Peak Care health plan guide. For businesses headquartered in Pierce County with 51+ employees enrolled on the plan

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1 2019 Peak Care health plan guide For businesses headquartered in Pierce County with 51+ employees enrolled on the plan

2 Table of contents MEDICAL PLANS Peak Care EPO plans...5 PHARMACY PLANS Essentials and Preferred drug lists...8 Benefits for Essentials and Preferred pharmacy plans...9 DENTAL PLANS Optima...12 Preference...13 Essentials...14 Preventive More options...16 VISION AND HEARING PLANS The following tables list the highlights of your healthcare coverage and compare deductible, copay, and coinsurance information for your Peak Care plan options. To find out more about Peak Care, read the 2019 Peak Care brochure or visit peakcare.com. Peak Care is also an option for businesses with employees participating in the Premera Preferred Choice program. Read the Preferred Choice brochure for more details. 2

3 Included in this guide are your 2019 Peak Care plan options for: MEDICAL PHARMACY DENTAL VISION HEARING 3

4 Medical plans Peak Care is an exclusive provider organization (EPO) plan designed for Pierce County-based employers. An EPO is a hybrid health plan in which a primary care provider referral is not required when seeking specialty care, but care must be provided within network. With an EPO plan, your employees receive care at a lower cost of coverage versus other plan types. Peak Care plans provide your employees with a smooth healthcare experience, allowing them to focus on their health. 4

5 Peak Care EPO plans FOR FULLY INSURED GROUPS* Cost-share options Cost-share amounts represent customers costs. Not all plan option combinations are offered. See your sales representative for clarification. PCY = per calendar year. Individual deductible PCY Family deductible PCY IN-NETWORK $0 / $100 / $200 / $250 / $300 / $500 / $750 / $1,000 / $1,500 / $2,000 $2,500 / $3,000 / $4,000 / $5,000 / $6,350 / $6,600 / $6,850 / $7,900 2x Individual 3x Individual Coinsurance 0% 10% 20% 30% Individual out-of-pocket maximum PCY (includes deductible, coinsurance, and copay) Family out-of-pocket maximum PCY (includes deductible, coinsurance, and copay) Fourth quarter deductible carryover Office visit (OV) cost share Inpatient cost share Annual Plan Maximum $1,000 / $1,100 / $1,200 / $1,250 / $1,300 / $1,500 / $1,750 / $2,000 / $2,100 $2,200 / $2,250 / $2,300 / $2,500 / $2,750 / $3,000 / $3,500 / $4,000 $4,500 / $5,000 / $6350 / $6,600 / $6,850 / $7,150 / $7,350 / $7,900 2x Individual / 3x Individual Included / Excluded Split copay options: $25 specialist / $40 non-specialist and $30 specialist / $45 non-specialist In-network deductible and coinsurance Single copay of: $10 / $15 / $20 / $25 / $30 / $35 / $40 In-network deductible and coinsurance $250 per admit no day maximum $250 per day up to 5 days per admit $100 per day no day maximum Note: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross. In-network out-of-pocket maximum must not exceed the federally mandated maximum of $7,900 for an individual or $15,800 for a family. None Comprehensive provider network Our comprehensive provider network is comprised of the MultiCare Connected Care Clinically Integrated Network, which offers more than 3,500 providers and practices across Washington state. Additionally, customers will have access to chiropractors, acupuncturists, and massage therapists to ensure they have access to a full range of services to meet their needs. The network name that will appear on member ID cards is the Tahoma provider network. For more information about the Tahoma network, go to peakcare.com. *Other funding types may be eligible for Peak Care. Contact your producer or Premera representative. 5

