Page 4 - Benefit Guide_SIPS_2020_Revised 2-12-21
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Medical Options:


          Blue Cross Blue Shield



               2020 Rate Information

                                H.S.A Plan   H.S.A Plan  Base Plan   Base Plan   Buy-Up   Buy-Up  Premium   Premium

                                 MTBCP78AH   MTBCP78AH   MTBCBA7DB   MTBCBA7DB   MTBCP617A   MTBCP617A   MTBCP617A    MTBCP617A
             Per Pay Period      Bi-Weekly    Weekly    Bi-Weekly   Weekly   Bi-Weekly   Weekly   Bi-Weekly   Weekly
         Employee Only            $  32.82    $  16.41   $  41.98   $  20.99   $105.91   $  52.96   $133.89   $  66.94

         Employee + Spouse        $176.40     $  88.20   $194.72    $  97.36   $322.68   $161.34   $378.54   $189.27
         Employee + Child(ren)    $121.95     $  60.98   $137.83    $  68.92   $248.74   $124.37   $297.15   $148.57

         Employee + Family        $348.36     $174.18    $377.07    $188.53   $577.55   $288.78   $665.06   $332.53

        SIPS Consults offers employees the opportunity to cover their spouses and dependent children. Children can
        join or remain on a parent’s medical plan until age 26.  When a child turns 26, they will lose medical coverage
        on the last day of their birth month.

          In-Network          H.S.A Plan                  Base Plan          Buy-Up Plan                  Premium Plan
           Benefits        3500  Deductible        5000 Deductible          3000 Deductible        1000 Deductible
         Members Pays        MTBCP78AH              MTBCBA7DB                MTBCP617A               MTBCP2163
                          PPO (In and Out of  Network)   PPO (In and Out of  Network)   PPO (In and Out of  Network)   PPO (In and Out of  Network)
        (CYD) Calendar      Individual: $3,500      Individual: $5,000       Individual: $3,000     Individual: $1,000
        Year Deductible      Family: $7,000          Family: $14,700          Family: $9,000         Family: $3,000
        Coinsurance     Carrier 80% Member: 20%  Carrier 70% Member: 30%   Carrier 100% Member: 0%  Carrier 100% Member: 0%
        Annual (CYD)
                            Individual:$5,000       Individual:$5,600        Individual:$3,500       Individual:3,000
        Out of Pocket        Family:$10,000          Family:$14,700           Family:$10,500          Family:$9,000
        Maximum
                                                    $45 Copay PCP
        Office Visit  - PCP /   20% after CYD                                $35 Copay PCP           $30 Copay PCP
        Specialist Copay                          $90 Copay Specialist                  $70 Copay Specialist                $60 Copay Specialist
                                                    (Dr. Services Only)
                        $0 (COVID) period after Up   $0 (COVID) period after        $0 (COVID) period after        $0 (COVID) period after
        Virtual Visits
                           to $44 Copay/Fee           $45 Copay                $35 Copay              $30 Copay
        Diagnostic X-Ray/    20% after CYD           30% after CYD             No Charge               No Charge
        Lab tests
        Imaging (CT/PET      20% after CYD           30% after CYD            0% after CYD           0% after CYD
        scans, MRI’s)
        Preventive Care      Covered 100%            Covered 100%            Covered 100%            Covered 100%
                                                $75 Copay (Dr. Fees) after
        Urgent Care          20% after CYD                                     $75 Copay              $75 Copay
                                                 CYD for Others Services
                                                  $500 Copay plus 30%
        Emergency Room       20% after CYD                                $500 Copay after CYD    $500 Copay after CYD
                                                 Coinsurance after CYD
        Prescription Drugs     AFTER CYD         Participating / Non Participating                      ticipating / Non Participating                      cipating / Non Participating
                                                                           r
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                         Participating / Non Participating
        30 Day Supply* 90   Tier 110%/20% Tier 2 10% /20% Tier   Tier 1$0/$10  Tier 2 $10/$20                     Tier 1$0/$10  Tier 2 $10/$20                    Tier 1$0/$10  Tier 2 $10/$20
        mail order 3 times   3 20%/30% Tier 4 30% /40%        Tier 3:$50/$70 Tier  4 $100/$120        Tier 3:$50/$70 Tier  4 $100/$120        Tier 3:$50/$70 Tier  4 $100/$120
        the retail copay   Specialty Rx T5-T6:40%-50%   Specialty Rx T5-T6:$150-$250   Specialty Rx T5-T6:$150-$250   Specialty Rx T5-T6:$150-$250
        * Members electing to purchase preferred/non-preferred brand name drugs (Tier 2 and 3) when a generic equivalent is available will be required to pay the
        difference between the cost of the generic and preferred/non-preferred brand name drug, plus the preferred brand copayment amount.
           THIS IS ONLY A BRIEF SUMMARY Please reference your policy/SBC’s or contact  insurance carrier for specific
                                                benefit details and limitations.
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