Page 4 - Brown PC 12-1-2022 Benefit Guide

Medical Option:

Blue Cross Blue Shield

2022-2023 Plan Year Dependent Information

For rates please see the age rate sheet. Brown, PC offers employees the opportunity to
cover their spouse and dependent children.
For cost information please refer to HR or your Children can join or remain on a parent’s
Broker, IFC Benefit Solutions. All contact infor- medical plan until age 26. When a child turns
mation can be found on page 11. 26, they will lose medical coverage on the last
day of their birth month.

S661CHC In- Non-Network B661CHC In-Network Non-Network
Benefits
Network Services Services Services Services

Calendar Year Deductible Individual: $3,000 Individual: $6,000 Individual: $6,900 Individual: $13,500
(CYD) Family: $9,000 Family: $18,000 Family: $13,800 Family: $27,000

Member Coinsurance after 100%
CYD 30% 50%
Individual: $8,700 Individual: Unlimited Individual: $6,900 Individual: $13,500
Out of Pocket Maximum
Family: $17,400 Family: Unlimited Family: $13,800 Family: $27,000
Office Visit—(Dr. Service Only) $50 Copay 50% after CYD 100% after CYD
Primary Care Physician

Office Visit - (Dr. Service Only) $80 Copay 50% after CYD 100% after CYD
Specialist

Virtual Physician Visit (24/7) $50 Copay N/A 100% after CYD N/A
Covered 100% (No Covered 100% (No CYD or
Preventive Care 50% after CYD 100% after CYD
CYD or Copay) Copay)
Basic Outpatient Lab Lab: 30% After CYD
X Ray: $100 Copay 50% after CYD 100% after CYD
X-Rays 30% After CYD
50% after CYD /
$100 Copay / other
Urgent Care other charges may 100% after CYD / other changes my apply
charges may apply
apply
Emergency Room Copay $600 copay/ per visit + 30% after CYD 100% after CYD

Prescription Drugs - 31 Day In-Network Services In-Network Services
Supply Retail Generic Drugs $10 / $20 Copay Generic Drugs 100% after CYD
90 Day Supply Mail Order at Preferred Brand Drugs $50 / $70 Copay Preferred Brand Drugs 100% after CYD
3 X Retail Copay.
Non Preferred Brand Drugs $100 / $120 Copay Non Preferred Brand Drugs 100% after CYD
Specialty Drugs
$150 / $250 Copay 100% after CYD
See summary for details

NOTE: This is only a brief overview. Please see Benefit Summary or SBC for more details.
Support Tools @ www.bcbs.com

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