BHT Investment - 2022 Employee Benefit Guide

MEDICAL INSURANCE
CARRIER: QualChoice
Plan Options: High-Deductible Health Plan (HDHP) (Option 1) or two PPO Plans
(Options 2 or 3).
Please refer to the official plan documents for additional information on coverage and exclusions.
COVERED BENEFITS
Option 1
HDHP Plan
Option 2
PPO Buy-Up Plan
Option 3
PPO Buy-Up Plan
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Year Deductible
Individual $5,700 $3,000 $6,000 $1,000 $2,000
Family $11,400 $6,000 $12,000 $2,000 $4,000
Out of Pocket Maximum Included Deductible, Copays & Coins. Included Deductible, Copays & Coins. Included Deductible, Copays & Coins.
Individual $5,700 $10,700 $5,500 $9,000 $2,000 $7,000
Family $11,400 $21,400 $11,000 $18,000 $4,000 $14,000
Coinsurance (Plan Pays) 100% after Ded. 50% after Ded. 80% after Ded. 60% after Ded. 80% after Ded. 60% after Ded.
Preventive Care Plan pays 100% N/A Plan pays 100% N/A Plan pays 100% N/A
Physician Services
Primary Care 0% after Ded. 50% after Ded. $30 Copay 40% after Ded. $20 Copay 40% after Ded.
Specialist 0% after Ded. 50% after Ded. $50 Copay 40% after Ded. $35 Copay 40% after Ded.
Urgent Care 0% after Ded. 50% after Ded. $50 Copay 40% after Ded. $35 Copay 40% after Ded.
Emergency Services
Emergency Room 0% after Ded. 0% after Ded. $250 Copay $250 Copay 20% after Ded. 20% after Ded.
Ambulance 0% after Ded. 0% after Ded. 20% after Ded. 20% after Ded. 20% after Ded. 20% after Ded.
Hospital Services
Inpatient 0% after Ded. 50% after Ded. 20% after Ded. 40% after Ded. 20% after Ded. 40% after Ded.
Outpatient 0% after Ded. 50% after Ded. 20% after Ded. 40% after Ded. 20% after Ded. 40% after Ded.
Prescription Drugs
Tier 1 0% after Ded. Not Covered $15 Copay Not Covered $10 Copay Not Covered
Tier 2 $35 Copay $30 Copay
Tier 3 $50 Copay $50 Copay
Tier 4 $100 Copay $100 Copay
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