Page 4 - NTNSC Benefit Guide 2020

Medical Options:

Blue Cross Blue Shield

2020 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 $120.29 $ 59.18 offers employees the opportunity to cover their

Employee + Spouse $492.66 $370.43 spouse and dependent children. Children can
join or remain on a parent’s dental plan until age
Employee + Child(ren) $492.66 $370.43
26. When a child turns 26, they will lose dental
Employee + Family $865.02 $681.68 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: $4,000
Annual Deductible (CYD)
Family: 3,750 Family: $12,000
Coinsurance 80% Carrier / 20% Member after CYD 70% Carrier / 30% Member after CYD

Individual: $4,500 Individual: $8,150
Out of Pocket Maximum
Family: $9,000 Family: $16,300
Office Visit - PCP $30 Copay for PCP’s $40 Copay for PCP’s
Specialist $60 Copay for Specialist’s $80 Copay for Specialist’s

Virtual Network Providers $30 Copay $40 Copay
(Telehealth 24/7) $0 Copay Due to COVID $0 Copay Due to COVID

Basic Lab/X-Ray 20% after CYD 30% after CYD
Imaging (CT/PET Scans, 20% after CYD 30% after $250 Copay
MRI’s)

Preventive Care Covered 100% (No Deductible or Copay) Covered 100% (No Deductible or Copay)

$30 Copay $80 Copay
Urgent Care
(Other changes my apply, i.e.-rays/labs) (Other changes my apply, i.e.-rays/labs)

Emergency Room Copay 20% after CYD and $400 Copay 30% after CYD and $500 Copay

Inpatient: 20% after CYD and $100 Copay Inpatient: 30% after CYD and $250 Copay
Hospital
Outpatient:20% after CYD and $150 Copay Outpatient:30% after CYD and $250 Copay
PREFERRED PHARMACIES PREFERRED PHARMACIES
Prescription Drugs Preferred Generic $0 Preferred Generic $0
Copays Non-Preferred Generic $10 Non-Preferred Generic $10
30 Day Supply Preferred Name Brand $50 Preferred Name Brand $50
90 mail order 3 times Non-Preferred Brand $100 Non-Preferred Brand $100
Preferred Rx retail copay Specialty Preferred $150 Specialty Preferred $150
Specialty Non Preferred $250 Specialty 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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