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Highline Public Schools
15675 Ambaum Blvd. SW Burien,WA 98166

Office Hours:

Monday-Friday: 7:30 a.m. - 4:30 p.m.

Premera PPO

This is a consolidated view of your Premera health insurance benefits. To access your full benefits, for additional information, or to find a provider please visit the Premera website.

Premeral Education Program Booklet

For questions on the specific plans and for help choosing the plan that is best for you please contact the Premera Blue Cross dedicated school district phone number at 855-756-0798.

To enroll onto a Premera plan, complete an enrollment form and return it to the Human Resources Benefits Office.  If you are indicating on your enrollment form that you have other coverage please also fill out the Premera Other Coverage Form.

All Premera plans include a life insurance policy, to change your beneficiary designation please fill out the Beneficiary Form and return it to HR. 

Premera - Heritage Plan 2

Plan Network

 

 

Premera/Heritage Plan 2

 

 

 

 

In Network

 

 

Out of Network

 

 

Medical Deductible

 

 

$300 individual

(3x family)

 

 

$300 individual

(3x family)

 

 

Rx Deductible

 

 

None

 

 

None

 

 

Carrier Coinsurance

 

 

80%

 

 

60%

 

 

Medical OOP Max

 

 

$2,000 (3x family)

 

 

$3,400 (3x family)

 

 

Office Visit Copay

Primary/Specialist

 

 

$25 / $35 (dw)

 

 

$30 / $40 (dw)

 

 

Rx OOP Max

 

 

Included in Medical

 

 

Included in Medical

 

 

Prescriptions

 

 

Generic/Preferred/Non-Preferred

At Participating Pharmacies

 

 

Generic/Preferred/Non-Preferred

At Participating Pharmacies

 

 

Retail Cost Share Copay

 

 

$10 / $20 / $35 / $50

 

 

$10 / $20 / $35 / $50

 

Premera - Heritage Plan 3

Premera/Heritage Plan 3

 

 

 

 

In Network

 

 

Out of Network

 

 

Medical Deductible

 

 

$500 individual

(3x family)

 

 

$500 individual

(3x family)

 

 

Rx Deductible

 

 

None

 

 

None

 

 

Carrier Coinsurance

 

 

80%

 

 

60%

 

 

Medical OOP Max

 

 

$3,000 individual

(3x family)

 

 

$5,900 individual

(3x family)

 

 

Office Visit Copay

Primary/Specialist

 

 

$30 / $40 (dw)

 

 

$40 / $50 (dw)

 

 

Rx OOP Max

 

 

Included in Medical

 

 

Included in Medical

 

 

Prescriptions

 

 

Generic/Preferred/Non-Preferred

At Participating Pharmacies

 

 

Generic/Preferred/Non-Preferred

At Participating Pharmacies

 

 

Retail Cost Share Copay

 

 

$15 / $25 / $40 / $60

 

 

$15 / $25 / $40 / $60

Premera - Heritage EasyChoice A

Plan Network

 

 

Premera/Heritage EasyChoice A

 

 

 

 

In Network

 

 

Out of Network

 

 

Medical Deductible

 

 

$1,250 individual (3x family)

 

 

$2,000 individual (3x family)

 

 

Rx Deductible

 

 

$500 (waived for generic)

 

 

$500 (waived for generic)

 

 

Carrier Coinsurance

 

 

80%

 

 

50%

 

 

Medical OOP Max

 

 

$4,000 individual

(2x family)

 

 

Unlimited

 

 

Office Visit Copay

Primary/Specialist

 

 

$25 / $35 (dw)

 

 

50%

 

 

Rx OOP Max

 

 

Included in Medical

 

 

Included in Medical

 

 

Prescriptions

 

 

Generic/Preferred/Non-Preferred

At Participating Pharmacies

 

 

Generic/Preferred/Non-Preferred

At Participating Pharmacies

 

 

Retail Cost Share Copay

 

 

$10 / 30% / 30% / 30%

 

