Premera Blue Cross
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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.
Balance is a PPO using Heritage Signature, a smaller network than Premera’s Heritage network, with out-of-network benefits at higher member costs. Office visits use deductible and coinsurance; eligible ambulatory surgery centers have lower coinsurance.
Premera · Heritage Signature and Dental Choice · Issuer 49831. Confirm current provider participation and exact coverage in the plan documents.
| Benefit | Premera Blue Cross Balance HSA Qualified 3600 Silver + Family Dental |
|---|---|
Medical and prescription drug deductibleNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 individual: $3,600 In-network tier 1 family: $3,600 per person | $7,200 per group In-network tier 1 coinsurance: 30.00% Out-of-network individual: $7,200 Out-of-network family: $7,200 per person | $14,400 per group Combined in/out-of-network individual: Not Applicable Combined in/out-of-network family: per person not applicable | per group not applicable |
| Benefit | Premera Blue Cross Balance HSA Qualified 3600 Silver + Family Dental |
|---|---|
Maximum Out of Pocket for Medical and Drug Benefits (Total)Notes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 individual: $8,650 In-network tier 1 family: $8,650 per person | $17,300 per group Out-of-network individual: Not Applicable Out-of-network family: per person not applicable | per group not applicable Combined in/out-of-network individual: Not Applicable Combined in/out-of-network family: per person not applicable | per group not applicable |
| Benefit | Premera Blue Cross Balance HSA Qualified 3600 Silver + Family Dental |
|---|---|
Combined medical and drug deductibleNotes & sourceWhether covered medical and prescription costs count toward the same deductible. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Yes |
Combined medical and drug spending limitNotes & sourceWhether covered medical and prescription costs count toward the same out-of-pocket limit. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Yes |
Specialty drug coinsurance capNotes & sourceA filed cap on the member’s percentage-based specialty drug cost, if supplied. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Hospital copay day limitNotes & sourceThe maximum number of hospital days charged a daily copay under the filed rule. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Unknown |
Primary care visits before cost sharingNotes & sourceThe filed number of primary care visits before member charges begin. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Primary care copays before other chargesNotes & sourceThe filed number of copay visits before a deductible or coinsurance rule begins. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Unknown |
| Benefit | Premera Blue Cross Balance HSA Qualified 3600 Silver + Family Dental |
|---|---|
Primary Care Visit to Treat an Injury or IllnessNotes & sourceA visit with a primary care clinician for an illness or injury. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Benefit details: There are no differences in cost sharing or benefit characteristics between in-person and virtual care services. See Professional Visits and Services and Virtual Care in the plan benefit booklet. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Specialist VisitNotes & sourceA visit with a clinician who focuses on a particular condition or area of medicine. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% 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 Practitioner Office Visit (Nurse, Physician Assistant)Notes & sourceAn office visit with a nurse practitioner, physician assistant, or another listed clinician. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Benefit details: There are no differences in cost sharing or benefit characteristics between in-person and virtual care services. See Professional Visits and Services and Virtual Care in the plan benefit booklet. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Preventive Care/Screening/ImmunizationNotes & sourceServices intended to prevent illness or detect health problems early. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: No Charge In-network tier 1 coinsurance: No Charge Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Well Baby Visits and CareNotes & sourceRoutine visits to check a baby’s health and development. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: No Charge In-network tier 1 coinsurance: Not Applicable 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: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | Premera Blue Cross Balance HSA Qualified 3600 Silver + Family Dental |
|---|---|
Imaging (CT/PET Scans, MRIs)Notes & sourceAdvanced scans used to examine the inside of the body. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Laboratory Outpatient and Professional ServicesNotes & sourceLaboratory testing without inpatient admission. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% 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 |
X-rays and Diagnostic ImagingNotes & sourceX-rays and other listed images used to help diagnose a health problem. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | Premera Blue Cross Balance HSA Qualified 3600 Silver + Family Dental |
|---|---|
Urgent Care Centers or FacilitiesNotes & sourceCare at an urgent care center for problems that need prompt attention. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% 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 |
Emergency Room ServicesNotes & sourceEvaluation and treatment of a medical emergency in an emergency department. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 30.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Emergency Transportation/AmbulanceNotes & sourceAmbulance or other listed transportation for an emergency. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 30.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | Premera Blue Cross Balance HSA Qualified 3600 Silver + Family Dental |
|---|---|
