MEDICAL PLANS
Your needs are unique to you, so Ambipar provides you with different medical options from which to choose. Each plan offers comprehensive benefits to help you and your family stay healthy throughout the year.
| | PPO 750 | CDHP 2000 | PPO 4000 | ||
|---|---|---|---|---|---|
| IN-NETWORK | IN-NETWORK | IN-NETWORK | |||
| CALENDAR YEAR DEDUCTIBLE | Embedded | Aggregate | Embedded | ||
| Individual | $750 | $2,000 | $4,000 | ||
| Family | $2,250 | $4,000 | $8,000 | ||
| Coinsurance (Plan Pays) | *80% | *80% | *80% | ||
| HSA Contribution (Individual/Family) | N/A | $500/$1,000 | N/A | ||
| CALENDAR YEAR OUT-OF-POCKET MAXIMUM | (MAXIMUM INCLUDES DEDUCTIBLE) | ||||
| Individual | $2,500 | $4,000 | $6,000 | ||
| Family | $7,500 | $8,000 | $12,000 | ||
| COPAYS/COINSURANCE | |||||
| Preventive Care | Covered at 100% | Covered at 100% | Covered at 100% | ||
| Virtual Visit | $30 copay | *80% | $30 copay | ||
| Office Visit: PCP / Specialist | $30/$50 copay | *80% | $30/$60 copay | ||
| Mental Health Inpatient Services | *80% | *80% | *80% | ||
| Mental Health Outpatient Services | *80% or subject to office visit copay | *80% | *80% or subject to office visit copay | ||
| Urgent Care | $40 copay | *80% | $75 copay | ||
| Emergency Room | $300 copay then 80% | *80% | $500 copay then 80% | ||
| Inpatient Hospital Services | *80% | *80% | *80% | ||
| Outpatient Surgery | *80% | *80% | *80% | ||
| RX CALENDAR YEAR OUT-OF-POCKET MAXIMUM | $2,500/$7,500 | ||||
| RETAIL RX (30-DAY SUPPLY) | |||||
| Generic | $15 copay | *80% | $20 copay | ||
| Preferred Brand | $35 copay | *80% | $40 copay | ||
| Non-preferred Brand | $55 copay | *80% | $60 copay | ||
| Specialty | $15/$35/$50 copay | *80% | $100 copay | ||
| MAIL ORDER RX (30-DAY SUPPLY) | |||||
| Generic | $30 copay | *80% | $40 copay | ||
| Preferred Brand | $70 copay | *80% | $80 copay | ||
| Non-preferred Brand | $110 copay | *80% | $120 copay | ||
| Specialty | N/A | *80% | N/A | ||
*After Deductible
| Payroll Deductions | PPO 750 | CDHP 2000 | PPO 4000 | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Monthly | Weekly | Monthly | Weekly | Monthly | Weekly | ||||
| Employee Only | $164.11 | $37.87 | $101.67 | $23.46 | $85.68 | $19.77 | |||
| Employee+Spouse | $506.53 | $116.89 | $371.26 | $85.68 | $341.84 | $78.89 | |||
| Employee+Child(ren) | $367.77 | $84.87 | $249.39 | $57.55 | $215.81 | $49.80 | |||
| Employee+Family | $722.91 | $166.82 | $470.40 | $108.55 | $469.90 | $108.44 | |||
With these medical plans administered by BlueCross BlueShield, you choose your own doctors (including specialists) for all your healthcare needs. Both plans pay 100% of the cost for in-network preventive care, including annual physicals. For detailed Plan information please refer to the Summary of Benefits Coverage located under the Documents. Whichever plan you choose, whichever doctors you choose, Own It!
You will receive an ID card in the mail directly from BlueCross BlueShield of TX within 14 days of your benefit start date – watch for your mail accordingly.
Visit bcbstx.com for a current list of BCBSTX network providers.
MDLIVE
When you’re under the weather, there’s no place like home, and if you’re busy with work and family, scheduling an in-person doctor’s appointment can be a pain. We got you covered! Virtual medicine is a convenient and easy way to connect with a doctor on your time and in the convenience of your home. MDLIVE gives you 24/7 access to board-certified doctors by phone, video, or app for non-emergency conditions.
MDLIVE doctors can treat many common medical conditions like:
- Cold & flu
- Allergies
- Bronchitis
- Bladder infection / urinary tract infection
- Respiratory infection
- Pink eye
- Sore throat
- Stomachache
- Sinus problems
Visit MDLIVE.com/bcbstx, download the app, or call 888.680.8646 to learn more.
For more information, reference these informational flyers: MDLive, Virtual Visit Registration.
This Benefits Website provides general information for our benefits-eligible employees; however, more detailed information is available within the plan documents and legal contracts between our company and the insurance providers. In case of any discrepancy between this Benefits Website and the plan documents, the plan documents always govern and determine your exact benefits. In addition, the company reserves the right to modify or terminate any benefit plan at any time. Benefits are not a guarantee of employment.