Highlights of your Health Care Coverage
The University of Puget Sound
Group Number: 1003592
Any deductibles, copays, and coinsurance percentages shown are amounts for which you’re responsible.
Medical Benefits apply after the calendar-year deductible is met unless otherwise noted, or if the cost share is a copay.
MEDICAL PLAN
Effective Date: 01/01/2016
Your Choice HRA NGF
HERITAGE PRIME
IN-NETWORK
OUT-OF-NETWORK
$1,500 PCY
$3,000 PCY
20%
40%
$4,000 PCY
$8,500 PCY
In Network Deductible, then 20%
Out of Network Deductible, then 40%
Covered in Full
Covered in Full
Covered In Full
Covered In Full
Covered In Full
Covered in Full
Covered in Full
Not Covered
Not Covered
Not Covered
In Network Deductible, then 20%
In Network Deductible, then 20%
Covered In Full
Out of Network Deductible, then 40%
Out of Network Deductible, then 40%
Out of Network Deductible, then 40%
Covered In Full
Out of Network Deductible, then 40%
In Network Deductible, then 20%
In Network Deductible, then 20%
In Network Deductible, then 20%
Out of Network Deductible, then 40%
Out of Network Deductible, then 40%
Out of Network Deductible, then 40%
In Network Deductible, then 20%
In Network Deductible, then 20%
Out of Network Deductible, then 40%
Out of Network Deductible, then 40%
In Network Deductible, then 20%
Out of Network Deductible, then 40%
$150 Copay, then In Network
Deductible, 20%
In Network Deductible, then 20%
In Network Deductible, then 20%
In Network Deductible, then 20%
$150 Copay, then In Network
Deductible, 20%
In Network Deductible, then 20%
In Network Deductible, then 20%
In Network Deductible, then 20%
MEDICAL COST SHARE OPTIONS
Individual Deductible PCY (Family embedded deductible 2X Individual)
Coinsurance (Member's percentage of costs after deductible based
on allowable charges)
Individual Out of Pocket Maximum PCY, includes deductible,
coinsurance, copay and pharmacy if applicable
(Family embedded OOP max 2X Individual)
Office Visit Cost Share
PREVENTIVE CARE OPTIONS AND HEALTH EDUCATION
Preventive Office Visit (Unlimited)
Immunizations (Unlimited)
Health Education (HE) (Unlimited)
Nicotine Dependency Programs (ND) (Unlimited)
Diabetes Health Education (DE) (Unlimited)
PROFESSIONAL CARE
Professional Office Visit Including Urgent Care
Inpatient Professional Services
Contraceptive Management Services (Unlimited)
DIAGNOSTIC SERVICE OPTIONS
Preventive Professional Diagnostic Imaging and Laboratory
Services - Including Mammogram and PAP/PSA
Other Professional Diagnostic Imaging
Other Professional Diagnostic Laboratory/Pathology
Diagnostic Mammography
FACILITY CARE OPTIONS
Inpatient Facility
Outpatient Surgery Facility
Hospice Inpatient Facility (10 days Inpatient; within the 6 month lifetime
maximum)
EMERGENCY CARE AND TRANSPORTATION OPTIONS
Emergency Care (If applicable, waive copay if admitted to inpatient
facility)
Emergency Room Physician
Ambulance Transportation
Air Ambulance
1-49YR7F Rev #1 Q
11/9/2015 10:02 AM
An Independent Licensee of the Blue Cross Blue Shield Association
Highlights of your Health Care Coverage
The University of Puget Sound
Group Number: 1003592
Any deductibles, copays, and coinsurance percentages shown are amounts for which you’re responsible.
Medical Benefits apply after the calendar-year deductible is met unless otherwise noted, or if the cost share is a copay.
