Page 6 - Impact Floors 2022 Benefit Guide

Medical and pharmacy coverage

Core Medical Plan
PPO HDHP with HSA
Medical Plan Provisions In-Network Out-of-Network
CALENDAR YEAR DEDUCTIBLE & COINSURANCE
Individual $6,000 $12,000
Family $12,000 $24,000
Coinsurance 100% 70%
CALENDAR YEAR OUT-OF-POCKET MAXIMUM (Includes deductible, coinsurance, and all copays)
Individual $6,000 Unlimited

Family $12,000 Unlimited
COINSURANCE / COPAYS
Preventive Care No Charge 70%*
Primary Care Physician/Specialist 100%* 70%*
MDLive Virtual Visits $44 copay N/A
Diagnostics Lab & X-Ray 100%* 70%*
Complex Imaging 100%* 70%*
Urgent Care 100%* 70%*
Emergency Room 100%*
Inpatient Hospital Care 100%* 70%*
Outpatient Surgery 100%* 70%*
PHARMACY (up to 30 day supply) – Preferred Rx Network Applies
Preferred Generic 100%* 50%*
Non-Preferred Generic 100%* 50%*
Preferred Brand 100%* 50%*
Non-Preferred Brand 100%* 50%*
Specialty 100%* 50%*
*After deductible

RATES
Semi-Monthly Bi-Weekly Weekly
Employee Only $25.38 $23.24 $11.71
Employee + Spouse $260.50 $240.46 $120.23
Employee + Child(ren) $194.63 $179.65 $89.83
Employee + Family $429.75 $396.69 $198.35

The High Deductible Health Plan (HDHP) offers a lower per-paycheck cost, but a higher deductible that applies to almost all
healthcare expenses, including those for prescription drugs. Once your deducible and out-of-pocket maximum have been met,
BCBSTX will pay 100% of your covered healthcare expenses for the remainder of 2022. You are eligible to open up and fund a
Health Savings Account (HSA) if enrolled on the HDHP medical plan.

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