Page 17 - 2021 Mid Year Open Enrollment Guide

Medical Plan Choices Medical Plan Choices

Nothing is more important than the health of you and your family. That is why BFS offers you a STANDARD PPO PLAN CORE OR BUY-UP HDHP PLANS
choice of medical plan options designed to help you get the care you need. See the table below for
a comparison of plan features. $0 You pay nothing for eligible $0 You pay nothing for eligible
CORE HDHP STANDARD PPO PLAN HDHP BUY-UP PLAN in-network preventive care in-network preventive care
Premium Cost Lowest Moderate High
For certain health care services, you pay You pay your nonpreventive medical and
Doctor Visit CoPay (for non-preventive care) only a copay and that’s it! The copay prescription expenses out-of-pocket until
Virtual $44 (applied to deductible) $10 copay $44 (applied to deductible) applies to your out-of-pocket maximum. you reach your annual deductible.
Primary Care Physician All costs up to Deductible, then $30 copay All costs up to Deductible, then
20% Coinsurance to Out of 20% Coinsurance to Out of Certain services, like surgery, apply to your Once the deductible is met, you pay
Pocket Limit, then $0 (except for Pocket Limit, then $0 (except for 30% deductible. Once you meet the deductible, 20% coinsurance of 20% for non-preventive
Specialist Preventive Care, which is free) $50 copay Preventive Care, which is free) you will pay 30% for in-network services. medical and prescription expenses.
Deductible (by coverage tier) Non-Embedded Non-Embedded Non-Embedded
Employee Only $2,600 $2,250 $1,400 If your out-of-pocket costs reach the annual If your out-of-pocket costs reach the annual
Employee + 1 Dependent $5,200 $3,375 $2,800 maximum, the plan pays 100% for eligible 100% maximum, the plan pays 100% for eligible 100%
Employee + 2 or more Dependents $5,200 $4,500 $2,800 care for the remainder of the plan year. care for the remainder of the plan year.
Coinsurance (% you pay after deductible) 20% 30% 20%
TIP: If you contribute to a Health Flexible Spending Account, you TIP: If you open a Health Savings Account, you can use the money in
can use the money in your FSA to help pay your out-of-pocket costs, your HSA to help pay your out-of-pocket costs, including your deductible,
Out-of-Pocket Maximum* (by coverage tier) including you deductible, coinsurance and prescriptions. coinsurance & prescriptions.
Employee Only $7,000 $6,350 $3,500
Employee + 1 Dependent $14,000 (limit of $7,000/person) $10,475 (limit of $6,350/person) $7,000 (limit of $3,500/person) This plan might be for you if... This plan might be for you if...
Employee + 2 or more Dependents $14,000 (limit of $7,000/person) $12,700 (limit of $6,350/person) $7,000 (limit of $3,500/person) • You/your dependents expect to have moderate • You/your dependents only expect the usual
to numerous non-preventive doctor’s office visits preventive care services each year.
Preventive Care No cost to you No cost to you No cost to you every year. • You want to allocate the premium savings
Diagnostic Tests (x-rays, labs) Deductible, then 20% No cost to you (unless in-patient) Deductible, then 20% • You have limited cash flow and you like the into an HSA to pay the full cost of discounted
security of set office visit copay amounts for non- non-preventive services up to the in-network
Emergency Room Deductible, then 20% $300 copay, then 30% Deductible, then 20%
preventive services. deductible and out-of-pocket maximums, should
In-Patient (hospitalization - all costs) Deductible, then 20% Deductible, then 30% Deductible, then 20% something occur.
• You take several generic maintenance
Out-Patient (all costs) Deductible, then 20% Deductible, then 30% Deductible, then 20%
medications that are free to you in a 90-day • You can afford to pay the full cost of medications
Imaging (CT/PET/MRI) Deductible, then 20% Deductible, then 30% Deductible, then 20% supply through Mail Order or pick up at the CVS up to the deductible and 20% coinsurance
Health Savings Account (HSA) Qualified Plan Yes No Yes store. thereafter (deductible waived if drug is on
Preventive Therapy List).
Flexible Savings Account (FSA) Qualified Plan Not if contributing to the HSA Yes Not if contributing to the HSA
Unless “preventive”, medical Unless “preventive”, medical All in-network preventive care services are offered at no cost to you,
Prescription Drug Deductible $100/person
deductible applies. deductible applies. regardless of the health insurance plan you are enrolled in, including:
Prescription Medications - 30-Day Supply • Annual physical exams (e.g. well-woman, well-child etc.)
Generic 25%, $15 min, $30 Max • Preventive cancer screenings
Brand/Formulary 40%, $35 Min, $100 Max
Deductible, than 20% (Drugs Deductible, than 20% (Drugs • Preventive mammograms
Brand/Non-Formulary on the Preventive Therapy List 50%, $45 Min, $150 Max on the Preventive Therapy List
bypass the deductible) bypass the deductible) • Biometric screenings (e.g. cholesterol, blood pressure, diabetes, etc.)
Insulin/Formulary 40%, $50 Max
• Flu shots and other immunizations
Specialty Rx 40%, $250 Max
Prescription Medications - 90-Day Supply • Diabetes prevention programs
Generic $0 Summary of Benefits & Coverage (SBC) Documents
Brand/Formulary Deductible, than 20% (Drugs 30%, $45 min, $200 Max Deductible, than 20% (Drugs
on the Preventive Therapy List on the Preventive Therapy List For each health plan we offer, we provide an SBC document so that you can compare them in
Brand/Non-Formulary bypass the deductible) 50%, $65 min, $300 Max bypass the deductible) specific terms and scenarios. Please review the SBC document for any plan you are considering.
Insulin/Formulary 30%, $150 Max
CORE HDHP STANDARD PPO PLAN HDHP BUY-UP PLAN
Specialty Rx N/A N/A N/A
*Medical and prescription drug deductibles, copays and coinsurance ALL apply to the annual out-of-pocket maximum for a
single covered individual. Mid-year to date accumulators for deductibles and out-of-pocket limits will transfer in the mid-year
enrollment.

14 • 2021 BUILDERS FIRSTSOURCE MID-YEAR BENEFITS GUIDE 2021 BUILDERS FIRSTSOURCE MID-YEAR BENEFITS GUIDE • 15