Page 4 - Anzea 2020 Benefit Guide_Revised 9-25-2020
P. 4
Medical Option
Blue Cross Blue Shield
2020 Rate Information—Per Pay Period
Plan Options PPO HMO Dependent Information
Employee Only $ 41.68 $ 27.27 Anzea Textiles offers employees the opportunity
to cover their spouses and dependent children.
Employee + Spouse $ 166.73 $ 109.08 Children can join or remain on a parent’s
medical plan until age 26. When a child turns 26,
Employee + Child(ren) $ 166.73 $ 109.08 they will lose medical coverage on the last day
of their birth month.
Employee + Family $ 291.77 $ 190.90
BCBS PPO BCBS HMO
In-Network Benefits In-Network (OUT OF NETWORK COVERED) In-Network (OUT OF NETWORK NOT COVERED)
Calendar Year Deductible (CYD) Individual: $1,500 Individual: $1,500
Family: $3,000 Family: $4,500
Coinsurance after CYD Carrier: 80% Member: 20% Carrier: 80% Member: 20%
Annual Out of Pocket Maximum Individual: $5,000 Individual: $5,000
(OOP) Family: $10,000 Family: $10,000
Office Visit - PCP $30 Copay $30 Copay
Office Visit - Specialist $60 Copay $60 Copay Referral from PCP Required
Preventive Care Covered 100% Covered 100%
Virtual Visits ($0 During COVID)
period $30 Copay ($0 COVID) $30 Copay ($0 COVID)
Diagnostic Lab and X-Ray 20% after CYD 20% after CYD
Imaging (CT/PET scans, MRI’s) 20% after CYD $250 Copay Referral from PCP Required
$30 cop
$30 copay (Dr. Services Only) ay (Dr. Services Only)
Urgent Care
(CYD apply to all other services) (CYD apply to all other services)
Emergency Room $400 Copay plus 20% after CYD $400 Copay plus 20% after CYD
Hospitalization (In-Patient/Out-
20% after CYD 20% after CYD Referral from PCP Required
Patient)
Retail Prescription Drugs - Preferred Generic: $0 Copay/$10 Copay Preferred Generic: $0 Copay/$10 Copay
30 Day Supply Non-preferred Generic: $10/$20 Copay Non-preferred Generic: $10/$20 Copay
Preferred Brand: $50/$70 Copay Preferred Brand: $50/$70 Copay
Non-preferred Brand: $100/$120 Copay Non-preferred Brand: $100/$120 Copay
Specialty Drugs Preferred- $150 Copay Preferred- $150 Copay
Non-preferred-$250 Copay Non-preferred-$250 Copay
3 Times Retail 3 Times Retail
Mail Order-90 Day Supply
Please note: This summary is intended for general information purposes.
It is not a guarantee of benefits. Please reference the SBC or contact the carrier for specific details.
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Website: www.bcbstx.com
