Cobalt 1000

Premera Blue Cross · BHT Industry Health Trust

Annual in-network deductible: $1,000
Metal level: N/A (similar to Gold)
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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109 benefit rows

Annual deductibles: Cobalt 1000
Benefit	Cobalt 1000
Medical deductible	In-network: $1,000 Benefit details: Individual Deductible PCY (Family embedded deductible 2X Individual) Out-of-network: $2,000
Prescription drug deductible	In-network: $0 Benefit details: Individual Deductible PCY
SBC deductible and family structure	Benefit details: In-network: $1,000 Individual / $2,000 Family. Out-of-network: $2,000 Individual / $4,000 Family. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Other source benefits: Cobalt 1000
Benefit	Cobalt 1000
Non Specialist Office Visit Cost Share	In-network: $35 Copay, applies to the $7,500 Out of Pocket Maximum Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Immunizations (Unlimited, subject to standard medical guidelines)	In-network: Covered in Full Out-of-network: Not Covered
Health Education (HE) (Unlimited)	In-network: Covered in Full Out-of-network: Not Covered
Nicotine Dependency Programs (ND) (Unlimited)	In-network: Covered in Full Out-of-network: Not Covered
Diabetes Health Education (DE) (Unlimited)	In-network: Covered in Full Out-of-network: Not Covered
Diabetes Management Plus	In-network: Excluded Out-of-network: Excluded
Diabetes Prevention Plus	In-network: Excluded Out-of-network: Excluded
Hypertension Plus	In-network: Excluded Out-of-network: Excluded
Weight Management	In-network: Excluded Out-of-network: Excluded
Comprehensive Weight Care	In-network: Excluded Out-of-network: Excluded
Preventive Imaging and Laboratory	In-network: Covered in Full Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Inpatient Professional Services	In-network: $1,000 Deductible, then 30% Coinsurance, applies to $7,500 Out of Pocket Maximum Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Birth Center	In-network: $1,000 Deductible, then 30% Coinsurance, applies to $7,500 Out of Pocket Maximum Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Transplant Travel & Lodging ($7,500 per transplant)	In-network: $1,000 Deductible, 0% Coinsurance, applies to $7,500 Out of Pocket Maximum Out-of-network: $1,000 Deductible, 0% Coinsurance, applies to $7,500 Out of Pocket Maximum
Emergency Room Physician	In-network: $1,000 Deductible, then 30% Coinsurance, applies to $7,500 Out of Pocket Maximum Out-of-network: $1,000 Deductible, then 30% Coinsurance, applies to $7,500 Out of Pocket Maximum
Inpatient Rehab (30 days PCY)	In-network: $1,000 Deductible, then 30% Coinsurance, applies to $7,500 Out of Pocket Maximum Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Outpatient Rehab for Chronic Conditions, Including Cardiac, Pulmonary Rehab, and Cancer (Unlimited)	In-network: $65 Copay, applies to the $7,500 Out of Pocket Maximum Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Outpatient Massage Therapy (Applies to the outpatient rehab limit)	In-network: $65 Copay, applies to the $7,500 Out of Pocket Maximum Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Inpatient Neurodevelopmental Therapy	In-network: $1,000 Deductible, then 30% Coinsurance, applies to $7,500 Out of Pocket Maximum Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Transplants (Unlimited)	In-network: Covered as any other service Out-of-network: Not Covered

Annual out-of-pocket limits: Cobalt 1000
Benefit	Cobalt 1000
Maximum Out of Pocket for Medical and Drug Benefits (Total)	In-network: $7,500 Benefit details: Individual Out of Pocket Maximum PCY, includes deductible, coinsurance, copay and pharmacy if applicable (Family embedded OOP max 2X Individual) Out-of-network: Unlimited
Costs excluded from the out-of-pocket limit	Benefit details: Premium, balance-billed charges, penalties for failure to obtain prior authorization for services, and health care this plan doesn't cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Office and routine care: Cobalt 1000
Benefit	Cobalt 1000
Specialist Visit	In-network: $65 Copay, applies to the $7,500 Out of Pocket Maximum Benefit details: Specialist Office Visit Cost Share Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Preventive Care/Screening/Immunization	In-network: Covered in Full Benefit details: Preventive Office Visit (Unlimited, subject to standard medical guidelines) Benefit details: You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. Out-of-network: Not Covered
Primary Care Visit to Treat an Injury or Illness	In-network: Non Specialist: $35 Copay, applies to the $7,500 Out of Pocket Maximum; Specialist: $65 Copay, applies to the $7,500 Out of Pocket Maximum Benefit details: Professional Office Visit Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum

