Page 5 - 2022 Benefit Guide Bronx

Medical Coverage

The Company offers a choice of medical plan options through BCBS of Michigan so you can
choose the plan that best meets your needs and those of your family. Prescription coverage is
through Express Scripts Inc (ESI). This is a summary of coverage. Please refer to the Summary
of Benefit Coverage and Benefits at a Glance for additional coverage and limitations.
https://www.express-scripts.com/

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)
Medical: $3,500 Medical: $7,000
Single Out-of-Pocket Rx: $2,000 Rx: $2,000 $4,500 $9,000
Maximum *
TOTAL: $5,500 TOTAL: $9,000
Medical: $7,000 Medical: $14,000
Family Out-of-Pocket Rx: $4,000 Rx: $ 4,000 $9,000 $18,000
Maximum *
TOTAL: $11,000 TOTAL: $18,000
Preventive Care Covered 100% Not covered Covered 100% Not covered

Office Visits
Online Health $10 copay 60% after deductible 80% after deductible 60% after deductible
Primary Care $25 copay
Specialist $35 copay
In and Outpatient Hospital
Services** 80% after deductible 60% after deductible 80% after deductible 60% after deductible

Urgent Care $45 copay 60% after deductible 80% after deductible 60% after deductible

Emergency Room $250 copay, waived if admitted 80% after deductible 60% after deductible

Retail Prescriptions In Network - 30 day supply In Network - 30 day supply
Generic $10 copay 80% after deductible
Preferred 25% copay ($20 min, $75 max)
Non-preferred 30% copay ($35 min, $100 max)
Mail Order / Retail In Network -90 day supply In Network-90 day supply
Generic $20 copay
Brand Preferred 25% copay ($40 min, $150 max) 80% after deductible
Brand Non-preferred 30% copay ($70 min, $200 max)
HSA Company Not Applicable Single - $500 per year
Contribution Family - $1,000 per year
Monthly Premiums
(bi-weekly)
Employee Only 38.00 13.00
Employee +Spouse 76.00 31.00
Employee+Child(ren) 69.00 29.00
Family 115.00 70.00

Note:
* Maximum Out of Pocket Includes: deductible, office copays and coinsurance. A separate maximum applies to Prescriptions (Rx) for PPO Plans.
** Hospital services performed at a BCBS Blue Distinction Center (BDC) will be covered at 90% after deductible.

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