Page 5 - 2022 Benefit Guide NA Construction

Medical Coverage

.express-scripts.com/
Below is a summary of coverage; refer to the Summary of Benefit Coverage for additional coverage and limitations. www.alabamablue.com

Spousal Surcharge : If your spouse (i) is employed, (ii) is eligible to enroll in his/her employer-sponsored medical benefits but declines
enrollment and (iii) elects Fives’ medical benefits as primary coverage, a Spousal Surcharge will apply ($75/ pay for bi-weekly and $37.50/pay
for weekly-paid employees.) The Spousal Surcharge offsets Fives’ cost of providing medical benefits to spouses who have other medical
benefits available to them from their employer in an effort to control premiums for Fives’ employees.

All employees electing Fives’ medical benefits for a spouse must complete a Spouse Medical Insurance Verification Form to obtain
medical coverage for a spouse regardless of his/her spouse’s employment status.
BCBS $500 PPO BCBS CDHP/HSA
Plan Provisions
In-Network Out-of-Network In-Network Out-of-Network
Annual Deductible $500 / $1,000 $1,000 / $2,000 $1,500 / $3,000 $3,000 / $6,000
(Individual/Family)
Out-of-Pocket Maximum $5,000 / $10,000 No out of pocket $5,000 / $10,000 No out of pocket
Single / Family maximums maximums

Preventive Care Covered 100% Not covered Covered 100% Not covered
Office Visits $35 copay 80% after deductible 50% after deductible
Phone and Online Health $35 copay 80% after deductible $45 copay Not covered
Specialist $50 copay 80% after deductible 80%
100% of the allowed
amount after applicable
In and Outpatient Hospital copay In Alabama: not covered In Alabama, not covered
Services or limited coverage or limited coverage
(precertification required for inpatient Lower Cost Share: 80% after deductible
admissions and some outpatient 80% after $800.00 per
hospital benefits $200.00 copay days 1-5 admission deductible 50% after deductible
Higher Cost Share:
$400.00 copay days 1-5
MRI, CAT Scan, PET, 100% after $200 copay per AL: 50% after deductible 80% after deductible 50% after deductible
Colonoscopy procedure 80% after deductible In Alabama, not covered
Therapy (30 visits) AL: 50% after deductible
50% after deductible
Chiropractic (15 visits) 80% after deductible AL: not covered 80% after deductible In Alabama, not covered
80% after deductible
$200 copay and
Emergency Room $200 copay 80% after deductible 80% after deductible
subject to deductible
Retail Prescriptions In Network only - 30 day supply In Network Only-30 day supply (after deductible)
Tier 1 $15 copay $15 copay
Tier 2 $40 copay $50 copay
Tier 3 $60 copay $75 copay
Tier 4-Specialty $100 copay $395 copay
Mail Order / Retail In Network only -90 day supply In Network only-90 day supply (after deductible)
Tier 1 $37.50 copay $45 copay
Tier 2 $100 copay $125 copay
Tier 3 $150 copay $187.50 copay
Tier 4-Specialty Not Covered Not Covered
(bi-weekly)
Single - $500 per year
HSA Company Contribution Not Applicable
Family - $1,000 per year
2022 Medical Rates (Monthly)

Employee Only $133.60 $88.44
Employee +Spouse $302.57 $249.17
Employee + Child(ren) $253.85 $206.72
Family $315.57 $274.45

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