Page 4 - National Door_Benefit Guide 2025a

Medical Options:

BCBS of Texas

Coverage Tier Buy Up (PPO) Core (HMO)
Cost Per Pay Period (26) Plan Plan Employees can cover their spouse &
dependent children. Children can remain
Employee Only $ 220.10 $ 69.55 on a parent’s medical plan until age 26.

Employee + Spouse $ 800.37 $446.05 When a child turns 26, they will lose
medical coverage on the last day of their
Employee + Child(ren) $ 553.20 $285.68
birth month. This is an automatic process.
Employee + Family $1,133.48 $662.18

BCBS PPO (Buy-Up) Medical BCBS HMO (Core) Medical
In-Network Benefits $2.500 Deductible $4,000 Deductible
In and OUT of Network Coverage In Network Coverage ONLY

Calendar Year Deductible (CYD) Individual: $2,500 Individual: $4,000
January 1st to December 31st Family: $7,500 Family: $12,000
Coinsurance Carrier 80% / Member 20% Carrier 80% / Member 20%
Network: Blue Choice PPO Network Blue Essentials HMO Network

Out of Pocket Maximum: Individual: $5,500 Individual: $8,150
(Includes CYD, Copays, Co-Ins) Family: $14,700 Family: $16,300

Office Visit - PCP $30 Copay; No CYD $35 Copay *Must Select PCP
$70 Copay
*MUST get referral from your PCP Not need-
Office Visit—Specialist $60 Copay; No CYD
ed for OB/GYN, Urgent Care, Behavioral
Health or Addiction Professionals.
Telemedicine 24/7 $0 Copay; No CYD $0 Copay; No CYD
BCBS-MDLive or HealthiestYou

Preventive Care, See Page 5 Covered 100%; No CYD, Copays, Co-Ins. Covered 100%; No CYD, Copays, Co-Ins

Lab Work & X-Rays (Basic) Covered 100%; No CYD 20% After CYD

(Imaging) MRI’s, CT, PET 20% After CYD 20% After CYD
$75 Copay
Urgent Care $75 Copay
(CYD may apply to other services)

Emergency Room $500 Copay, plus 20% After CYD $500 Copay, plus 20% After CYD

Hospitalization
(Inpatient/Outpatient) 20% After CYD 20% After CYD

ef
r
Preferred Generic:$0/$10 erred Generic:$0/$10
P
IN-NETWORK
Non-Preferred Generic:$10/$20 Non-Preferred Generic:$10/$20
Preferred / Non-Preferred Preferred Name Brand: $50/$70 Preferred Name Brand: $50/$70
Pharmacies Non-Preferred Brand: $100/$120 Non-Preferred Brand: $100/$120
Prescription Drugs 30 Day Supply Mail Specialty Preferred:$150 Specialty Preferred:$150
Order 3 X the retail Participation copay Specialty Non Preferred:$250 Specialty Non Preferred:$250

NOTE: This is only a brief overview. Please see the SBC for details.
Website: www.BCBSTX.com or Customer Service : 1-800-521-2227
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