Page 4 - Tritrax Benefit Guide Effective 9-1-2020

Medical Options:

Blue Cross Blue Shield

Per Pay Period Core Buy-Up Dependent Information
Bi-Weekly 2020
TriTrax Rehabilitation offers employees the opportunity to
Employee Only $130.59 $147.29
cover their dependent children. Children can join or
Employee + Spouse $391.76 $441.88 remain on a parent’s medical plan until age 26.
Employee + Child(ren) $391.76 $441.88 When a child turns 26, they will lose medical coverage
on the last day of their birth month.
Employee + Family $652.92 $736.47

HMO Core Plan PPO Buy-Up Plan
In-Network Benefits $1,250 Deductible $3,000 Deductible
In-Network Coverage Only In and OUT of Network Coverage

Individual: $1,250 Individual: $3,000
Calendar Year Deductible (CYD)
Family: $3,750 Family: $9,000
Coinsurance Carrier 100% / Member 0% Carrier 70% / Member 30%

Out of Pocket Maximum: Individual: $1,250 Individual: $8,150
(Includes CYD, Copays, Co-Ins) Family: $3,750 Family: $16,300
Office Visit - PCP $25 Copay $50 Copay

$45 Copay
Office Visit—Specialist $80 Copay
(Referral Required by PCP)
$25 Copay $50 Copay
Telemedicine 24/7 (MDLive)
($0 Copay during COVID Period) ($0 Copay during COVID Period)
COVID-19 Coverage (during Paid 100% for Testing and Treatment Paid 100% for Testing and Treatment
COVID period)
Preventive Care Covered 100% Covered 100%

Lab Work & X-Rays (Basic) 0%, After CYD 30% After CYD

$250 Copay
(Imaging) MRI’s, CT, PET $200 Copay, plus 30% After CYD
(Referral Required by PCP)
Urgent Care $25 Copay, No CYD $40 Copay, No CYD

Emergency Room $400 Copay, plus 0% After CYD $500 Copay, plus 30% After CYD

$150 Copay, plus 0% After CYD
Hospitalization (Inpatient) $250 Copay, plus 30% After CYD
(Referral Required by PCP)
Preferred Generic:$0/$10
Preferred Generic:$0/$10
IN-NETWORK Non-Preferred Generic:$20/$30 Non-Preferred Generic:$20/$30
Participating Pharmacies / Non Preferred Name Brand: $50/$70 Preferred Name Brand: $50/$70
Participating Pharmacies Non-Preferred Brand: $100/$120 Non-Preferred Brand: $100/$120
Prescription Drugs 30 Day Supply Mail Specialty Preferred:$150 Specialty Preferred:$150
Order 3 X the retail Participation copay
Specialty Non Preferred:$250 Specialty Non Preferred:$250

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