Page 3 - Eles Place Renewal 2020

Ele’s Place

Group Benefit Offerings

Medical – BCN HMO Gold PCP Focus – Mapped Renewal

$1500/$3000 per family deductible followed by an 80/20
coinsurance to an embedded coinsurance maximum of
$2500/$5000, then to an overall out of pocket maximum of
$8150/$16,300, $20 PCP Office Visit and Online Visit Copay, $40
Specialist Copay, $50 Urgent Care Copay, $250 Emergency Room
Copay after deductible, $6 Generic (Tier 1), $25 Generic (Tier
2)/$50 Preferred Brand name/$80 Non Preferred Brand Name
Copay/20% Preferred Specialty Copay/20% Non Preferred
Specialty for Prescription Drugs. (Previous copays were $1500/$3000
ECM, $6600/$13,200 OOP, and RX: $4/$15/$40/$80/20%/20%)

Dental – Delta Dental – Voluntary

$75 deductible per person, 100% Preventive Services, 80% Basic
and 50% Major Services to a yearly maximum of $1000.