Page 5 - 2024 HCTec Benefits Guide

Medical and Pharmacy Coverage

Base CDHP Buy Up CDHP
Medical Plan PPO Plan
Provision
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Annual Deductible Embedded Embedded Embedded Embedded Embedded Embedded
Individual $5,000 $10,000 $3,200 $10,000 $3,000 $10,000
Family $10,000 $20,000 $6,400 $20,000 $6,000 $20,000

Out-of-Pocket
Embedded Embedded Embedded Embedded Embedded Embedded
Maximum $7,250 $25,000 $5,000 $20,000 $7,000 $20,000
Individual $14,500 $50,000 $10,000 $40,000 $14,000 $40,000
Family

Coinsurance 60% 50% 60% 50% 60% 50%

Preventative Care 100% Not Covered 100% Not Covered 100% Not Covered

Office Visit
Primary Care 60% after 50% after 60% after 50% after $30 Copay* 50% after
Specialist Deductible Deductible Deductible Deductible $60 Copay* Deductible
Inpatient and 60% after 50% after 60% after 50% after 60% after 50% after
Outpatient Services Deductible Deductible Deductible Deductible Deductible Deductible
60% after 50% after 60% after 50% after 50% after
Urgent Care $60 Copay*
Deductible Deductible Deductible Deductible Deductible
Emergency Room
60% after Deductible 60% after Deductible 60% after Deductible
Care
Pharmacy Plan In-Network In-Network In-Network
Design**

Retail Prescription

(30-day supply)
Generic $10 Copay after Deductible $10 Copay after Deductible $15 Copay*
Brand Preferred $35 Copay after Deductible $35 Copay after Deductible $45 Copay*
Brand Non-preferred $60 Copay after Deductible $60 Copay after Deductible $90 Copay*
Specialty $120 Copay after Deductible $120 Copay after Deductible $180 Copay*

*Copays do not count towards meeting your deductible, but they do count against your out-of-pocket costs. **Pharmacy Out-Of-Network is 50% after Deductible

Important notice if you use nicotine/tobacco

Going nicotine- and tobacco-free is one of the most important steps you can take to maintain good health. If you enroll in our medical plan and
you use nicotine/tobacco or have used tobacco products during the last twelve months, you will be required to pay a tobacco surcharge of $30
per month in addition to your regular medical premiums. Call 1-866-498-9806 or visit bcbst.com and choose Managing Your Health to begin the
process of quitting today.

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