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

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
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