Namara Marketplace

QHP Landscape SHOP Market Medical

State

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County

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Metal Level

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Issuer Name

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Plan Id (Standard Component)

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Plan Marketing Name

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Plan Type

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Rating Area

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Child Only Offering

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Source

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Customer Service Phone Number Local

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Customer Service Phone Number Toll Free

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Customer Service Phone Number Tty

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Network Url

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Plan Brochure Url

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Summary Of Benefits Url

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Drug Formulary Url

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Adult Dental

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Child Dental

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Premium Scenarios

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Premium Child

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Premium Adult Individual Age 21

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Premium Adult Individual Age 27

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Premium Adult Individual Age 30

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Premium Adult Individual Age 40

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Premium Adult Individual Age 50

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Premium Adult Individual Age 60

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Premium Couple 21

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Premium Couple 30

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Premium Couple 40

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Premium Couple 50

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Premium Couple 60

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Couple+1 Child, Age 21

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Couple+1 Child, Age 30

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Couple+1 Child, Age 40

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Couple+1 Child, Age 50

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Couple+2 Children, Age 21

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Couple+2 Children, Age 30

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Couple+2 Children, Age 40

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Couple+2 Children, Age 50

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Couple+3 Or More Children, Age 21

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Couple+3 Or More Children, Age 30

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Couple+3 Or More Children, Age 40

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Couple+3 Or More Children, Age 50

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Individual+1 Child, Age 21

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Individual+1 Child, Age 30

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Individual+1 Child, Age 40

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Individual+1 Child, Age 50

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Individual+2 Children, Age 21

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Individual+2 Children, Age 30

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Individual+2 Children, Age 40

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Individual+2 Children, Age 50

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Individual+3 Or More Children, Age 21

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Individual+3 Or More Children, Age 30

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Individual+3 Or More Children, Age 40

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Individual+3 Or More Children, Age 50

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Standard Plan Cost Sharing

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Medical Deductible - Individual

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Drug Deductible - Individual

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Medical Deductible -Family

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Drug Deductible -Family

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Medical Maximum Out Of Pocket -Individual

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Drug Maximum Out Of Pocket - Individual

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Medical Maximum Out Of Pocket -Family

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Drug Maximum Out Of Pocket - Family

