Premera Blue Cross · BHT Industry Health Trust
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All supported filed details, including known conditions and limits. This is not the entire insurance contract. Unknown does not mean $0 or not covered.
| Benefit | HSA 2500 |
|---|---|
Medical deductible | In-network: $2,500/$5,000 Benefit details: Individual Deductible PCY (Family aggregate deductible 2x Individual) Out-of-network: Shared with In-Network |
SBC deductible and family structure | Benefit details: Calendar year aggregate deductible. $2,500 Individual / $5,000 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 policy, the overall family deductible must be met before the plan begins to pay. |
| Benefit | HSA 2500 |
|---|---|
Office Visit Cost Share | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Out-of-network: Shared with In-Network 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: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Inpatient Professional Services | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Birth Center | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Transplant Travel & Lodging ($7,500 per transplant) | In-network: $2,500/$5,000 Deductible, 0% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Out-of-network: $2,500/$5,000 Deductible, 0% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum |
Emergency Care | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Out-of-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum |
Emergency Room Physician | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Out-of-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum |
Inpatient Rehab (30 days PCY) | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Out-of-network: Shared with In-Network 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: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Outpatient Massage Therapy (Applies to the outpatient rehab limit) | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Inpatient Neurodevelopmental Therapy | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Out-of-network: Shared with In-Network 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 |
| Benefit | HSA 2500 |
|---|---|
Maximum Out of Pocket for Medical and Drug Benefits (Total) | In-network: $6,500 / $13,000 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. |
| Benefit | HSA 2500 |
|---|---|
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: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Benefit details: Professional Office Visit Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Specialist Visit | In-network: 20% 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 |
| Benefit | HSA 2500 |
|---|---|
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: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Benefit details: Telemedicine with Traditional Providers - General Medical Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Virtual General Medical | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Benefit details: Telemedicine - General Medical (Virtual Care Only) Out-of-network: Not Covered |
Virtual Mental Health | In-network: Subject to Mental Health Outpatient Professional Care In-Network Cost Share Benefit details: Telemedicine - Mental Health (Virtual Care Only) Benefit details: Referenced Mental Health Outpatient Professional Care (Unlimited): $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Out-of-network: Not Covered |
Virtual Chemical Dependency | In-network: Subject to Chemical Dependency Outpatient Office Visit Cost Share Benefit details: Telemedicine - Chemical Dependency (Virtual Care Only) Benefit details: Referenced Chemical Dependency Outpatient Professional Care (Unlimited): $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Out-of-network: Not Covered |
| Benefit | HSA 2500 |
|---|---|
Breast Cancer Screening (including mammography) | In-network: Covered in Full Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Allergy/Therapeutic Injections | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Laboratory Outpatient and Professional Services | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Benefit details: Diagnostic Laboratory Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
X-rays and Diagnostic Imaging | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Benefit details: Basic Diagnostic Imaging Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Imaging (CT/PET Scans, MRIs) | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 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: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Diagnostic Test (X-Ray and Blood Work) | In-network: 20% 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 |
| Benefit | HSA 2500 |
|---|---|
Ambulatory Surgery Center | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Inpatient Hospital Services (e.g., Hospital Stay) | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 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: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 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: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Outpatient Surgery Physician/Surgical Services | In-network: 20% 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: 20% 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 SurgeryNotes & sourceListed 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 |
| Benefit | HSA 2500 |
|---|---|
Hospice Care (Hospice Home Visits: Unlimited; Respite: 240 hours; within the 6 month lifetime maximum) | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Skilled Nursing Facility | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Benefit details: Skilled Nursing Facility (60 days PCY; includes room and board, and facility billed professional and ancillary fees) Benefit details: Limited to 60 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: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Hospice Services | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Benefit details: Hospice Inpatient Facility (10 days Inpatient; within the 6 month lifetime maximum) Benefit details: Limited to 240 respite hours, limited to 10 inpatient days - 6 month overall lifetime benefit limit, except when approved otherwise. Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Rehabilitative Occupational and Rehabilitative Physical Therapy | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Benefit details: Outpatient Rehab, Including Physical and Occupational Therapy (45 visits PCY) Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Rehabilitative Speech Therapy | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Benefit details: Outpatient Speech Therapy (Applies to the outpatient rehab limit) Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Outpatient Neurodevelopmental Therapy | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Benefit details: Outpatient Neurodevelopmental Therapy (45 visits PCY) Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Durable Medical Equipment | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 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: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Home Health Care Services | In-network: 20% 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: 20% 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: 20% 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 |
