Page 10 - Allegacy 2019 Benefit Guide Part Time

Medical &Prescription Drug Plan

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You have an option to choose between two medical plans. Both medical plans are High Deductible Health Plans that are Health Savings
Account compatible. This means that both you and Allegacy may contribute toward your HSA if you enroll in either plan below:

Blue Cross NC

Core Plan Buy- Up Plan
Benefit Highlights
In-Network Member Pays In-Network Member Pays
Primary Care Physician Copay
100% covered after Deductible 100% covered after Deductible
Specialist Office Visit Copay
Preventive Care Visits Plan Covers 100% Plan Covers 100%
Emergency Room Services (waived if
admitted)
Urgent Care Center Copay
100% covered after Deductible 100% covered after Deductible
Inpatient Hospital & Professional Charges
Outpatient Facility & Physician Charges

Prescription Medication Copay:
Tier 1

Tier 2 100% covered after Deductible 100% covered after Deductible
Tier 3
Individual Annual Deductible $6,550 $3,700

Individual Annual Coinsurance Maximum $0 $0
Individual Annual Out-of-Pocket Maximum $6,550 $3,700

Family Annual Deductible $13,100 $7,400
Family Annual Coinsurance Maximum $0 $0
Family Annual Out-of-Pocket Maximum $13,100 $7,400

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