Time is Up!
| In-Network benefits | Plan A | Plan B | Plan C | Plan D |
|---|---|---|---|---|
| Replacing 2020 Plan | Plan 1 | Plan 4 & 6 | Plan 2 | Plan 5 |
| Individual/Family Calendar Year Deductible | $500 / $1,000 | $1,000 / $2,000 | $2800 / $5600 | $5000 / $10000 |
| Preventive Visit Copay | 100% covered, No charge | 100% covered, No charge | 100% covered, No charge | 100% covered, No charge |
| Physician Office Visits | $0 Copay Children 18 and Under 1st Sick Visit $0 $35 Copay/Visit | $0 Copay Children 18 and Under 1st Sick Visit $0 $35 Copay/Visit | 20% after deductible | 20% after deductible |
| Specialist Visits | $50 Copay/Visit | $80 Copay/Visit | 20% after deductible | 20% after deductible |
| Diagnostic Test (Lab and X-Ray) | No Charge | No Charge | 20% after deductible | 20% after deductible |
| Imaging (CT, MRI, etc.) | 20% after deductible | $500 Copay/Visit | 20% after deductible | 20% after deductible |
| Walk-In Clinic | $35 Copay/Visit | $35 Copay/Visit | 20% after deductible | 20% after deductible |
| Urgent Care Copay | $75 Copay/Visit | $75 Copay/Visit | 20% after deductible | 20% after deductible |
| Emergency Room Copay | $300 Copay (Waived if admitted) | $500 Copay (Waived if admitted) | 20% after deductible | 20% after deductible |
| Outpatient Services | 20% after deductible | 20% after deductible | 20% after deductible | 20% after deductible |
| Inpatient Hospital | 20% after deductible | $1,500/Day Copay (max 3 Days) | 20% after deductible | 20% after deductible |
| Co-Insurance | 20% | 20% | 20% | 20% |
| Individual/Family Out of Pocket Maximum (Includes Deductible) | $7,350 / $14,700 | $7,350 / $14,700 | $6,650 / $13,300 | $6,650 / $13,300 |
| Prescription Benefits | $10/$50/$90 | $10/$50/$90 | Free Preventive Medications Prescriptions not on list are 20% after deductible | Free Preventive Medications Prescriptions not on list are 20% after deductible |
| Virtual Health | $0 Copay Per Consultation | $0 Copay Per Consultation | $0 Copay Per Consultation | $0 Copay Per Consultation |
| PCP Required | No | No | No | No |
| Network | BSW Preferred | NationCare | BSW Preferred | BSW Preferred |
| Out of Network Benefits | No | YES | No | No |
| Medical Rates | Employee Premium | Employee Premium | Employee Premium | Employee Premium |
| Employee | $202.00 | $272.00 | $90.00 | $0.00 |
| Employee + Spouse | $1,168.00 | $1,346.00 | $872.00 | $652.00 |
| Employee + Child/ren | $710.00 | $834.00 | $500.00 | $336.00 |
| Employee + Family | $1,494.00 | $1,706.00 | $1,138.00 | $856.00 |
| Medical Rates | Full Premium | Full Premium | Full Premium | Full Premium |
| Employee | $602.00 | $672.00 | $490.00 | $400.00 |
| Employee + Spouse | $1,568.00 | $1,746.00 | $1,272.00 | $1,052.00 |
| Employee + Child/ren | $1,110.00 | $1,234.00 | $900.00 | $736.00 |
| Employee + Family | $1,894.00 | $2,106.00 | $1,538.00 | $1,256.00 |
| ★ Save Plan A To My List | ★ Save Plan B To My List | ★ Save Plan C To My List | ★ Save Plan D To My List |
