Alternate HDHP
Plan type: HDHP · Network: BlueCross BlueShield · Administrator: BlueCross BlueShield
Alternate HDHP
Plan Details
HSA Eligible
Yes
FSA Eligible
Limited Use FSA only
Premiums - Alternate HDHP
| Coverage Tier | Bi-weekly |
|---|---|
| Employee Only | $41.03 |
| Employee + Spouse | $126.02 |
| Employee + Children | $102.94 |
| Family | $199.99 |
Employee Only
Bi-weekly$41.03
Employee + Spouse
Bi-weekly$126.02
Employee + Children
Bi-weekly$102.94
Family
Bi-weekly$199.99
Deductible, Out-of-Pocket & Coinsurance
| Feature | In-Network | Out-of-Network |
|---|---|---|
| Deductible (Individual) | $3,400 | $5,000 |
| Deductible (Family) | $6,800 | $10,000 |
| Out-of-Pocket Max (Individual) | $6,350 | $10,000 |
| Out-of-Pocket Max (Family) | $12,700 | $20,000 |
| Coinsurance | 80% after deductible (member pays 20%) | 60% after deductible (member pays 40%, plus balance billing) |
Deductible (Individual)
In-Network$3,400
Out-of-Network$5,000
Deductible (Family)
In-Network$6,800
Out-of-Network$10,000
Out-of-Pocket Max (Individual)
In-Network$6,350
Out-of-Network$10,000
Out-of-Pocket Max (Family)
In-Network$12,700
Out-of-Network$20,000
Coinsurance
In-Network80% after deductible (member pays 20%)
Out-of-Network60% after deductible (member pays 40%, plus balance billing)
Covered Services
| Service | You Pay |
|---|---|
| Preventive Care | 100% Covered |
| Primary Care Visit | 20% after deductible |
| Specialist Visit | 20% after deductible |
| Diagnostic Care | 20% after deductible |
| Urgent Care | 20% after deductible |
| Emergency Room | 20% after deductible |
| Convenience Clinic Visit | 20% after deductible |
| Teladoc Virtual Visits | 20% after deductible |
| Inpatient Hospitalization | 20% after deductible |
| Outpatient Surgery | 20% after deductible |
Preventive Care
You Pay100% Covered
Primary Care Visit
You Pay20% after deductible
Specialist Visit
You Pay20% after deductible
Diagnostic Care
You Pay20% after deductible
Urgent Care
You Pay20% after deductible
Emergency Room
You Pay20% after deductible
Convenience Clinic Visit
You Pay20% after deductible
Teladoc Virtual Visits
You Pay20% after deductible
Inpatient Hospitalization
You Pay20% after deductible
Outpatient Surgery
You Pay20% after deductible
Pharmacy Benefits
| Drug Tier | Retail30-day supply | Mail order90-day supply |
|---|---|---|
| Tier one | $15 | $30 |
| Tier two | $50 | $100 |
| Tier three | $90 | $180 |
| Specialty | $15/$50/$90 | $30/$100/$180 |
Tier one
Retail30-day supply$15
Mail order90-day supply$30
Tier two
Retail30-day supply$50
Mail order90-day supply$100
Tier three
Retail30-day supply$90
Mail order90-day supply$180
Specialty
Retail30-day supply$15/$50/$90
Mail order90-day supply$30/$100/$180
Plan Notes
| Detail | Information |
|---|---|
| Pharmacy Deductible | Combined with Medical |
| Preventive Medication | Covered 100% |
| HSA eligible | Associates $800, All Others: $1400 |
| Limited Purpose FSA | Dental and Vision only |
Pharmacy Deductible
InformationCombined with Medical
Preventive Medication
InformationCovered 100%
HSA eligible
InformationAssociates $800, All Others: $1400
Limited Purpose FSA
InformationDental and Vision only
Blue Cross Blue Shield
Group: 71-6192N