Page 4 - 2024 Premier Pools and Spas Benefit Guide V2

Medical Options:

Blue Cross Blue Shield

Effective 3-1-24 S9E5ADT S667CHC G660ADT G650CHC
Bi-Weekly (26) Pay Period Silver HMO Silver PPO Gold HMO Gold PPO Dependent Information

Premier Pools and Spas offers
Employee Only $ 115.65 $ 167.49 $ 130.55 $ 190.03
employees the opportunity to cover
Employee + Spouse $ 346.94 $ 502.48 $ 391.65 $ 570.09 their dependent children. Children
Employee + Child(ren) $ 346.94 $ 502.48 $ 391.65 $ 570.09 can join or remain on a parent’s
medical plan until age 26.
Employee + Family $ 578.23 $ 837.47 $ 652.75 $ 950.16

Brief Member S9E5ADT S667CHC G660ADT G650CHC
In-Network Silver HMO Silver PPO Gold HMO Gold PPO
Summary $6,000 Deductible $6,000 Deductible $3,250 Deductible $3,250 Deductible

Network Blue Advantage HMO Blue Choice PPO Blue Advantage HMO Blue Choice PPO
(CYD) Calendar Year Individual: $6,000 Individual: $6,000 Individual: $3,250 Individual: $3,250
Deductible (Jan .1st to
Family: $12,000 Family: $12,000 Family: $9,750 Family: $9,750
Dec. 31st)
Coinsurance Carrier: 80% Carrier: 80% Carrier: 100% Carrier: 100%
(After CYD) Member: 20% Member: 20% Member: 0% Member: 0%

Annual (OOP) Out of Individual: $8,250 Individual: $8,250 Individual: $3,250 Individual: $3,250
Pocket Maximum Family: 16,500 Family: 16,500 Family: $9,750 Family: $9,750

(PCP) Primary Care $50 Copay $50 Copay $50 Copay $50 Copay
Physician Referral Required for Specialists Referral Required for Specialists

Specialist Physicians $90 Copay $90 Copay $90 Copay $90 Copay

Dr. Consultation Virtu-
$50 Copay $50 Copay $50 Copay $50 Copay
al Visits, See Pg. 7
Basic: Lab, X-Rays /
Labs: 20% After CYD Labs: 20% After CYD Labs: No Charge After CYD Labs: No Charge After CYD
Diagnostic
XRay: $150/test + 20% After CYD XRay: $150/test + 20% After CYD XRay: $100/test After CYD XRay: $100/test After CYD
Major: Diagnostic/
Major: $200/test + 20% After CYD Major: $200/test + 20% After CYD Major: $300/test; No CYD Major: $300/test; No CYD
Imaging
Annual Preventive Care
Covered 100% Covered 100% Covered 100% Covered 100%
Certain Rx are covered
(No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)
too, See Page 5
Urgent Care $100 Copay; No CYD $100 Copay; No CYD $75 Copay; No CYD $75 Copay; No CYD
Emergency Room $750 Copay + 20% after CYD $750 Copay + 20% after CYD $400 Copay After CYD $400 Copay After CYD

Hospitalization: In / IN: $350 Copay + 20% after CYD IN: $350 Copay + 20% after CYD IN: $350 Copay After CYD IN: $350 Copay After CYD
Outpatient OUT: $300 Copay + 20% After CYD OUT: $300 Copay + 20% After CYD OUT: $250 Copay After CYD OUT: $250 Copay After CYD

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Tier 1: $0-$10 Copay er 1: $0-$10 Copay o charge After CYD Tier 1: No charge After CYD
Prescription Drugs - 31
Tier 2: $10-$20 Copay r 2: $10-$20 Copay o charge After CYD Tier 2: No charge After CYD
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Day Supply Retail
90 Day Supply Mail Tier 3: $50-$70 Copay Tier 3: $50-$70 Copay Tier 3: No charge After CYD Tier 3: No charge After CYD
Order at 3 x Retail Tier 4: $100-$120 Tier 4: $100-$120 Tier 4: No charge After CYD Tier 4: No charge After CYD
Specialty: $150-$250 Specialty: $150-$250 Specialty: No charge After CYD Specialty: No charge After CYD
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