Page 4 - UPDATED - 8-1-24 Heritage School Benefit Guide

Medical Options

Baylor Scott & White (BSW)

2024 Rate Information - See Page 5
Dependent Information
Heritage School of Texas offers employees two major medical Heritage School of Texas offers our
options to meet your individual needs and pays up to $600 for employees the opportunity to cover their
spouse and dependent children. Children
employee only medical, dental and vision premiums. can join or remain on a parent’s plan until
the last day of their birth month at age 26.

Silver PPO 80 4250 Gold PPO 80 1500
In-Network Benefits
Core Plan Buy Up Plan
Summary In and Out of Network Benefits Covered In and Out of Network Benefits Covered

Calendar Year Deductible Individual: $4,250 Individual: $1,500
(CYD) Family: $8,500 Family: $3,000

Coinsurance after CYD Carrier 80% Member 20% Carrier 80% Member 20%
Annual Out of Pocket Individual: $9,100 Individual: $7,000
Maximum (OOP) Family: $18,200 Family: $14,000
Office Visit Copay - Under Age 19: $0 Under Age 19: $0
PCP / Specialist $50 Copay/$95 Copay $25 Copay/$60 Copay

Virtual Visits $0 Copay $0 Copay

Diagnostic X-Ray/Lab tests 20% after CYD 20% after CYD
Preventive Care (see Pg. 6) Covered 100% Covered 100%

$95 Copay $60 Copay
Urgent Care
(Does not include lab/ x-ray) (Does not include lab/ x-ray)
Emergency Room $750 Copay + 20% After CYD $750 + 20% After CYD

Basic Lab/X-Ray 20% after CYD 20% after CYD

Imaging (CT/PET scans, 20% after CYD 20% after CYD
MRI’s)

Hospital Inpatient/ 20% after CYD 20% after CYD
Outpatient

IN-NETWORK ACA Preventive: $0 ACA Preventive: $0
Participating Pharmacies / Generic:$15 Generic:$15
Non Participating Pref Brand:$55 Pref Brand:$55
Prescription Drugs Non-Pref Brand: $150 Non-Pref Brand: $150
30 Day Supply* 90 mail order Specialty: $500 Specialty: $500
3 times the retail copay
Members electing to purchase preferred/non-preferred brand name drugs when a generic equivalent is available will be required to pay
the difference between the cost of the generic and preferred/non-preferred brand name drug, plus the preferred brand copayment
amount. 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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