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Notes & sourceThe charge for using an outpatient facility, separate from a clinician’s professional fee. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Benefit details: Services rendered at an ambulatory surgery center is covered at lower cost share. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Outpatient Surgery Physician/Surgical ServicesNotes & sourceThe surgeon’s or other clinician’s services for surgery without inpatient admission. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Inpatient Hospital Services (e.g., Hospital Stay)Notes & sourceHospital facility services after admission as an inpatient. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Inpatient Physician and Surgical ServicesNotes & sourceClinicians’ professional services during an inpatient hospital stay. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Cosmetic SurgeryNotes & sourceSurgery mainly intended to change appearance. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Benefit details: Covers cosmetic surgery when medically necessary. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
TransplantNotes & sourceMedical care involving transplantation of an organ or tissue. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Reconstructive SurgeryNotes & sourceSurgery to restore function or repair a body part affected by injury, illness, or a birth condition. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Benefit details: Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state-base benchmark plan. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | Premera Blue Cross Balance HSA Qualified 3600 Silver + Family Dental |
|---|---|
Mental/Behavioral Health Outpatient ServicesNotes & sourceMental or behavioral health care without inpatient admission. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Benefit details: Office visits are subject to copay; other outpatient services in Silver plans are subject to deductible and coinsurance; other outpatient services in Gold plans are subject to coinsurance, deductible waived. See Mental Health Care in the plan benefit booklet. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Mental/Behavioral Health Inpatient ServicesNotes & sourceMental or behavioral health treatment during an inpatient stay. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Substance Abuse Disorder Outpatient ServicesNotes & sourceTreatment for substance use disorders without inpatient admission. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Benefit details: Office visits are subject to copay; other outpatient services in Silver plans are subject to deductible and coinsurance; other outpatient services in Gold plans are subject to coinsurance, deductible waived. See Substance Use Disorder in the plan benefit booklet. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Substance Abuse Disorder Inpatient ServicesNotes & sourceTreatment for substance use disorders during an inpatient stay. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | Premera Blue Cross Balance HSA Qualified 3600 Silver + Family Dental |
|---|---|
Generic DrugsNotes & sourceMedicines classified by the plan as generic drugs. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 30 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. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Preferred Brand DrugsNotes & sourceBrand-name medicines placed in the plan’s preferred drug category. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 30 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. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Non-Preferred Brand DrugsNotes & sourceBrand-name medicines outside the plan’s preferred drug category. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 30 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. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Specialty DrugsNotes & sourceMedicines placed in the plan’s specialty category, often requiring special handling or monitoring. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible 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. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Supply limits and coverage conditionsNotes & sourceRetail, mail-order and specialty prescription terms, with the source drug tiers and exceptions retained. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Generic Drugs; Preferred Brand Drugs; 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. Specialty Drugs · Benefit details: First fill allowed at a retail pharmacy. Additional fills must be provided at a specialty pharmacy. Coverage is limited to a 30-day supply for specialty and self-administrable cancer chemotherapy medications from a specialty pharmacy per fill or refill. |
Formulary tier 1Notes & sourceFiled formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Drug category: Zero Cost Share Preventive Drugs Three-month in-network mail order: No |
Formulary tier 2Notes & sourceFiled formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Drug category: Generic, Brand Three-month in-network mail order: Yes |
Formulary tier 3Notes & sourceFiled formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Drug category: Specialty Drugs Three-month in-network mail order: No |
Formulary tier 4Notes & sourceFiled formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Drug category: Medical Service Drugs Three-month in-network mail order: No |
| Benefit | Premera Blue Cross Balance HSA Qualified 3600 Silver + Family Dental |
|---|---|
Prenatal and Postnatal CareNotes & sourceCare during pregnancy and after childbirth. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: No Charge In-network tier 1 coinsurance: No Charge Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Delivery and All Inpatient Services for Maternity CareNotes & sourceCare for childbirth and related inpatient services. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Benefit details: Services rendered at a birthing center is covered at lower cost share. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Abortion for Which Public Funding is ProhibitedNotes & sourceThe filing’s category for abortion services that cannot receive public funding. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: No Charge after deductible In-network tier 1 coinsurance: No Charge after deductible Coverage: Covered Benefit details: Coverage includes termination of pregnancy for all female members. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | Premera Blue Cross Balance HSA Qualified 3600 Silver + Family Dental |
