Page 4 - NTNSC_Benefit Guide 2021

Medical Options:

Blue Cross Blue Shield

2021 Rate Information - Per Pay Period
Dependent Information
Per Pay Period Buy-Up Plan Core Plan
North Texas Neuroscience and Sleep Center, P.A.
Employee Only $123.83 $73.20 offers employees the opportunity to cover their

Employee + Spouse $499.74 $398.46 spouse and dependent children. Children can
join or remain on a parent’s dental plan until age
Employee + Child(ren) $499.74 $398.46
26. When a child turns 26, they will lose medical
Employee + Family $875.64 $723.73 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: $5,000 Individual: $8,550
Out of Pocket Maximum
Family: $10,000 Family: $17,100
Office Visit - PCP $40 Copay for PCP’s $40 Copay for PCP’s
Specialist $80 Copay for Specialist’s $80 Copay for Specialist’s

Virtual Network Providers $40 Copay $40 Copay
(Telehealth 24/7)

Basic Lab/X-Ray Labs 20% after CYD / X-Ray $150 Plus 20% after CYD 30% after CYD
Imaging (CT/PET Scans, $200 Plus 20% after CYD $250 Copay / CYD Waived
MRI’s)
Preventive Care Covered 100% (No Deductible or Copay) Covered 100% (No Deductible or Copay)
$75 Copay $100 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 $600 Copay 30% after CYD and $500 Copay

Inpatient: 20% after CYD and $300 Copay Inpatient: 30% after CYD and $300 Copay
Hospital
Outpatient:20% after CYD and $250 Copay Outpatient:30% after CYD and $250 Copay
Retail Preferred Generic: Retail Preferred Generic:
Prescription Drugs $0 Preferred Participating / $10 Participating $0 Preferred Participating / $10 Participating
Copays Retail Non-Preferred Generic: Retail Non-Preferred Generic:
30 Day Supply $10 Preferred Participating / $20 Participating $10 Preferred Participating / $20 Participating
90 mail order 3 times
Preferred Rx retail copay Retail Preferred Name Brand: Retail Preferred Name Brand:
$50 Preferred Participating / $70 Participating $50 Preferred Participating / $70 Participating
Retail Non-Preferred Brand: Retail Non-Preferred Brand:
$100 Preferred Participating / $120Participating $100 Preferred Participating / $120Participating
Specialty Drugs: Specialty Drugs:
Preferred $150 / Non Preferred $250 Preferred $150 / 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.

4