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Primary Care Physician

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Specialist

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Emergency Room

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Inpatient Facility

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Inpatient Physician

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Generic Drugs

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Preferred Brand Drugs

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Non-Preferred Brand Drugs

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Specialty Drugs

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AK
ALEUTIANS EAST
Bronze
Moda Health Plan, Inc.
73836AK0680019
Beneficial 5000
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/producers/grp/med.shtml#tbd
https://www.modahealth.com/producers/grp/med.shtml
https://www.modahealth.com/medical/formularies.shtml?dn=ods
217.31
342.22
358.65
388.42
495.43
611.2
1052.1
684.44
776.84
990.86
1222.4
2104.21
901.75
994.15
1208.17
1439.71
1119.06
1211.46
1425.48
1657.02
1336.37
1428.77
1642.79
1874.33
559.53
605.73
712.74
828.51
776.84
823.04
930.05
1045.82
994.15
1040.35
1147.36
1263.13
5000
Included in Medical
10000
Included in Medical
6350
Included in Medical
12700
Included in Medical
$35 Copay and 50% Coinsurance
50%
50%
50%
50%
45%
45%
45%
45%
AK
ALEUTIANS EAST
Bronze
Moda Health Plan, Inc.
73836AK0680042
Beneficial 5000
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/producers/grp/med.shtml#tbd
https://www.modahealth.com/producers/grp/med.shtml
https://www.modahealth.com/medical/formularies.shtml?dn=ods
217.31
342.22
358.65
388.42
495.43
611.2
1052.1
684.44
776.84
990.86
1222.4
2104.21
901.75
994.15
1208.17
1439.71
1119.06
1211.46
1425.48
1657.02
1336.37
1428.77
1642.79
1874.33
559.53
605.73
712.74
828.51
776.84
823.04
930.05
1045.82
994.15
1040.35
1147.36
1263.13
5000
Included in Medical
10000
Included in Medical
6350
Included in Medical
12700
Included in Medical
$35 Copay and 50% Coinsurance
50%
50%
50%
50%
45%
45%
45%
45%
AK
ALEUTIANS EAST
Bronze
Premera Blue Cross Blue Shield of Alaska
38344AK0980011
Blue Cross Blue Shield Plus 5500, a Multi-State Plan
PPO
Rating Area 2
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028490.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
258
407
426
461
510
725
1083
814
922
1020
1450
2166
1072
1180
1278
1708
1330
1438
1536
1966
1588
1696
1794
2224
665
719
768
983
923
977
1026
1241
1181
1235
1284
1499
5500
Included in Medical
11000
Included in Medical
6350
Included in Medical
12700
Included in Medical
$15
$50
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
$25
50% Coinsurance after deductible
50% Coinsurance after deductible
20% Coinsurance after deductible
AK
ALEUTIANS EAST
Gold
Premera Blue Cross Blue Shield of Alaska
38344AK0930003
Blue Cross Blue Shield Select 1000, a Multi-State Plan
PPO
Rating Area 2
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028524.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
366
577
604
654
723
1030
1536
1154
1308
1446
2060
3072
1520
1674
1812
2426
1886
2040
2178
2792
2252
2406
2544
3158
943
1020
1089
1396
1309
1386
1455
1762
1675
1752
1821
2128
1000
$0
2000
See Plan Brochure
5000
Included in Medical
10000
Included in Medical
$30
$30
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
$10
$25
$45
20%
AK
ALEUTIANS EAST
Gold
Premera Blue Cross Blue Shield of Alaska
38344AK0980003
Blue Cross Blue Shield Plus 1000, a Multi-State Plan
PPO
Rating Area 2
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028492.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
355
559
585
634
701
997
1488
1118
1268
1402
1994
2976
1473
1623
1757
2349
1828
1978
2112
2704
2183
2333
2467
3059
914
989
1056
1352
1269
1344
1411
1707
1624
1699
1766
2062
1000
$0
2000
See Plan Brochure
5000
Included in Medical
10000
Included in Medical
$10
$40
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
$10
$40
50%
20%
AK
ALEUTIANS EAST
Gold
Premera Blue Cross Blue Shield of Alaska
38344AK0980004
Blue Cross Blue Shield Plus Gold 1500, a Multi-State Plan
PPO
Rating Area 2
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028493.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
348
549
575
622
688
979
1461
1098
1244
1376
1958
2922
1446
1592
1724
2306
1794
1940
2072
2654
2142
2288
2420
3002
897
970
1036
1327
1245
1318
1384
1675
1593
1666
1732
2023
1500
$0
3000
See Plan Brochure
4500
Included in Medical
9000
Included in Medical
$10
$40
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
$10
$40
$80
20%
AK
ALEUTIANS EAST
Silver
Moda Health Plan, Inc.
73836AK0680015
Beneficial 2000
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/producers/grp/med.shtml#tbd
https://www.modahealth.com/producers/grp/med.shtml
