Page 8 - HIMSS 2021 Annual Benefits Enrollment

MEDICAL PLAN COMPARISON

BCBS BLUE
PLAN PROVISION BCBS HIGH DEDUCTIBLE BCBS PPO ADVANTAGE
PPO + HSA
HMO
OUT-OF-
OUT-OF-
IN-NETWORK NETWORK IN-NETWORK NETWORK IN-NETWORK
ONLY
COMPANY CONTRIBUTION TO HSA
Individual $500 N/A N/A N/A
Family $1,000 N/A N/A N/A

ANNUAL DEDUCTIBLE
Individual $3,000 $6,000 $1,500 $3,000 N/A

Family $6,000 $12,000 $3,000 $6,000 N/A
ANNUAL OUT-OF-POCKET MAXIMUM (INCLUDES DEDUCTIBLE)

Individual $4,500 $9,000 $3,000 $6,000 $1,500
Family $9,000 $18,000 $6,000 $12,000 $3,000

YOU PAY YOU PAY YOU PAY
Preventive Care $0 40% $0 40% $0
Primary Care Provider
Office Visit 20%* 40%* $30 40%* $30
Specialist Office Visit 20%* 40%* $40 40%* $30

Urgent Care 20%* 40%* 20%* 40%* $30
Emergency Room 20%* $300 $300

X-Ray and Lab 20%* 40%* 20%* 40%* $0*
Inpatient Hospital
Services 20%* 40%* 20%* 40%* $0*
Outpatient Hospital
Services 20%* 40%* 20%* 40%* $0*
RETAIL RX (UP TO 30-DAY SUPPLY)

Generic $10 $10
Brand Preferred 20%* 25% of eligible $40 $40
amount
Brand Non-preferred $60 $60
MAIL ORDER RX (UP TO 90-DAY SUPPLY)

Generic $20 $20
Brand Preferred 20%* 25% of eligible $80 $80
amount
Brand Non-preferred $120 $120
* After deductible
Note: This is a summary only of your coverage. Please refer to your summary plan descriptions for the full scope of coverage. In-network services are
based on negotiated charges; out-of-network services are based on reasonable and customary (R&C) charges.

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