|---|---|
Hospice ServicesNotes & sourceCare focused on comfort and support near the end of life. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 14 Limit unit: Days per Lifetime Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Home Health Care ServicesNotes & sourceMedical care delivered at home under a care plan. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 130 Limit unit: Visit(s) per Year Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Skilled Nursing FacilityNotes & sourceCare in a facility providing skilled nursing or rehabilitation. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 60 Limit unit: Days per Year Benefit details: Coverage is limited to 60-inpatient days/year. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Outpatient Rehabilitation ServicesNotes & sourceTherapy to help restore abilities after illness or injury without inpatient admission. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 25 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 |
Habilitation ServicesNotes & sourceTherapy to help develop or maintain skills needed for daily activities. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Days per Year Benefit details: Coverage for habilitative services is limited to 30-inpatient days/year. Coverage for habilitative services is limited to 25-outpatient visits/year. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Rehabilitative Speech TherapyNotes & sourceTherapy to restore speech, communication, or swallowing abilities. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible 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. 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 |
Rehabilitative Occupational and Rehabilitative Physical TherapyNotes & sourceTherapy to restore movement or the ability to carry out everyday tasks. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible 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. 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 |
Infusion TherapyNotes & sourceTreatment that delivers medicine or fluids through a needle or catheter. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Benefit details: Covered under applicable benefit (such as office visit). Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Durable Medical EquipmentNotes & sourceMedical equipment for repeated use, such as a wheelchair or home oxygen equipment. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | Premera Blue Cross Balance HSA Qualified 3600 Silver + Family Dental |
|---|---|
Infertility TreatmentNotes & sourceMedical services to evaluate or treat difficulty becoming pregnant. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Benefit details: Coverage is limited to evaluation and diagnosis for infertility and in vivo fertilization. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Chiropractic CareNotes & sourceCare provided by a chiropractor, including listed spinal or joint treatments. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 10 Limit unit: Visit(s) per Year Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Hearing AidsNotes & sourceDevices that help improve hearing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: No Charge after deductible In-network tier 1 coinsurance: No Charge after deductible 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 are also covered. Out-of-network copay: No Charge after deductible Out-of-network coinsurance: No Charge after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Routine Foot CareNotes & sourceRegular foot care, such as listed nail or callus services. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
AcupunctureNotes & sourceTreatment using thin needles placed at specific points on the body. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% 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 |
DialysisNotes & sourceTreatment that filters the blood when the kidneys cannot do so adequately. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
ChemotherapyNotes & sourceDrug treatment used for cancer and certain other conditions. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Benefit details: Covered under the base benchmark plan. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
RadiationNotes & sourceTreatment using targeted radiation, commonly for cancer. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Benefit details: Covered under the base benchmark plan; covered under applicable benefit (such as office visit). Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Diabetes EducationNotes & sourceInstruction to help a person manage diabetes. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: No Charge In-network tier 1 coinsurance: No Charge Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Prosthetic DevicesNotes & sourceDevices that replace a missing body part. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Temporomandibular joint (TMJ) treatmentNotes & sourceTreatment for problems affecting the jaw joint and nearby muscles. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Nutritional CounselingNotes & sourceProfessional guidance on food choices and nutrition. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: 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 |
Gender Affirming CareNotes & sourceHealth services that support a person’s gender identity. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% 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 |
Diabetes Care ManagementNotes & sourceCoordinated support for managing diabetes and its treatment. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: No Charge In-network tier 1 coinsurance: No Charge Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Inherited Metabolic Disorder - PKUNotes & sourceCare for phenylketonuria, an inherited condition affecting how the body processes part of dietary protein. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% 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 |
