Page 4 - Crosbyton Benefit Guide 4-1-24a
P. 4

Medical Options:


          BCBS of Texas (HMO)



           24 Pay Periods       P610ADT (HMO)  G664ADT (HMO)   S9J7ADT (HMO)   We offer our full-time employees and their
                                 Platinum Plan   Gold Plan     Silver Plan
                                                                           eligible  dependents  coverage.  Children
         Employee Only            $175.00       $125.00        $  95.00    can join or remain on a parent’s medical
         Employee + Spouse        $450.00       $350.00        $275.00     plan until age 26.  When a child turns 26,
         Employee + Child(ren)    $450.00       $350.00        $275.00     they  will  lose  medical  coverage  on  the
                                                                           last day of their birth month.
         Employee + Family        $725.00       $600.00        $525.00

             Brief Member                       PLATINUM                              GOLD                                             SILVER
                                                 P610ADT
                                                                            G664ADT
                                                                                                       S9J7ADT
        In-Network Summary                   IN-NETWORK ONLY            IN-NETWORK ONLY            IN-NETWORK ONLY
      Network                                Blue Advantage  HMO         Blue Advantage  HMO        Blue Advantage  HMO
      (CYD) Calendar Year Deductible                 Individual: $250     Individual: $2,000         Individual: $3,000
      (Jan .1st to Dec. 31st)                   Family: $750               Family: $6,000             Family: $9,000

      Coinsurance                               Carrier: 80%                Carrier: 80%               Carrier 70%
      (After CYD Calendar Year Deductible)       Member: 20%                 Member: 20%              Member: 30%

      Annual (OOP) Out of Pocket               Individual: $1,500         Individual: $6,000         Individual: $9,000
      Maximum                                   Family: $4,500             Family: $17,100            Family $18,000

      (PCP) Primary Care Physician                                   $30 Copay    $30 Copay             $45 Copay

                                                 $60 Copay                  $60 Copay                  $90 Copay
      Specialist Physicians and         (You must have a referral from your   (You must have a referral from your  (You must have a  referral from your
      Providers
                                                  PCP)                        PCP)                       PCP)

      Dr. Consultation  - Virtual Visits,        $30 Copay                  $30 Copay                  $45 Copay

      Basic: Lab, X-Rays & Diagnostic        Basic:  20% after CYD      Basic:  20% after CYD      Basic:  30% after CYD
      Major: Diagnostic & Imaging           Major:  $250 CYD Waived    Major:  $250 CYD Waived     Major:  30% after CYD
      Annual Preventive Care Certain Rx         Covered 100%                          Covered 100%                          Covered 100%
      are covered too (Page 6)                 (No CYD, Co-Ins. Copays)       (No CYD, Co-Ins. Copays)     (No CYD, Co-Ins. Copays)
                                                 $30 Copay                  $75 Copay                                                 $100 Copay
      Urgent Care
                                         (CYD may apply to other services)    (CYD may apply to other services)    (CYD may apply to other services)

      Emergency Room                      $300 Copay plus 20% after CYD   $300 Copay plus 20% after CYD   $600 Copay plus 30% after CYD

      Hospitalization:                   In Patient: $100 + 20% after CYD   In Patient: $100 + 20% after CYD   In Patient: $350 + 30% after CYD
      In Patient/ Outpatient             Outpatient: $150 + 20% after CYD   Outpatient: $150 + 20% after CYD   Outpatient: $300 + 30% after CYD
                                           Preferred Pharmacy / Network   Preferred Pharmacy / Network   Preferred Pharmacy / Network
      Prescription Drugs - 31 Day Supply   Generic (Preferred): $0-$10 Copay   Generic (Preferred) $0-$10 Copay   Generic (Preferred) $0-$10 Copay
      Retail                            Generic: (Non-Preferred): $10-$20 Copay    Generic: (Non Preferred) $10-$20 Copay    Generic: (Non Preferred) $10-$20 Copay
      90 Day Supply  Mail Order at 2.5    Brand (Preferred):  $35-$55 Copay    Brand (Preferred):  $50-$70 Copay    Brand (Preferred):  $50-$70 Copay
      Times Retail                       Brand (Non-Preferred): $75-$95 Copay   Brand (Non Preferred): $100-$120 Copay   Brand (Non Preferred): $100-$120 Copay
                                           Specialty (Preferred): $150 Copay   Specialty (Preferred): $150 Copay   Specialty (Preferred): $150 Copay
                                         Specialty (Non-Preferred): $250 Copay   Specialty (Non-Preferred): $250 Copay   Specialty (Non-Preferred): $250 Copay


            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
                                                              4
   1   2   3   4   5   6   7   8   9