Page 5 - Lakeside Benefit Guide 4-1-24a

Medical Options:

BCBS of Texas (PPO)

P621CHC (PPO) G9L1CHC (PPO) S663CHC (PPO)
24 Pay Periods We offer our full-time employees and
Platinum Plan Gold Plan Silver Plan their eligible dependents coverage.
Employee Only $ 350.00 $ 275.00 $200.00 Children can join or remain on a
Employee + Spouse $ 800.00 $ 625.00 $500.00 parent’s medical plan until age 26.
When a child turns 26, they will lose
Employee + Child(ren) $ 800.00 $ 625.00 $500.00
medical coverage on the last day of
Employee + Family $1,250.00 $1,025.00 $800.00

Brief Member PLATINUM GOLD SILVER
P621CHC G9L1CHC 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, (Page 6) (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
90 Day Supply Mail Order at 2.5 Brand (Preferred): $35-$55 Copay Brand (Preferred): $50-$70 Copay Brand (Preferred): $50-$70 Copay
Times Retail Brand (Non-Preferred): $75-$95 Copay Brand (Non Preferred): $100-$120 Copay Brand (Non Preferred): $100-$120 Copay
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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