Page 4 - 2023-24 Gas Clip Technologies Benefit Guide EXECUTIVES

Medical Options:

Blue Cross Blue Shield

P620CHC
Effective 12-1-23 S666CHC G652CHC Platinum
Semi-Monthly (24) Pay Period Silver PPO Gold PPO
PPO Dependent Information

Employee Only $123.77 $142.73 $166.98 Gas Clip Technologies offers employees the
Employee + Spouse $247.54 $285.46 $333.95 opportunity to cover their dependent children.
Children can join or remain on a parent’s
Employee + Child(ren) $247.54 $285.46 $333.95
medical plan until age 26.
Employee + Family $371.30 $428.19 $500.93

S666CHC G652CHC P620CHC
Brief Member In- Platinum
Network Summary Silver PPO Gold PPO
$4,250 Deductible $1,500 Deductible PPO $250 Deductible

Network Blue Choice PPO Blue Choice PPO Blue Choice PPO
(CYD) Calendar Year Deductible Individual: $4,250 Individual: $1,500 Individual: $250
(Jan .1st to Dec. 31st) Family: $12,750 Family: $4,500 Family: $750
Coinsurance Carrier: 70% Carrier: 80% Carrier: 80%
(After CYD) Member: 30% Member: 20% Member: 20%

Annual (OOP) Out of Pocket Individual: $9,000 Individual: $5,250 Individual: $1,500
Maximum Family: 18,000 Family: $10,500 Family: $4,500

(PCP) Primary Care Physician $50 Copay $45 Copay $30 Copay

Specialist Physicians and Pro-
$90 Copay $90 Copay $60 Copay
viders
Dr. Consultation Virtual Visits,
$50 Copay $45 Copay $30 Copay
See Pg. 7
Basic: Lab, X-Rays & Diagnostic Basic: 30% after CYD Basic: 20% after CYD Basic: 20% after CYD
Major: Diagnostic & Imaging Major: $300 Copay; No CYD Major: $300 Copay; No CYD Major: $250 Copay; No CYD

Annual Preventive Care Certain Covered 100% Covered 100% Covered 100%
Rx are covered too, See Page 5 (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)

Urgent Care $100 Copay; No CYD $100 Copay; No CYD $30 Copay; No CYD

Emergency Room $650 Copay + 30% after CYD $500 Copay + 20% after CYD $100 Copay + 20% after CYD

IN: $300 Copay + 30% after CYD/ IN: $250 Copay + 30% after CYD
Hospitalization: In / Outpatient 20% after CYD
OUT: $250 Copay + 30% After CYD OUT: $150 Copay + 30% After CYD

i
e
i
T
e
T
Tier 1: $5-$15 Copay r 1: $0-$10 Copay r 1: $0-$10 Copay
Prescription Drugs - 31 Day
Tier 2: $15-$25 Copay r 2: $10-$20 Copay $10-$20 Copay
i
e
T
i
e
T
r 2:
Supply Retail
Tier 3: $50-$70 Copay Tier 3: $50-$70 Copay Tier 3: $35-$55 Copay
90 Day Supply Mail Order at
Tier 4: $100-$120 Tier 4: $100-$120 Tier 4: $75-$95
3 x Retail
Specialty: $250-$350 Specialty: $150-$250 Specialty: $150-$250
4