City of Nacogdoches 2021 Enrollment Guide

MEDICAL INSURANCE
CARRIER: BLUE CROSS BLUE SHIELD
COVERED BENEFITS
Buy-Up PLAN
IN-NETWORK
NON-NETWORK
Calendar Year Deductible - Individual/Family
Per Admission
$1,500/$3,000
None
Three month deductible carryover applies
$3,000/$6,000
None
Three month deductible carryover applies
Out of Pocket Maximum - Individual/Family $7,150/$14,300 $10,000/$20,000
Coinsurance 80 / 20% 60 / 40%
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) 80% of allowable amount after deductible 60% of allowable amount after deductible
Urgent Care 100% of allowable amount after $65 copay 70% of allowable amount after deductible
Inpatient Services
Penalty for failure to preauthorize
80% of allowable amount after deductible
None
60% of allowable amount after deductible
$250
Emergency Room
80% of allowable amount after $300 copay for facility, copay waived if admitted
Physician charges 80% 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 $68.20
Employee & Spouse $650.69
Employee & Child(ren) $599.75
Employee & Family $1,092.35
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