Premera Multi-State Plan Blue Cross Silver 3000 CSR 73 (Washington)

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Company Premera Blue Cross
Plan Year 2014
State Washington
Metal Tier Silver
Plan Type PPO
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Cost Sharing Benefits (In Network)

These details are for the standard Silver plan. For reduced Cost Sharing versions scroll down below

Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.

Deductible (Individual) $3,000
Deductible (Family) $6,000
Coinsurance 20%
Out of Pocket Maximum (Individual) $5,000
Out of Pocket Maximum (Family) $10,000

Doctors Visits

Primary Care Visit $15 copay
Specialist Visit $45 copay
In Patient Hospital Services 20% coinsurance
Emergency Room Services $250 copay

Tests and Imaging

Imaging (CT/PET Scans, MRIs) 20% coinsurance
Laboratory Outpatient and Professional Services 20% coinsurance
X-ray and Diagnostic Imaging 20% coinsurance


Mental / Behavioral Health 20% coinsurance
Rehabilitative Speech Therapy 20% coinsurance
Rehabilitative Occupational & Physical Therapy 20% coinsurance
Outpatient Facility 20% coinsurance
Outpatient Surgery 20% coinsurance

Prescription Drugs

Generic Rx $10 copay
Preferred Brand Rx $50 copay
Non Preferred Brand Rx $0
Specialty Drugs 0.2

Other Plans

Other plans that are available in the state.

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