Carrier virtual care: Cobalt 1000
Benefit	Cobalt 1000
Kinwell Connect Cost Share Waiver (Excluded)	In-network: All services rendered and billed by any Kinwell clinic are subject to standard cost shares Out-of-network: Not Applicable
Telemedicine with Traditional Providers	In-network: $35 Non Specialist Copay, applies to the $7,500 Out of Pocket Maximum Benefit details: Telemedicine with Traditional Providers - General Medical Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Virtual General Medical	In-network: $35 Non Specialist Copay, applies to the $7,500 Out of Pocket Maximum Benefit details: Telemedicine - General Medical (Virtual Care Only) Out-of-network: Not Applicable
Virtual Mental Health	In-network: $35 Non Specialist Copay, applies to the $7,500 Out of Pocket Maximum Benefit details: Telemedicine - Mental Health (Virtual Care Only) Out-of-network: Not Applicable
Virtual Chemical Dependency	In-network: $35 Non Specialist Copay, applies to the $7,500 Out of Pocket Maximum Benefit details: Telemedicine - Chemical Dependency (Virtual Care Only) Out-of-network: Not Applicable

Tests and imaging: Cobalt 1000
Benefit	Cobalt 1000
Breast Cancer Screening (including mammography)	In-network: Covered in Full Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Allergy/Therapeutic Injections	In-network: $1,000 Deductible, then 30% Coinsurance, applies to $7,500 Out of Pocket Maximum Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Laboratory Outpatient and Professional Services	In-network: $1,000 Deductible, then 30% Coinsurance, applies to $7,500 Out of Pocket Maximum Benefit details: Diagnostic Laboratory Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
X-rays and Diagnostic Imaging	In-network: $1,000 Deductible, then 30% Coinsurance, applies to $7,500 Out of Pocket Maximum Benefit details: Basic Diagnostic Imaging Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Imaging (CT/PET Scans, MRIs)	In-network: $1,000 Deductible, then 30% Coinsurance, applies to $7,500 Out of Pocket Maximum Benefit details: Major Diagnostic Imaging Benefit details: Prior authorization required for some outpatient imaging tests. Penalty for out-of- network: 50% of allowable charge to $1,500 per occurrence. Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Diagnostic Test (X-Ray and Blood Work)	In-network: 30% coinsurance Benefit details: SBC basis: All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Out-of-network: 50% coinsurance

Hospital and surgery: Cobalt 1000
Benefit	Cobalt 1000
Ambulatory Surgery Center	In-network: $1,000 Deductible, then 30% Coinsurance, applies to $7,500 Out of Pocket Maximum Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Inpatient Hospital Services (e.g., Hospital Stay)	In-network: $1,000 Deductible, then 30% Coinsurance, applies to $7,500 Out of Pocket Maximum Benefit details: Inpatient Facility Benefit details: Prior authorization required for all planned inpatient stays. Penalty for out-of-network: 50% of allowable charge to $1,500 per stay. Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	In-network: $1,000 Deductible, then 30% Coinsurance, applies to $7,500 Out of Pocket Maximum Benefit details: Hospital Outpatient Surgery Facility Benefit details: Prior authorization required for some services. Penalty for out-of-network: 50% of allowable charge to $1,500 per occurrence. Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Outpatient Surgery Physician/Surgical Services	In-network: 30% coinsurance Benefit details: SBC basis: All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Out-of-network: 50% coinsurance
Inpatient Physician and Surgical Services	In-network: 30% coinsurance Benefit details: SBC basis: All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Out-of-network: 50% coinsurance
Cosmetic Surgery Notes & source Listed in the source exclusion summary. Check its exceptions and the issued contract for the exact terms.	Source statement: Cosmetic Surgery is listed in the source exclusions; review the qualifications. Source exclusion context: (Check your policy or plan document for more information and a list of any other excluded services.) • Bariatric surgery • Cosmetic surgery • Dental care (Adult) • Infertility treatment • Long-term care • Private-duty nursing • Routine eye care (Adult) • Weight loss programs

