City of Nacogdoches 2021 Enrollment Guide

MEDICAL INSURANCE
CARRIER: BLUE CROSS BLUE SHIELD
Please refer to the official plan documents for additional information on coverage
and exclusions.
COVERED BENEFITS
BASE PLAN
IN-NETWORK
NON-NETWORK
Calendar Year Deductible - Individual/Family
Per Admission
$3,000/$6,000
None
Three month deductible carryover applies
$6,000/$12,000
None
Three month deductible carryover applies
Out of Pocket Maximum - Individual/Family $7,900/$15,800 $10,000/$20,000
Coinsurance 70 / 30% 50 / 50%
Preventive Care 100% of allowable amount 70% of allowable amount after deductible
Primary Office Visit 100% of allowable amount after $45 copay 70% of allowable amount after deductible
Specialist Office Visit 100% of allowable amount after $45 copay 70% of allowable amount after deductible
Virtual Visit MDLive (Medical or Behavioral Health) 100% of allowable amount N/A
Diagnostic Test (x-ray, bloodwork) 100% of allowable amount 70% of allowable amount after deductible
Imaging (CT/PET scans, MRI’s) 70% of allowable amount after deductible 50% of allowable amount after deductible
Urgent Care 100% of allowable amount after $75 copay 70% of allowable amount after deductible
Inpatient Services
Penalty for failure to preauthorize
70% after Calendar Year Deductible
None
50% of allowable amount after deductible
$250
Emergency Room
70% of allowable amount after $400 copay for facility; copay waived if admitted
Physician charges: 70% after calendar year deductible
RETAIL PHARMACY In-Network Non-Network
Generic
Preferred
Non-Preferred
Specialty Drugs
$20 copay
$50 copay
$75 copay
$150 copay
80% of allowable amount minus applicable copay
COVERAGE LEVEL
MONTHLY EMPLOYEE COST
Employee Only
No cost to employee; paid by City
Employee & Spouse $497.05
Employee & Child(ren) $454.38
Employee & Family $867.08
6