Premera Blue Cross - High Deductible Plan F

High Deductible Plan F

High deductible and lower monthly rate. You can use funds in an existing HSA to pay for medical expenses applied to your deductible.

Common Terms

Medicare (Part A) - Hospital Services - Per Benefit Period

Medicare (Part A) - Hospital Services - Per Benefit Period
Services	Medicare Pays	After You Pay $2070 Deductible** Plan F Pays	In Addition to $2070 Deductible** You Pay
Hospitalization* Semi-private room and board, general nursing and miscellaneous services and supplies
First 60 days	All but $1,156	$1,156 (Part A Deductible)	$0
61st through 90th day	All but $289 a day	$289 a day	$0
91st day and after: (while using 60 lifetime reserve days)	All but $578 a day	$578 a day	$0
Once lifetime reserve days are used: Additional 365 days	$0	100% of Medicare eligible expenses	$0***
Once lifetime reserve days are used: Beyond the additional 365 days	$0	$0	All costs
Skilled Nursing Facility Care* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days	All approved amounts	$0	$0
21st through 100th day	All but $144.50 a day	Up to $144.50 a day	$0
101st day and after	$0	$0	All costs
Blood
First 3 pints	$0	3 pints	$0
Additional amounts	100%	$0	$0
Hospice Care You must meet Medicare's requirements, including a doctor's certification of terminal illness.	All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care	Medicare copayment / coinsurance	$0

Services

Medicare Pays

After You Pay
$2070 Deductible**
Plan F Pays

In Addition to
$2070 Deductible**
You Pay

Hospitalization*

Semi-private room and board, general nursing and miscellaneous services and supplies

First 60 days

All but $1,156

$1,156 (Part A Deductible)

61st through 90th day

All but $289 a day

$289 a day

91st day and after:
(while using 60 lifetime reserve days)

All but $578 a day

$578 a day

Once lifetime reserve days are used:
Additional 365 days

100% of Medicare eligible expenses

$0***

Once lifetime reserve days are used:
Beyond the additional 365 days

All costs

Skilled Nursing Facility Care*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days

All approved amounts

21st through 100th day

All but $144.50 a day

Up to $144.50 a day

101st day and after

All costs

Blood

First 3 pints

3 pints

Additional amounts

100%

Hospice Care

You must meet Medicare's requirements, including a doctor's certification of terminal illness.

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment / coinsurance

Medicare (Part B) - Medical Services - Per Calendar Year

Medicare (Part B) - Medical Services - Per Calendar Year
Services	Medicare Pays	After You Pay $2070 Deductible** Plan F Pays	In Addition to $2070 Deductible** You Pay
Medical Expenses In or out of the Hospital and Outpatient Hospital Treatment, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment.
First $140 of Medicare approved amounts****	$0	$140 (Part B Deductible)	$0
Remainder of Medicare approved amounts	Generally 80%	Generally 20%	$0
Part B Excess Charges (Above Medicare approved amounts)	$0	100%	$0
Blood
First 3 pints	$0	All costs	$0
Next $140 of Medicare approved amounts****	$0	$140 (Part B Deductible)	$0
Remainder of Medicare approved amounts	80%	20%	$0
Clinical Laboratory Services Tests For Diagnostic Services	100%	$0	$0

Services

Medicare Pays

After You Pay
$2070 Deductible**
Plan F Pays

In Addition to
$2070 Deductible**
You Pay

Medical Expenses

In or out of the Hospital and Outpatient Hospital Treatment, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment.

First $140 of Medicare approved amounts****

$140 (Part B Deductible)

Remainder of Medicare approved amounts

Generally 80%

Generally 20%

Part B Excess Charges

(Above Medicare approved amounts)

100%

Blood

First 3 pints

All costs

Next $140 of Medicare approved amounts****

$140 (Part B Deductible)

Remainder of Medicare approved amounts

80%

20%

Clinical Laboratory Services

Tests For Diagnostic Services

100%

Medicare (Parts A and B)

Medicare (Parts A and B)
Services	Medicare Pays	After You Pay $2070 Deductible** Plan F Pays	In Addition to $2070 Deductible** You Pay
Home Health Care Medicare approved services
Medically Necessary Skilled Care Services and Medical Supplies	100%	$0	$0
Durable Medical Equipment
First $140 of Medicare approved amounts****	$0	$140 (Part B Deductible)	$0
Remainder of Medicare approved amounts	80%	20%	$0

Services

Medicare Pays

After You Pay
$2070 Deductible**
Plan F Pays

In Addition to
$2070 Deductible**
You Pay

Home Health Care

Medicare approved services

Medically Necessary Skilled Care Services and Medical Supplies

100%

Durable Medical Equipment

First $140 of Medicare approved amounts****

$140 (Part B Deductible)

Remainder of Medicare approved amounts

80%

20%

Other Benefits - Not Covered by Medicare

Other Benefits - Not Covered by Medicare
Services	Medicare Pays	After You Pay $2070 Deductible** Plan F Pays	In Addition to $2070 Deductible** You Pay
Foreign Travel (Not covered by Medicare) Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
First $250 each calendar year	$0	$0	$250
Remainder of charges	$0	80% to a lifetime maximum benefit of $50,000	20% and amounts over the $50,000 lifetime maximum

Services

Medicare Pays

After You Pay
$2070 Deductible**
Plan F Pays

In Addition to
$2070 Deductible**
You Pay

Foreign Travel (Not covered by Medicare)

Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

First $250 each calendar year

$250

Remainder of charges

80% to a lifetime maximum benefit of $50,000

20% and amounts over the $50,000 lifetime maximum

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

**This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,070 deductible. Benefits from the High Deductible Plan F will not begin until out of pocket expenses are $2,070. Out-of-pocket expenses for this deductible are expenses ordinarily paid by the plan. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the carrier stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the plan’s Basic Benefits. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

****Once you have been billed $140 of Medicare-approved amounts for covered services (which are noted with four asterisks), your Part B deductible will have been met for the calendar year.

Once you know your Medicare effective dates, and have your Medicare card, you’re ready to go.

Shop for Plans in Washington

High Deductible Plan F

Medicare (Part A) - Hospital Services - Per Benefit Period

Medicare (Part B) - Medical Services - Per Calendar Year

Part B Excess Charges

Medicare (Parts A and B)

Medically Necessary Skilled Care Services and Medical Supplies

Durable Medical Equipment

Other Benefits - Not Covered by Medicare

Common Terms