Page 8 - Impact Floors 2022 Benefit Guide

Medical and pharmacy

coverage (continued)

Buy-Up Medical Plan
Traditional PPO
Medical Plan Provisions In-Network Out-of-Network
CALENDAR YEAR DEDUCTIBLE & COINSURANCE
Individual $2,500 $5,000
Family $7,500 $15,000
Coinsurance 80% 60%
CALENDAR YEAR OUT-OF-POCKET MAXIMUM (Includes deductible, coinsurance, and all copays)
Individual $5,500 Unlimited

Family $14,700 Unlimited
COINSURANCE / COPAYS
Preventive Care No Charge 60%*
Primary Care Physician/Specialist $30/$60 copay 60%*
MDLive Virtual Visits $0 copay Not Covered
Diagnostics Lab & X-Ray No Charge 60%*
Complex Imaging 80%* 60%*
Urgent Care $75 copay 60%*
Emergency Room 80%* + $500 copay
Inpatient Hospital Care 80%* 60%*
Outpatient Surgery 80%* 60%*
PHARMACY (up to 31 day supply) – Preferred Rx Network Applies
Preferred Generic $0/$10 copay $10 copay + 50%
Non-Preferred Generic $10/$20 copay $20 copay + 50%
Preferred Brand $50/$70 copay $70 copay + 50%
Non-Preferred Brand $100/$120 copay $120 copay + 50%
Specialty $150/$250 copay $150/$250 copay + 50%
*After Deductible

RATES
Semi-Monthly Bi-Weekly Weekly
Employee Only $114.50 $105.69 $52.85
Employee + Spouse $477.00 $440.31 $220.15
Employee + Child(ren) $375.50 $346.62 $173.31
Employee + Family $738.50 $681.69 $340.85

The Buy Up PPO plan allows you to pay a single copay for most of your medical and prescriptions expenses. This plan has the
lowest deductible and out-of-pocket-max. Once your deductible has been met, you will continue to pay applicable copays and
cost share of 20% for covered expenses until you reach your out-of-pocket max. This plan has an unlimited out-of-network, out of
pocket maximum. Once your in-network deducible and out-of-pocket maximum have been met, BCBSTX will pay 100% of your
covered health care expenses for the remainder of 2022.

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