Page 4 - Benefit Guide_Heritage School 2020_Revised 9-25-2020
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Medical Options
Blue Cross Blue Shield
2019 Rate Information—See Page 5
Dependent Information
Heritage School of Texas offers employees three medical Heritage School of Texas offers our
options to meet your individual needs and pays up to $500 for employees the opportunity to cover their
spouse and dependent children. Children
employee only medical, dental and vision premiums can join or remain on a parent’s plan until
the last day of their birth month at age 26.
B661CHC S663CHC G652CHC
In-Network Benefits H.S.A. Core Plan Buy Up Plan
Summary In and Out of Network In and Out of Network In and Out of Network
Benefits Covered Benefits Covered Benefits Covered
Calendar Year Deductible Individual: $6,750 Individual: $3,000 Individual: $1,500
(CYD) Family: $13,500 Family: $9,000 Family: $4,500
Coinsurance after CYD Carrier 100% Member 0% Carrier 70% Member 30% Carrier 80% Member 20%
Annual Out of Pocket Individual: $6,750 Individual: $8,150 Individual: $5,000
Maximum (OOP) Family: $13,500 Family: $16,300 Family: $10,000
Office Visit Copay - $40 Copay/$80 Copay $30 Copay/$60 Copay
PCP / Specialist 0% after CYD
Virtual Visits ($0 During $40 Copay ($0 COVID) $30 Copay ($0 COVID)
COVID) period $44 Fee ($0 COVID)
Diagnostic X-Ray/Lab tests 0% after CYD 30% after CYD 20% after CYD
Preventive Care (see Pg. 6) Covered 100% Covered 100% Covered 100%
Urgent Care 0% after CYD $80 Copay $30 Copay
(Does not include lab/ x-ray) (Does not include lab/ x-ray)
Emergency Room $650 Copay after CYD $600 Copay after CYD and $400 after CYD and
30% Co-Ins. 20% Co-Ins.
Basic Lab/X-Ray 0% after CYD 30% after CYD 20% after CYD
Imaging (CT/PET scans, $250 Copay after CYD and 20% after CYD
MRI’s) 0% after CYD 30% Co-Ins.
Hospital Inpatient/ $350 Copay / $300 after CYD 20% after CYD
Outpatient 0% after CYD and 30% Co-Ins.
IN-NETWORK Pref Generic:$0/$10 Pref Generic:$0/$10
Participating Pharmacies / Non-Pref Generic:$20/$30 Non-Pref Generic:$20/$30
Non Participating 0% after CYD Pref Name Brand: $50/$70 Pref Name Brand: $50/$70
Prescription Drugs Non-Pref Brand: $100/$120 Non-Pref Brand: $100/$120
30 Day Supply* 90 mail order Specialty Pref:$150 Specialty Pref:$150
3 times the retail copay Specialty Non Pref:$250 Specialty Non Pref:$250
Members electing to purchase preferred/non-preferred brand name drugs 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.
Please note: This is intended for general comparison purposes.
It is not a guarantee of benefits. Please reference the SBC or contact the carrier for specific details.
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