Page 4 - 2023 North Texas Neurscience Benefit Guide

Medical Options:

Blue Cross Blue Shield

2023 Rate Information - Per Pay Period
Dependent Information
Per Pay Period Buy-Up Plan Core Plan
North Texas Neuroscience and Sleep Centers, P.A.
Employee Only $122.01 $ 70.84 offers employees the opportunity to cover their

Employee + Spouse $511.71 $409.38 spouse and dependent children. Children can
join or remain on a parent’s dental plan until age
Employee + Child(ren) $511.71 $409.38 26. When a child turns 26, they will lose dental

Employee + Family $901.41 $747.91 coverage on the last day of their birth month.

Buy Up Plan (G654CHC) Core Plan (S666CHC)
Your Cost Blue Choice Network Blue Choice Network
In-Network Summary In-Network Summary
Individual: $1,250 Individual: $4,250
Annual Deductible (CYD)
Family: 3,750 Family: $12,750
Coinsurance 80% Carrier / 20% Member After CYD 70% Carrier / 30% Member after CYD
Individual: $5,250 Individual: $9,000
Out of Pocket Maximum
Family: $10,500 Family: $18,000
Office Visit - PCP $45 Copay for PCP’s $50 Copay for PCP’s
Specialist $90 Copay for Specialist’s $90 Copay for Specialist’s

Virtual Network Providers $45 Copay $50 Copay
(Telehealth 24/7)
Labs: 20% After CYD
Basic Lab/X-Ray 30% after CYD
X-Ray: $150/test + 20% After CYD
Imaging (CT/PET Scans, $250/test + 20% After CYD $300 Copay / CYD Waived
MRI’s)

Preventive Care Covered 100% (No Deductible or Copay) Covered 100% (No Deductible or Copay)
$75 Copay $100 Copay
Urgent Care
(Other changes my apply, i.e.-rays/labs) (Other changes my apply, i.e.-rays/labs)
Emergency Room Copay $600 Copay + 20% After CYD $600 Copay + 20% After CYD

Inpatient: $300 Copay + 20% After CYD Inpatient: $300 Copay + 30% After CYD
Hospital
Outpatient: $250 Copay + 20% After CYD Outpatient: $250 Copay + 30% After CYD
Retail Preferred Generic: Retail Preferred Generic:
Prescription Drugs $0 Preferred Participating / $10 Participating $0 Preferred Participating / $10 Participating
Copays Retail Non-Preferred Generic: Retail Non-Preferred Generic:
30 Day Supply $10 Preferred Participating / $20 Participating $10 Preferred Participating / $20 Participating
90 mail order 3 times
Preferred Rx retail copay Retail Preferred Name Brand: Retail Preferred Name Brand:
$50 Preferred Participating / $70 Participating $50 Preferred Participating / $70 Participating
Retail Non-Preferred Brand: Retail Non-Preferred Brand:
$100 Preferred Participating / $120Participating $100 Preferred Participating / $120Participating
Specialty Drugs: Specialty Drugs:
Preferred $150 / Non Preferred $250 Preferred $150 / Non Preferred $250

Please note: This is intended for general comparison purposes.
It is not a guarantee of benefits. Please reference the SBC or contact the carrier for specific details.

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