https://www.modahealth.com/medical/formularies.shtml?dn=ods
275.13
433.28
454.08
491.77
627.27
773.84
1332.09
866.56
983.54
1254.54
1547.68
2664.18
1141.69
1258.67
1529.67
1822.81
1416.82
1533.8
1804.8
2097.94
1691.94
1808.92
2079.92
2373.07
708.41
766.9
902.4
1048.97
983.54
1042.03
1177.53
1324.1
1258.67
1317.15
1452.65
1599.23
2000
Included in Medical
4000
Included in Medical
6000
Included in Medical
12000
Included in Medical
$35 Copay and 30% Coinsurance
30%
30%
30%
30%
$15
45%
45%
45%
AK
ALEUTIANS EAST
Silver
Moda Health Plan, Inc.
73836AK0680038
Beneficial 2000
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/producers/grp/med.shtml#tbd
https://www.modahealth.com/producers/grp/med.shtml
https://www.modahealth.com/medical/formularies.shtml?dn=ods
275.13
433.28
454.08
491.77
627.27
773.84
1332.09
866.56
983.54
1254.54
1547.68
2664.18
1141.69
1258.67
1529.67
1822.81
1416.82
1533.8
1804.8
2097.94
1691.94
1808.92
2079.92
2373.07
708.41
766.9
902.4
1048.97
983.54
1042.03
1177.53
1324.1
1258.67
1317.15
1452.65
1599.23
2000
Included in Medical
4000
Included in Medical
6000
Included in Medical
12000
Included in Medical
$35 Copay and 30% Coinsurance
30%
30%
30%
30%
$15
45%
45%
45%
AK
ALEUTIANS EAST
Silver
Premera Blue Cross Blue Shield of Alaska
38344AK0930005
Blue Cross Blue Shield Select 2000, a Multi-State Plan
PPO
Rating Area 2
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028526.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
336
530
554
601
664
945
1410
1060
1202
1328
1890
2820
1396
1538
1664
2226
1732
1874
2000
2562
2068
2210
2336
2898
866
937
1000
1281
1202
1273
1336
1617
1538
1609
1672
1953
2000
Included in Medical
4000
Included in Medical
6350
Included in Medical
12700
Included in Medical
$35
$35
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
$15
$50
$100
30% Coinsurance after deductible
AK
ALEUTIANS EAST
Silver
Premera Blue Cross Blue Shield of Alaska
38344AK0950001
Blue Cross Blue Shield Select 1700 HSA, a Multi-State Plan
PPO
Rating Area 2
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028489.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
324
510
534
579
640
911
1359
1020
1158
1280
1822
2718
1344
1482
1604
2146
1668
1806
1928
2470
1992
2130
2252
2794
834
903
964
1235
1158
1227
1288
1559
1482
1551
1612
1883
1700
Included in Medical
3400
Included in Medical
4600
Included in Medical
9200
Included in Medical
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
AK
ALEUTIANS WEST
Bronze
Moda Health Plan, Inc.
73836AK0680019
Beneficial 5000
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/producers/grp/med.shtml#tbd
https://www.modahealth.com/producers/grp/med.shtml
https://www.modahealth.com/medical/formularies.shtml?dn=ods
217.31
342.22
358.65
388.42
495.43
611.2
1052.1
684.44
776.84
990.86
1222.4
2104.21
901.75
994.15
1208.17
1439.71
1119.06
1211.46
1425.48
1657.02
1336.37
1428.77
1642.79
1874.33
559.53
605.73
712.74
828.51
776.84
823.04
930.05
1045.82
994.15
1040.35
1147.36
1263.13
5000
Included in Medical
10000
Included in Medical
6350
Included in Medical
12700
Included in Medical
$35 Copay and 50% Coinsurance
50%
50%
50%
50%
45%
45%
45%
45%
AK
ALEUTIANS WEST
Bronze
Moda Health Plan, Inc.
73836AK0680042
Beneficial 5000
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/producers/grp/med.shtml#tbd
https://www.modahealth.com/producers/grp/med.shtml
https://www.modahealth.com/medical/formularies.shtml?dn=ods
217.31
342.22
358.65
388.42
495.43
611.2
1052.1
684.44
776.84
990.86
1222.4
2104.21
901.75
994.15
1208.17
1439.71
1119.06
1211.46
1425.48
1657.02
1336.37
1428.77
1642.79
1874.33
559.53
605.73
712.74
828.51
776.84
823.04
930.05
1045.82
994.15
1040.35
1147.36
1263.13
5000
Included in Medical
10000
Included in Medical
6350
Included in Medical
12700
Included in Medical
$35 Copay and 50% Coinsurance
50%
50%
50%
50%
45%
45%
45%
45%
AK
ALEUTIANS WEST
Bronze
Premera Blue Cross Blue Shield of Alaska
38344AK0980011
Blue Cross Blue Shield Plus 5500, a Multi-State Plan
PPO
Rating Area 2
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028490.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
258
407
426
461
510
725
1083
814
922
1020
1450
2166
1072
1180
1278
1708
1330
1438
1536
1966
1588
1696
1794
2224
665
719
768
983
923
977
1026
1241
1181
1235
1284
1499
5500
Included in Medical
11000
Included in Medical
6350
Included in Medical
12700
Included in Medical
$15
$50
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
$25
50% Coinsurance after deductible
50% Coinsurance after deductible
20% Coinsurance after deductible
AK
ALEUTIANS WEST
Gold
Premera Blue Cross Blue Shield of Alaska
38344AK0930003
Blue Cross Blue Shield Select 1000, a Multi-State Plan
PPO
Rating Area 2
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028524.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
366
577
604
654
723
