In-Network Deductible
(Individual/Family)
$1,500/$3,000
In-Network Out-of-Pocket Maximum
(Individual/Family)
$4,000/$8,000
Office Visits (PCP/Specialist)
$30/$50
Diagnostic Testing
Charges apply to deductible first then you pay 20% coinsurance.
Urgent Care:
$30
Prescription Drugs
Copays for 30 day supply (retail)
Generic: $10
Brand-Name: $25
Non- preferred brand: $50
Specialty: Above Copays Would Apply
Premera PPO 1500 Medical Plan Benefit Summary
Summary of Benefits & Coverage (SBC)