Hearing examsNotes & sourceAn assessment 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: 30.00% Coinsurance after deductible 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: 30.00% Coinsurance after deductible Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | Premera Blue Cross Balance HSA Qualified 3600 Silver + Family Dental |
|---|---|
Routine Dental Services (Adult)Notes & sourceRegular dental care for adults, such as exams and cleanings. 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: 1000 Limit unit: Dollars per Year Benefit details: $1,000 Annual Maximum; shared between both In-Network and Out-of-Network Out-of-network copay: Not Applicable Out-of-network coinsurance: 30.00% Essential benefit variation: Not an essential health benefit Excluded from in-network spending limit: Yes Excluded from out-of-network spending limit: Yes |
Routine Eye Exam for ChildrenNotes & sourceRegular vision exams for children. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coverage: Covered Service limit: Yes Limit amount: 1 Limit unit: Exam(s) per Year Out-of-network copay: Not Applicable Out-of-network coinsurance: 20.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Eye Glasses for ChildrenNotes & sourcePrescription eyeglasses for children. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: No Charge In-network tier 1 coinsurance: No Charge Coverage: Covered Service limit: Yes Limit amount: 1 Limit unit: Item(s) per Year Benefit details: Coverage is limited to one frame and one pair (two lenses)/ calendar year or contacts (in lieu of glasses). Out-of-network copay: 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: No |
Dental Check-Up for ChildrenNotes & sourceRoutine dental exams for children. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable 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: Not Applicable Out-of-network coinsurance: 30.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Basic Dental Care - ChildNotes & sourceDental services classified as basic care for children, such as listed fillings. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 40.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Orthodontia - ChildNotes & sourceTreatment to align children’s teeth or jaws, such as braces. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 50.00% Coinsurance after deductible Coverage: Covered Benefit details: Medically necessary orthodontia must be 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 |
Major Dental Care - ChildNotes & sourceDental services classified as major care for children. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 50.00% Coinsurance after deductible 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% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Basic Dental Care - AdultNotes & sourceDental services classified as basic care for adults, 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% Coinsurance after deductible Coverage: Covered Benefit details: $50 Individual Deductible (shared between Basic & Major Services); shared between both In-Network and Out-of-Network. $1,000 Annual Maximum; shared between both In-Network and Out-of-Network Out-of-network copay: Not Applicable Out-of-network coinsurance: 40.00% Coinsurance after deductible Essential benefit variation: Not an essential health benefit Excluded from in-network spending limit: Yes Excluded from out-of-network spending limit: Yes |
Major Dental Care - AdultNotes & sourceDental services classified as major care for adults. 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% Coinsurance after deductible Coverage: Covered Benefit details: $50 Individual Deductible (shared between Basic & Major Services); shared between both In-Network and Out-of-Network. $1,000 Annual Maximum; shared between both In-Network and Out-of-Network. 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: Yes Excluded from out-of-network spending limit: Yes |
Dental AnesthesiaNotes & sourceAnesthesia used during dental treatment. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | Premera Blue Cross Balance HSA Qualified 3600 Silver + Family Dental |
|---|---|
Provider networkNotes & sourceThe insurer’s name for the network linked to this plan. Check the current provider directory to confirm a doctor or hospital participates. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Heritage Signature and Dental Choice |
Specialist referralNotes & sourceWhether the plan generally requires a referral before seeing a specialist. Check the listed exceptions. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
Referral detailsNotes & sourceThe insurer’s explanation of when specialist referrals are needed. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | The plan’s specialist-referral requirement is listed separately as No. The 2027 highlights state that prior authorization is required for many services to be covered; consult the benefit booklet. A referral and prior authorization are different requirements. |
Provider tiersNotes & sourceWhether in-network providers are grouped into tiers with different member costs. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
National networkNotes & sourceWhether the filing lists a national provider network; this does not confirm any particular provider participates. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Yes |
Care outside the countryNotes & sourceWhether the filing lists coverage outside the country; restrictions may apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Yes |
International care detailsNotes & sourceThe insurer’s explanation of coverage and restrictions outside the country. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Covered as any other non-contracted provider |
Care outside the service areaNotes & sourceWhether the filing lists coverage away from the plan’s normal service area. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Yes |
Outside-area care detailsNotes & sourceThe insurer’s explanation of care covered away from the normal service area. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | We have in-network providers available throughout the United States. |
