| PLAN DESIGN | In-Network | Out-of-Network |
| Office Visit (Primary Care)Physicians | $0 copay | Deductible + 50% coinsurance |
| Office Visit (Specialists) | $15 copay | Deductible + 50% coinsurance |
| Airrosti Services | $40 copay | Deductible + 50% coinsurance |
| Urgent Care | $35 copay | Deductible + 50% coinsurance |
| Emergency Room | 20% coinsurance
after $300 copay | 20% coinsurance
after $300 copay |
| Preventive Services | You Pay 0% | Deductible + 50% coinsurance |
| Deductible (Individual) | $400 | $2,000 |
| Deductible (Family) | $800 | $6,000 |
| Co-Insurance | 20% | 50% |
| Out of Pocket Maximum (Individual) | $9,100 | $18,200 |
| Out of Pocket Maximum (Family) | $18,200 | $36,400 |
Employees may utilize Health Advocate through your Freshbenies account to help guide you and your dependents in your healthcare decisions. To contact your Health
Advocate:
Phone: 1-877-412-3108
Email: [email protected]
To find out if your doctor participates in the BCBS network, go to www.bcbstx.com; Network name: Blue Choice PPO (BCA)
Customer Service: 800-521-2227; Group #153601
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