Texas Farm Enrollment Guide 2023

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Medical Coverage Plan A Non-Network Individual Family Prescripon Drug Deducble $1,000 $3,000 $100 combined Retail & Mail Service $3,000 $9,000 80 / 20% 60 / 40% Prevenve 100% of allowable Office Visit (Primary/Specialist) Virtual Visit (MD Live) Urgent Care 80% of allowable aer deducble 80% of allowable aer deducble <strong>2023</strong> contracted fee: $48 80% of allowable aer deducble N/A Diagnosc Test (x-ray, blood work) 80% of allowable aer deducble 60% of allowable aer deducble Imaging (CT/PET scans, MRI) 80% of allowable aer deducble 60% of allowable aer deducble Emergency Room Facility charges Physician charges 80% of allowable amount aer $300 Copay 80% of allowable aer deducble Inpaent Facility Deducble and copay amounts apply to the Out of Pocket Maximum. Copayment amounts and per admission deducble are applied but will connue to be required aer the benefit percentages increase to 100% Tier Level Retail (30 day) Mail Order (90 day) Generic Preferred/Non-Preferred Brand Specialty Drugs Prime Specialty Pharmacy Only Coverage Type 100% of allowable aer prescripon deducble 80% of allowable aer prescripon deducble Generic: 100% allowable aer prescripon deducble Preferred/Non-Preferred Brand: 80% of allowable aer prescripon deducble Medical – Employee Contribuons Employee Only $87.26 $189.07 Employee + 1 $183.73 $398.08 Employee + 2 or more $245.70 $532.36 8
Medical Coverage Plan B Non-Network Individual Family Prescripon Drug Deducble $3,000 $9,000 $100 combined Retail & Mail Service $6,000 $18,000 $8,000 $24,000 80 / 20% 60 / 40% Prevenve 100% of allowable Office Visit (Primary/Specialist) $40 / $60 Copay Virtual Visit (MD Live) $40 Copay N/A Urgent Care $75 Copay Diagnosc Test (x-ray, blood work) 80% of allowable aer deducble 60% of allowable aer deducble Imaging (CT/PET scans, MRI) 80% of allowable aer deducble 60% of allowable aer deducble Emergency Room Facility charges Physician charges 80% of allowable amount aer $500 Copay 80% of allowable aer deducble Inpaent Facility Deducble and copay amounts apply to the Out of Pocket Maximum. Copayment amounts and per admission deducble are applied but will connue to be required aer the benefit percentages increase to 100% Tier Level Retail (30 day) Mail Order (90 day) Generic Preferred/Non-Preferred Brand Specialty Drugs (Prime Specialty Pharmacy Only) 100% of allowable aer prescripon deducble 80% of allowable aer prescripon deducble Generic: 100% allowable aer prescripon deducble Preferred/Non-Preferred Brand: 80% of allowable aer prescripon deducble Medical – Employee Contribuons Coverage Type Employee Only $23.32 $50.53 Employee + 1 $136.20 $295.09 Employee + 2 or more $200.74 $434.95 9
Page 1 and 2: Plan Year 2023 Effecve January 1, 2
Page 3 and 4: Resource Directory Coverage Carrier
Page 5 and 6: Membership Guidelines Pre-Tax Payro
Page 7: Medical Coverage Your employer will
Page 11 and 12: Medical Coverage 11
Page 13 and 14: Medical Coverage 13
Page 15 and 16: Medical Employer Coverage Paid—Ba
Page 17 and 18: Medical Coverage Employer Paid—ST
Page 19 and 20: Medical Employer Coverage Paid—ST
Page 21 and 22: Medical Employer Coverage Paid—LT
Page 23 and 24: Medical Employer Coverage Paid—LT
Page 25 and 26: Dental Coverage 25
Page 27 and 28: Vision Coverage 27
Page 29 and 30: Voluntary Life 29
Page 31 and 32: New benefit offering Accident 31
Page 33 and 34: New benefits offering Crical Illnes
Page 35 and 36: Crical Illness You will be able to
Page 37: 37

Texas Farm Enrollment Guide 2023

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