Metal Tier
Gold
Silver
Silver
Bronze
Bronze (HSA)
Plan Name MODA – Be Serene MODA – Be Agile MODA – Be Reliable Premera – Preferred Bronze Premera – Preferred Bronze “HSA”
Network First Choice Health First Choice Health First Choice Health Premera Signature Premera Signature
Type PPO PPO PPO PPO PPO
Copay $15 $20 $25/visit for first 4 visits, 25% subsequent visits Unlimited office visits, $15 copay PCP, specialists $45 copay 20%
Deductible per Person $650 $1,250 $2,750 $5,500 $5,250 per individual, x2 if family
Coinsurance 85%  / 15% 70% / 30% 75% / 25% 80% N/A
Maximum Out of Pocket (includes deductible) $4,000 $6,350 $6,600 $6,350 $5,250, x2 if family
Value $2 $2 $2 N/A N/A
Generic 50% 50% 50% $25 copay After deductible 100% covered
Brand 50% 50% 50% Deductible then 50% covered After deductible 100% covered
Additional Info A great option with greatest benefits at the core of the plan. A plan with high benefits at a greater value without a limit on office visits with copay only. A plan with high benefits at a greater value with limited office visits with copay only. A great option with value at the core of the plan. A great value for those who don’t need the benefits of the higher plans. HSA plans require the deductible be met prior to benefits being paid.
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