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OTHER SERVICESType of Coverage In-Network Out-of-NetworkDiagnostic Labs You pay 30% after deductibleYou pay 50% after deductibleHigh-Tech Radiology You pay 30% after deductibleYou pay 50% after deductibleOutpatient Costs(Professional and facility)You pay 30% after deductibleYou pay 50% after deductible Inpatient Costs(Professional and facility)You pay 30% after deductibleYou pay 50% after deductible($500 facility perday maximum)Bariatric Surgery Not CoveredAnnual Vision Examination (One per plan year; performed by an ophthalmologist or optometrist) You pay 30% after deductibleYou pay 50% after deductibleAnnual Hearing Exam (One per plan year)You pay 30% after deductibleYou pay 50% after deductibleOverview of Plan Benefits and CostsTRS-ACTIVECARE HDPLAN FEATURESType of Coverage In-Network Out-of-NetworkIndividual/Family Deductible $3,200/$6,400 $6,400/$12,800Coinsurance You pay 30% after deductibleYou pay 50% after deductibleIndividual/Family MOOP $8,050/$16,100 $20,250/$40,500Network NationwidePCP Required NoDOCTOR VISITSPrimary Care You pay 30% after deductibleYou pay 50% after deductibleSpecialist You pay 30% after deductibleYou pay 50% after deductibleMental Health You pay 30% after deductibleYou pay 50% after deductibleTRS Virtual HealthTeladocMedicalMental HealthRediMD$42 consultation fee30% coinsurance after deductible, behavioral health consult fees apply to deductible: %u2022 psychiatrist (initial visit) $185.00 %u2022 psychiatrist (ongoing visit) $95.00 %u2022 psychologist, licensed clinical social worker $85.00$30 consultation feeIMMEDIATE CAREUrgent Care You pay 30% after deductibleYou pay 50% after deductibleEmergency Care You pay 30% after deductibleFreestanding Emergency RoomYou pay a $500copay + 30% after deductibleYou pay a $500copay + 50% after deductible28 www.bcbstx.com/trsactivecare