Page 4 - Tritrax 2019 Benefit Guide

Medical Options:

Blue Cross Blue Shield

2019 Rate Information

Per Pay Period
Core Buy-Up
Dependent Information
Employee Only $130.59 $147.29 TriTrax Rehabilitation offers employees the opportunity to
cover their dependent children. Children can join or
Employee + Spouse $391.76 $441.88 remain on a parent’s medical plan until age 26.

Employee + Child(ren) $391.76 $441.88 When a child turns 26, they will lose medical coverage
on the last day of their birth month.
Employee + Family $652.92 $736.47

Core Plan Buy-Up Plan
In-Network Benefits
HMO $1,250 Deductible EPO $3,000 Deductible

Calendar Year Deductible Individual: $1,250 Individual: $3,000
(CYD) Family: $3,750 Family: $9,000

Coinsurance Carrier 100% / Member 0% Carrier 70% / Member 30%

Out of Pocket Maximum: Individual: $1,250 Individual: $7,350
(Includes CYD, Copays, Co-Ins) Family: $3,750 Family: $14,700

Office Visit - PCP $25 Copay $40 Copay

Office Visit—Specialist $45 Copay $80 Copay

Telemedicine 24/7 $25 Copay $40 Copay
Preventive Care Covered 100% Covered 100%

Lab Work & X-Rays (Basic) Covered 100%, No CYD 30% After CYD

X-Rays (Imaging) MRI’s, CT, 0% After CYD $200 Copay, plus 30% After CYD
PET

Urgent Care $25 Copay, No CYD $40 Copay, No CYD

Emergency Room $400 Copay, plus 0% After CYD $500 Copay, plus 30% After CYD

Hospitalization (Inpatient) $150 Copay, plus 0% After CYD $250 Copay, plus 30% After CYD

Retail Prescription Drugs - Preferred Generic: $10 Copay Preferred Generic: $10 Copay
30 Day Supply Non-Preferred Generic: $20 Copay Non-Preferred Generic: $20 Copay
Preferred Brand: $55 Copay Preferred Brand: $55 Copay
Specialty Drugs Non-Preferred Brand: $95 Copay Non-Preferred Brand: $95 Copay
$150 / $250 $150 / $250
Mail Order
90 Day Supply 3 Times Retail 3 Times Retail

Please note: This summary is intended for general information purposes.
It is not a guarantee of benefits. Please reference the SBC or contact the carrier for specific details.
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