Page 5 - 2018 NextCare Enrollment

Medical and Prescription Drugs

We partner with Blue Cross Blue Shield (BCBS) to offer you and your family members medical and prescription
drug coverage. You have two different plans to choose from depending on your needs. Both plans utilize the
same BCBS network and plan discounts. Additionally, both plans cover in-network preventive care at 100%.

PPO Plan HDHP Plan
In-Network
Calendar Year Deductible
Individual $750 $3,000
Family $1,500 $5,000
Out-of-Pocket Maximum
Individual $4,000 $5,000
Family $8,000 $9,000
Health Savings Account Eligibility Not eligible Eligible; see HSA section of guide for
additional guidance
Physician Ofice Visits
Wellness/Preventive 100% covered 100% covered
Primary Care $30 copay Deductible, then 20% coinsurance
Specialist $50 copay Deductible, then 20% coinsurance
Urgent Care $100 copay Deductible, then 20% coinsurance
Hospital Services
Inpatient/Outpatient Deductible, then 20% coinsurance Deductible, then 20% coinsurance
Emergency Room $500 copay Deductible, then 20% coinsurance
Prescription Drugs
Retail (up to 30-day supply)
Tier 1 $10 copay Deductible, then $10 copay
Tier 2 $35 copay Deductible, then $35 copay
Tier 3 $60 copay Deductible, then $60 copay
Tier 4 $100 copay Not applicable
Mail Order (up to 90-day supply)
Tier 1 $25 copay Deductible, then $25 copay
Tier 2 $87 .50 copay Deductible, then $87 .50 copay
Tier 3 $150 copay Deductible, then $150 copay
Tier 4 $250 copay Not applicable

Please see the BCBS summary on the NextCare Intranet beneits page for out-of-network beneits.

Employee Medical and Rx Cost Per Pay Period

PPO HDHP
Employee Only $118 .57 $53 .70
Employee and Spouse $261 .72 $120 .86
Employee and Child(ren) $241 .34 $108 .84
Family $380 .23 $178 .29

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