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Medical

Plan Design

PPO Plan

Blue Edge $2,500 HDHP Plan*

Blue Edge $5,000 HDHP Plan*

 

In-Network

Out-of-Network

In-Network

Out-of-Network

In-Network

Out-of-Network

Deductible

Single

Family

 

$1,500

$4,500

 

$3,000

$9,000

 

$2,500

$5,000

 

$5,000

$10,000

 

$5,000

$10,000

 

$10,000

$20,000

Coinsurance

80%

60%

80%

70%

80%

50%

Out-of-Pocket Max

Single

Family

 

$6,500

$15,000

 

$13,000

$31,000

 

$7,500

$15,000

 

$14,000

$30,000

 

$8,500

$17,000

 

$20,000

$40,000

Preventive Care

100%

60% after deductible

100%

70% after deductible

100%

50% after deductible

Doctors Office Visit

$30 copay then 100%—PCP

$50 copay then 100%—SPC

60% after deductible

80% after deductible

70% after deductible

80% after deductible

50% after deductible

Medical/Surgical Services

80% after deductible

60% after deductible

80% after deductible

70% after deductible

80% after deductible

50% after deductible

Emergency Room

(copay waived if admitted to hospital)

$300 copay then 100%

$300 copay then 100%

80% after deductible

80% after deductible

80% after deductible

80% after deductible

Inpatient Services

80% after deductible

$300 per admission then 60% after deductible

80% after deductible

$300 per admission then 70% after deductible

80% after deductible

$300 per admission then 50% after deductible

Outpatient Services

80% after deductible

60% after deductible

80% after deductible

70% after deductible

80% after deductible

50% after deductible

Prescription Drugs (Retail)

Generic

Formulary

Non-Formulary

Specialty

 

$10 copay

$40 copay

$60 copay

20% to $250

 

$10 copay

$40 copay

$60 copay

20% to $250

 

80% after deductible

 

80% after deductible

 

80% after deductible

 

80% after deductible

Prescription Drugs (Mail Order)

Generic

Formulary

Non-Formulary

Specialty

 

$20 copay

$80 copay

$120 copay

N/A

 

Not Covered

 

80% after deductible

 

Not Covered

 

80% after deductible

 

Not Covered

* Shorr Packaging Corp. provides HDHP matching contributions up to $500 for employee only coverage tiers and $1,000 for employee plus one and family coverage tiers per year.

In the chart above, PCP refers to primary care provider and SPC refers to a specialist.

Note: This is a summary of benefits, please see Shorr Packaging Corp. Human Resources for a detailed plan description. Member pays coinsurance after deductible is met.

Under the PPO plan, you pay a lower deductible compared to the Blue Edge HDHP (HDHP). You will pay a higher monthly premium compared to the Blue Edge HDHP plans. You do not need a referral to see a specialist in-network and have the option to use providers outside of the network for an additional cost.

You are also eligible to enroll in the Flexible Spending Account to pay for qualified expenses with pre-tax dollars. More details are found here.

You may search for in-network providers by visiting www.bcbsil.com/find-care/providers-in-your-network/find-a-doctor-or-hospital and select Participating Provider Organization under the plan options.

Plan Design

PPO Plan

 

In-Network

Out-of-Network

Deductible: Single/Family

$1,500/$4,500

$3,000/$9,000

Coinsurance

80%

60%

Out-of-Pocket Max: Single/Family

$6,500/$15,000

$13,000/$31,000

Preventive Care

100%

60% after deductible

Doctors Office Visit

$30 copay then 100%—PCP

$50 copay then 100%—SPC

60% after deductible

Medical/Surgical Services

80% after deductible

60% after deductible

Emergency Room
(copay waived if admitted to hospital)

$300 copay then 100%

$300 copay then 100%

Inpatient Services

80% after deductible

$300 per admission then 60% after deductible

Outpatient Services

80% after deductible

60% after deductible

Prescription Drugs (Retail)

Generic/Formulary/Non-Formulary/Specialty

$10 copay/$40 copay/$60 copay/20% to $250

$10 copay/$40 copay/$60 copay/20% to $250

Prescription Drugs (Mail Order)

Generic/Formulary/
Non-Formulary/Specialty

$20 copay/$80 copay/$120 copay/N/A

Not Covered

This is a high-deductible health plan (HDHP) which means that you will pay more out of pocket until you hit the level where the plan begins to pay. You pay a lower monthly premium compared to the PPO plan currently offered. You do not need a referral to see a specialist in-network and have the option to use providers outside of the network for an additional cost.

