelect Platinum 250 Preferred
Benefit	Asuris EmployeeSelect Platinum 250 Preferred
Virtual care options Notes & source 2027 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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Plan documents

2027 · Public plan ID 69364WA0930003 · Benefit variant 69364WA0930003-00

Summary of Benefits and Coverage (SBC)

Document notes

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 document index

Document notes

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.

2027 Medical Benefit Summary — Asuris EmployeeSelect Platinum 250 Preferred

Document notes

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.

2027 Sample Benefit Booklet — Asuris EmployeeSelect Platinum 250 Preferred

Document notes

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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Asuris EmployeeSelect Platinum 250 Preferred

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Plan benefits

▾Network overview

▾Annual deductibles (2)

Medical deductible

Prescription drug deductible

▾Annual out-of-pocket limits (1)

Maximum Out of Pocket for Medical and Drug Benefits (Total)

▾How costs are shared (6)

Combined medical and drug deductible

Combined medical and drug spending limit

Specialty drug coinsurance cap

Hospital copay day limit

Primary care visits before cost sharing

Primary care copays before other charges

▾Office and routine care (5)

Primary Care Visit to Treat an Injury or Illness

Specialist Visit

Other Practitioner Office Visit (Nurse, Physician Assistant)

Preventive Care/Screening/Immunization

Well Baby Visits and Care

▾Tests and imaging (4)

Imaging (CT/PET Scans, MRIs)

Laboratory Outpatient and Professional Services

X-rays and Diagnostic Imaging

Allergy Testing

▾Urgent and emergency care (3)

Urgent Care Centers or Facilities

Emergency Room Services

Emergency Transportation/Ambulance

▾Hospital and surgery (7)

Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

Outpatient Surgery Physician/Surgical Services

Inpatient Hospital Services (e.g., Hospital Stay)

Inpatient Physician and Surgical Services

Cosmetic Surgery

Transplant

Reconstructive Surgery

▾Mental health and substance use (4)

Mental/Behavioral Health Outpatient Services

Mental/Behavioral Health Inpatient Services

Substance Abuse Disorder Outpatient Services

Substance Abuse Disorder Inpatient Services

▾Prescription drugs (12)

Generic Drugs

Preferred Brand Drugs

Non-Preferred Brand Drugs

Specialty Drugs

Supply limits and coverage conditions

Formulary tier 1

Formulary tier 2

Formulary tier 3

Formulary tier 4

Formulary tier 5

Formulary tier 6

Formulary tier 7

▾Pregnancy and childbirth (3)

Prenatal and Postnatal Care

Delivery and All Inpatient Services for Maternity Care

Abortion for Which Public Funding is Prohibited

▾Therapy and recovery (9)

Hospice Services

Home Health Care Services

Skilled Nursing Facility

Outpatient Rehabilitation Services

Habilitation Services

Rehabilitative Speech Therapy

Rehabilitative Occupational and Rehabilitative Physical Therapy

Infusion Therapy

Durable Medical Equipment

▾Other services (17)

Infertility Treatment

Chiropractic Care

Hearing Aids

Routine Foot Care

Acupuncture

Dialysis

Chemotherapy

Radiation