Page 4 - Brown PC 12-1-2023 Benefit Guide

Medical Option:

Blue Cross Blue Shield

2023-2024 Plan Year Dependent Information

Rates are shown on Page 5 Brown, PC offers employees the opportunity to
cover their spouse and dependent children.
Rates are shown on page 5. Children can join or remain on a parent’s
All contact information medical plan until age 26. When a child turns
26, they will lose medical coverage on the last
can be found on page 13. day of their birth month.

S9M2CHC S9M2CHC B661CHC B661CHC
Benefits
In-Network Non-Network In-Network Non-Network

Calendar Year Deductible Individual: $3,750 Individual: $6,000 Individual: $6,900 Individual: $13,500
(CYD) Family: $11,250 Family: $18,000 Family: $13,800 Family: $27,000

Member Coinsurance after 100%
CYD 20% 60%

Individual: $9,000 Individual: Unlimited Individual: $6,900 Individual: $13,500
Out of Pocket Maximum
Family: $18,000 Family: Unlimited Family: $13,800 Family: $27,000

Office Visit—(Dr. Service Only) $45 Copay 40% after CYD No Charge after CYD
Primary Care Physician
Office Visit - (Dr. Service Only) $90 Copay 40% after CYD No Charge after CYD
Specialist

Virtual Physician Visit (24/7) $45 Copay N/A No Charge after CYD N/A
Covered 100% (No Covered 100%
Preventive Care 40% after CYD 100% after CYD
CYD or Copay) (No CYD or Copay)
Basic Outpatient Lab Lab: 20% After CYD
X Ray: $100 Copay 40% after CYD No Charge after CYD
X-Rays 20% After CYD

40% after CYD /
$75 Copay / other
Urgent Care other charges may No Charge after CYD
charges may apply
apply
Emergency Room Copay $500 copay/ per visit + 20% after CYD No Charge after CYD

In-Network Services In-Network Services
Prescription Drugs - 31 Day
Supply Retail Generic Drugs $10 / $20 Copay Generic Drugs: No Charge after CYD
90 Day Supply Mail Order at Preferred Brand Drugs $50 / $70 Copay Preferred Brand Drugs No Charge after CYD
3 X Retail Copay. Non Preferred Brand Drugs $100 / $120 Copay Non Preferred Brand Drugs No Charge after CYD

Specialty Drugs $150 / $250 Copay No Charge after CYD
See summary for details
NOTE: This is only a brief overview. Please see Benefit Summary or SBC for more details.
Support Tools @ www.bcbs.com

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