Coulson Oil - Petro - 2022 Benefits Guide

MEDICAL INSURANCE
CARRIER: Arkansas Blue Cross Blue Shield / Health Advantage
Plan Options: A POS plan (Option 1) or a high-deductible health plan (Option 2)
Please refer to the official plan documents for additional information on coverage and exclusions.
COVERED BENEFITS
Year Deductible
Option 1
Traditional POS Plan
Option 2
HSA Plan
In-Network Out-of-Network In-Network Out-of-Network
Individual
$1,000
$3,000
$3,000
$6,000
Family
$3,000
$9,000
$6,000
$12,000
Out-of-Pocket Maximum
Individual
$3,000
$11,000
$3,000
Unlimited
Family
$9,000
$33,000
$6,000
Unlimited
Coinsurance (Plan Pays) 80% 60% 100% 80%
Preventive Care
Physician Services
Immunizations covered
in full; Exams $25 copay
40% after deductible Plan pays 100% 20% after deductible
Primary Care $25 copay 40% after deductible 0% after deductible 20% after deductible
Virtual Visit $25 copay Not covered $45 copay Not covered
Specialist $35 copay 40% after deductible 0% after deductible 20% after deductible
Urgent Care $35 copay 40% after deductible 0% after deductible 20% after deductible
Emergency Room
$100 copay,
20% coinsurance
$100 copay,
20% coinsurance
0% after deductible 0% after deductible
Hospital Services
Inpatient
Outpatient
Prescription Drugs
$200 copay,
20% coinsurance
$100 copay,
20% coinsurance
40% after deductible 0% after deductible 20% after deductible
40% after deductible 0% after deductible 20% after deductible
Tier 1 $10 copay Not covered 0% after deductible Not covered
Tier 2 $40 copay Not covered 0% after deductible Not covered
Tier 3 $60 copay Not covered 0% after deductible Not covered
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