Page 4 - Catalyst 2022 Benefit Guide

Medical Options

Blue Cross Blue Shield

2022 Rate Information - See Page 5
Dependent Information
Catalyst Urban Development offers employees two medical Catalyst Urban Development, LLC offers our
options to meet your individual needs. employees the opportunity to cover their
spouse and dependent children. Children
Catalyst pays 100% of the Employee Only for the Silver can join or remain on a parent’s plan until
Option S667CHC Medial Plan. the last day of their birth month at age 26.

G9K4CHC S667CHC
In-Network Benefits
Gold Option H.S.A. Silver Option
Summary In and Out of Network Benefits Covered In and Out of Network Benefits Covered

Calendar Year Deductible Individual: $2,800 Individual: $6,000
(CYD) Family: $8,400 Family: $12,000
Coinsurance after CYD Carrier 90% Member 10% Carrier 80% Member 20%

Annual Out of Pocket Maxi- Individual: $3,500 Individual: $7,900
mum (OOP) Family: $10,500 Family: $15,800
Office Visit Copay:
- PCP / Specialist 10% after CYD $40 Copay/$70 Copay

Virtual Visits 10% after CYD $40 Copay

Diagnostic X-Ray/Lab tests 10% after CYD 20% after CYD

Preventive Care (see Pg. 6) Covered 100% Covered 100%

Urgent Care 10% after CYD $100 Copay
(Does not include lab/ x-ray)
Emergency Room 10% after CYD $750 Copay after CYD and 20% Co-Ins.

Basic Lab/X-Ray Covered 100% after CYD 20% after CYD

Imaging (CT/PET scans, MRI’s) 10% after CYD $250 Copay after CYD and 20% Co-Ins.

Hospital Inpatient/Outpatient 10% after CYD $250 Copay / $200 after CYD 20% Co-Ins.

AFTER CYD
Participating / Non Participating
IN-NETWORK Participating / Non Participating
Participating Pharmacies Pref Generic: 10%/20% Pref Generic:$0/$10
/ Non Participating Non-Pref Generic: 10%/20% Non-Pref Generic:$10/$20
Prescription Drugs Pref Name Brand: 20%/30% Pref Name Brand: $50/$70
30 Day Supply* 90 mail order Non-Pref Brand: 30%/40% Non-Pref Brand: $100/$120
3 times the retail copay Specialty Pref: 40% Specialty Pref:$150
Specialty Non Pref: 50% Specialty Non Pref:$250
Members electing to purchase preferred/non-preferred brand name drugs when a generic equivalent is available will be required to pay
the difference between the cost of the generic and preferred/non-preferred brand name drug, plus the preferred brand copayment
amount.
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.

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