Page 5 - Lakeside Benefit Guide 1-1-25

Medical Options:

BCBS of Texas (PPO)

P621CHC (PPO) G9L1CHC (PPO) S663CHC (PPO)
24 Pay Periods We offer our full-time employees and
Platinum Plan Gold Plan Silver Plan their eligible dependents coverage.
Employee Only $385.00 $300.00 $225.00 Children can join or remain on a
Employee + Spouse $880.00 $680.00 $555.00 parent’s medical plan until age 26.
When a child turns 26, they will lose
Employee + Child(ren) $880.00 $680.00 $555.00
medical coverage on the last day of
Employee + Family $1,375.00 $1,120.00 $890.00

Brief Member PLATINUM GOLD SILVER
P621CHC G9L1CHC S663CHC
In-Network Summary IN-NETWORK ONLY IN-NETWORK ONLY IN-NETWORK ONLY
Network Blue Choice PPO Blue Choice PPO Blue Choice PPO

(CYD) Calendar Year Deductible Individual: $1,350 Individual: $2,250 Individual: $3,100
(Jan .1st to Dec. 31st) Family: $4,050 Family: $6,750 Family: $9,200
Coinsurance Carrier: 100% Carrier: 80% Carrier 70%
(After CYD Calendar Year Deductible) Member: 0% Member: 20% Member: 30%

Annual (OOP) Out of Pocket Maxi- Individual: $1,350 Individual: $6,750 Individual: $9,200
mum Family: $4,050 Family: $18,400 Family $18,400

(PCP) Primary Care Physician $30 Copay $35 Copay $50 Copay

Specialist Physicians and $55 Copay $70 Copay $100 Copay
Providers

Dr. Consultation - Virtual Visits, $30 Copay $35 Copay $50 Copay

Basic: Lab, X-Rays & Diagnostic Basic: Paid 100% after CYD Basic: 20% after CYD Basic: 30% after CYD
Major: Diagnostic & Imaging Major: $250 CYD Waived Major: $250 CYD Waived Major: $250 plus 30% after CYD
Annual Preventive Care Certain Rx Covered 100% Covered 100% Covered 100%
are covered too, (Page 6) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)

$30 Copay $75 Copay $100 Copay
Urgent Care
(CYD may apply to other services) (CYD may apply to other services) (CYD may apply to other services)

Emergency Room $400 Copay after CYD $500 Copay plus 20% after CYD $600 Copay plus 30% after CYD

Hospitalization: In Patient: $100 after CYD In Patient: $100 + 20% after CYD In Patient: $350 + 30% after CYD
In Patient/ Outpatient Outpatient: $150 after CYD Outpatient: $150 + 20% after CYD Outpatient: $300 + 30% after CYD
Preferred Pharmacy / Network Preferred Pharmacy / Network Preferred Pharmacy / Network
Prescription Drugs - 31 Day Supply Generic (Preferred): $0-$10 Copay Generic (Preferred) $0-$10 Copay Generic (Preferred) $0-$10 Copay
Retail Generic: (Non-Preferred): $10-$20 Copay Generic: (Non Preferred) $10-$20 Copay Generic: (Non Preferred) $10-$20 Copay
90 Day Supply Mail Order at 2.5 Brand (Preferred): $35-$55 Copay Brand (Preferred): $50-$70 Copay Brand (Preferred): $50-$70 Copay
Times Retail Brand (Non-Preferred): $75-$95 Copay Brand (Non Preferred): $100-$120 Copay Brand (Non Preferred): $100-$120 Copay
Specialty (Preferred): $150 Copay Specialty (Preferred): $150 Copay Specialty (Preferred): $150 Copay
Specialty (Non-Preferred): $250 Copay Specialty (Non-Preferred): $250 Copay Specialty (Non-Preferred): $250 Copay

NOTE: This is only a brief overview. Please see Benefit Summary and SBC for more details. Please Register and use BCBS Member Services: 800-521-2227

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