Page 4 - Tritrax 2023 Benefit Guide
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Medical Options:




         Blue Cross Blue Shield



           Per Pay Period            Core        Buy-Up                    Dependent Information
           Bi-Weekly 2023
                                                             TriTrax Rehabilitation offers employees the opportunity to
           Employee Only            $162.69      $182.57
                                                             cover their dependent children. Children can join or
           Employee + Spouse        $488.06      $558.02     remain on a parent’s medical plan until age 26.
           Employee + Child(ren)    $488.06      $558.02     When a child turns 26, they will lose medical coverage
                                                             on the last day of their birth month.
           Employee + Family        $813.07      $929.89


                                                      HMO Core Plan                       PPO Buy-Up Plan
              In-Network Benefits                     $1,250 Deductible                    $3,500 Deductible
                                                   In-Network Coverage  Only         In and OUT of Network Coverage

                                                     Individual: $1,250                   Individual: $3,500
          Calendar Year Deductible (CYD)
                                                      Family: $3,750                       Family: $10,500
          Coinsurance                            Carrier 100% / Member 0%             Carrier 70% / Member 30%

          Out of Pocket Maximum:                     Individual: $1,250                   Individual: $9,000
          (Includes CYD, Copays, Co-Ins)              Family: $3,750                       Family: $18,000
          Office Visit  - PCP                           $25 Copay                            $50 Copay

                                                        $45 Copay
          Office Visit—Specialist                                                            $90 Copay
                                                 (Referral Required by PCP)
          Telemedicine 24/7 (MDLive)                    $25 Copay                            $50 Copay

          Preventive Care                             Covered 100%                         Covered 100%

          Lab Work & X-Rays (Basic)                    0%, After CYD             30% After CYD Plus $150 for X-Rays
                                                        $250 Copay
          (Imaging) MRI’s, CT, PET                                                 $250 Copay, plus 30% After CYD
                                                 (Referral Required by PCP)
          Urgent Care                               $25 Copay, No CYD                   $100 Copay, No CYD


          Emergency Room                       $400 Copay, plus 0% After CYD       $750 Copay, plus 30% After CYD
                                               $150 Copay, plus 0% After CYD
          Hospitalization (Inpatient)                                              $350 Copay, plus 30% After CYD
                                                 (Referral Required by PCP)
                                                                                       P
                                                                                        r
                                                  Preferred Generic:$0/$10                                  erred Generic:$0/$10
                                                                                         ef
          IN-NETWORK                           Non-Preferred Generic:$10/$20        Non-Preferred Generic:$10/$20
          Participating Pharmacies / Non       Preferred Name Brand: $35/$55        Preferred Name Brand: $50/$70
          Participating Pharmacies              Non-Preferred Brand: $75/$95       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






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