Page 5 - 2023 Stamford Benefit Guide

Medical Options:

Blue Cross Blue Shield (BCBS TX)

Effective 5/1/2023 Buy-Up
Base
We offer our full-time employees and their eligible
Bi-Weekly Pay Period S9M2CHC (PPO) G9L5CHC (PPO)
dependents coverage. Children can join or remain
Employee Only $ 101.97 $145.49
on a parent’s medical plan until age 26. When a
Employee + Spouse $308.35 $394.77 child turns 26, they will lose medical coverage on the
Employee + Child(ren) $279.80 $361.95 last day of their birth month.
Employee + Family $456.41 $597.48

Summary of Plan BASE PLAN BUP-UP PLAN
In-Network Benefits and Member PPO Silver S9M2CHC PPO Gold G9L5CHC
Costs $3,750 Deductible $3,000 Deductible

BCBS Network Blue Choice Network Blue Choice Network
(CYD) Calendar Year Deductible January Individual: $3,750 Individual: $3,000
1st to December 31st Family: $11,250 Family: $9,000

Coinsurance Carrier: 80% / Member: 20% Carrier: 80% / Member: 20%
Calendar Year Annual Out of Pocket Maxi-
Individual: $9,000 Individual: $8,700
mum (Copays, CYD Deductibles and Coin-
Family: $18,000 Family: $17,400
surance)
(PCP) Primary Care Physician $45 Copay $0 Copay
Specialist Physicians & Providers $90 Copay $80 Copay

Dr. Consultation Virtual Visits $45 Copay $0 Copay

Basic: Lab Tests 20% after CYD 20% after CYD
Basic: X-Rays $100/test + 20% after CYD 20% after CYD
Major: Diagnostic & Imaging $200/test + 20% after CYD 20% after CYD

Preventive Care Covered 100% Covered 100%
(Certain Rx are covered too) (No CYD, Co-Ins. Copay) (No CYD, Co-Ins. Copay)

Urgent Care $75 copay (CYD may apply to other services) $150 copay (CYD may apply to other services)

Emergency Room $500 Copay + 20% after CYD 20% after CYD

Hospitalization: In / Out Patient $300/$350 Copay + 20% after CYD 20% after CYD
Exams, Lenses, Frames paid after Copays up to Exams, Lenses, Frames paid after Copays up to
Vision—Pediatric Only to Age 19
plan limits plan limits

Pref Generic:$0/$10 Pref Generic:$0/$10
Non-Pref Generic:$10/$20 Non-Pref Generic:$10/$20
Prescription Drugs : 31 Day Supply Retail Pref Name Brand: $50/$70 Pref Name Brand: $50/$70
90 Day Supply Mail Order 3 Times Retail
Non-Pref Brand: $100/$120 Non-Pref Brand: $100/$120

Specialty Pref:$150 Specialty Pref:$150
Specialty Non Pref:$250 Specialty Non Pref:$250

NOTE: This is only a brief overview. Please see Benefit Summary and SBC for more details. Please Register and use
BCBS Member www.bcbstx.com or BlueCross Customer Service: 800-528-7264
5