Page 7 - 2018 BH Management Guide

BH Management Services, LLC

Plan Details

In-Network Out-of-Network
Calendar Year Deductible Embedded
Individual $1,500 $3,000
Family $4,500 $9,000
Out-of-Pocket Maximum
Individual $4,000 $8,000
Family $12,000 $16,000
Physician Ofice Visits
Primary Care $25 copay Covered at 55%
Specialist $25 copay Covered at 55%
Preventive Covered at 100% Covered at 55%
Urgent Care $55 copay Covered at 55%
Hospital Services
Inpatient Covered at 85% Covered at 55%
Outpatient Covered at 85% Covered at 55%
Emergency Room $300 copay
Chiropractic Care $25 copay Covered at 55%
Prescription Drugs
Retail—Supply Limit Non-maintenance drugs: 30-day supply
maintenance drugs: 90-day supply
(60-day copay = 2 × 30-day copay; 90-day copay = 3 × 30-day copay)
Tier 1 $7 copay Reimbursement of maximum allowable
fee, less the in-network copay amount
Tier 2 $25 copay Reimbursement of maximum allowable
fee, less the in-network copay amount
Tier 3 $45 copay Reimbursement of maximum allowable
fee, less the in-network copay amount
Tier 4 $45 copay Reimbursement of maximum allowable
fee, less the in-network copay amount
Mail Order—Supply Limit Non-maintenance drugs: 30-day supply
maintenance drugs: 90-day supply
(60-day copay = 2 × 30-day copay; 90-day copay = 3 × 30-day copay)
Tier 1 $17.50 copay Reimbursement of maximum allowable
fee, less the in-network copay amount
Tier 2 $62.50 copay Reimbursement of maximum allowable
fee, less the in-network copay amount
Tier 3 $112.50 copay Reimbursement of maximum allowable
fee, less the in-network copay amount
Tier 4 $112.50 copay Reimbursement of maximum allowable
fee, less the in-network copay amount

This is a high level summary of your beneit coverage. Full coverage details are available in your summary
plan description (SPD). In the event there is a discrepancy between what is relected in this guide and what is
communicated in your SPD, the terms of your SPD will prevail.

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