6 Covered services Preventive care and counseling visit Preventive screenings Vaccinations (including seasonal vaccinations received at a pharmacy or other mass vaccination location paid as in-network) Benefits apply after calendar-year deductible is met, unless otherwise noted. Benefits subject to medical necessity except for preventive care. PCY = per calendar year BENEFIT LIMITS IN-NETWORK Subject to federal and state guidelines 1 Covered in full 2 Professional office visit (including urgent care) Other outpatient professional services Inpatient professional services Manipulations (spinal and other) Acupuncture Naturopathic services Mammography (non-preventive) Outpatient diagnostic imaging and laboratory services Emergency room care (copay waived if directly admitted to inpatient facility) Ambulance transportation (Air and ground) Inpatient hospital care Outpatient facility care Skilled nursing facility Maternity care (prenatal, delivery, and postnatal care) Mental health and chemical dependency treatment Rehabilitation (including physical, occupational, speech, and massage therapy) (including cardiac/pulmonary rehab and chronic pain) Supplies, equipment, prosthetics, and orthotics Temporomandibular joint disorders (TMJ) No visit limits 12 visits PCY / 24 visits PCY / No visit limits No visit limits No visit limits No maximum No trip or dollar maximum No limit on number of days or visits 60 days PCY / 90 days PCY 120 days PCY / 180 days PCY No visit or day maximum. Covered for: subscriber; spouse/domestic partner; and dependents subscriber, spouse/domestic partner only No visit or day maximums 15 visits / 30 days PCY 25 visits / 30 days PCY 45 visits / 30 days PCY 60 visits / 60 days PCY No visit maximum No maximum, except $300 maximum PCY for foot orthotics that are not diabetes related No dollar maximum Office visit cost share Office visit cost share (deductible waived) Covered in full 2 PLUS copay of: $50 / $75 / $100 $150 / $200 / $300 $50 copay (deductible waived) Inpatient cost share Inpatient cost share Outpatient: Office visit cost share Inpatient: Inpatient cost share Outpatient: Office visit cost share Inpatient: Inpatient cost share Home health agency services 130 visits PCY / No visit limit Hospice care Outpatient: No visit limits (within 6-month lifetime maximum) Respite: 240 hours (within 6-month lifetime maximum) Inpatient options: 10 days / 30 days No day limit (within 6-month lifetime maximum) Outpatient and respite: Inpatient: Inpatient cost share Transplants (organ and bone marrow) No dollar maximums, except for $7,500 travel and lodging limit per transplant Outpatient: Office visit cost share Inpatient: Inpatient cost share Note: Amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross. 1 A list of preventive screenings and other preventive services is available on premera.com in the Miscellaneous Forms page of the producer and employer websites. 2 Not subject to copay, deductible, or coinsurance. This is only a brief summary of the major benefits provided by our plans. This is not a contract. For information and details regarding general exclusions and limitations, please contact your Premera representative. 6

7 Pharmacy plans We make healthcare work better when everything works together. By integrating a Premera pharmacy plan with your Peak Care medical plan, we can help you drive down costs by reducing waste and increasing the quality of care through greater coordinated insight. 7

8 Essentials and Preferred pharmacy plans Choose your pharmacy plan Essentials is a restricted list of prescription drugs that meets basic pharmacy needs and has a new benefit structure, outlined below. Essentials keeps costs as low as possible by focusing on high-value drugs that are approved by the U.S. Food and Drug Administration (FDA). Preferred is comprehensive and provides access to a full spectrum of brandname medications. See how the pharmacy options compare ESSENTIALS FIRST TIER SECOND TIER THIRD TIER FOURTH TIER PLANS WITH 4 TIERS Preferred generic drugs Preferred brand-name drugs Preferred specialty 1 drugs Non-preferred drugs (generic, brand, specialty) PREFERRED PLANS WITH 4 TIERS FIRST TIER Generic drugs SECOND TIER Preferred brand-name drugs THIRD TIER Non-preferred brand-name drugs FOURTH TIER Specialty drugs 1 PLANS WITH 3 TIERS FIRST TIER Generic drugs SECOND TIER Preferred brand-name drugs THIRD TIER Non-preferred brand-name drugs PLANS WITH 2 TIERS FIRST TIER Generic drugs SECOND TIER Brand-name drugs Contact your producer or Premera account manager for your options. 1 Specialty Pharmacy Program: Both Essentials and Preferred pharmacy options include beneftis for specialty drugs. Specialty drugs are used for treating complex or rare conditions and require special handling, storage, administration, or patient monitoring. Coverage requires these prescriptions be filled through our Specialty Pharmacy Program, which uses pharmacies dedicated to supporting specialty drugs and those who need them. Employers can have a choice between our specialty pharmacy providers. 8

