Page 5 - Crosbyton Benefit Guide 4-1-25

Medical Options:

BCBS of Texas

We offer our full-time employees
24 Pay Periods MTBEE032 MTBC024 MTBC014 MTBC014
(HMO) (PPO) (PPO) (PPO) and their eligible dependents
coverage. Children can join or
Employee Only $ 95.00 $200.00 $ 275.00 $ 350.00 remain on a parent’s medical
Employee + Spouse $350.00 $550.00 $ 650.00 $ 950.00 plan until age 26. When a child
turns 26, they will lose medical
Employee + Child(ren) $350.00 $550.00 $ 650.00 $ 850.00 coverage on the last day of
their birth month.
Employee + Family $625.00 $850.00 $1,050.00 $1,400.00

Member HMO PPO PPO PPO

In-Network MTBEE032 MTBCB024 MTBCB014 MTBCB002
Summary IN-NETWORK ONLY IN & OUT OF NETWORK IN & OUT OF NETWORK IN & OUT OF NETWORK

Network Blue Essentials HMO Blue Choice PPO Blue Choice PPO Blue Choice PPO
Calendar Year Deductible Individual: $3,500 Individual: 2,500 Individual: $1,500 Individual: $500
CYD (Jan .1st to Dec. 31st) Family: $10,500 Family: $7,500 Family: $4,500 Family: $1,500
Coinsurance: Carrier 70% Carrier 70% Carrier 80% Carrier 100%
(After CYD Calendar Year
Deductible) Member: 30% Member: 30% Member: 20% Member: 0%
Annual Out of Pocket Individual: $7,900 Individual: $5,500 Individual: $4,500 Individual: $1,500
Maximum (OOP) Family $15,800 Family $14,700 Family $13,500 Family: $4,500
Primary Care Physician
(PCP $35 Copay $35 Copay $35 Copay $30 Copay
$70 Copay
Specialist Physicians and (You must have a referral $70 Copay 0 Copay
$7
$60 Copay
Providers (No referrals required) (No referrals required) (No referrals required)
from your PCP)
Dr. Consultation - Virtual
Visits, No Charge No Charge No Charge No Charge
Diagnostic: Lab, X-Rays Basic: 30% after CYD Basic: 30% after CYD Basic: 20% after CYD No Charge
CT, MRI, EEG, PET Scans Major: 30% after CYD Major: 30% after CYD Major: 20% after CYD Major: 30% after CYD

Annual Preventive Care Covered 100% Covered 100% Covered 100% Covered 100%
Certain Rx are covered too
(Page 5) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)
o
$75 Copay ay pay
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o
C
p
$
7
5
5
$
7
Urgent Care $75 Copay
(CYD may apply to other services) (CYD may apply to other services) (CYD may apply to other services)
$500 Copay plus $500 Copay plus $500 Copay plus
Emergency Room $500 Copay after CYD
30% after CYD 30% after CYD 20% after CYD
Hospitalization: In Patient: 30% after CYD In Patient: 30% after CYD In Patient: 20% after CYD In Patient: 20% after CYD
In Patient/ Outpatient Outpatient: 30% after CYD Outpatient: 30% after CYD Outpatient: 20% after CYD Outpatient: 20% after CYD
Preferred Pharmacy / Network Preferred Pharmacy / Network Preferred Pharmacy / Network Preferred Pharmacy / Network
Prescription Drugs - 31 Tier 1 $0-$10 Copay Tier 1 $0-$10 Copay Tier 1 $0-$10 Copay Tier 1 $0-$10 Copay
Day Supply Retail Tier 2 $10-$20 Copay Tier 2 $10-$20 Copay Tier 2 $10-$20 Copay Tier 2 $10-$20 Copay
Tier 3 $50-$70 Copay
Tier 3 $50-$70 Copay
Tier 3 $50-$70 Copay
Tier 3 $50-$70 Copay
90 Day Supply Mail Order Tier 4 $100-$120 Copay Tier 4 $100-$120 Copay Tier 4 $100-$120 Copay Tier 4 $100-$120 Copay
at 2.5 Times Retail
Specialty Tier 5 $150 Copay Specialty Tier 5 $150 Copay Specialty Tier 5 $150 Copay Specialty Tier 5 $150 Copay
Specialty Tier 6 $250 Copay Specialty Tier 6 $250 Copay Specialty Tier 6 $250 Copay Specialty Tier 6 $250 Copay
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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