Page 8 - Technip Energies 2022 benefits guide

2022 Employee Benefits

Medical Plan –

BlueCross BlueShield

of Texas (BCBSTX)

Technip Energies offers two medical Consumer Driven Health Plans (CDHPs): Prime Plus and Prime
administered by BlueCross BlueShield of Texas. You have the option to open a Health Savings Account (HSA)
alongside your medical plan choice. The HSA is administered by Fidelity Investments. If you cover a spouse
who has coverage available through his or her employer, you will pay a $60 bi-weekly spousal surcharge.

Prime Plus Prime
IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK

Calendar Year Deductible
Individual $1,750 $3,750 $3,250 $7,250
Family $3,250 $7,250 $6,250 $14,250
Calendar Year Out-of-Pocket Maximum (Includes Deductible)

Individual $3,750 $10,750 $6,250 $14,250
Family $7,250 $21,250 $12,250 $21,250
You pay You pay
Coinsurance
Coinsurance 20% 50% 20% 50%

Pharmacy
Retail Rx * **
Generic $5 $5
Formulary 30% to $75 30% to $75
Non-Formulary 50% to $100 50% to $100
Mail Order Rx (up to 90-day supply)
Generic $12.50 N/A $12.50 N/A
Formulary 30% to $200 N/A 30% to $200 N/A
Non-Formulary 50% to $250 N/A 50% to $250 N/A

* 90-day prescriptions are available for retail and mail order. The pharmacy benefit management is administered by CVS Caremark.
** Copays apply after the deductible has been met.
Please refer to your plan booklet for details.

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