Medical Plan Option
The medical options available for the plan year January 1, 2024 – December 31, 2024 include:
Preferred Provider Organization (PPO)
- HIGH DEDUCTIBLE PPO HDHP/HSA $3,200
- PPO $500 DED
- BASIC PPO $1,500 DED
Medical Summary
Full PPO plans offer direct access to our large network of physicians and specialists without referrals. They provide the flexibility to see non-network providers (but which may incur a higher cost than network providers). To use the maximum benefit and reduce your out-of-pocket expenses it is in your best interest to stay within Blue Cross Blue Shield network.
Plan Features | High Deductible PPO HDHP/HAS $3,200 |
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| In-Network | Out-Of-Network | |
| Annual Deductible (Individual / Family) | $3,200 / $6,400 | $6,400 / $12,800 |
| Out-of-Pocket Maximums (Individual / Family) | $6,400 / $12,800 | Unlimited |
| Preventative Services | Covered at 100% | Not covered |
| Primary/Specialist Office Visit | You pay 20% after deductible | You pay 40% after deductible |
| Virtual Care Services MD Live | $48 copay | Not covered |
| Diagnostic Lab & X-ray | You pay 20% after deductible | You pay 40% after deductible |
| Advanced Diagnostic Imaging | You pay 20% after deductible | You pay 40% after deductible |
| Urgent Care | You pay 20% after deductible | You pay 40% after deductible |
| Inpatient Hospital Stays | You pay 20% after deductible | You pay 40% after deductible |
| Outpatient Surgery | You pay 20% after deductible | You pay 40% after deductible |
| Emergency Room | You pay 20% after deductible | |
| Chiropractic Care | You pay 20% after deductible | You pay 40% after deductible |
| Preferred Pharmacy – Prescription 30-day supply | ||
| Generic drugs | 10% coinsurance | 10% coinsurance + 50% |
| Brand drugs | 20% coinsurance | 30% coinsurance + 50% |
| Speciality drugs | 40% coinsurance | 40% coinsurance + 50% |
| Non-Preferred Pharmacy – Prescription 30-day supply | ||
| Generic drugs | 20% coinsurance | 20% coinsurance + 50% |
| Brand drugs | 30% coinsurance | 30% coinsurance + 50% |
| Speciality drugs | 50% coinsurance | 50% coinsurance + 50% |
Plan Features | Basic PPO $1,500 DED | PPO $500 DED |
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| In-Network | Out-Of-Network | In-Network | Out-Of-Network | |
| Annual Deductible (Individual / Family) | $1,500 / $4,500 | $3,000 / $9,000 | $500 / $1,500 | $1,000 / $3,000 |
| Out-of-Pocket Maximums (Individual / Family) | $4,500 / $13,500 | Unlimited | $3,000 / $9,000 | Unlimited |
| Preventive Care | Covered at 100% | Not covered | Covered at 100% | Not covered |
| Primary/Specialist Office | $35 copay OV $70 copay SP | You pay 40% after deductible | $30 copay OV $60 copay SP | You pay 40% after deductible |
| Virtual Care Services MD Live | No copay | Not covered | No copay | Not covered |
| Diagnostic Lab & X-ray | You pay 20% after deductible | You pay 40% after deductible | No copay | You pay 40% after deductible |
| Advanced Diagnostic Imaging | You pay 20% after deductible | You pay 40% after deductible | You pay 20% after deductible | You pay 40% after deductible |
| Urgent Care | Urgent Care $75 copay | You pay 40% after deductible | $75 copay | You pay 40% after deductible |
| Inpatient Hospital Stays | You pay 20% after deductible | You pay 40% after deductible | You pay 20% after deductible | You pay 40% after deductible |
| Outpatient Surgery | You pay 20% after deductible | You pay 40% after deductible | You pay 20% after deductible | You pay 40% after deductible |
| Emergency Room | $500 copay + 20% after deductible copay waived if admitted | $500 copay + 20% after deductible copay waived if admitted |
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| Chiropractic Care | You pay 20% after deductible | You pay 40% after deductible | You pay 20% after deductible | You pay 40% after deductible |
| Preferred Pharmacy – Prescription 30-day supply | ||||
| Generic drugs Preferred / Formulary | No charge | $10 copay + 50% | No charge | $10 copay + 50% |
| Brand drugs Preferred / Formulary | $50 copay | $70 copay + 50% | $50 copay | $70 copay + 50% |
| Specialty drugs Preferred / Formulary | $150 copay | $150 copay + 50% | $150 copay | $150 copay + 50% |
| Non-Preferred Pharmacy – Prescription 30-day supply | ||||
| Generic drugs Preferred / Formulary | $10 copay | $10 copay + 50% | $10 copay | $10 copay + 50% |
| Brand drugs Preferred / Formulary | $70 copay | $70 copay + 50% | $70 copay | $70 copay + 50% |
| Specialty drugs Preferred / Formulary | $250 copay | $250 copay + 50% | $250 copay | $250 copay + 50% |
Definitions:
Co-pay
A fixed amount you pay for a covered health service, usually when you receive the service. The amount can vary by the type of covered health care service.
Deductible
The amount you owe for health care services your plan covers before your health insurance or plan begins to pay. The deductible may not apply to all services.
Co-insurance
Once the deductible is met, you and the plan share any further health care costs until you meet your out-of-pocket maximum. This is your share of the costs of a covered health care service, calculated as a percent for the service.
Out-of-pocket maximum
The medical plan limits the total amount you pay each year for medical care. Once you meet your out-of-pocket maximum, the plan pays 100% of your eligible expenses for the remainder of the calendar year.
Preferred pharmacies are as follows: Walgreens, HEB, Kroger, Albertsons, Walmart, Brookshire Grocery, & independents per pharmacy directory. CVS is Out-of-Network.