1030
1536
1154
1308
1446
2060
3072
1520
1674
1812
2426
1886
2040
2178
2792
2252
2406
2544
3158
943
1020
1089
1396
1309
1386
1455
1762
1675
1752
1821
2128
1000
$0
2000
See Plan Brochure
5000
Included in Medical
10000
Included in Medical
$30
$30
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
$10
$25
$45
20%
AK
ALEUTIANS WEST
Gold
Premera Blue Cross Blue Shield of Alaska
38344AK0980003
Blue Cross Blue Shield Plus 1000, a Multi-State Plan
PPO
Rating Area 2
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028492.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
355
559
585
634
701
997
1488
1118
1268
1402
1994
2976
1473
1623
1757
2349
1828
1978
2112
2704
2183
2333
2467
3059
914
989
1056
1352
1269
1344
1411
1707
1624
1699
1766
2062
1000
$0
2000
See Plan Brochure
5000
Included in Medical
10000
Included in Medical
$10
$40
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
$10
$40
50%
20%
AK
ALEUTIANS WEST
Gold
Premera Blue Cross Blue Shield of Alaska
38344AK0980004
Blue Cross Blue Shield Plus Gold 1500, a Multi-State Plan
PPO
Rating Area 2
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028493.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
348
549
575
622
688
979
1461
1098
1244
1376
1958
2922
1446
1592
1724
2306
1794
1940
2072
2654
2142
2288
2420
3002
897
970
1036
1327
1245
1318
1384
1675
1593
1666
1732
2023
1500
$0
3000
See Plan Brochure
4500
Included in Medical
9000
Included in Medical
$10
$40
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
$10
$40
$80
20%
AK
ALEUTIANS WEST
Silver
Moda Health Plan, Inc.
73836AK0680015
Beneficial 2000
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/producers/grp/med.shtml#tbd
https://www.modahealth.com/producers/grp/med.shtml
https://www.modahealth.com/medical/formularies.shtml?dn=ods
275.13
433.28
454.08
491.77
627.27
773.84
1332.09
866.56
983.54
1254.54
1547.68
2664.18
1141.69
1258.67
1529.67
1822.81
1416.82
1533.8
1804.8
2097.94
1691.94
1808.92
2079.92
2373.07
708.41
766.9
902.4
1048.97
983.54
1042.03
1177.53
1324.1
1258.67
1317.15
1452.65
1599.23
2000
Included in Medical
4000
Included in Medical
6000
Included in Medical
12000
Included in Medical
$35 Copay and 30% Coinsurance
30%
30%
30%
30%
$15
45%
45%
45%
AK
ALEUTIANS WEST
Silver
Moda Health Plan, Inc.
73836AK0680038
Beneficial 2000
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/producers/grp/med.shtml#tbd
https://www.modahealth.com/producers/grp/med.shtml
https://www.modahealth.com/medical/formularies.shtml?dn=ods
275.13
433.28
454.08
491.77
627.27
773.84
1332.09
866.56
983.54
1254.54
1547.68
2664.18
1141.69
1258.67
1529.67
1822.81
1416.82
1533.8
1804.8
2097.94
1691.94
1808.92
2079.92
2373.07
708.41
766.9
902.4
1048.97
983.54
1042.03
1177.53
1324.1
1258.67
1317.15
1452.65
1599.23
2000
Included in Medical
4000
Included in Medical
6000
Included in Medical
12000
Included in Medical
$35 Copay and 30% Coinsurance
30%
30%
30%
30%
$15
45%
45%
45%
AK
ALEUTIANS WEST
Silver
Premera Blue Cross Blue Shield of Alaska
38344AK0930005
Blue Cross Blue Shield Select 2000, a Multi-State Plan
PPO
Rating Area 2
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028526.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
336
530
554
601
664
945
1410
1060
1202
1328
1890
2820
1396
1538
1664
2226
1732
1874
2000
2562
2068
2210
2336
2898
866
937
1000
1281
1202
1273
1336
1617
1538
1609
1672
1953
2000
Included in Medical
4000
Included in Medical
6350
Included in Medical
12700
Included in Medical
$35
$35
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
$15
$50
$100
30% Coinsurance after deductible
AK
ALEUTIANS WEST
Silver
Premera Blue Cross Blue Shield of Alaska
38344AK0950001
Blue Cross Blue Shield Select 1700 HSA, a Multi-State Plan
PPO
Rating Area 2
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028489.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
324
510
534
579
640
911
1359
1020
1158
1280
1822
2718
1344
1482
1604
2146
1668
1806
1928
2470
1992
2130
2252
2794
834
903
964
1235
1158
1227
1288
1559
1482
1551
1612
1883
1700
Included in Medical
3400
Included in Medical
4600
Included in Medical
9200
Included in Medical
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
AK
ANCHORAGE
Bronze
Moda Health Plan, Inc.
73836AK0680019
Beneficial 5000
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/producers/grp/med.shtml#tbd
https://www.modahealth.com/producers/grp/med.shtml
https://www.modahealth.com/medical/formularies.shtml?dn=ods
217.31
342.22
358.65
388.42
495.43
611.2
1052.1
684.44
776.84
990.86
1222.4
2104.21
901.75
994.15
1208.17
1439.71
1119.06
1211.46
1425.48
1657.02
1336.37
1428.77
1642.79
1874.33
559.53
605.73
712.74
828.51
776.84
823.04
930.05
1045.82
994.15
1040.35
1147.36
1263.13
5000
Included in Medical
10000
Included in Medical
6350
Included in Medical
12700
Included in Medical
$35 Copay and 50% Coinsurance
