Page 7 - Gerald R Ford International Airport Authority 2022 Benefits Guide

Medical and pharmacy coverage

BCBSM PPO Plan BCBSM HDHP w/HSA
Medical Plan Provisions In-Network Out-of-Network In-Network Out-of-Network

GFIAA contribution to HSA N/A $130 / $312 / $390
(Individual / Individual + 1 / Family)
Annual Deductible
(Individual / Family) $250 / $500 $500 / $1,000 $1,400 / $2,800 $2,800 / $5,600
Out-of-Pocket Maximum $1,250 / $2,500 $3,500 / $7,000 $2,250 / $4,500 N/A
(Includes Deductible)

Preventive Care Covered at 100% Not covered Covered at 100% Not covered
Primary Care Provider Office Visit $20 copay 60%* 100%* 80%*

Specialist Office Visit $20 copay 60%* 100%* 80%*
X-Ray and Lab 80%* 60%* 100%* 80%*
Inpatient Hospital Services 80%* 60%* 100%* 80%*

Outpatient Hospital Services 80%* 60%* 100%* 80%*
Covered 100%
Urgent Care after $20 copay 60%* 100%* 80%*
Covered 100% after $150 copay;
Emergency Room copay waived if admitted or 100%*
for accidental injury

Pharmacy Provisions
Prescription Drug Deductible Included in Medical OOP Maximum Included in Medical OOP Maximum
(Individual / Family)

Retail Pharmacy (up to a 30-day supply)
Generic $15 copay* $15 copay + 20%* $15 copay* $15 copay + 20%*

Brand Preferred $30 copay* $30 copay + 20%* $30 copay* $30 copay + 20%*

Brand Non-Preferred $60 copay* $60 copay + 20%* $60 copay* $60 copay + 20%*
Mail Order Pharmacy (90-day supply)
Generic $30 copay* $30 copay + 20%* $30 copay* $30 copay + 20%*

Brand Preferred $60 copay* $60 copay + 20%* $60 copay* $60 copay + 20%*

Brand Non-Preferred $120 copay* $120 copay + 20%* $120 copay* $120 copay + 20%*
*After deductible
Note: Optum Rx will be replacing Express Scripts effective January 1, 2022.

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