If you are enrolled in an HDHP, you have access to a Health Savings Account (HSA). An HSA allows you to set aside funds on a pre-tax basis to pay for eligible medical expenses. Shorr will also make an annual contribution to your HSA. Additional information on HSAs can be found here.

You can also sign up for a limited purpose FSA to use pre-tax dollars vision and dental expenses. More details on the limited purpose FSA More details are found here.

You may search for in-network providers by visiting www.bcbsil.com/find-care/providers-in-your-network/find-a-doctor-or-hospital and select Participating Provider Organization under the plan options.

Plan Design

Blue Edge $2,500 HDHP Plan* 

 

In-Network

Out-of-Network

Deductible: Single/Family

$2,500/$5,000

$5,000/$10,000

Coinsurance

80%

70%

Out-of-Pocket Max: Single/Family

$7,500/$15,000

$14,000/$30,000

Preventive Care

100%

70% after deductible

Doctors Office Visit

80% after deductible

70% after deductible

Medical/Surgical Services

80% after deductible

70% after deductible

Emergency Room
(copay waived if admitted to hospital)

80% after deductible

80% after deductible

Inpatient Services

80% after deductible

$300 per admission then 70% after deductible

Outpatient Services

80% after deductible

70% after deductible

Prescription Drugs (Retail)

Generic/Formulary/Non-Formulary/Specialty

80% after deductible

80% after deductible

Prescription Drugs (Mail Order)

Generic/Formulary/Non-Formulary/Specialty

80% after deductible

Not Covered

* Shorr Packaging Corp. provides HDHP contributions up to $500 for employee-only coverage tier and up to $1,000 for employee plus one and family coverage tiers per year, paid bi-weekly.

This is a high-deductible health plan (HDHP) which means that you will pay more out of pocket until you hit the level where the plan begins to pay. You pay a lower monthly premium compared to the PPO plan currently offered. You do not need a referral to see a specialist in-network and have the option to use providers outside of the network for an additional cost.

If you are enrolled in an HDHP, you have access to a Health Savings Account (HSA). An HSA allows you to set aside funds on a pre-tax basis to pay for eligible medical expenses. Shorr will also make an annual contribution to your HSA. Additional information on HSAs can be found here.

You can also sign up for a limited purpose FSA to use pre-tax dollars vision and dental expenses. More details on the limited purpose FSA More details are found here.

You may search for in-network providers by visiting www.bcbsil.com/find-care/providers-in-your-network/find-a-doctor-or-hospital and select Participating Provider Organization under the plan options.

Plan Design

Blue Edge $5,000 HDHP Plan* 

 

In-Network

Out-of-Network

Deductible: Single/Family

$5,000/$10,000

$10,000/$20,000

Coinsurance

80%

50%

Out-of-Pocket Max: Single/Family

$8,500/$17,000

$20,000/$40,000

Preventive Care

100%

50% after deductible

Doctors Office Visit

80% after deductible

50% after deductible

Medical/Surgical Services

80% after deductible

50% after deductible

Emergency Room

(copay waived if admitted to hospital)

80% after deductible

80% after deductible

Inpatient Services

80% after deductible

$300 per admission then 50% after deductible

Outpatient Services

80% after deductible

50% after deductible

Prescription Drugs (Retail)

Generic/Formulary/Non-Formulary/Specialty

80% after deductible

80% after deductible

Prescription Drugs (Mail Order)

Generic/Formulary/Non-Formulary/Specialty

80% after deductible

Not Covered

* Shorr Packaging Corp. provides HDHP contributions up to $500 for employee-only coverage tier and up to $1,000 for employee plus one and family coverage tiers per year, paid bi-weekly.

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