Page 7 - Premier EE Guide 01-20 - TX

BENEFITS

MEDICAL INSURANCE

Blue Shield Blue Shield
Plan Name Full PPO Combined Deductible Full PPO Savings Two-Tier
(PPO Medical) Embedded Deductible
(HDHP PPO Medical)

Network Name Full PPO Non-Network Full PPO Non-Network
Health Benefits

Deductible (Annual)
- Individual $500 $1,500
- Family $1,500 $2,800/Ind; $3,000/family
Co-Insurance (Plan Pays) 90% 60% 90% 60%
Office Visit Copay
- Primary Care Physician $30 Copay/visit Deductible, 40% Deductible, 10% Deductible, 40%
- Specialist Office Visit $30 Copay/visit Deductible, 40% Deductible, 10% Deductible, 40%

Out-of-Pocket Maximum
- Individual $4,000 $8,000 $3,500 $6,000
- Family $8,000 $16,000 $7,000 $12,000
Hospitalization
- Inpatient Deductible, 10% Deductible, 40% up Deductible, 10% Deductible, 40%
to $600/day up to $600/day
Ded., 15% Hosp. Ded., 15% Hosp.
- Outpatient Surgery Ded., 5% Ambulatory Deductible, 40% Ded., 5% Ambulatory Deductible, 40%
Surgery Center up to $350/day Surgery Center up to $350/ day

Lab and X-Ray Deductible +$30
Deductible, 40% Deductible, 10% Deductible, 40%
Copay/visit
Emergency Services $150/visit plus 10% Deductible, $150/ visit plus 10%
Urgent Care $30 Copay/visit Deductible, 40% Deductible, 10% Deductible, 40%

Preventive Care $0 Copay Not Covered $0 Copay Not Covered
Physical, Occupational, Respiratory Deductible + $30/ Deductible, 40% Deductible, 10% Deductible, 40%
and Speech Therapy visit
Pharmacy Benefits Health Deductible Health Deductible
Applies Applies

Retail Pharmacy (Up to 30 Days)
Tier 1 drugs $15 Copay $15 Copay + 25% $10 Copay $10 Copay + 25%
Tier 2 drugs $30 Copay $30 Copay + 25% $25 Copay $25 Copay + 25%
Tier 3 drugs $45 Copay $45 Copay + 25% $40 Copay $40 Copay + 25%
Tier 4 drugs 30% up to $200/Rx 30% + 25% up to 30% up to $200/Rx 30% + 25% up to
$200/Rx $200/Rx
Mail Order Pharmacy (Up to 90 Days)
Tier 1 drugs $30 Copay Not Covered $20 Copay Not Covered
Tier 2 drugs $60 Copay Not Covered $50 Copay Not Covered
Tier 3 drugs $90 Copay Not Covered $80 Copay Not Covered
Tier 4 drugs (Specialty 30 Days) 30% up to $400/Rx Not Covered 30% up to $400/Rx Not Covered
*Limitations apply. See SBC for details.

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