Therapy and recovery: Cobalt 1000
Benefit	Cobalt 1000
Hospice Care (Hospice Home Visits: Unlimited; Respite: 240 hours; within the 6 month lifetime maximum)	In-network: $1,000 Deductible, then 30% Coinsurance, applies to $7,500 Out of Pocket Maximum Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Skilled Nursing Facility	In-network: $1,000 Deductible, then 30% Coinsurance, applies to $7,500 Out of Pocket Maximum Benefit details: Skilled Nursing Facility (90 days PCY; includes room and board, and facility billed professional and ancillary fees) Benefit details: Limited to 90 days per calendar year. Prior authorization required for all planned inpatient stays. Penalty for out-of-network: 50% of allowable charge to $1,500 per stay. Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Hospice Services	In-network: $1,000 Deductible, then 30% Coinsurance, applies to $7,500 Out of Pocket Maximum Benefit details: Hospice Inpatient Facility (Unlimited; within the 6 month lifetime maximum) Benefit details: Limited to 240 respite hours - 6 month overall lifetime benefit limit, except when approved otherwise. Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Rehabilitative Occupational and Rehabilitative Physical Therapy	In-network: $65 Copay, applies to the $7,500 Out of Pocket Maximum Benefit details: Outpatient Rehab, Including Physical and Occupational Therapy (45 visits PCY) Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Rehabilitative Speech Therapy	In-network: $65 Copay, applies to the $7,500 Out of Pocket Maximum Benefit details: Outpatient Speech Therapy (Applies to the outpatient rehab limit) Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Outpatient Neurodevelopmental Therapy	In-network: $65 Copay, applies to the $7,500 Out of Pocket Maximum Benefit details: Outpatient Neurodevelopmental Therapy (45 visits PCY) Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Durable Medical Equipment	In-network: $1,000 Deductible, then 30% Coinsurance, applies to $7,500 Out of Pocket Maximum Benefit details: Medical Supplies, Equipment, Prosthetics (Unlimited) Benefit details: Prior authorization required to buy some medical equipment. Penalty for out-of-network: 50% of allowable charge to $1,500 per occurrence. Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Home Health Care Services	In-network: 30% coinsurance Benefit details: Limited to 130 visits per calendar year Benefit details: SBC basis: All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Out-of-network: 50% coinsurance
Rehabilitation Services	In-network: Outpatient: $65 copay/visit Inpatient: 30% coinsurance Benefit details: Limited to 45 outpatient visits per calendar year, limited to 30 inpatient days per calendar year. Includes physical therapy, speech therapy, and occupational therapy. Prior authorization required for all planned inpatient stays. Penalty for out-of-network: 50% of allowable charge to $1,500 per stay. Benefit details: SBC basis: All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Out-of-network: 50% coinsurance
Habilitation Services	In-network: Outpatient: $65 copay/visit Inpatient: 30% coinsurance Benefit details: Limited to 45 outpatient visits per calendar year, limited to 30 inpatient days per calendar year. Includes physical therapy, speech therapy, and occupational therapy. Prior authorization required for all planned inpatient stays. Penalty for out-of-network: 50% of allowable charge to $1,500 per stay. Benefit details: SBC basis: All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Out-of-network: 50% coinsurance

Urgent and emergency care: Cobalt 1000
Benefit	Cobalt 1000
Emergency Room Services	In-network: $250 Copay then $1,000 Deductible and 30% Coinsurance; all cost shares apply to the $7,500 Out of Pocket Maximum Benefit details: Emergency Care (If applicable, waive copay if admitted to inpatient facility) Benefit details: Emergency room copay waived if admitted to hospital. Out-of-network: $250 Copay then $1,000 Deductible and 30% Coinsurance; all cost shares apply to the $7,500 Out of Pocket Maximum
Urgent Care Centers or Facilities	In-network: $65 Copay, applies to the $7,500 Out of Pocket Maximum Benefit details: Urgent Care Center Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Emergency Transportation/Ambulance	In-network: $1,000 Deductible, then 30% Coinsurance, applies to $7,500 Out of Pocket Maximum Benefit details: Ambulance Transportation (Unlimited) Out-of-network: $1,000 Deductible, then 30% Coinsurance, applies to $7,500 Out of Pocket Maximum