| Benefit | Premera Blue Cross Balance HSA Qualified 3600 Silver + Family Dental |
|---|---|
HSA-compatible planNotes & sourceWhether the filing identifies the plan as HSA-compatible; your personal ability to contribute also depends on other rules. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Yes |
Filed employer account contributionNotes & sourceWhether the plan filing includes an employer HSA or HRA contribution; it does not describe your employer’s actual contribution. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
Filed contribution amountNotes & sourceThe employer account contribution amount included in the filing, if supplied. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
HSA in source plan nameNotes & sourceSource name evidence only; this does not establish personal HSA eligibility. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Yes |
| Benefit | Premera Blue Cross Balance HSA Qualified 3600 Silver + Family Dental |
|---|---|
Wellness programNotes & sourceWhether the filing lists a program intended to support healthy habits. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
Condition support programsNotes & sourcePrograms listed to help members manage ongoing health conditions. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Asthma, Heart Disease, Diabetes |
Plan designNotes & sourceThe plan design description supplied by the insurer. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Unknown |
Unique plan designNotes & sourceWhether the insurer marked the benefit design as distinct in its filing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
Plan exclusionsNotes & sourceServices or situations the insurer lists as excluded from coverage. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | The 2027 highlights exclude assisted reproduction treatments other than artificial insemination in vivo, which is covered. This is a partial exclusion list; consult the benefit booklet for all exclusions, limitations and coverage conditions. |
Pregnancy noticeNotes & sourceWhether the filing indicates a pregnancy-related notice requirement. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
Adult dental waiting periodNotes & sourceWhether the filing lists a wait before adult dental benefits begin. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Waiting period lengthNotes & sourceHow long the filed waiting period lasts, if supplied. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Child-only coverageNotes & sourceHow the filing describes coverage offered for children without an enrolled adult. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Allows Adult and Child-Only |
| Benefit | Premera Blue Cross Balance HSA Qualified 3600 Silver + Family Dental |
|---|---|
Having a baby exampleNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Example deductible: $3,600 Example copays: $0 Example coinsurance: $2,700 Example uncovered costs: $60 |
Managing diabetes exampleNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Example deductible: $3,600 Example copays: $0 Example coinsurance: $500 Example uncovered costs: $20 |
Simple fracture exampleNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Example deductible: $2,800 Example copays: $0 Example coinsurance: $0 Example uncovered costs: $0 |
| Benefit | Premera Blue Cross Balance HSA Qualified 3600 Silver + Family Dental |
|---|---|
Calculated actuarial valueNotes & sourceAn estimate of the share of covered costs the plan pays for a standard population, not your expected spending. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | 0.69965775676028 |
Insurer actuarial valueNotes & sourceThe insurer’s estimate of the plan’s share of covered costs for a standard population. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Unknown |
Tier 1 filing assumptionNotes & sourceThe use of tier 1 providers assumed in the filing, not a prediction of your care. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | 100% |
Tier 2 filing assumptionNotes & sourceThe use of tier 2 providers assumed in the filing, not a prediction of your care. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Unknown |
Essential benefit premium shareNotes & sourceThe filed portion of the premium allocated to essential health benefits. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Children’s dental allocationNotes & sourceThe filed allocation for children’s dental benefits. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Composite premium availableNotes & sourceWhether the filing offers a shared premium rate instead of separate age-based rates. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
Rate descriptionNotes & sourceWhether the insurer labels its filed rate as guaranteed or estimated. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
| Benefit | Premera Blue Cross Balance HSA Qualified 3600 Silver + Family Dental |
|---|---|
Plan IDNotes & sourceThe identifier used to distinguish this plan in the filing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | 49831WA1910004 |
Plan variation IDNotes & sourceIdentifies this plan’s specific version of benefits and cost sharing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | 49831WA1910004-00 |
Plan variation nameNotes & sourceThe insurer’s name for this version of the plan. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Premera Blue Cross Balance HSA Qualified 3600 Silver + Family Dental |
Cost-sharing variationNotes & sourceThe filed category for this version of the plan’s member costs. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Standard Silver Off Exchange Plan |
Product IDNotes & sourceThe identifier for the product family this plan belongs to. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | 49831WA191 |
Network IDNotes & sourceIdentifies this plan’s provider network within this insurer’s filing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | WAN003 |
Service area IDNotes & sourceIdentifies the area where the insurer offers this plan. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | WAS001 |
Drug list IDNotes & sourceIdentifies the prescription drug list referenced by this plan. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | WAF003 |
