BHT Investment - 2023 Benefit Guide FINAL
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MEDICAL INSURANCE<br />
CARRIER: QualChoice<br />
Plan Options: High-Deductible Health Plan (HDHP) (Option 1) or two PPO Plans<br />
(Options 2 or 3).<br />
Please refer to the official plan documents for additional information on coverage and exclusions.<br />
COVERED BENEFITS<br />
Year Deductible<br />
Option 1<br />
HDHP Plan<br />
Option 2<br />
PPO Buy-Up Plan<br />
Option 3<br />
PPO Buy-Up Plan<br />
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network<br />
Individual $5,700 $3,000 $6,000 $1,000 $2,000<br />
Family $11,400 $6,000 $12,000 $2,000 $4,000<br />
Out-of-Pocket Maximum<br />
Included Deductible, Copays & Coins.<br />
Individual $5,700 $10,700 $5,500 $9,000 $2,000 $7,000<br />
Family $11,400 $21,400 $11,000 $18,000 $4,000 $14,000<br />
Coinsurance (Plan Pays)<br />
100% after<br />
deductible<br />
50% after<br />
deductible<br />
80% after<br />
deductible<br />
60% after<br />
deductible<br />
80% after<br />
deductible<br />
60% after<br />
deductible<br />
Preventive Care Plan pays 100% N/A Plan pays 100% N/A Plan pays 100% N/A<br />
Physician Services<br />
Primary Care<br />
Specialist<br />
Urgent Care<br />
Emergency Services<br />
Emergency Room<br />
Ambulance<br />
Hospital Services<br />
Inpatient<br />
Outpatient<br />
Prescription Drugs<br />
Tier 1<br />
Tier 2<br />
Tier 3<br />
Tier 4<br />
0% after<br />
deductible<br />
0% after<br />
deductible<br />
0% after<br />
deductible<br />
0% after<br />
deductible<br />
0% after<br />
deductible<br />
0% after<br />
deductible<br />
0% after<br />
deductible<br />
0% after<br />
deductible<br />
0% after<br />
deductible<br />
0% after<br />
deductible<br />
0% after<br />
deductible<br />
50% after<br />
deductible<br />
50% after<br />
deductible<br />
50% after<br />
deductible<br />
0% after<br />
deductible<br />
0% after<br />
deductible<br />
50% after<br />
deductible<br />
50% after<br />
deductible<br />
$30 copay<br />
$50 copay<br />
$50 copay<br />
40% after<br />
deductible<br />
40% after<br />
deductible<br />
40% after<br />
deductible<br />
$250 copay $250 copay<br />
20% after<br />
deductible<br />
20% after<br />
deductible<br />
20% after<br />
deductible<br />
20% after<br />
deductible<br />
40% after<br />
deductible<br />
40% after<br />
deductible<br />
$20 copay<br />
$35 copay<br />
$35 copay<br />
20% after<br />
deductible<br />
20% after<br />
deductible<br />
20% after<br />
deductible<br />
20% after<br />
deductible<br />
40% after<br />
deductible<br />
40% after<br />
deductible<br />
40% after<br />
deductible<br />
20% after<br />
deductible<br />
20% after<br />
deductible<br />
40% after<br />
deductible<br />
40% after<br />
deductible<br />
Not Covered $15 copay Not Covered $10 copay Not Covered<br />
Not Covered $35 copay Not Covered $30 copay Not Covered<br />
Not Covered $50 copay Not Covered $50 copay Not Covered<br />
Not Covered $100 copay Not Covered $100 copay Not Covered<br />
6
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