YOUR HEALTH

Medical Plan

You and Powell share the cost of this benefit.  You have the option of three Medical plans, all through BlueCross BlueShield of Texas.  You have the choice of selecting a traditional PPO Plan, or one of two Consumer Driven Health Plans (CDHPs), the Premier and Basic.  All three plans give you access to the same in- and out-of-network doctors and hospitals, prescription plan and preventive care services like yearly wellness exams and well-baby care as well as a $25 copay for Telemedicine with MDLIVE and musculoskeletal rehabilitation with Airrosti.

Not sure which plan to choose?  Check out the Understanding Your Medical Plans video and the interactive selection tool, PLANselect, below. 

Powell Medical Plans

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PPO Plan
Plan Highlights PPO Plan
In-Network Out-of-Network
Powell HRA Contributions Employee Only n/a n/a
Employee + Spouse
Employee + Child(ren)
Family
Annual Deductible Individual $1,500 $3,000
Family $3,000 $6,000
Annual Out-of-Pocket Maximum Individual $3,000 $6,000
Family $6,000 $12,000
MDLIVE Telemedicine $25 copay n/a
Airrosti Musculoskeletal Rehabilitation $25 copay n/a
Doctor’s Office Visit PCP: $30 Copay Specialist: $50 Copay 50% after Deductible
Preventative Care Covered at 100% No Deductible 50% after Deductible
Urgent Care Services 80% after Deductible 50% after Deductible
Emergency Room Services 80% after Deductible
Inpatient/Outpatient Services 80% after Deductible 50% after Deductible
Radiation, Dialysis, Chemotherapy Treatment 80% after Deductible 50% after Deductible
Outpatient Diagnostic Services CT Scans, Pet Scans, MRI & Nuclear Medicine, etc. 80% after Deductible 50% after Deductible
Lab Coverage Covered at 100% No Deductible 50% after Deductible
Premier CDHP Plan
Plan Highlights Premier CDHP Plan
In-Network Out-of-Network
Powell HRA Contributions Employee Only $750
Employee + Spouse $1,000
Employee + Child(ren)
Family $1,500
Annual Deductible Individual $2,000 $4,000
Family $4,000 $8,000
Annual Out-of-Pocket Maximum Individual $4,000 $8,000
Family $8,000 $16,000
MDLIVE Telemedicine $25 copay n/a
Airrosti Musculoskeletal Rehabilitation $25 copay n/a
Doctor’s Office Visit 80% after Deductible 50% after Deductible
Preventative Care Covered at 100% No Deductible 50% after Deductible
Urgent Care Services 80% after Deductible 50% after Deductible
Emergency Room Services 80% after Deductible
Inpatient/Outpatient Services 80% after Deductible 50% after Deductible
Radiation, Dialysis, Chemotherapy Treatment 80% after Deductible 50% after Deductible
Outpatient Diagnostic Services CT Scans, Pet Scans, MRI & Nuclear Medicine, etc. 80% after Deductible 50% after Deductible
Lab Coverage 80% after Deductible 50% after Deductible
Basic CDHP Plan
Plan Highlights Basic CDHP Plan
In-Network Out-of-Network
Powell HRA Contributions Employee Only $500
Employee + Spouse $750
Employee + Child(ren)
Family $1,000
Annual Deductible Individual $3,000 $6,000
Family $6,000 $12,000
Annual Out-of-Pocket Maximum Individual $6,000 $12,000
Family $12,000 $24,000
MDLIVE Telemedicine $25 copay n/a
Airrosti Musculoskeletal Rehabilitation $25 copay n/a
Doctor’s Office Visit 60% after Deductible 40% after Deductible
Preventative Care Covered at 100% No Deductible 40% after Deductible
Urgent Care Services 60% after Deductible 40% after Deductible
Emergency Room Services 60% after Deductible
Inpatient/Outpatient Services 60% after Deductible 40% after Deductible
Radiation, Dialysis, Chemotherapy Treatment 60% after Deductible 40% after Deductible
Outpatient Diagnostic Services CT Scans, Pet Scans, MRI & Nuclear Medicine, etc. 60% after Deductible 40% after Deductible
Lab Coverage 60% after Deductible 40% after Deductible


Medical Monthly Costs
View Large Table | Download PDF

Medical Plan PPO Premier CDHP Basic CDHP
Employee Premiums
Weekly Semi-Monthly Weekly Semi-Monthly Weekly Semi-Monthly
Employee Only $66.46 $144.00 $39.00 $84.50 $21.00 $45.50
Employee + Spouse $123.00 $266.50 $76.85 $166.50 $54.00 $117.00
Employee + Child(ren) $105.00 $227.50 $68.08 $147.50 $45.00 $97.50
Employee + Family $156.00 $338.00 $102.00 $221.00 $72.00 $156.00

Medical Plan Resources

www.bcbstx.com

Group #: 079163
800-521-2227

www.MDLIVE.com

Group #: 079163
888‐680‐8646

www.Airrosti.com
Group #: 079163
800‐404‐6050