Page 4 - TMED 2024 Benefit Guide - Employee Navigator

Medical Options:

Blue Cross Blue Shield

Per Pay Period MTBCP028 MTBCP019 Dependent Information
Bi-Weekly 2024 Core Buy-Up
Monitoring Concepts offers employees the opportunity
Employee Only $ 95.00 $142.00
to cover their dependent children. Children can join or
Employee + Spouse $164.00 $247.00 remain on a parent’s medical plan until age 26.

Employee + Child(ren) $332.00 $451.00 When a child turns 26, they will lose medical coverage

Employee + Family $398.00 $529.00 on the last day of their birth month.

PPO Core Plan PPO Buy-Up Plan
In-Network Benefits $3,000 Deductible $2,000 Deductible
In and OUT of Network Coverage In and OUT of Network Coverage

Calendar Year Deductible (CYD) Individual: $3,000 Individual: $2,000
January 1st to December 31st Family: $9,000 Family: $6,000
Coinsurance Carrier 80% / Member 20% Carrier 80% / Member 20%

Out of Pocket Maximum: Individual: $8,150 Individual: $5,000
(Includes CYD, Copays, Co-Ins) Family: $16,300 Family: $14,700

Office Visit - PCP $35 Copay $30 Copay
Office Visit—Specialist $70 Copay $60 Copay

Telemedicine 24/7 (MDLive) $35 Copay $30 Copay

Preventive Care Covered 100% Covered 100%

Lab Work & X-Rays (Basic) Covered 100% Covered 100%

(Imaging) MRI’s, CT, PET 20% After CYD 20% After CYD

Urgent Care $75 Copay $75 Copay

Emergency Room $500 Copay, plus 20% After CYD $500 Copay, plus 20% After CYD

Hospitalization (Inpatient) 20% After CYD 20% After CYD

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Preferred Generic:$0/$10 erred Generic:$0/$10
P
IN-NETWORK Non-Preferred Generic:$10/$20 Non-Preferred Generic:$10/$20
Participating Pharmacies / Non Preferred Name Brand: $50/$70 Preferred Name Brand: $50/$70
Participating Pharmacies Non-Preferred Brand: $100/$120 Non-Preferred Brand: $100/$120
Prescription Drugs 30 Day Supply Mail Specialty Preferred:$150 Specialty Preferred:$150
Order 3 X the retail Participation copay
Specialty Non Preferred:$250 Specialty Non Preferred:$250

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 or go to: www.bcbstx.com

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