50%
50%
50%
50%
45%
45%
45%
45%
AK
ANCHORAGE
Bronze
Moda Health Plan, Inc.
73836AK0680042
Beneficial 5000
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/producers/grp/med.shtml#tbd
https://www.modahealth.com/producers/grp/med.shtml
https://www.modahealth.com/medical/formularies.shtml?dn=ods
217.31
342.22
358.65
388.42
495.43
611.2
1052.1
684.44
776.84
990.86
1222.4
2104.21
901.75
994.15
1208.17
1439.71
1119.06
1211.46
1425.48
1657.02
1336.37
1428.77
1642.79
1874.33
559.53
605.73
712.74
828.51
776.84
823.04
930.05
1045.82
994.15
1040.35
1147.36
1263.13
5000
Included in Medical
10000
Included in Medical
6350
Included in Medical
12700
Included in Medical
$35 Copay and 50% Coinsurance
50%
50%
50%
50%
45%
45%
45%
45%
AK
ANCHORAGE
Bronze
Premera Blue Cross Blue Shield of Alaska
38344AK0980012
Blue Cross Blue Shield Plus 6350, a Multi-State Plan
PPO
Rating Area 1
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028491.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
271
428
448
485
537
764
1140
856
970
1074
1528
2280
1127
1241
1345
1799
1398
1512
1616
2070
1669
1783
1887
2341
699
756
808
1035
970
1027
1079
1306
1241
1298
1350
1577
6350
Included in Medical
12700
Included in Medical
6350
Included in Medical
12700
Included in Medical
$25
$50
No Charge after Deductible
No Charge after Deductible
No Charge after Deductible
No Charge after Deductible
No Charge after Deductible
No Charge after Deductible
No Charge after Deductible
AK
ANCHORAGE
Bronze
Premera Blue Cross Blue Shield of Alaska
38344AK1000003
Blue Cross Blue Shield Plus 3850 HSA, a Multi-State Plan
PPO
Rating Area 1
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028496.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
258
407
426
461
510
726
1084
814
922
1020
1452
2168
1072
1180
1278
1710
1330
1438
1536
1968
1588
1696
1794
2226
665
719
768
984
923
977
1026
1242
1181
1235
1284
1500
3850
Included in Medical
7700
Included in Medical
6350
Included in Medical
12700
Included in Medical
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
AK
ANCHORAGE
Gold
Premera Blue Cross Blue Shield of Alaska
38344AK0980003
Blue Cross Blue Shield Plus 1000, a Multi-State Plan
PPO
Rating Area 1
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028492.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
362
570
597
646
715
1017
1517
1140
1292
1430
2034
3034
1502
1654
1792
2396
1864
2016
2154
2758
2226
2378
2516
3120
932
1008
1077
1379
1294
1370
1439
1741
1656
1732
1801
2103
1000
$0
2000
See Plan Brochure
5000
Included in Medical
10000
Included in Medical
$10
$40
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
$10
$40
50%
20%
AK
ANCHORAGE
Silver
Moda Health Plan, Inc.
73836AK0680015
Beneficial 2000
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/producers/grp/med.shtml#tbd
https://www.modahealth.com/producers/grp/med.shtml
https://www.modahealth.com/medical/formularies.shtml?dn=ods
275.13
433.28
454.08
491.77
627.27
773.84
1332.09
866.56
983.54
1254.54
1547.68
2664.18
1141.69
1258.67
1529.67
1822.81
1416.82
1533.8
1804.8
2097.94
1691.94
1808.92
2079.92
2373.07
708.41
766.9
902.4
1048.97
983.54
1042.03
1177.53
1324.1
1258.67
1317.15
1452.65
1599.23
2000
Included in Medical
4000
Included in Medical
6000
Included in Medical
12000
Included in Medical
$35 Copay and 30% Coinsurance
30%
30%
30%
30%
$15
45%
45%
45%
AK
ANCHORAGE
Silver
Moda Health Plan, Inc.
73836AK0680038
Beneficial 2000
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/producers/grp/med.shtml#tbd
https://www.modahealth.com/producers/grp/med.shtml
https://www.modahealth.com/medical/formularies.shtml?dn=ods
275.13
433.28
454.08
491.77
627.27
773.84
1332.09
866.56
983.54
1254.54
1547.68
2664.18
1141.69
1258.67
1529.67
1822.81
1416.82
1533.8
1804.8
2097.94
1691.94
1808.92
2079.92
2373.07
708.41
766.9
902.4
1048.97
983.54
1042.03
1177.53
1324.1
1258.67
1317.15
1452.65
1599.23
2000
Included in Medical
4000
Included in Medical
6000
Included in Medical
12000
Included in Medical
$35 Copay and 30% Coinsurance
30%
30%
30%
30%
$15
45%
45%
45%
AK
ANCHORAGE
Silver
Premera Blue Cross Blue Shield of Alaska
38344AK0950001
Blue Cross Blue Shield Select 1700 HSA, a Multi-State Plan
PPO
Rating Area 1
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028489.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
330
521
545
590
653
929
1386
1042
1180
1306
1858
2772
1372
1510
1636
2188
1702
1840
1966
2518
2032
2170
2296
2848
851
920
983
1259
1181
1250
1313
1589
1511
1580
1643
1919
1700
Included in Medical
3400
Included in Medical
4600
Included in Medical
9200
Included in Medical
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
AK
BETHEL
Bronze
Moda Health Plan, Inc.
73836AK0680019
Beneficial 5000
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/producers/grp/med.shtml#tbd
https://www.modahealth.com/producers/grp/med.shtml
