Page 5 - 2017 Benefits Enrollment

Medical Benefits 2017 Beneits Enrollment

BCBS TX
PPO 1000
HDHP 2000 HDHP 3000
(For Employees 64 and Over Only)
In-Network In-Network In-Network
Dependent Eligibility Children covered up to age 26 regardless of marital, student, or dependency status
Calendar Year Not embedded—family ded applies Not embedded—family ded applies Embedded—no one individual must
Deductible if one or more dependents are if one or more dependents are meet more than the individual limit
covered covered
Individual $2,000 $3,000 $1,000
Family $4,000 $6,000 $2,000
Out-of-Pocket Maximum Embedded—out-of-pocket Embedded—out-of-pocket Embedded—out-of-pocket
maximum includes deductible, maximum includes deductible, maximum includes deductible,
coinsurance, and medical copays coinsurance, and medical copays coinsurance, and medical copays
Individual $4,000 $6,000 $4,500
Family $8,000 $9,000 $9,000
Physician Office Visits
Primary Care 90% after ded 80% after ded $25 copay
Specialist 90% after ded 80% after ded $40 copay
Urgent Care 90% after ded 80% after ded $40 copay
Wellness/Preventive Covered at 100% Covered at 100% Covered at 100%
Lab Services
Physicians Office 90% after ded 80% after ded $25 copay
Outpatient Facility 90% after ded 80% after ded 80% after ded
Outpatient Hospital 90% after ded 80% after ded 80% after ded
X-Ray/Radiology Services
Physicians Office 90% after ded 80% after ded $25 copay
Outpatient Facility 90% after ded 80% after ded 80% after ded
Outpatient Hospital 90% after ded 80% after ded 80% after ded
Hospital Services
Inpatient 90% after ded 80% after ded 80% after $500 per admission ded
Outpatient 90% after ded 80% after ded 80% after ded and $250 copay
Emergency Room 90% after ded 80% after ded $150 copay
Ambulance 90% after ded 80% after ded 100% of allowable amount
Urgent Care 90% after ded 80% after ded $40 copay

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