Page 4 - FW Specialty Surgical Care Benefit Guide 8-1-24 Rev

Medical Options:

BCBS of Texas

26 Pay Periods S9L1ADT (HMO) S9K1CHC (PPO) We offer our full-time employees and their
BASE Plan Buy-Up Plan eligible dependents coverage. Children

Employee Only $111.40 $171.14 can join or remain on a parent’s medical
plan until age 26. When a child turns 26,
Employee + Spouse $334.19 $513.42
they will lose medical coverage on the
Employee + Child(ren) $334.19 $513.42 last day of their birth month.
Employee + Family $556.98 $855.70

Brief Member BASE Plan Buy-Up Plan
S9L1ADT — HMO S9K1CHC — PPO
In-Network Summary IN-NETWORK ONLY IN & Out of NETWORK

Network Blue Advantage HMO Blue Choice PPO

(CYD) Calendar Year Deductible Individual: $5,000 Individual: $5,000
(Jan .1st to Dec. 31st) Family: $15,000 Family: $15,000

Coinsurance Carrier: 70% Carrier: 70%
(After CYD Calendar Year Deductible) Member: 30% Member: 30%

Annual (OOP) Out of Pocket Individual: $9,000 Individual: $9,000
Maximum Family: $18,000 Family: $18,000

(PCP) Primary Care Physician $40 Copay
$40 Copay (PCP Must be Assigned)

Specialist Physicians and $80 Copay $80 Copay
Providers (You must have a referral from your PCP)

Dr. Consultation - Virtual Visits, $40 Copay $40 Copay

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

$75 Copay $75 Copay
Urgent Care
(CYD may apply to other services) (CYD may apply to other services)
Emergency Room $500 Copay plus 30% after CYD $500 Copay plus 30% after CYD

Hospitalization: In Patient: $250 + 30% after CYD In Patient: $250 + 30% after CYD
In Patient/ Outpatient Outpatient: $200 + 30% after CYD Outpatient: $200 + 30% after CYD
Preferred Pharmacy / Network Preferred Pharmacy / Network
Prescription Drugs - 31 Day Supply Generic (Preferred): $0-$10 Copay Generic (Preferred) $0-$10 Copay
Retail Generic: (Non-Preferred): $10-$20 Copay Generic: (Non Preferred) $10-$20 Copay
90 Day Supply Mail Order at 2.5 Brand (Preferred): $50-$70 Copay Brand (Preferred): $50-$70 Copay
Times Retail Brand (Non-Preferred): $100-$120 Copay Brand (Non Preferred): $100-$120 Copay
Specialty (Preferred): $150 Copay Specialty (Preferred): $150 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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