Other services: Cobalt 1000
Benefit	Cobalt 1000
Contraceptive Management Services (Unlimited)	In-network: Covered in Full Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Sterilization - Female (Unlimited)	In-network: Covered in Full Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Sterilization - Male (Unlimited)	In-network: Covered in Full Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Acupuncture	In-network: $35 Copay, applies to the $7,500 Out of Pocket Maximum Benefit details: Acupuncture (12 visits PCY) Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Chiropractic Care	In-network: $35 Copay, applies to the $7,500 Out of Pocket Maximum Benefit details: Manipulations (Spinal and other) (12 visits PCY) Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Routine Hearing Exam (Adult)	In-network: $35 Copay, applies to the $7,500 Out of Pocket Maximum Benefit details: Routine Hearing Exam (1 PCY) Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Hearing Aids	In-network: Covered in Full Benefit details: Hearing Hardware (1 device per ear every 3 years) Out-of-network: Covered in Full
Bariatric Surgery Notes & source Listed in the source exclusion summary. Check its exceptions and the issued contract for the exact terms.	Source statement: Bariatric Surgery is listed in the source exclusions; review the qualifications. Source exclusion context: (Check your policy or plan document for more information and a list of any other excluded services.) • Bariatric surgery • Cosmetic surgery • Dental care (Adult) • Infertility treatment • Long-term care • Private-duty nursing • Routine eye care (Adult) • Weight loss programs

Mental health and substance use: Cobalt 1000
Benefit	Cobalt 1000
Substance Abuse Disorder Inpatient Services	In-network: $1,000 Deductible, then 30% Coinsurance, applies to $7,500 Out of Pocket Maximum Benefit details: Chemical Dependency Inpatient Facility Care (Unlimited) Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Substance Abuse Disorder Outpatient Services	In-network: $35 Copay, applies to the $7,500 Out of Pocket Maximum Benefit details: Chemical Dependency Outpatient Professional Care (Unlimited) Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Mental/Behavioral Health Inpatient Services	In-network: $1,000 Deductible, then 30% Coinsurance, applies to $7,500 Out of Pocket Maximum Benefit details: Mental Health Inpatient Facility Care (Unlimited) Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Mental/Behavioral Health Outpatient Services	In-network: $35 Copay, applies to the $7,500 Out of Pocket Maximum Benefit details: Mental Health Outpatient Professional Care (Unlimited) Out-of-network: $2,000 Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum
Mental health and substance use outpatient services (SBC)	In-network: Office Visit: $35 copay/visit Facility: 30% coinsurance Benefit details: SBC basis: All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Out-of-network: 50% coinsurance
Mental health and substance use inpatient services (SBC)	In-network: 30% coinsurance Benefit details: Prior authorization required for all planned inpatient stays. Penalty for out-of-network: 50% of allowable charge to $1,500 per stay. Benefit details: SBC basis: All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Out-of-network: 50% coinsurance

Prescription drugs: Cobalt 1000
Benefit	Cobalt 1000
Formulary Drug List	In-network: Preferred B4 Tier 1 = generic Tier 2 = preferred brand Tier 3 = non-preferred brands Tier 4 = specialty
Annual Benefit Maximum	In-network: Unlimited
Family Deductible PCY	In-network: No Family Deductible
Out of Network (Non-participating retail pharmacies)	Out-of-network: Cost Share, then 40% (to allowable)
Out of Pocket Maximum	In-network: Applies to the medical out of pocket maximum
Retail Cost Shares	In-network: $20/$50/50%/50%
Mail Cost Shares	In-network: $60/$150/50%/50%
Day Supply	In-network: Retail: 90 Days, if applicable one copay every 30 day supply; Mail: 90 Days; Specialty: 30 Days
Generic Drugs	Retail: $20 Mail: $60 Benefit details: Retail: 90 Days, if applicable one copay every 30 day supply; Mail: 90 Days; Specialty: 30 Days Benefit details: Covers up to a 90 day supply (retail and mail). Retail pharmacies: One copay for each 30 day supply. No charge for specific preventive drugs. Prior authorization required for some drugs. Out-of-network: $20 copay/prescription + 40% coinsurance (retail), not covered (mail)
Preferred Brand Drugs	Retail: $50 Mail: $150 Benefit details: Retail: 90 Days, if applicable one copay every 30 day supply; Mail: 90 Days; Specialty: 30 Days Benefit details: Covers up to a 90 day supply (retail and mail). Retail pharmacies: One copay for each 30 day supply. Prior authorization required for some drugs. Out-of-network: $50 copay/prescription + 40% coinsurance (retail), not covered (mail)
Non-Preferred Brand Drugs	Retail: 50% Mail: 50% Benefit details: Retail: 90 Days, if applicable one copay every 30 day supply; Mail: 90 Days; Specialty: 30 Days Benefit details: Covers up to a 90 day supply (retail and mail). Prior authorization required for some drugs. Out-of-network: 50% coinsurance + 40% coinsurance (retail), not covered (mail)
Specialty Drugs	Retail: 50% Mail: 50% Benefit details: Retail: 90 Days, if applicable one copay every 30 day supply; Mail: 90 Days; Specialty: 30 Days Benefit details: Covers up to a 30 day supply. Prior authorization required for some drugs. Out-of-network: Not covered

