Page 4 - 2024-25 Gas Clip Technologies Benefit Guide EXECUTIVES

Medical Options:

Blue Cross Blue Shield

P620CHC
Effective 12-1-24 S666CHC G652CHC Platinum
Semi-Monthly (24) Pay Period Silver PPO Gold PPO Dependent Information
PPO

Employee Only $143.61 $165.15 $192.63 Gas Clip Technologies offers employees the
opportunity to cover their dependent chil-
Employee + Spouse $287.21 $330.30 $385.25 dren. Children can join or remain on a

Employee + Child(ren) $287.21 $330.30 $385.25 parent’s medical plan until age 26.
Employee + Family $430.82 $495.45 $577.88 When a child turns 26, they will lose medical

S666CHC G652CHC P620CHC
Brief Member In- Platinum
Network Summary Silver PPO Gold PPO
$4,250 Deductible $1,500 Deductible PPO $250 Deductible
Network Blue Choice PPO Blue Choice PPO Blue Choice PPO
Individual: $4,250 Individual: $1,500 Individual: $250
(CYD) Calendar Year Deductible
(Jan .1st to Dec. 31st)
Family: $12,750 Family: $4,500 Family: $750
Coinsurance Carrier: 70% Carrier: 80% Carrier: 80%
(After CYD) Member: 30% Member: 20% Member: 20%
Annual (OOP) Out of Pocket Maxi- Individual: $9,000 Individual: $5,250 Individual: $1,500
mum Family: 18,000 Family: $10,500 Family: $4,500

(PCP) Primary Care Physician $50 Copay $45 Copay $30 Copay

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

Dr. Consultation Virtual Visits,
$50 Copay $45 Copay $30 Copay
See Pg. 7
Basic: Lab, X-Rays & Diagnostic Basic: 30% after CYD Basic: 20% after CYD Basic: 20% after CYD
Major: Diagnostic & Imaging Major: $300 Copay; No CYD Major: $300 Copay; No CYD Major: $250 Copay; No CYD

Annual Preventive Care Certain Rx Covered 100% Covered 100% Covered 100%
are covered too, See Page 5 (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)

Urgent Care $100 Copay; No CYD $100 Copay; No CYD $30 Copay; No CYD

Emergency Room $650 Copay + 30% after CYD $500 Copay + 20% after CYD $100 Copay + 20% after CYD
IN: $300 Copay + 30% after CYD/ IN: $250 Copay + 30% after CYD
Hospitalization: In / Outpatient 20% after CYD
OUT: $250 Copay + 30% After CYD OUT: $150 Copay + 30% After CYD

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Prescription Drugs - 31 Day Supply Tier 1: $5-$15 Copay r 1: $0-$10 Copay r 1: $0-$10 Copay
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Retail Tier 2: $15-$25 Copay r 2: $10-$20 Copay $10-$20 Copay
Tier 3: $50-$70 Copay Tier 3: $50-$70 Copay Tier 3: $35-$55 Copay
90 Day Supply Mail Order at
Tier 4: $100-$120 Tier 4: $100-$120 Tier 4: $75-$95
3 x Retail
Specialty: $250-$350 Specialty: $150-$250 Specialty: $150-$250
Please note: This summary is intended for general information purposes.
It is not a guarantee of benefits. Please reference the SBC or contact the carrier for specific details.
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