Page 4 - Wesco Benefit Guide Effective 9-1-2024

Medical Options:

BCBS of Texas

S9E5ADT S9E5ADT G9K5ADT G9K5ADT
Effective 9-1-2024 Weekly Semi-Monthly Weekly Semi-Monthly We offer our full-time
(52) (24) (52) (24) employees and their eligible
dependents coverage.
Employee Only $ 43.48 $ 94.21 $ 63.30 $ 137.15 Children can join or remain on
a parent’s medical plan until
Employee + Spouse $215.04 $465.91 $254.67 $551.79 age 26. When a child turns 26,
they will lose medical
Employee + Child $215.04 $465.91 $254.67 $551.79 coverage on the last day of
their birth month.
Employee + Family $386.59 $837.62 $446.05 $966.44

Brief Member S9E5ADT (HMO) G9K5ADT (HMO)
Blue Advantage HMO Silver Blue Advantage HMO Gold
In-Network Summary IN-NETWORK ONLY IN-NETWORK ONLY

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

Individual: $8,250 Individual: $8,700
Annual (OOP) Out of Pocket Maximum
Family: $16,500 Family: $17,400
(PCP) Primary Care Physician
(Dr. Services Only) $50 Copay $0 Copay
$90 Copay $80 Copay
Specialist Physicians and Providers (You must have a referral from your PCP) (You must have a referral from your PCP)
(Dr. Services Only) Not needed for (OB/GYN’s)., Urgent Care, Behavioral Not needed for (OB/GYN’s)., Urgent Care, Behavioral
health or use disorder clinicians. health or use disorder clinicians.

Dr. Consultation - Virtual Visits, See Pg. 7 $50 Copay $0 Copay

Basic: Lab, X-Rays & Diagnostic Basic: $150/test + 20% after CYD Basic: 20% after CYD
Major: Diagnostic & Imaging Major: $200/test + 20% after CYD Major: 20% after CYD

Annual Preventive Care Certain Rx are covered too, Covered 100% Covered 100%
See Page 5 (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)

$150 co
$100 copay (Dr. Services Only) . Services Only)
p
ay
r
D
(
Urgent Care
(CYD apply to other services) (CYD apply to other services)
Emergency Room $750 Copay plus 20% after CYD 20% after CYD
Hospitalization: In Patient: $350 Copay + 20% after CYD
20% after CYD
In Patient/ Outpatient Outpatient: $300 Copay + 20% after CYD
Tier 1: $0-$10 Copay Tier 1: $0-$10 Copay
Prescription Drugs - 31 Day Supply Retail Tier 2: $10-$20 Copay Tier 2: $10-$20 Copay
90 Day Supply Mail Order at 2.5 Times Retail Tier 3: $50-$70 Copay Tier 3: $50-$70 Copay
Tier 4: $100-$120 Tier 4: $100-$120
Specialty: $150/$250 Copay Specialty: $150/$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