9 Benefits for Essentials and Preferred pharmacy plans Copays and coinsurance represent customers cost PCY = per calendar year 4-TIER ESSENTIALS Retail pharmacy (up to 30-day supply per Rx) $10 / $25 / $45 / 30% $10 / $30 / $30 / 30% $10 / $30 / $50 / 30% $15 / $30 / $50 / 30% $15 / $60 / $100 / 50% $20 / $50 / 30% / 50% Mail order (up to 90-day supply per Rx) $25 / $62.50 / $45 1 / 30% $25 / $75 / $30 1 / 30% $25 / $75 / $50 1 / 30% $37.50 / $75 / $50 1 / 30% $37.50 / $150 / $100 1 / 50% $50 / $125 / 30% / 50% Rx individual deductible 2 PCY (separate from medical deductible) None, $150, $300, $500 Rx family deductible 2 PCY None, or same as medical 3 Individual out-of-pocket maximum PCY Drug list Participating pharmacy cost shares accrue to the in-network medical out-of-pocket maximum. Essentials E4 4-TIER PREFERRED Retail pharmacy (up to 30-day supply per Rx) $15 / 35% / 50% / 30% $20 / $50 / 50% / 30% Mail order (up to 90-day supply per Rx) $37.50 / 35% / 50% / 30% $50 / $125 / 50% / 30% Rx individual deductible 2 PCY (separate from medical deductible) None, $150, $300, $500 Rx family deductible 2 PCY None, or same as medical 3 Individual out-of-pocket maximum PCY Participating pharmacy cost shares accrue to the out-of-pocket maximum for in-network medical. Drug list Standard Copay Plans Preferred B4 3-TIER PREFERRED Configurable Copay Plans Retail pharmacy (up to 30-day supply per Rx) $10 / $25 / $45 1 $10 / $30 / $50 1 $10 / $20 / $40 1 $15 / $25 / $40 4 $15 / $30 / $50 4 Mail order 4 (up to 90-day supply per Rx) $25 / $62 / $112 1 $25 / $75 / $125 1 $20 / $40 / $80 $25 / $50 / $100 1 $30 / $50 / $80 $37 / $62 / $100 1 $30 / $60 / $100 $37 / $75 / $125 1 Rx individual deductible 2 PCY (separate from medical plan deductible) Rx family deductible 2 PCY Individual out-of-pocket maximum PCY None None, same as medical 3 None, $150, $300, $500 None, or same as medical3 Participating pharmacy cost shares accrue to the out-of-pocket maximum for in-network medical. Drug list Standard Coinsurance Plan Preferred B3 2-TIER PREFERRED Configurable Copay Plans Retail pharmacy (up to 30-day supply per Rx) $10 / 50% $10 / $30 $15 / $35 Mail order (up to 90-day supply per Rx) $25 / 45% $20 / $60 or $25 / $75 $30 / $70 or $37 / $87 Rx individual deductible 2 PCY (separate from medical plan deductible) None / $150 / $300 / $500 Rx family deductible 2 PCY None, or same as medical 3 Individual out-of-pocket maximum PCY Drug list Participating pharmacy cost shares accrue to the out-of-pocket maximum for in-network medical. Preferred A2 1 Up to 30-day supply for specialty drugs only from Premera s specialty pharmacy provider. 2 Deductible waived for generics and preferred generics on Essentials. 3 Family deductible is separate from medical deductible; value uses same multiplier as medical deductible. 4 A buy-up option is available with this plan to extend certain generic preventive drugs to be covered in full. Ask your sales representative for more details. 9

10 Dental plans Good oral health is pivotal to your employee s overall health. Here s why regular preventive oral health visits assist with early detection and management of diseases. When you offer your employees a Peak Care medical plan, also offer them a dental plan from Premera to help your employees stay healthy. 10

11 Choose from four dental plans to offer with your Peak Care health plan You get: Administrative ease. If you already offer a medical plan from Premera, you ll simplify your work by dealing with only one health plan for medical and dental administration. Well-rounded benefits. Job seekers look for well-rounded benefit packages. You ll be able to attract and retain the best talent by offering an appealing benefits package that supports the total health of your employees. Attractive savings. Whether you want to offer comprehensive coverage or just the core essentials you can choose from a variety of plans that work best for your needs and budget. Additionally, you can take advantage of exclusive savings when you bundle a Premera medical plan with a Premera dental plan. Healthier, happier, employees. Oral health is key to overall health. If your employees get the care they need for healthy smiles, they ll be better prepared to meet the needs of your business. Your employees get: A broad network. We offer access to a large network of dentists. Premera contracts with thousands of network dentists in the state of Washington and nearly 82,000 dentists nationally. Emphasis on prevention. When you offer your employees Premera dental benefits, they will not pay a deductible for routine oral exams, and most plans will cover preventive services in full. Dedicated customer service team. Our trained representatives are ready to help every step of the way. Easy online tools. Your employees and their covered dependents can find in-network care, see how much dental services will cost, or even a licensed dentist. Dental expertise. We ve been serving dental customers for more than 30 years. One ID Card for both medical and dental. 11