https://www.modahealth.com/medical/formularies.shtml?dn=ods
217.31
342.22
358.65
388.42
495.43
611.2
1052.1
684.44
776.84
990.86
1222.4
2104.21
901.75
994.15
1208.17
1439.71
1119.06
1211.46
1425.48
1657.02
1336.37
1428.77
1642.79
1874.33
559.53
605.73
712.74
828.51
776.84
823.04
930.05
1045.82
994.15
1040.35
1147.36
1263.13
5000
Included in Medical
10000
Included in Medical
6350
Included in Medical
12700
Included in Medical
$35 Copay and 50% Coinsurance
50%
50%
50%
50%
45%
45%
45%
45%
AK
BETHEL
Bronze
Moda Health Plan, Inc.
73836AK0680042
Beneficial 5000
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/producers/grp/med.shtml#tbd
https://www.modahealth.com/producers/grp/med.shtml
https://www.modahealth.com/medical/formularies.shtml?dn=ods
217.31
342.22
358.65
388.42
495.43
611.2
1052.1
684.44
776.84
990.86
1222.4
2104.21
901.75
994.15
1208.17
1439.71
1119.06
1211.46
1425.48
1657.02
1336.37
1428.77
1642.79
1874.33
559.53
605.73
712.74
828.51
776.84
823.04
930.05
1045.82
994.15
1040.35
1147.36
1263.13
5000
Included in Medical
10000
Included in Medical
6350
Included in Medical
12700
Included in Medical
$35 Copay and 50% Coinsurance
50%
50%
50%
50%
45%
45%
45%
45%
AK
BETHEL
Bronze
Premera Blue Cross Blue Shield of Alaska
38344AK0980012
Blue Cross Blue Shield Plus 6350, a Multi-State Plan
PPO
Rating Area 1
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028491.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
271
428
448
485
537
764
1140
856
970
1074
1528
2280
1127
1241
1345
1799
1398
1512
1616
2070
1669
1783
1887
2341
699
756
808
1035
970
1027
1079
1306
1241
1298
1350
1577
6350
Included in Medical
12700
Included in Medical
6350
Included in Medical
12700
Included in Medical
$25
$50
No Charge after Deductible
No Charge after Deductible
No Charge after Deductible
No Charge after Deductible
No Charge after Deductible
No Charge after Deductible
No Charge after Deductible
AK
BETHEL
Bronze
Premera Blue Cross Blue Shield of Alaska
38344AK1000003
Blue Cross Blue Shield Plus 3850 HSA, a Multi-State Plan
PPO
Rating Area 1
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028496.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
258
407
426
461
510
726
1084
814
922
1020
1452
2168
1072
1180
1278
1710
1330
1438
1536
1968
1588
1696
1794
2226
665
719
768
984
923
977
1026
1242
1181
1235
1284
1500
3850
Included in Medical
7700
Included in Medical
6350
Included in Medical
12700
Included in Medical
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
AK
BETHEL
Gold
Premera Blue Cross Blue Shield of Alaska
38344AK0980003
Blue Cross Blue Shield Plus 1000, a Multi-State Plan
PPO
Rating Area 1
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028492.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
362
570
597
646
715
1017
1517
1140
1292
1430
2034
3034
1502
1654
1792
2396
1864
2016
2154
2758
2226
2378
2516
3120
932
1008
1077
1379
1294
1370
1439
1741
1656
1732
1801
2103
1000
$0
2000
See Plan Brochure
5000
Included in Medical
10000
Included in Medical
$10
$40
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
$10
$40
50%
20%
AK
BETHEL
Silver
Moda Health Plan, Inc.
73836AK0680015
Beneficial 2000
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/producers/grp/med.shtml#tbd
https://www.modahealth.com/producers/grp/med.shtml
https://www.modahealth.com/medical/formularies.shtml?dn=ods
275.13
433.28
454.08
491.77
627.27
773.84
1332.09
866.56
983.54
1254.54
1547.68
2664.18
1141.69
1258.67
1529.67
1822.81
1416.82
1533.8
1804.8
2097.94
1691.94
1808.92
2079.92
2373.07
708.41
766.9
902.4
1048.97
983.54
1042.03
1177.53
1324.1
1258.67
1317.15
1452.65
1599.23
2000
Included in Medical
4000
Included in Medical
6000
Included in Medical
12000
Included in Medical
$35 Copay and 30% Coinsurance
30%
30%
30%
30%
$15
45%
45%
45%
AK
BETHEL
Silver
Moda Health Plan, Inc.
73836AK0680038
Beneficial 2000
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/producers/grp/med.shtml#tbd
https://www.modahealth.com/producers/grp/med.shtml
https://www.modahealth.com/medical/formularies.shtml?dn=ods
275.13
433.28
454.08
491.77
627.27
773.84
1332.09
866.56
983.54
1254.54
1547.68
2664.18
1141.69
1258.67
1529.67
1822.81
1416.82
1533.8
1804.8
2097.94
1691.94
1808.92
2079.92
2373.07
708.41
766.9
902.4
1048.97
983.54
1042.03
1177.53
1324.1
1258.67
1317.15
1452.65
1599.23
2000
Included in Medical
4000
Included in Medical
6000
Included in Medical
12000
Included in Medical
$35 Copay and 30% Coinsurance
30%
30%
30%
30%
$15
45%
45%
45%
AK
BETHEL
Silver
Premera Blue Cross Blue Shield of Alaska
38344AK0950001
Blue Cross Blue Shield Select 1700 HSA, a Multi-State Plan
PPO
Rating Area 1
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028489.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
330
521
545
590
653
929
1386
1042
1180
1306
1858
2772
1372
1510
1636