Marketplace statusNotes & sourceWhether the filing describes the plan as offered through the health insurance marketplace. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Off the Exchange |
New or existing planNotes & sourceWhether the insurer filed this as a new or continuing plan. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Existing |
Child-only plan IDNotes & sourceIdentifies a related child-only plan when one is supplied. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Tribal cost-sharing variationNotes & sourceIdentifies a special cost-sharing variation, if one is listed. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Effective dateNotes & sourceThe start date listed for this plan in the filing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | 1/1/2027 |
Expiration dateNotes & sourceThe end date listed in the filing; a blank does not mean coverage continues indefinitely. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Unknown |
Plan nameNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Premera Blue Cross Balance HSA Qualified 3600 Silver + Family Dental |
Legal issuerNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Premera Blue Cross |
Plan typeNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | PPO |
| Benefit | Premera Blue Cross Balance HSA Qualified 3600 Silver + Family Dental |
|---|---|
Virtual care optionsNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | 2027 highlights — Virtual Care Only, in network: General medical: $3,600 Deductible, then 30% Coinsurance, applies to $8,650 Out of Pocket Maximum. Mental health uses the mental health outpatient professional in-network cost share; chemical dependency uses the chemical dependency outpatient office-visit cost share. These virtual-only services are not covered out of network. Traditional-provider telemedicine is listed separately; confirm the provider and service in the benefit booklet. |
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2027 · Public plan ID 49831WA1910004 · Benefit variant 49831WA1910004-00
SBC unavailableYou can still review this plan’s other details.
Carrier source index; formats and available documents vary. No exact 2027 SBC acquired. The separately linked 2027 benefit highlights are summaries, not SBCs or complete coverage contracts.
Original identity review: Heritage Signature network reference, September 2025; provider counts and participation can change. This is not a 2027 coverage guarantee or a network eligibility/rating source. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.
Original identity review: PPO Heritage / Heritage Signature network comparison, September 2025. Provider participation and counts require current confirmation. Embedded and stand-alone dental networks differ; this does not change plan eligibility or pricing. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.
Original identity review: 2027 plan-specific benefit highlights, effective January 1, 2027. This is a summary that may change, not an SBC or a complete contract. See the benefit booklet for full terms, exclusions and waiting periods. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.
Original identity review: Virtual-care vendor reference, October 2025. Use the plan-specific 2027 highlights for cost sharing; included access does not mean free visits. Substance-use services depend on geography and prescribing rules; optional self-funded terms do not apply to these fully insured plans. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.
Original identity review: Public program reference linked from Premera’s current producer resources. Program availability and eligibility require confirmation; this reference does not establish plan-specific prices or replace the benefit booklet. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.
Original identity review: Public program reference linked from Premera’s current producer resources. Program availability and eligibility require confirmation; this reference does not establish plan-specific prices or replace the benefit booklet. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.
Original identity review: Public program reference linked from Premera’s current producer resources. Program availability and eligibility require confirmation; this reference does not establish plan-specific prices or replace the benefit booklet. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.
Original identity review: Small-group Diabetes Management Plus reference, November 2024. Enrollment requires a diabetes diagnosis; other eligibility and current availability require confirmation. It is not a standalone weight-loss benefit or a plan-specific price. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.
Original identity review: Public program reference linked from Premera’s current producer resources. Program availability and eligibility require confirmation; this reference does not establish plan-specific prices or replace the benefit booklet. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.
Original identity review: 2027 guide covers PPO, HSA-qualified, family-dental and HMO plans plus separate adult dental products. Use the matching plan section; stand-alone adult dental prices, contributions and waiting periods do not describe embedded family dental. Not an SBC or complete contract. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.
Original identity review: Small-group Medicare Part D creditable-coverage reference with separate 2026 and 2027 test columns, August 2026. Employer notice/testing duties remain; not an SBC, HMO-specific determination or pricing source. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.
Adams, Asotin, Benton, Chelan, Clallam, Columbia, Cowlitz, Douglas, Ferry, Franklin, Garfield, Grant, Grays Harbor, Island, Jefferson, King, Kitsap, Kittitas, Klickitat, Lewis, Lincoln, Mason, Okanogan, Pacific, Pend Oreille, Pierce, San Juan, Skagit, Skamania, Snohomish, Spokane, Stevens, Thurston, Wahkiakum, Walla Walla, Whatcom, Whitman, Yakima. Availability still depends on the coverage start and employer eligibility.
Estimate this plan and compare alternatives here, with the existing comparison PDF.