Plan features and exclusions: Cobalt 1000
Benefit	Cobalt 1000
Annual Plan Maximum	In-network: Unlimited Out-of-network: Unlimited
Condition support programs	Benefit details: Diabetes Health Education (DE) (Unlimited): Covered in Full; Diabetes Management Plus: Excluded; Diabetes Prevention Plus: Excluded; Hypertension Plus: Excluded; Weight Management: Excluded; Comprehensive Weight Care: Excluded
Plan exclusions	Benefit details: (Check your policy or plan document for more information and a list of any other excluded services.) • Bariatric surgery • Cosmetic surgery • Dental care (Adult) • Infertility treatment • Long-term care • Private-duty nursing • Routine eye care (Adult) • Weight loss programs
Other covered services	Benefit details: : Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Chiropractic care or other spinal manipulations • Foot care • Hearing aids • Non-emergency care when traveling outside the U.S.

Network and access: Cobalt 1000
Benefit	Cobalt 1000
Provider network	HERITAGE
Specialist referrals	No. You can see the specialist you choose without a referral.
International coverage	Benefit details: Non-emergency care when traveling outside the U.S. Listed under Other Covered Services; limitations may apply. See the plan document for terms.

Pregnancy and childbirth: Cobalt 1000
Benefit	Cobalt 1000
Prenatal and Postnatal Care	In-network: No charge Benefit details: Cost sharing does not apply for preventive services. Depending on the type of services, a coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (such as, ultrasound). Benefit details: SBC basis: All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Out-of-network: Not covered
Delivery and All Inpatient Services for Maternity Care (Professional)	In-network: 30% coinsurance Benefit details: Cost sharing does not apply for preventive services. Depending on the type of services, a coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (such as, ultrasound). Benefit details: SBC basis: All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Out-of-network: 50% coinsurance
Delivery and All Inpatient Services for Maternity Care	In-network: 30% coinsurance Benefit details: Cost sharing does not apply for preventive services. Depending on the type of services, a coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (such as, ultrasound). Benefit details: SBC basis: All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Out-of-network: 50% coinsurance

Dental and vision: Cobalt 1000
Benefit	Cobalt 1000
Routine Eye Exam for Children	In-network: Not covered Benefit details: SBC basis: All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Out-of-network: Not covered
Eye Glasses for Children	In-network: Not covered Benefit details: SBC basis: All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Out-of-network: Not covered
Dental Check-Up for Children	In-network: Not covered Benefit details: SBC basis: All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Out-of-network: Not covered

Standardized coverage examples: Cobalt 1000
Benefit	Cobalt 1000
Having a baby example	Deductibles: $1,000 Copayments: $10 Coinsurance: $2,700 Limits or exclusions: $60 Benefit details: Standardized example based on self-only coverage, not a cost estimator. Actual care and costs will differ.
Managing diabetes example	Deductibles: $900 Copayments: $1,200 Coinsurance: $0 Limits or exclusions: $20 Benefit details: Standardized example based on self-only coverage, not a cost estimator. Actual care and costs will differ.
Simple fracture example	Deductibles: $1,000 Copayments: $700 Coinsurance: $300 Limits or exclusions: $0 Benefit details: Standardized example based on self-only coverage, not a cost estimator. Actual care and costs will differ.

Plan identifiers and filing context: Cobalt 1000
Benefit	Cobalt 1000
IHT source ID	iht-2027-premera-cobalt-1000
Plan name	Cobalt 1000
Legal issuer	Premera Blue Cross
Plan type	PPO
Effective date	2027-01-01
BHT metal classification Notes & source BHT plan-design similarity classification, not a carrier metal designation or actuarial-value calculation. Unknown is retained when reference evidence is insufficient or disagrees.	BHT classification: N/A (similar to Gold)

Health accounts: Cobalt 1000
Benefit	Cobalt 1000
HSA in source plan name Notes & source Whether the IHT source plan name contains HSA, including PHSA or HHSA.	No
HSA-compatible plan Notes & source BHT IHT name rule: HSA anywhere (including PHSA/HHSA) means Yes; otherwise No. Personal contribution eligibility is separate.	No

