Page 3 - Murphy Research 2020-21 Employee Benefits

12/1/2020-11/30/2021 Employee Benefits Brochure

Medical Plans – Blue Shield

Bronze Full PPO
Silver Full PPO 1800 / 55 Gold Full PPO 750/30
Your Copay/ Coinsurance OffEx Savings 5300/40% OffEx
OffEx
In-Network In-Network In-Network

Calendar Year Deductible:
Individual $1,800 $5,300 $750

Family $3,600 $10,600 $1,500

Annual Out of Pocket Maximum:
Individual $7,800 $6,900 $7,800

Family $15,600 $13,800 $15,600

Hospital Services:
Inpatient 35% coinsurance* 40% coinsurance* 20% coinsurance*

Outpatient Surgery 35% coinsurance* 40% coinsurance* 20% coinsurance*
-Ambulatory Surgery Center
Emergency Room $300 + 35% coinsurance* $250 + 40% coinsurance* $250 + 20% coinsurance*

Physician Services:
Office Visit (PCP/Specialist) $55 / $80 40% coinsurance* $30 / $50

Urgent Care $55 40% coinsurance* $30

Preventive Care: No charge No charge No charge

Prescription Drugs:
Rx Deductible** $300 ind / $600 fam Combined with medical $250 ind / $500 fam

Tier 1 $20 40% up to $500 per Rx* $10
Tier 2 $75** 40% up to $500 per Rx* $40**
Tier 3 $115** 40% up to $500 per Rx* $70**
Tier 4 30% up to $250 per Rx** 40% up to $500 per Rx* 30% up to $250 per Rx**

*Calendar year deductible applies
Please refer to carrier benefit summaries for more detailed information & out-of-network benefits

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