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

Medical Options:

Blue Cross Blue Shield

S666CHC G652CHC
Effective 12-1-24 Silver Gold
Semi-Monthly (24) Pay Period
Base PPO Buy-Up PPO Dependent Information

Employee Only $143.61 $165.15 Gas Clip Technologies offers employees the
Employee + Spouse $287.21 $330.30 opportunity to cover their dependent children.
Children can join or remain on a parent’s
Employee + Child(ren) $287.21 $330.30
medical plan until age 26.
Employee + Family $430.82 $495.45

S666CHC G652CHC
Brief Member
In-Network Summary Silver PPO Gold PPO
$4,250 Deductible $1,500 Deductible

Network Blue Choice PPO Blue Choice PPO
(CYD) Calendar Year Deductible (Jan .1st to Individual: $4,250 Individual: $1,500
Dec. 31st) Family: $12,750 Family: $4,500
Coinsurance Carrier: 70% Carrier: 80%
(After CYD) Member: 30% Member: 20%

Individual: $9,000 Individual: $5,250
Annual (OOP) Out of Pocket Maximum
Family: 18,000 Family: $10,500

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

Specialist Physicians and Providers $90 Copay $90 Copay

Dr. Consultation Virtual Visits, See Pg. 7 $50 Copay $45 Copay

Basic: Lab, X-Rays & Diagnostic Basic: 30% after CYD Basic: 20% after CYD
Major: Diagnostic & Imaging Major: $300 Copay; No CYD Major: $300 Copay; No CYD
Annual Preventive Care Certain Rx are
Covered 100% (No CYD, Co-Ins. Copays) Covered 100% (No CYD, Co-Ins. Copays)
covered too, See Page 5

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

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

Tier 1: $5-$15 Copay Tier 1: $0-$10 Copay
Prescription Drugs - 31 Day Supply Retail Tier 2: $15-$25 Copay Tier 2: $10-$20 Copay
90 Day Supply Mail Order at Tier 3: $50-$70 Copay Tier 3: $50-$70 Copay
3 x Retail Tier 4: $100-$120 Tier 4: $100-$120
Specialty: $250-$350 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.
4