City of Nacogdoches 2021 Enrollment Guide
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MEDICAL INSURANCE<br />
CARRIER: BLUE CROSS BLUE SHIELD<br />
COVERED BENEFITS<br />
Buy-Up PLAN<br />
IN-NETWORK<br />
NON-NETWORK<br />
Calendar Year Deductible - Individual/Family<br />
Per Admission<br />
$1,500/$3,000<br />
None<br />
Three month deductible carryover applies<br />
$3,000/$6,000<br />
None<br />
Three month deductible carryover applies<br />
Out <strong>of</strong> Pocket Maximum - Individual/Family $7,150/$14,300 $10,000/$20,000<br />
Coinsurance 80 / 20% 60 / 40%<br />
Preventive Care 100% <strong>of</strong> allowable amount 70% <strong>of</strong> allowable amount after deductible<br />
Primary Office Visit 100% <strong>of</strong> allowable amount after $45 copay 70% <strong>of</strong> allowable amount after deductible<br />
Specialist Office Visit 100% <strong>of</strong> allowable amount after $45 copay 70% <strong>of</strong> allowable amount after deductible<br />
Virtual Visit MDLive (Medical or Behavioral Health) 100% <strong>of</strong> allowable amount N/A<br />
Diagnostic Test (x-ray, bloodwork) 100% <strong>of</strong> allowable amount 70% <strong>of</strong> allowable amount after deductible<br />
Imaging (CT/PET scans, MRI’s) 80% <strong>of</strong> allowable amount after deductible 60% <strong>of</strong> allowable amount after deductible<br />
Urgent Care 100% <strong>of</strong> allowable amount after $65 copay 70% <strong>of</strong> allowable amount after deductible<br />
Inpatient Services<br />
Penalty for failure to preauthorize<br />
80% <strong>of</strong> allowable amount after deductible<br />
None<br />
60% <strong>of</strong> allowable amount after deductible<br />
$250<br />
Emergency Room<br />
80% <strong>of</strong> allowable amount after $300 copay for facility, copay waived if admitted<br />
Physician charges 80% after calendar year deductible<br />
RETAIL PHARMACY In-Network Non-Network<br />
Generic<br />
Preferred<br />
Non-Preferred<br />
Specialty Drugs<br />
$20 copay<br />
$50 copay<br />
$75 copay<br />
$150 copay<br />
80% <strong>of</strong> allowable amount minus applicable copay<br />
COVERAGE LEVEL<br />
MONTHLY EMPLOYEE COST<br />
Employee Only $68.20<br />
Employee & Spouse $650.69<br />
Employee & Child(ren) $599.75<br />
Employee & Family $1,092.35<br />
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