| Benefit | HSA 2500 |
|---|---|
Urgent Care Centers or Facilities | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Benefit details: Urgent Care Center Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Emergency Transportation/Ambulance | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Benefit details: Ambulance Transportation (Unlimited) Out-of-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum |
Emergency Room Services | In-network: 20% 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: 20% coinsurance |
| Benefit | HSA 2500 |
|---|---|
Contraceptive Management Services (Unlimited) | In-network: Covered in Full Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Sterilization - Female (Unlimited) | In-network: Covered in Full Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Sterilization - Male (Unlimited) | In-network: Subject to the IRS Minimum Deductible, then 0% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Acupuncture | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Benefit details: Acupuncture (12 visits PCY) Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Chiropractic Care | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Benefit details: Manipulations (Spinal and other) (12 visits PCY) Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Routine Hearing Exam (Adult) | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Benefit details: Routine Hearing Exam (1 PCY) Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Hearing Aids | In-network: Subject to the IRS Minimum Deductible, then 0% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Benefit details: Hearing Hardware (1 device per ear every 3 years) Out-of-network: Subject to the IRS Minimum Deductible, then 0% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum |
Bariatric SurgeryNotes & sourceListed 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 |
| Benefit | HSA 2500 |
|---|---|
Substance Abuse Disorder Inpatient Services | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Benefit details: Chemical Dependency Inpatient Facility Care (Unlimited) Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Substance Abuse Disorder Outpatient Services | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Benefit details: Chemical Dependency Outpatient Professional Care (Unlimited) Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Mental/Behavioral Health Inpatient Services | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Benefit details: Mental Health Inpatient Facility Care (Unlimited) Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Mental/Behavioral Health Outpatient Services | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Benefit details: Mental Health Outpatient Professional Care (Unlimited) Out-of-network: Shared with In-Network Deductible, then 50% Coinsurance, applies to Unlimited Out of Pocket Maximum |
Mental health and substance use outpatient services (SBC) | In-network: 20% 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: 20% 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 |
| Benefit | HSA 2500 |
|---|---|
Formulary Drug List | In-network: Open A1 No Tiers Out-of-network: Open A1 No Tiers |
Prescription Drugs - Retail | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Benefit details: Prescription Drugs - Retail (Retail: 90 Days, if applicable one copay every 30 day supply; Mail: 90 Days; Specialty: 30 Days) Out-of-network: Specialty Drugs: Not Covered; All other Drugs: Same as In-network cost share |
Prescription Drugs - Mail | In-network: $2,500/$5,000 Deductible, then 20% Coinsurance, applies to $6,500 / $13,000 Out of Pocket Maximum Benefit details: Prescription Drugs - Mail (Retail: 90 Days, if applicable one copay every 30 day supply; Mail: 90 Days; Specialty: 30 Days) Out-of-network: Not Covered |
Generic Drugs | In-network: 20% coinsurance Benefit details: Covers up to a 90 day supply (retail and mail). No charge for specific preventive drugs. Prior authorization required for some drugs. 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: 20% coinsurance (retail), not covered (mail) |
Preferred Brand Drugs | In-network: 20% coinsurance Benefit details: Covers up to a 90 day supply (retail and mail). Prior authorization required for some drugs. 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: 20% coinsurance (retail), not covered (mail) |
Non-Preferred Brand Drugs | In-network: 20% coinsurance Benefit details: Covers up to a 90 day supply (retail and mail). Prior authorization required for some drugs. 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: 20% coinsurance (retail), not covered (mail) |
Specialty Drugs | In-network: 20% coinsurance Benefit details: Covers up to a 30 day supply. Prior authorization required for some drugs. 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 |
| Benefit | HSA 2500 |
|---|---|
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. |
| Benefit | HSA 2500 |
|---|---|
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. |
| Benefit | HSA 2500 |
|---|---|
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: 20% 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: 20% 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 |
| Benefit | HSA 2500 |
|---|---|
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 |
| Benefit | HSA 2500 |
|---|---|
Having a baby example | Deductibles: $2,500 Copayments: $0 Coinsurance: $1,500 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: $2,500 Copayments: $0 Coinsurance: $600 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: $2,500 Copayments: $0 Coinsurance: $60 Limits or exclusions: $0 Benefit details: Standardized example based on self-only coverage, not a cost estimator. Actual care and costs will differ. |
| Benefit | HSA 2500 |
|---|---|
IHT source ID | iht-2027-premera-hsa-2500 |
Plan name | HSA 2500 |
Legal issuer | Premera Blue Cross |
Plan type | PPO |
Effective date | 2027-01-01 |
BHT metal classificationNotes & sourceBHT 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) |
| Benefit | HSA 2500 |
|---|---|
HSA in source plan nameNotes & sourceWhether the IHT source plan name contains HSA, including PHSA or HHSA. | Yes |
HSA-compatible planNotes & sourceBHT IHT name rule: HSA anywhere (including PHSA/HHSA) means Yes; otherwise No. Personal contribution eligibility is separate. | Yes |
| Benefit | HSA 2500 |
|---|---|
Coinsurance (Member's percentage of costs after deductible based on allowable charges) | In-network: 20% Out-of-network: 50% |
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2027 · IHT plan ID iht-2027-premera-hsa-2500
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 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 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 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 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.
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 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.