MEDICAL PLAN
Effective Date: 01/01/2016
Your Choice HRA NGF
HERITAGE PRIME
IN-NETWORK
HERITAGE OUT-OF-NETWORK
In Network Deductible, then 20%
In Network Deductible, then 20%
In Network Deductible, then 20%
In Network Deductible, then 20%
In Network Deductible, then 20%
In Network Deductible, then 20%
Out of Network Deductible, then 40%
Out of Network Deductible, then 40%
Out of Network Deductible, then 40%
Out of Network Deductible, then 40%
Out of Network Deductible, then 40%
Out of Network Deductible, then 40%
In Network Deductible, then 20%
Out of Network Deductible, then 40%
In Network Deductible, then 20%
Out of Network Deductible, then 40%
In Network Deductible, then 20%
Out of Network Deductible, then 40%
In Network Deductible, then 20%
Out of Network Deductible, then 40%
In Network Deductible, then 20%
Out of Network Deductible, then 40%
In Network Deductible, then 20%
Out of Network Deductible, then 40%
Covered as any other service
Covered as any other service
Covered as any other service
Not Covered
In Network Deductible, then 20%
In Network Deductible, then 20%
Covered In Full
Out of Network Deductible, then 40%
Out of Network Deductible, then 40%
Out of Network Deductible, then 40%
In Network Deductible, then 20%
Waive In Network Deductible, then 20%
Exam: Subject to Office Visit Cost Share;
Test: Covered in Full
Out of Network Deductible, then 40%
Waive In Network Deductible, then 20%
Exam: Subject to Office Visit Cost
Share; Test: Covered in Full
Unlimited
Unlimited
OTHER SERVICES
Allergy/Therapeutic Injections
Mental Health Inpatient Facility Care (Unlimited)
Mental Health Outpatient Professional Care (Unlimited)
Chemical Dependency Inpatient Facility Care (Unlimited)
Chemical Dependency Outpatient Professional Care (Unlimited)
Rehab Inpatient Facility (60 days PCY)
Rehab Outpatient Care, Including Physical, Occupational, Speech
and Massage Therapy (60 visits PCY)
Rehab Outpatient Care Chronic Conditions, Including Cardiac,
Pulmonary Rehab, Chronic Pain and Cancer
Medical Supplies, Equipment, Prosthetics (MS: Unlimited, ME:
Unlimited, Pro: Unlimited)
Foot Orthotics, Orthopedic Shoes and Accessories ($300 PCY
(Unlimited Diabetes Related))
Home Health Visits (130 visits PCY)
Hospice Care (Hospice Home Visits: Unlimited; Respite: 240 hours;
within the 6 month lifetime maximum)
TMJ (Temporomandibular Joint Disorders) (Unlimited (Medical and
Dental services - Medical and Dental cost shares based on type of
service))
Transplants (Unlimited; $7,500 travel and lodging limits)
ALTERNATIVE CARE
Manipulations (Spinal and other) (12 visits PCY)
Acupuncture (12 visits PCY)
Nutritional Therapy (Unlimited)
SUPPLEMENTAL BENEFITS
Routine Vision Exam (1 PCY)
Pediatric Vision Exam (1 PCY under age 19)
Routine Hearing Exam (1 PCY)
ANNUAL PLAN MAXIMUM
Annual Plan Maximum
Copays are not subject to the deductible unless otherwise noted.
Prior Authorization is required for many services to be covered. For more information please refer to your benefit booklet.
PCY = Per Calendar Year. Balance billing may apply if a provider is not contracted with Premera Blue Cross. Members are responsible for amounts in excess of the allowable
charge.
This is not a complete explanation of covered services, exclusions, limitations, reductions or the terms under which the program may be continued in force. This benefit highlight
is not a contract. For full coverage provisions, including a description of waiting periods, limitations and exclusions please contact Customer Service.
1-49YR7F Rev #1 Q
11/9/2015 10:02 AM
An Independent Licensee of the Blue Cross Blue Shield Association
Highlights of your Health Care Coverage
The University of Puget Sound
Group Number: 1003592
Pharmacy Benefits
Tier 1 = Generic
Tier 2 = Preferred Brand Name
Tier 3 = Non Preferred Brand Name
Below is a brief overview of what you can expect to pay for a prescription drug, depending on which "tier" category it falls under in the Preferred Drug List
for your plan when using an In-Network Pharmacy. For more information on your pharmacy benefits, including Out-of-Network benefits, see your benefit
booklet. To find out what tier applies to a specific medication, see out Preferred Drug List in your pharmacy packet or at www.premera.com.
Any deductibles, copays, and coinsurance percentages shown are amounts for which you’re responsible.
PHARMACY PLAN
Effective Date: 01/01/2016
RX
Cost Share Category
Tier1/Tier2/Tier3
PRESCRIPTION DRUGS
Retail Cost Shares
$10/$30/$60
Mail Cost Shares
$20/$60/$120
Retail: 30 Days; Mail: 90 Days; Specialty: 30 Days
Day Supply
$0
Individual Deductible PCY
Cost Share, then 40% (to allowable)
Out of Network (Non-participating retail pharmacies)
Applies to the medical out of pocket maximum
Out of Pocket Maximum
Unlimited
Annual Benefit Maximum
Preferred B3
Drug List
PCY = Per Calendar Year. Balance billing may apply if a provider is not contracted with Premera Blue Cross. Members are responsible for amounts in excess of the allowable
charge.
This is not a complete explanation of covered services, exclusions, limitations, reductions or the terms under which the program may be continued in force. This benefit highlight
is not a contract. For full coverage provisions, including a description of waiting periods, limitations and exclusions please contact Customer Service.
1-49YR7F Rev #1 Q
11/9/2015 10:02 AM
An Independent Licensee of the Blue Cross Blue Shield Association