How costs are shared: Cobalt 1000
Benefit	Cobalt 1000
Coinsurance (Member's percentage of costs after deductible based on allowable charges)	In-network: 30% Out-of-network: 50%

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Plan documents

2027 · IHT plan ID iht-2027-premera-cobalt-1000

2027 IHT benefit highlights

Document notes

2027 BHT/IHT Premera source only. Medical benefits apply after the calendar-year deductible unless otherwise noted or the cost share is a copay. SBC cost shares are after deductible if applicable. Confirm the employer’s contract, Heritage/Heritage Prime network and renewal applicability. Industry-specific EOC booklets are marked tbd on the source page. No IHT premium is supplied.

2027 IHT Summary of Benefits and Coverage

Document notes

2027 IHT Side by Side Comparison

Document notes

2027 IHT BHT Med D, Creditable Coverage Notice

Document notes

2027 IHT Dual Choice Matrix

Document notes

2027 IHT Summary of Changes

Document notes

General insured large-group change summary; it explicitly says not all changes apply. It does not replace this plan’s exact highlights/SBC. 2027 BHT/IHT Premera source only. Medical benefits apply after the calendar-year deductible unless otherwise noted or the cost share is a copay. SBC cost shares are after deductible if applicable. Confirm the employer’s contract, Heritage/Heritage Prime network and renewal applicability. Industry-specific EOC booklets are marked tbd on the source page. No IHT premium is supplied.

2027 IHT Underwriting Guidelines

Document notes

Cobalt 1000

Plan benefits

▾Annual deductibles (3)

Medical deductible

Prescription drug deductible

SBC deductible and family structure

▾Other source benefits (20)

Non Specialist Office Visit Cost Share

Immunizations (Unlimited, subject to standard medical guidelines)

Health Education (HE) (Unlimited)

Nicotine Dependency Programs (ND) (Unlimited)

Diabetes Health Education (DE) (Unlimited)

Diabetes Management Plus

Diabetes Prevention Plus

Hypertension Plus

Weight Management

Comprehensive Weight Care

Preventive Imaging and Laboratory

Inpatient Professional Services

Birth Center

Transplant Travel & Lodging ($7,500 per transplant)

Emergency Room Physician

Inpatient Rehab (30 days PCY)

Outpatient Rehab for Chronic Conditions, Including Cardiac, Pulmonary Rehab, and Cancer (Unlimited)

Outpatient Massage Therapy (Applies to the outpatient rehab limit)

Inpatient Neurodevelopmental Therapy

Transplants (Unlimited)

▾Annual out-of-pocket limits (2)

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

Costs excluded from the out-of-pocket limit

▾Office and routine care (3)

Specialist Visit

Preventive Care/Screening/Immunization

Primary Care Visit to Treat an Injury or Illness

▾Carrier virtual care (5)

Kinwell Connect Cost Share Waiver (Excluded)

Telemedicine with Traditional Providers

Virtual General Medical

Virtual Mental Health

Virtual Chemical Dependency

▾Tests and imaging (6)

Breast Cancer Screening (including mammography)

Allergy/Therapeutic Injections

Laboratory Outpatient and Professional Services

X-rays and Diagnostic Imaging

Imaging (CT/PET Scans, MRIs)

Diagnostic Test (X-Ray and Blood Work)

▾Hospital and surgery (6)

Ambulatory Surgery Center

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

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

Outpatient Surgery Physician/Surgical Services

Inpatient Physician and Surgical Services

Cosmetic Surgery

▾Therapy and recovery (10)

Hospice Care (Hospice Home Visits: Unlimited; Respite: 240 hours; within the 6 month lifetime maximum)

Skilled Nursing Facility

Hospice Services

Rehabilitative Occupational and Rehabilitative Physical Therapy

Rehabilitative Speech Therapy

Outpatient Neurodevelopmental Therapy

Durable Medical Equipment

Home Health Care Services

Rehabilitation Services

Habilitation Services

▾Urgent and emergency care (3)

Emergency Room Services

Urgent Care Centers or Facilities

Emergency Transportation/Ambulance

▾Other services (8)

Contraceptive Management Services (Unlimited)

Sterilization - Female (Unlimited)

Sterilization - Male (Unlimited)

Acupuncture

Chiropractic Care

Routine Hearing Exam (Adult)

Hearing Aids

Bariatric Surgery

▾Mental health and substance use (6)

Substance Abuse Disorder Inpatient Services