Page 5 - Lakeside 2024 Benefit Guide Final
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Medical Options:


          BCBS of Texas (PPO)




            24 Pay Periods        P621CHC (PPO)   G9L1CHC (PPO)   S663CHC (PPO)   We  offer  our  full-time  employees  and  their
                                   Platinum Plan   Gold Plan       Silver Plan
                                                                                 eligible  dependents  coverage.  Children
        Employee Only              $   350.00     $   275.00       $200.00       can  join  or  remain  on  a  parent’s  medical
        Employee + Spouse          $   800.00     $   625.00       $500.00       plan  until  age  26.    When  a  child  turns  26,
                                                                                 they will lose medical coverage on the last
        Employee + Child(ren)      $   800.00     $   625.00       $500.00       day of their birth month.

        Employee + Family          $1,250.00      $1,025.00        $800.00

            Brief Member                        PLATINUM                              GOLD                                             SILVER
                                                                            G9L1CHC
                                                P621CHC
                                                                                                        S663CHC
        In-Network Summary                  IN-NETWORK ONLY              IN-NETWORK ONLY            IN-NETWORK ONLY
      Network                                 Blue Choice PPO             Blue Choice PPO             Blue Choice PPO

      (CYD) Calendar Year Deductible                 Individual: $1,250   Individual: $2,000          Individual: $3,000
      (Jan .1st to Dec. 31st)                  Family: $3,750              Family: $6,000              Family: $9,000

      Coinsurance                              Carrier: 100%                Carrier: 80%                Carrier 70%
      (After CYD Calendar Year Deductible)       Member: 0%                  Member: 20%               Member: 30%

      Annual (OOP) Out of Pocket Maxi-        Individual: $1,250          Individual: $6,000          Individual: $9,000
      mum                                      Family: $3,750              Family: $17,100             Family $18,000

      (PCP) Primary Care Physician                                   $25 Copay    $30 Copay              $45 Copay


      Specialist Physicians and                 $45 Copay                   $60 Copay                   $90 Copay
      Providers

      Dr. Consultation  - Virtual Visits,       $25 Copay                    $30 Copay                  $45 Copay

      Basic: Lab, X-Rays & Diagnostic       Basic:  Paid 100% after CYD   Basic:  20% after CYD     Basic:  30% after CYD
      Major: Diagnostic & Imaging          Major:  $250 CYD Waived      Major:  $250 CYD Waived    Major:  $250 plus 30% after CYD

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

                                                $25 Copay                    $75 Copay                                                 $100 Copay
      Urgent Care
                                         (CYD may apply to other services)    (CYD may apply to other services)    (CYD may apply to other services)

      Emergency Room                        $400 Copay after CYD      $300 Copay plus 20% after CYD   $600 Copay plus 30% after CYD

      Hospitalization:                     In Patient: $100 after CYD   In Patient: $100 + 20% after CYD   In Patient: $350 + 30% after CYD
      In Patient/ Outpatient               Outpatient: $150 after CYD   Outpatient: $150 + 20% after CYD   Outpatient: $300 + 30% after CYD
                                           Preferred Pharmacy / Network   Preferred Pharmacy / Network   Preferred Pharmacy / Network
      Prescription Drugs - 31 Day Supply   Generic (Preferred): $0-$10 Copay   Generic (Preferred) $0-$10 Copay   Generic (Preferred) $0-$10 Copay
      Retail                            Generic: (Non-Preferred): $10-$20 Copay    Generic: (Non Preferred) $10-$20 Copay    Generic: (Non Preferred) $10-$20 Copay
                                                                      Brand (Preferred):  $50-$70 Copay
                                                                                                  Brand (Preferred):  $50-$70 Copay
                                          Brand (Preferred):  $35-$55 Copay
      90 Day Supply  Mail Order at 2.5   Brand (Non-Preferred): $75-$95 Copay   Brand (Non Preferred): $100-$120 Copay   Brand (Non Preferred): $100-$120 Copay
      Times Retail
                                          Specialty (Preferred): $150 Copay   Specialty (Preferred): $150 Copay   Specialty (Preferred): $150 Copay
                                         Specialty (Non-Preferred): $250 Copay   Specialty (Non-Preferred): $250 Copay   Specialty (Non-Preferred): $250 Copay
             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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