Texas Farm Enrollment Guide 2023
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Medical Coverage<br />
Plan A<br />
Non-Network<br />
Individual<br />
Family<br />
Prescripon Drug Deducble<br />
$1,000<br />
$3,000<br />
$100 combined Retail & Mail Service<br />
$3,000<br />
$9,000<br />
80 / 20% 60 / 40%<br />
Prevenve<br />
100% of allowable<br />
Office Visit (Primary/Specialist)<br />
Virtual Visit (MD Live)<br />
Urgent Care<br />
80% of allowable aer deducble<br />
80% of allowable aer deducble<br />
<strong>2023</strong> contracted fee: $48<br />
80% of allowable aer deducble<br />
N/A<br />
Diagnosc Test (x-ray, blood work) 80% of allowable aer deducble 60% of allowable aer deducble<br />
Imaging (CT/PET scans, MRI) 80% of allowable aer deducble 60% of allowable aer deducble<br />
Emergency Room<br />
Facility charges<br />
Physician charges<br />
80% of allowable amount aer $300 Copay<br />
80% of allowable aer deducble<br />
Inpaent Facility<br />
Deducble and copay amounts apply to the Out of Pocket Maximum. Copayment amounts and per admission deducble are applied<br />
but will connue to be required aer the benefit percentages increase to 100%<br />
Tier Level<br />
Retail (30 day)<br />
Mail Order (90 day)<br />
Generic<br />
Preferred/Non-Preferred Brand<br />
Specialty Drugs<br />
Prime Specialty Pharmacy Only<br />
Coverage Type<br />
100% of allowable aer prescripon deducble<br />
80% of allowable aer prescripon deducble<br />
Generic: 100% allowable aer prescripon deducble<br />
Preferred/Non-Preferred Brand: 80% of allowable aer prescripon deducble<br />
Medical – Employee Contribuons<br />
Employee Only $87.26 $189.07<br />
Employee + 1 $183.73 $398.08<br />
Employee + 2 or more $245.70 $532.36<br />
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