Page 4 - Ally Office Solutions - 2023 Benefit Guide

Medical Options:

Baylor Scott & White (BSW)

2023 Rate Information — Per Pay Period

Gold PPO 3700 Silver PPO 5900 Dependent Information
Per Pay Period
(Buy-Up) (Base)
Ally Office Solutions offers employees the
Employee Only $196.29 $150.70 opportunity to cover their spouse and

Employee + Spouse $600.28 $509.10 dependent children. Children can join or
remain on a parent’s plan until age 26. They
Employee + Child(ren) $600.28 $509.10 will lose medical coverage on the last day of

Employee + Family $1004.26 $867.49 their birth month.
Gold PPO 3700 Silver PPO 5900
Brief In Network
Nationwide In & Out of Network Nationwide In & Out of Network
Summary
Benefits Benefits
Deductible – Calendar Individual: $3,700 Individual: $5,900
Year Deductible (CYD) Family: $7,400 Family: $11,800

Coinsurance Carrier 100% / Member 0% Carrier 90% / Member 10%
Annual Out of Pocket Individual: $9,100 Individual: $9,100
Maximum Family: $18,200 Family: $18,200
Office Visit - Primary Care Under Age 19: $0 Copay Under Age 19: $0 Copay
Physician (PCP) Age 19 and Over: $0 Copay Age 19 and Over: $35 Copay
No REFERRAL NEEDED
Virtual Designated Net-
work Providers $0 Copay $0 Copay
(Telehealth) See Page 6
For More Details

Office Visit - Specialist $65 Copay $70 Copay

Preventive Care Covered at 100% Covered at 100%

Labs / X-rays 0% After CYD 10% After CYD
MRI’s / PT’s / CT’s, Etc. (No 0% After CYD 10% After CYD
CYD)

Urgent Care $65 Copay $70 Copay
$750 Copay after CYD $750 Copay after CYD
Emergency Room Copay Out of Network Emergency Room $750 Out of Network Emergency Room $750
Copay After CYD Copay After CYD
Hospital: 0% After CYD 10% After CYD
• Inpatient 0% After CYD 10% After CYD
• Outpatient
Prescription Drugs—31 Tier 1:$15 Copay Tier 1:$15 Copay
Day Supply Retail Tier 2:$55 Copay Tier 2:$55 Copay
(90 Day Mail Order at 2.5 Tier 3:$150 Copay Tier 3:$150 Copay
Times Retail Copay) Tier 4:$500 Copay Tier 4:$500 Copay
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