$10 / 30% / 30% / 30%

Premera - Heritage EasyChoice B

Premera/Heritage EasyChoice B

 

 

 

 

In Network

 

 

Out of Network

 

 

Medical Deductible

 

 

$750 individual

(3x family)

 

 

$1,500 individual

(3x family)

 

 

Rx Deductible

 

 

$250 

(waived for generic)

 

 

$250

(waived for generic)

 

 

Carrier Coinsurance

 

 

75%

 

 

50%

 

 

Medical OOP Max

 

 

$3,500 individual

(2x family)

 

 

Unlimited

 

 

Office Visit Copay

Primary/Specialist

 

 

$30 / $40 (dw)

 

 

50%

 

 

Rx OOP Max

 

 

Included in Medical

 

 

Included in Medical

 

 

Prescriptions

 

 

Generic/Preferred/Non-Preferred

At Participating Pharmacies

 

 

Generic/Preferred/Non-Preferred

At Participating Pharmacies

 

 

Retail Cost Share Copay

 

 

$5 / $30 / $45 / 30%

 

 

$5 / $30 / $45 / 30%

Premera - Heritage Plan 5

Plan Network

 

 

Premera/Heritage Plan 5

 

 

 

 

In Network

 

 

Out of Network

 

 

Medical Deductible

 

 

$200 individual

(3x family)

 

 

$350 per person

 

 

Rx Deductible

 

 

None

 

 

None

 

 

Carrier Coinsurance

 

 

90%

 

 

70%

 

 

Medical OOP Max

 

 

$1,000 individual

(3x family)

 

 

Unlimited

 

 

Office Visit Copay

Primary/Specialist

 

 

$20 / $30 (dw)

 

 

30%

 

 

Rx OOP Max

 

 

Included in Medical

 

 

Included in Medical

 

 

Prescriptions

 

 

Generic/Preferred/Non-Preferred At Participating Pharmacies

 

 

Generic/Preferred/Non-Preferred At Participating Pharmacies

 

 

Retail Cost Share Copay

 

 

$10 / $15 / $30 / $50

 

 

$10 / $15 / $30 / $50

 

Premera - Heritage Basic Plan

 

 

Premera/Heritage Basic Plan

 

 

 

 

In Network

 

 

Out of Network

 

 

Medical Deductible

 

 

$2,100 individual

(2x family)

 

 

$2,500 individual

(2x family)

 

 

Rx Deductible

 

 

$750 PCY

 

 

Not Covered

 

 

Carrier Coinsurance

 

 

70%

 

 

50%

 

 

Medical OOP Max

 

 

$6,600 Individual

(2x family)

 

 

Not applicable

 

 

Office Visit Copay

Primary/Specialist

 

 

 

$35 / $50 (dw)

 

 

50%

 

 

Rx OOP Max

 

 

Included in Medical

 

 

Not Covered

 

 

Prescriptions

 

 

Generic/Preferred/Non-Preferred

At Participating Pharmacies

 

 

Generic/Preferred/Non-Preferred

At Participating Pharmacies

 

 

Retail Cost Share Copay

 

 

$15 / $30 / $50 / 30%

 

 

Not Covered

Premera - Heritage QHDHP

Premera/Heritage QHDHP

 

 

 

 

In Network

 

 

Out of Network

 

 

Medical Deductible

 

 

$1,750 individual

(2x family)

 

 

$3,000 individual

(2x family)

 

 

Rx Deductible

 

 

None

 

 

None

 

 

Carrier Coinsurance

 

 

80%

 

 

50%

 

 

Medical OOP Max

 

 

$5,000 individual

(2x family)

 

 

Unlimited

 

 

Office Visit Copay

Primary/Specialist

 

 

20%

 

 

50%

 

 

Rx OOP Max

 

 

Included in Medical

 

 

Included in Medical

 

 

Prescriptions

 

 

Generic/Preferred/Non-preferred 

At Participating Pharmacies

 

 

Generic/Preferred/Non-preferred

At Participating Pharmacies

 

 

Retail Cost Share Copay

 

 

20%

 

 

20%