12 Dental Optima With Dental Optima, you can choose from several cost share options giving your employees and their covered dependents choice and control over their spending. You can decide to have routine diagnostic and preventive services that won t count toward the annual maximum on the plan. * To help encourage regular oral health maintenance, basic services such as fillings and extractions are covered. Additionally, there s no waiting period for major services such as crowns, implants, and dentures, so your employees can get the care they need as soon as their coverage starts. Covered services Annual deductible PCY Maximum allowance per person, PCY Benefits apply after calendar year deductible is met, unless otherwise noted. Deductible and coinsurance represent customers cost share PCY = per calendar year COST SHARES FOR DENTAL OPTIMA PLANS INDIVIDUAL $25 / $50 $0 / $25 / $50 / $75 1 $400 $500 2 $25 / $50 / $75 FAMILY $75 / $150 $0 / $75 / $150 / $225 $600 $1,500 2 $75 / $150 / $225 $1,000, $1,500, $2,000, or $2,500 $750 3, $1,000, $1,500, $2,000, or $2,500 $1,000 or $1,500 $1,000 or $1,500 $750, $1,000, or $1,500 IN- AND OUT-OF-NETWORK IN- AND OUT-OF-NETWORK IN- AND OUT-OF-NETWORK IN- AND OUT-OF-NETWORK IN- AND OUT-OF-NETWORK DIAGNOSTIC AND PREVENTIVE 4 Cleanings limited to 2 PCY Emergency exams unlimited Fluoride treatments limited to 2 applications PCY for customers under the age of 19 Routine oral exams limited to 2 PCY Routine x-rays bitewing x-rays unlimited; complete series or panoramic x-ray once per 36 consecutive months Sealants limited to permanent teeth for customers under age 19 Space maintainers for customers under age 19 BASIC Endodontic (root canal) treatment Fillings limited to once per tooth surface every 24 consecutive months General anesthesia limited to covered dental procedures at a dental-care provider s office when dentally necessary Oral surgery including simple and surgical extractions Periodontal maintenance limited to 4 visits PCY Periodontal surgery unlimited Periodontal scaling limited to once per quadrant every 2 calendar years Repair and recementing of crowns, inlays, bridgework, and dentures MAJOR Implants, dentures, partials, and fixed bridges replacements limited to once every 5 calendar years Inlays, onlays, and crowns replacements limited to once per tooth every 5 years 0% 0% 0% 0% 20% 10% 20% 20% 20% 20% 40% 50% 50% 50% 50% Note: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross. *This does not apply to the $400 and $500 deductible Dental Optima linear plan options. 1 $75 deductible is not available with $2,500 maximum allowance. 2 Deductible applies only to major services. 3 $750 maximum allowance only available with $50/$150 and $75/$225 deductibles. 4 Annual deductible waived for diagnostic and preventive services. 12

13 Dental Preference With Dental Preference, you can choose from several cost share options giving your employees and their covered dependents choice and control over their spending. To help encourage regular oral health maintenance, basic services such as fillings and extractions are covered. Additionally, there s no waiting period for major services such as crowns, implants, and dentures, so your employees can get the care they need as soon as their coverage starts. Covered services Annual deductible PCY Maximum allowance per person, PCY Benefits apply after calendar year deductible is met, unless otherwise noted. Deductible and coinsurance represent customers cost share PCY = per calendar year COST SHARES FOR DENTAL PREFERENCE PLANS INDIVIDUAL $25 / $50 $25 / $50 $25 / $50 / $75 $25 / $50 / $75 FAMILY $75 / $150 $75 / $150 $75 / $150 / $225 $75 / $150 / $225 $1,000, $1,500, $2,000 or $2,500 $1,000, $1,500, $2,000 or $2,500 $1,000, $1,500, or $2,000 $1,000, $1,500, or $2,000 IN-NETWORK OUT-OF- NETWORK IN-NETWORK OUT-OF- NETWORK IN-NETWORK OUT-OF- NETWORK IN-NETWORK OUT-OF- NETWORK DIAGNOSTIC AND PREVENTIVE 1 Cleanings limited to 2 PCY Fluoride treatments limited to 2 applications PCY for customers under the age of 19 Routine oral exams limited to 2 PCY Routine x-rays bitewing x-rays unlimited; complete series or panoramic x-ray once per 36 consecutive months Sealants limited to permanent teeth for customers under age 19 BASIC Emergency exams unlimited Fillings limited to once per tooth surface every 24 consecutive months Periodontal maintenance limited to 4 visits PCY Periodontal scaling limited to once per quadrant every 2 calendar years Recementing of crowns, inlays, bridgework, and dentures Simple and surgical extractions Space maintainers for customers under age 19 MAJOR Implants, dentures, partials, and fixed bridges replacements limited to once every 5 calendar years Endodontic (root canal) treatment limited to once per tooth every 2 calendar years General anesthesia limited to covered dental procedures at a dental-care provider s office when dentally necessary Inlays, onlays, and crowns replacements limited to once per tooth every 5 years Oral surgery Periodontal surgery limited to once per quadrant every 3 calendar years Repair of crowns, inlays, bridgework, and dentures 0% 20% 0% 20% 0% 20% 20% 30% 0% 20% 10% 20% 20% 40% 20% 40% 40% 60% 40% 60% 50% 60% 50% 60% Note: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross. 1 Annual deductible waived for diagnostic and preventive services. 13