2188
1702
1840
1966
2518
2032
2170
2296
2848
851
920
983
1259
1181
1250
1313
1589
1511
1580
1643
1919
1700
Included in Medical
3400
Included in Medical
4600
Included in Medical
9200
Included in Medical
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
AK
BRISTOL BAY BOROUGH
Bronze
Moda Health Plan, Inc.
73836AK0680019
Beneficial 5000
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/producers/grp/med.shtml#tbd
https://www.modahealth.com/producers/grp/med.shtml
https://www.modahealth.com/medical/formularies.shtml?dn=ods
217.31
342.22
358.65
388.42
495.43
611.2
1052.1
684.44
776.84
990.86
1222.4
2104.21
901.75
994.15
1208.17
1439.71
1119.06
1211.46
1425.48
1657.02
1336.37
1428.77
1642.79
1874.33
559.53
605.73
712.74
828.51
776.84
823.04
930.05
1045.82
994.15
1040.35
1147.36
1263.13
5000
Included in Medical
10000
Included in Medical
6350
Included in Medical
12700
Included in Medical
$35 Copay and 50% Coinsurance
50%
50%
50%
50%
45%
45%
45%
45%
AK
BRISTOL BAY BOROUGH
Bronze
Moda Health Plan, Inc.
73836AK0680042
Beneficial 5000
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/producers/grp/med.shtml#tbd
https://www.modahealth.com/producers/grp/med.shtml
https://www.modahealth.com/medical/formularies.shtml?dn=ods
217.31
342.22
358.65
388.42
495.43
611.2
1052.1
684.44
776.84
990.86
1222.4
2104.21
901.75
994.15
1208.17
1439.71
1119.06
1211.46
1425.48
1657.02
1336.37
1428.77
1642.79
1874.33
559.53
605.73
712.74
828.51
776.84
823.04
930.05
1045.82
994.15
1040.35
1147.36
1263.13
5000
Included in Medical
10000
Included in Medical
6350
Included in Medical
12700
Included in Medical
$35 Copay and 50% Coinsurance
50%
50%
50%
50%
45%
45%
45%
45%
AK
BRISTOL BAY BOROUGH
Bronze
Premera Blue Cross Blue Shield of Alaska
38344AK0980011
Blue Cross Blue Shield Plus 5500, a Multi-State Plan
PPO
Rating Area 2
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028490.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
258
407
426
461
510
725
1083
814
922
1020
1450
2166
1072
1180
1278
1708
1330
1438
1536
1966
1588
1696
1794
2224
665
719
768
983
923
977
1026
1241
1181
1235
1284
1499
5500
Included in Medical
11000
Included in Medical
6350
Included in Medical
12700
Included in Medical
$15
$50
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
$25
50% Coinsurance after deductible
50% Coinsurance after deductible
20% Coinsurance after deductible
AK
BRISTOL BAY BOROUGH
Gold
Premera Blue Cross Blue Shield of Alaska
38344AK0930003
Blue Cross Blue Shield Select 1000, a Multi-State Plan
PPO
Rating Area 2
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028524.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
366
577
604
654
723
1030
1536
1154
1308
1446
2060
3072
1520
1674
1812
2426
1886
2040
2178
2792
2252
2406
2544
3158
943
1020
1089
1396
1309
1386
1455
1762
1675
1752
1821
2128
1000
$0
2000
See Plan Brochure
5000
Included in Medical
10000
Included in Medical
$30
$30
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
$10
$25
$45
20%
AK
BRISTOL BAY BOROUGH
Gold
Premera Blue Cross Blue Shield of Alaska
38344AK0980003
Blue Cross Blue Shield Plus 1000, a Multi-State Plan
PPO
Rating Area 2
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028492.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
355
559
585
634
701
997
1488
1118
1268
1402
1994
2976
1473
1623
1757
2349
1828
1978
2112
2704
2183
2333
2467
3059
914
989
1056
1352
1269
1344
1411
1707
1624
1699
1766
2062
1000
$0
2000
See Plan Brochure
5000
Included in Medical
10000
Included in Medical
$10
$40
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
$10
$40
50%
20%
AK
BRISTOL BAY BOROUGH
Gold
Premera Blue Cross Blue Shield of Alaska
38344AK0980004
Blue Cross Blue Shield Plus Gold 1500, a Multi-State Plan
PPO
Rating Area 2
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028493.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
348
549
575
622
688
979
1461
1098
1244
1376
1958
2922
1446
1592
1724
2306
1794
1940
2072
2654
2142
2288
2420
3002
897
970
1036
1327
1245
1318
1384
1675
1593
1666
1732
2023
1500
$0
3000
See Plan Brochure
4500
Included in Medical
9000
Included in Medical
$10
$40
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
$10
$40
$80
20%
AK
BRISTOL BAY BOROUGH
Silver
Moda Health Plan, Inc.
73836AK0680015
Beneficial 2000
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/producers/grp/med.shtml#tbd
https://www.modahealth.com/producers/grp/med.shtml
https://www.modahealth.com/medical/formularies.shtml?dn=ods
275.13
433.28
454.08
491.77
627.27
773.84
1332.09
866.56
983.54
1254.54
1547.68
2664.18
1141.69
1258.67
1529.67
1822.81
1416.82
1533.8
1804.8
2097.94
1691.94
1808.92
2079.92
2373.07
708.41
766.9
902.4
1048.97
983.54
1042.03
1177.53
1324.1
1258.67
1317.15
1452.65
1599.23
2000
Included in Medical
4000
Included in Medical
6000
Included in Medical
12000
Included in Medical
