Page 4 - Tritrax 2024 Benefit Guide

Medical Options:

Blue Cross Blue Shield

Per Pay Period P611ADT S661CHC Dependent Information
(HMO)
Bi-Weekly 2024 Core Plan (PPO)
TriTrax Rehabilitation offers employees the opportunity to
Employee Only $ 177.73 $ 203.23 cover their dependent children. Children can join or

Employee + Spouse $ 533.19 $ 621.18 remain on a parent’s medical plan until age 26.
When a child turns 26, they will lose medical coverage
Employee + Child(ren) $ 533.19 $ 621.18
on the last day of their birth month.
Employee + Family $ 888.26 $1,035.16

P611ADT (HMO) Core Plan S661CHC (PPO) Buy-Up Plan
In-Network Benefits $1,250 Deductible $3,500 Deductible
In-Network Coverage Only In and OUT of Network Coverage

Individual: $1,250 Individual: $3,500
Calendar Year Deductible (CYD)
Family: $3,750 Family: $10,500
Coinsurance Carrier 100% / Member 0% Carrier 70% / Member 30%

Out of Pocket Maximum: Individual: $1,250 Individual: $9,000
(Includes CYD, Copays, Co-Ins) Family: $3,750 Family: $18,000

Office Visit - PCP $25 Copay $50 Copay

$45 Copay
Office Visit—Specialist $90 Copay
(Referral Required by PCP)
Telemedicine 24/7 (MDLive) $25 Copay $50 Copay

Preventive Care Covered 100% Covered 100%
30% After CYD Plus $150 Copay per
Lab Work & X-Rays (Basic) 0%, After CYD
Test for X-Rays
50
$2
$250 Copay per Test; No CYD Copay per Test; plus 30% After
(Imaging) MRI’s, CT, PET
(Referral Required by PCP) CYD
Urgent Care $25 Copay, No CYD $100 Copay, No CYD

Emergency Room $400 Copay, plus 0% After CYD $750 Copay, plus 30% After CYD
$150 Copay, plus 0% After CYD
Hospitalization (Inpatient) $350 Copay, plus 30% After CYD
(Referral Required by PCP)
P
r
ef
Preferred Generic:$0/$10 erred Generic:$0/$10
IN-NETWORK Non-Preferred Generic:$10/$20 Non-Preferred Generic:$10/$20
Participating Pharmacies / Non Preferred Name Brand: $35/$55 Preferred Name Brand: $50/$70
Participating Pharmacies Non-Preferred Brand: $75/$95 Non-Preferred Brand: $100/$120
Prescription Drugs 30 Day Supply Mail Specialty Preferred:$150 Specialty Preferred:$150
Order 3 X the retail Participation copay
Specialty Non Preferred:$250 Specialty Non Preferred:$250
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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