14 Dental Essentials With Dental Essentials, you can offer dental coverage at little or no cost to you. Choose between letting your employees and their covered dependents pay the full cost of their monthly health plan bills or funding up to 50 percent of the plan cost. To help encourage regular oral health maintenance, basic services such as fillings and extractions are covered. 14 Covered services Annual deductible PCY Benefits apply after calendar year deductible is met, unless otherwise noted. Deductible and coinsurance represent customer s cost share PCY = per calendar year COST SHARES FOR DENTAL ESSENTIALS PLANS INDIVIDUAL $25 / $50 / $75 $25 / $50 / $75 $25 / $50 / $75 FAMILY $75 / $150 / $225 $75 / $150 / $225 $75 / $150 / $225 Maximum allowance per person, PCY $750, $1,000, or $1,500 $750, $1,000, or $1,500 $750, $1,000, or $1,500 DIAGNOSTIC AND PREVENTIVE 1 Cleanings limited to 2 PCY Fluoride treatments limited to 2 applications PCY for customers under the age of 19 Routine oral exams limited to 2 PCY Routine x-rays bitewing x-rays unlimited; complete series or panoramic x-ray once per 36 consecutive months Sealants limited to permanent teeth for customers under age 19 BASIC Emergency exams unlimited Fillings limited to once per tooth surface every 24 consecutive months Periodontal maintenance limited to 4 visits PCY Periodontal scaling limited to once per quadrant every 2 calendar years Recementing of crowns, inlays, bridgework, and dentures Simple and surgical extractions Space maintainers for customers under age 19 MAJOR 2 Dentures, partials, and fixed bridges replacements limited to once every 5 calendar years Endodontic (root canal) treatment limited to once per tooth every 2 calendar years General anesthesia limited to covered dental procedures at a dental-care provider s office when dentally necessary Inlays, onlays, and crowns replacements limited to once per tooth every 5 years Periodontal surgery limited to once per quadrant every 3 calendar years Oral surgery Repair of crowns, inlays, bridgework, and dentures IN-NETWORK OUT-OF- NETWORK IN-NETWORK OUT-OF- NETWORK IN-NETWORK OUT-OF- NETWORK 0% 20% 0% 0% 20% 30% 20% 40% 20% 20% 20% 40% 50% 60% 50% 50% 50% 60% Note: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross. 1 Annual deductible waived for diagnostic and preventive services. 2 A 12-month waiting period for major services applies to customers who have not had continuous comparable dental coverage under the group s prior dental plan.

