Page 4 - Benefit Guide - Heritage School 2021

Medical Options

Blue Cross Blue Shield

2021 Rate Information - See Page 5
Dependent Information
Heritage School of Texas offers employees three medical Heritage School of Texas offers our
options to meet your individual needs and pays up to $550 for employees the opportunity to cover their
spouse and dependent children. Children
employee only medical, dental and vision premiums. can join or remain on a parent’s plan until
the last day of their birth month at age 26.

B661CHC S663CHC G652CHC
In-Network Benefits H.S.A. Core Plan Buy Up Plan

Summary In and Out of Network In and Out of Network In and Out of Network
Benefits Covered Benefits Covered Benefits Covered
Calendar Year Deductible Individual: $6,900 Individual: $3,000 Individual: $1,500
(CYD) Family: $13,800 Family: $9,000 Family: $4,500
Coinsurance after CYD Carrier 100% Member 0% Carrier 70% Member 30% Carrier 80% Member 20%

Annual Out of Pocket Individual: $6,900 Individual: $8,550 Individual: $5,000
Maximum (OOP) Family: $13,800 Family: $17,100 Family: $10,000
Office Visit Copay - $40 Copay/$80 Copay $40 Copay/$80 Copay
PCP / Specialist Covered 100% after CYD
Virtual Visits $44 Fee $40 Copay $40 Copay

Diagnostic X-Ray/Lab tests Covered 100% after CYD 30% after CYD 20% after CYD
Preventive Care (see Pg. 6) Covered 100% Covered 100% Covered 100%
$100 Copay $100 Copay
Urgent Care Covered 100% after CYD
(Does not include lab/ x-ray) (Does not include lab/ x-ray)
$600 Copay after CYD and $500 after CYD and
Emergency Room $650 Copay after CYD
30% Co-Ins. 20% Co-Ins.
Basic Lab/X-Ray Covered 100% after CYD 30% after CYD 20% after CYD

Imaging (CT/PET scans, $250 Copay after CYD and
MRI’s) Covered 100% after CYD 30% Co-Ins. $250 Copay CYD - Waived
Hospital Inpatient/ $350 Copay / $300 after CYD
Outpatient Covered 100% after CYD and 30% Co-Ins. 20% after CYD

IN-NETWORK Pref Generic:$0/$10 Pref Generic:$0/$10
Participating Pharmacies / Non-Pref Generic:$10/$20 Non-Pref Generic:$10/$20
Non Participating Covered 100% after CYD Pref Name Brand: $50/$70 Pref Name Brand: $50/$70
Prescription Drugs Non-Pref Brand: $100/$120 Non-Pref Brand: $100/$120
30 Day Supply* 90 mail order Specialty Pref:$150 Specialty Pref:$150
3 times the retail copay Specialty Non Pref:$250 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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