Page 5 - EMSAR 2022 Benefits Guide
P. 5
2022
Benefits Guide
Medical Benefits
BlueCross BlueShield of Texas | Group Number: 279163
EMSAR ofers three medical plans, a base PPO, a traditional PPO, and a HDHP. Each plan provides:
z Access to the BlueCross BlueShield network of Preferred Providers and ofer coverage for most
healthcare services
z Preventive care covered at 100% when using in-network providers
z Flexibility to see any provider you wish, but you will get more value when you receive in-network care
z Prescription drug coverage, with greater savings when using generics and the mail-order pharmacy
In-Network Beneits Base PPO PPO HDHP
Network Name Blue Choice PPO Blue Choice PPO Blue Choice PPO
Calendar Year Deductible
Individual $3,000 $1,000 $2,800
Family $6,000 $2,000 $5,600
You pay 20% after You pay 20% after You pay 0% after
Coinsurance Percentage
deductible deductible deductible
Maximum Out-of-Pocket (Includes Deductible, Coinsurance, and Rx)
Individual Max Out-of-Pocket $6,500 $5,000 $3,000
Family Max Out-of-Pocket $13,000 $10,000 $6,000
Physician Copays
Preventive Services Covered 100% Covered 100% Covered 100%
Physicians/Specialist/Virtual Oice Visit $0/$100/$0 copay $25/$50/$25 copay 0% after deductible
Diagnostic Lab & X ray Covered 100% Covered 100% 0% after deductible
Hospital Services
Inpatient Hospital Expenses 20% after deductible 20% after deductible 0% after deductible
Outpatient Surgery Facility 20% after deductible 20% after deductible 0% after deductible
Advanced Imaging (MRI, CT, PET) 20% after deductible 20% after deductible 0% after deductible
Emergency Medical Care
Urgent Care Facility $50 copay $50 copay 0% after deductible
$250 copay + 20% after $250 copay + 20% after
Emergency Room Facility 0% after deductible
deductible deductible
Emergency Room Physician 20% after deductible 20% after deductible 0% after deductible
Prescription Services
Rx Deductible $250 deductible N/A N/A
Generic Drug $5 copay $5 copay $10 copay after deductible
Preferred Brand Drug $50 copay $50 copay $35 copay after deductible
Non-Preferred Brand Name Drug & Preferred $100 copay $100 copay $60 copay after deductible
Specialty
Non-Preferred Specialty Drug $250 copay $250 copay N/A
Mail Order 3 × copay 3 × copay 2.5 × copay
Out-of-Network Beneits Base PPO PPO HDHP
Deductible $10,000/$20,000 $5,000/$10,000 $3,500/$7,000
Maximum Out-of-Pocket (includes deductible) $20,000/$40,000 $10,000/$20,000 $7,000/$14,000
Coinsurance Percentage 50% 70% or 50% 70% or 50%
Please see summary of beneits for more detailed information. Coverage levels above indicate the coinsurance percentage or copay amount
that you are responsible for.
5
Benefits Guide
Medical Benefits
BlueCross BlueShield of Texas | Group Number: 279163
EMSAR ofers three medical plans, a base PPO, a traditional PPO, and a HDHP. Each plan provides:
z Access to the BlueCross BlueShield network of Preferred Providers and ofer coverage for most
healthcare services
z Preventive care covered at 100% when using in-network providers
z Flexibility to see any provider you wish, but you will get more value when you receive in-network care
z Prescription drug coverage, with greater savings when using generics and the mail-order pharmacy
In-Network Beneits Base PPO PPO HDHP
Network Name Blue Choice PPO Blue Choice PPO Blue Choice PPO
Calendar Year Deductible
Individual $3,000 $1,000 $2,800
Family $6,000 $2,000 $5,600
You pay 20% after You pay 20% after You pay 0% after
Coinsurance Percentage
deductible deductible deductible
Maximum Out-of-Pocket (Includes Deductible, Coinsurance, and Rx)
Individual Max Out-of-Pocket $6,500 $5,000 $3,000
Family Max Out-of-Pocket $13,000 $10,000 $6,000
Physician Copays
Preventive Services Covered 100% Covered 100% Covered 100%
Physicians/Specialist/Virtual Oice Visit $0/$100/$0 copay $25/$50/$25 copay 0% after deductible
Diagnostic Lab & X ray Covered 100% Covered 100% 0% after deductible
Hospital Services
Inpatient Hospital Expenses 20% after deductible 20% after deductible 0% after deductible
Outpatient Surgery Facility 20% after deductible 20% after deductible 0% after deductible
Advanced Imaging (MRI, CT, PET) 20% after deductible 20% after deductible 0% after deductible
Emergency Medical Care
Urgent Care Facility $50 copay $50 copay 0% after deductible
$250 copay + 20% after $250 copay + 20% after
Emergency Room Facility 0% after deductible
deductible deductible
Emergency Room Physician 20% after deductible 20% after deductible 0% after deductible
Prescription Services
Rx Deductible $250 deductible N/A N/A
Generic Drug $5 copay $5 copay $10 copay after deductible
Preferred Brand Drug $50 copay $50 copay $35 copay after deductible
Non-Preferred Brand Name Drug & Preferred $100 copay $100 copay $60 copay after deductible
Specialty
Non-Preferred Specialty Drug $250 copay $250 copay N/A
Mail Order 3 × copay 3 × copay 2.5 × copay
Out-of-Network Beneits Base PPO PPO HDHP
Deductible $10,000/$20,000 $5,000/$10,000 $3,500/$7,000
Maximum Out-of-Pocket (includes deductible) $20,000/$40,000 $10,000/$20,000 $7,000/$14,000
Coinsurance Percentage 50% 70% or 50% 70% or 50%
Please see summary of beneits for more detailed information. Coverage levels above indicate the coinsurance percentage or copay amount
that you are responsible for.
5