15 Dental Preventive + Dental Preventive + is available as either an employer-sponsored plan or a voluntary plan. This means you can offer basic dental coverage to your employees at a lower cost than a comprehensive dental plan. In addition, there s no waiting period for services, so your employees and their covered dependents can get the care they need as soon as their coverage starts. This plan is available in one of two ways. Employer-sponsored: Employers pay from 50 to 100 percent of the premium. Voluntary: Employers pay from 0 to 49 percent of the premium. Covered services Benefits apply after calendar year deductible is met, unless otherwise noted Deductible and coinsurance represent customer s cost share PCY = per calendar year Annual deductible PCY COST SHARES FOR DENTAL PREVENTIVE + PLANS INDIVIDUAL $0 $0 FAMILY $0 $0 Maximum allowance per person, PCY $500 or $750 $500 or $750 DIAGNOSTIC AND PREVENTIVE Cleanings limited to 2 PCY Fluoride treatments limited to 2 applications PCY for customers under the age of 19 Routine oral exams limited to 2 PCY Routine x-rays bitewing x-rays unlimited; complete series or panoramic x-ray once per 36 consecutive months Sealants limited to permanent teeth for customers under age 19 BASIC Emergency exams unlimited Fillings limited to once per tooth surface every 24 consecutive months General anesthesia limited to covered dental procedures at a dental-care provider s office when dentally necessary Periodontal maintenance limited to 4 visits PCY Periodontal scaling limited to once per quadrant every 2 calendar years Recementing of crowns, inlays, and bridgework Simple extractions non-surgical Space maintainers for customers under age 19 IN- AND OUT-OF-NETWORK IN- AND OUT-OF-NETWORK 0% 0% 0% 20% Note: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross. 15

16 More dental options You can choose to offer additional dental coverage to customize your Premera dental plans. Optional benefits DENTAL OPTIMA DENTAL PREFERENCE DENTAL ESSENTIALS DENTAL PREVENTIVE + BENEFIT ENHANCEMENT OPTIONS Endodontic (root canal) and surgical periodontal treatment Covered under Major instead of Basic services Covered under Basic instead of Major services N/A N/A Preventive services do not count toward maximum allowance Optional 1 N/A N/A N/A ORTHODONTIA 2 Diagnostic services and active/retention treatment including appliances Monthly orthodontic adjustments including retention treatment Covered in full 3 up to lifetime maximum N/A N/A Lifetime maximum per person (choose one) $1,000, $1,500, or $2,000 Age limit (choose one) No age limit or under age 19 TMJ DENTAL SERVICES 4 Temporomandibular joint disorder (TMJ) exams and x-rays: occlusal guards; and TMJ surgical procedures, and manipulations under anesthesia Deductible and basic coinsurance apply Annual benefit maximum $1,000 Lifetime maximum per person $5,000 1 This does not apply to the $400 and $500 deductible Dental Optima linear plan options. 2 Not available for a voluntary plan. 3 Benefits provided at 100% of allowable charges; not subject to deductible or coinsurance. 4 Balance billing may apply if a provider is not contracting with Premera Blue Cross. 16

17 Vision and hearing plans Routine eye and hearing exams can lead to earlier diagnosis of chronic diseases. Offering vision and hearing benefits along with medical and dental coverage is easier to manage for both your business and your employees. 17

18 Benefits for vision and hearing plans You can choose to offer vision and hearing benefits with your Peak Care health plan. PCY = per calendar year ADULT VISION Vision exam only (in network only) Vision exam and eyeware (in and out of network) 1 routine exam, PCY 1 routine exam, PCY; Hardware: $150 PCY; $150 every 2 consecutive CY; $300 PCY; $300 every 2 consecutive CY BENEFIT LIMITS Covered in full or deductible / coinsurance or copay only Exam: covered in full or deductible / coinsurance or copay only Hardware: covered in full PEDIATRIC VISION (Pediatric exam cost shares count toward the out-of-pocket maximum) BENEFIT LIMITS Vision exam only (in network only) Vision exam and eyeware (in and out of network) 1 routine exam, PCY 1 routine exam, PCY; Hardware: 1 pair of glasses PCY (frames and lenses); 12-month supply of contact lenses in lieu of frames and lenses Office visit Cost share or waive deductible, then coinsurance Exam: office visit cost share or waive deductible, then coinsurance, or covered in full Eyeware: covered in full HEARING OPTIONAL RIDER Hearing exam only (in network only) 1 exam PCY or 1 exam every 2 CY Covered in full or deductible / coinsurance or copay only Hearing exam with aids and hardware (in and out of network) 1 exam PCY or 1 exam every 2 CY; Hardware: $1,000 every 3 CY or $3,000 every 3 CY Exam: covered in full or deductible / coinsurance or copay only Hardware: covered in full Talk to your producer or Premera account manager to add vision and hearing benefits to your Peak Care health plan. 18

19 FIND OUT MORE Read the 2019 Peak Care brochure Visit peakcare.com Talk with your Premera representative or producer This brochure is not a contract. It is only a summary of the major benefits provided by these plans. For full coverage provisions, including a description of waiting periods, limitations, and exclusions, please contact your Premera representative or producer ( )