Page 4 - Adolph's Litho Services - 2023 CLASS 3 - Graphic Movers - Benefit guide

Medical Options:

Baylor Scott & White (BSW)

2023 Rate Information — Per Pay Period

Employee Employer Dependent Information
Per Pay Period
Weekly Cost Weekly Cost
Adolph’s Litho Services offers employees the
Employee Only $0.00 $137.46 opportunity to cover their spouse and

Employee + Spouse $137.46 $274.92 dependent children. Children can join or
remain on a parent’s plan until age 26. They
Employee + Child(ren) $137.46 $274.92 will lose medical coverage on the last day of

Employee + Family $274.92 $412.38 their birth month.

Summary of Silver PPO 80 5000 PPO —
$5,000 Deductible Nationwide In & Out of Network Benefits

Deductible – Calendar Year Deductible Individual: $5,000
(CYD) Family: $10,000

Coinsurance Carrier 80% / Member 20%

Individual: $9,100
Annual Out of Pocket Maximum
Family: $18,200
Office Visit - Primary Care Physician (PCP) Under Age 19: $0 Copay
No REFERRAL NEEDED Age 19 and Over: $40 Copay
Virtual Designated Network Providers $0 Copay
(Telehealth) See Page 6 For More Details

Office Visit - Specialist $80 Copay

Preventive Care Covered at 100%

Labs / X-rays 20% After CYD

MRI’s / PT’s / CT’s, Etc. (No CYD) 20% After CYD

Urgent Care $80 Copay

$750 Copay after CYD
Emergency Room Copay Out of Network Emergency Room $750 Copay After CYD

Hospital: 20% After CYD
• Inpatient 20% After CYD
• Outpatient
Tier 1:$15 Copay
Prescription Drugs—31 Day Supply Retail Tier 2:$55 Copay
(90 Day Mail Order at 2.5 Times Retail Tier 3:$150 Copay
Copay)
Tier 4:$500 Copay

NOTE: This is only intended as a brief overview. Please see Benefit Summary or contact Baylor Scott & White (BSW) for more details.
Support Tools @ www.mybswhealth.com or Customer Service @ 844-279-3627
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