Page 9 - Avatar 2022 Flipbook
P. 9
MEDICAL COVERAGE PLAN B
Plan B: HDHP with HSA
Plan Provision
In-Network Out-of-Network
If you enroll in our Medical Plan B, the Rangers will
Company Contribution to HSA contribute $250 annually into your Health Savings
Account (H.S.A.); over 26 pay periods.
Annual Deductible
Individual $4,500 $9,000
Family $9,000 $18,000
Out-of-Pocket Maximum
Individual $6,350 $12,700
Family $12,700 $25,400
Lifetime Maximum Unlimited
Preventive Care 100% Not Covered
Primary Physician Office Visit 70% after Deductible 50% after Deductible
Specialist Office Visit 70% after Deductible 50% after Deductible
X-Ray and Lab 70% after Deductible 50% after Deductible
Inpatient Hospital Services 70% after Deductible 50% after Deductible
Outpatient Hospital Services 70% after Deductible 50% after Deductible
Urgent Care 70% after Deductible 50% after Deductible
Emergency Room Care 70% after Deductible
Retail Prescriptions 70% after Deductible
Plan B: Employee Cost
Tier
Monthly Bi-Weekly
Individual $33.00 $15.23
Employee+ Child(ren) $48.00 $22.15
Employee + Spouse $50.00 $23.08
Family $70.00 $32.31
The above is a summary of this benefit option.
Click here for more detailed information on this available benefit option.
2023 Rangers Baseball LLC (the Texas Rangers) Benefit Guide Page 9