$35 Copay and 30% Coinsurance
30%
30%
30%
30%
$15
45%
45%
45%
AK
BRISTOL BAY BOROUGH
Silver
Moda Health Plan, Inc.
73836AK0680038
Beneficial 2000
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/producers/grp/med.shtml#tbd
https://www.modahealth.com/producers/grp/med.shtml
https://www.modahealth.com/medical/formularies.shtml?dn=ods
275.13
433.28
454.08
491.77
627.27
773.84
1332.09
866.56
983.54
1254.54
1547.68
2664.18
1141.69
1258.67
1529.67
1822.81
1416.82
1533.8
1804.8
2097.94
1691.94
1808.92
2079.92
2373.07
708.41
766.9
902.4
1048.97
983.54
1042.03
1177.53
1324.1
1258.67
1317.15
1452.65
1599.23
2000
Included in Medical
4000
Included in Medical
6000
Included in Medical
12000
Included in Medical
$35 Copay and 30% Coinsurance
30%
30%
30%
30%
$15
45%
45%
45%
AK
BRISTOL BAY BOROUGH
Silver
Premera Blue Cross Blue Shield of Alaska
38344AK0930005
Blue Cross Blue Shield Select 2000, a Multi-State Plan
PPO
Rating Area 2
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028526.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
336
530
554
601
664
945
1410
1060
1202
1328
1890
2820
1396
1538
1664
2226
1732
1874
2000
2562
2068
2210
2336
2898
866
937
1000
1281
1202
1273
1336
1617
1538
1609
1672
1953
2000
Included in Medical
4000
Included in Medical
6350
Included in Medical
12700
Included in Medical
$35
$35
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
$15
$50
$100
30% Coinsurance after deductible
AK
BRISTOL BAY BOROUGH
Silver
Premera Blue Cross Blue Shield of Alaska
38344AK0950001
Blue Cross Blue Shield Select 1700 HSA, a Multi-State Plan
PPO
Rating Area 2
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028489.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
324
510
534
579
640
911
1359
1020
1158
1280
1822
2718
1344
1482
1604
2146
1668
1806
1928
2470
1992
2130
2252
2794
834
903
964
1235
1158
1227
1288
1559
1482
1551
1612
1883
1700
Included in Medical
3400
Included in Medical
4600
Included in Medical
9200
Included in Medical
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
AK
DENALI
Bronze
Moda Health Plan, Inc.
73836AK0680019
Beneficial 5000
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/producers/grp/med.shtml#tbd
https://www.modahealth.com/producers/grp/med.shtml
https://www.modahealth.com/medical/formularies.shtml?dn=ods
217.31
342.22
358.65
388.42
495.43
611.2
1052.1
684.44
776.84
990.86
1222.4
2104.21
901.75
994.15
1208.17
1439.71
1119.06
1211.46
1425.48
1657.02
1336.37
1428.77
1642.79
1874.33
559.53
605.73
712.74
828.51
776.84
823.04
930.05
1045.82
994.15
1040.35
1147.36
1263.13
5000
Included in Medical
10000
Included in Medical
6350
Included in Medical
12700
Included in Medical
$35 Copay and 50% Coinsurance
50%
50%
50%
50%
45%
45%
45%
45%
AK
DENALI
Bronze
Moda Health Plan, Inc.
73836AK0680042
Beneficial 5000
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/producers/grp/med.shtml#tbd
https://www.modahealth.com/producers/grp/med.shtml
https://www.modahealth.com/medical/formularies.shtml?dn=ods
217.31
342.22
358.65
388.42
495.43
611.2
1052.1
684.44
776.84
990.86
1222.4
2104.21
901.75
994.15
1208.17
1439.71
1119.06
1211.46
1425.48
1657.02
1336.37
1428.77
1642.79
1874.33
559.53
605.73
712.74
828.51
776.84
823.04
930.05
1045.82
994.15
1040.35
1147.36
1263.13
5000
Included in Medical
10000
Included in Medical
6350
Included in Medical
12700
Included in Medical
$35 Copay and 50% Coinsurance
50%
50%
50%
50%
45%
45%
45%
45%
AK
DENALI
Bronze
Premera Blue Cross Blue Shield of Alaska
38344AK0980011
Blue Cross Blue Shield Plus 5500, a Multi-State Plan
PPO
Rating Area 2
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028490.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
258
407
426
461
510
725
1083
814
922
1020
1450
2166
1072
1180
1278
1708
1330
1438
1536
1966
1588
1696
1794
2224
665
719
768
983
923
977
1026
1241
1181
1235
1284
1499
5500
Included in Medical
11000
Included in Medical
6350
Included in Medical
12700
Included in Medical
$15
$50
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
$25
50% Coinsurance after deductible
50% Coinsurance after deductible
20% Coinsurance after deductible
AK
DENALI
Gold
Premera Blue Cross Blue Shield of Alaska
38344AK0930003
Blue Cross Blue Shield Select 1000, a Multi-State Plan
PPO
Rating Area 2
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://www.premera.com/wa/visitor/
https://www.premera.com/documents/028524.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
366
577
604
654
723
1030
1536
1154
1308
1446
2060
3072
1520
1674
1812
2426
1886
2040
2178
2792
2252
2406
2544
3158
943
1020
1089
1396
1309
1386
1455
1762
1675
1752
1821
2128
1000
$0
2000
See Plan Brochure
5000
Included in Medical
10000
Included in Medical
$30
$30
20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
$10
$25
$45
20%

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