Page 4 - Mara's Med Spa 2024 Benefit Guide V2

Medical Options:

BCBS of Texas (PPO)

Effective 1-1-2024 S9M2CHC (PPO)
Per Pay Period (Bi-Weekly) (Bi-Weekly—26 Pay-Periods) We offer our full-time employees and their
eligible dependents coverage. Children
Employee Only $116.64 can join or remain on a parent’s medical
plan until age 26. When a child turns 26,
Employee + Spouse $505.44
they will lose medical coverage on the last
Employee + Child(ren) $505.44 day of their birth month.
Employee + Family $894.25

PPO Plan S9M2CHC
Brief Member
In-Network Summary $3,750 Deductible
In and OUT of Network Coverage

Network Blue Choice PPO

(CYD) Calendar Year Deductible Individual: $3,750
(Jan .1st to Dec. 31st) Family: $11,250

Coinsurance Carrier: 80%
(After CYD Calendar Year Deductible) Member: 20%

Individual: $9,000
Annual (OOP) Out of Pocket Maximum
Family: $18,000
(PCP) Primary Care Physician $45 Copay

Specialist Physicians and
Providers $90 Copay

Dr. Consultation - Virtual Visits, $45 Copay
Basic: Lab, X-Rays & Diagnostic Basic: Lab: 20% after CYD XRAY: $100/test + 20% After CYD
Major: Diagnostic & Imaging Major: $200/test + 20% After CYD
Annual Preventive Care Certain Rx are cov- Covered 100%
ered too (No CYD, Co-Ins. Copays)

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

Emergency Room $500 Copay plus 20% after CYD

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