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TRS-ACTIVECARE PLAN COMPARISON CHART TRS-ACTIVECARE PRIMARYTRS-ACTIVECARE PRIMARY+ TRS-ACTIVECARE HDTRS-ACTIVECARE 2NOTE: CLOSED PLAN;NO NEW ENROLLMENTS.PLAN FEATURESType of Coverage In-Network Coverage OnlyIn-Network Coverage OnlyIn-NetworkCoverageOut-of-Network CoverageIn-Network CoverageOut-of-NetworkCoverageIndividual andFamily Deductible$2,500/$5,000$1,200/$2,400$3,300/$6,600$6,600/$13,200$1,000/$3,000$2,000/$6,000Coinsurance You pay 30% after deductibleYou pay 20% after deductibleYou pay 30% after deductibleYou pay 50% after deductibleYou pay 20% after deductibleYou pay 40% after deductibleIndividual andFamily Maximum Out-of-Pocket$8,050/$16,100$6,900/$13,800$8,300/$16,600$20,500/$41,000$7,900/$15,800$23,700/$47,400Network Statewide Statewide Nationwide NationwidePCP Required Yes Yes No NoDOCTOR VISITSPrimary Care $30 copay $15 copay You pay 30% after deductibleYou pay 50% after deductible $30 copay You pay 40% after deductibleSpecialist $70 copay $70 copay You pay 30% after deductibleYou pay 50% after deductible $70 copay You pay 40% after deductibleMental Health $30 copay $15 copay You pay 30% after deductible $30 copayTRS Virtual HealthTeladoc - Medical $12 $12 $42 $12Teladoc - Mental Health Psychiatrist (initial visit) $0(ongoing visit) $0Psychologist, Licensed Clinical Social Worker $0Psychiatrist (initial visit) $0(ongoing visit) $0Psychologist, Licensed Clinical Social Worker $0Psychiatrist (initial visit) You pay 30% after deductible(ongoing visit) You pay 30% after deductiblePsychologist, Licensed Clinical Social Worker%u2014You pay 30% after deductiblePsychiatrist (initial visit) $0(ongoing visit) $0Psychologist, Licensed Clinical Social Worker $0RediMD - Medical $0 $0 $30 $0IMMEDIATE CAREUrgent Care $50 copay $50 copay You pay 30% after deductibleYou pay 50% after deductible $50 copay You pay 40% after deductibleEmergency Care You pay 30% after deductibleYou pay 20% after deductible You pay 30% after deductible You pay a $250 copay + 20% after deductibleFreestanding Emergency RoomYou pay a $500 copay + 30% after deductibleYou pay a $500 copay + 20% after deductibleYou pay $500 +30% after deductibleYou pay $500 + 50% after deductibleYou pay a $500 copay + 20% after deductibleYou pay a $500 copay + 40% after deductibleOTHER SERVICES Diagnostic labsOffice/Independent lab: You pay $0Office/Independent lab: You pay $0 You pay 30% after deductibleYou pay 50% after deductibleOffice/Independent lab: You pay $0 You pay 40%after deductible Outpatient: You pay 30% after deductibleOutpatient: You pay 20% after deductibleOutpatient: You pay 20% after deductibleHigh-Tech RadiologyYou pay 30% after deductibleYou pay 20% after deductibleYou pay 30% after deductibleYou pay 50% after deductibleYou pay 20% after deductible + $100 per procedure copayYou pay 40% after deductible + $100 per procedure copayOutpatient costs(Professional and facility)You pay 30% after deductibleYou pay 20% after deductibleYou pay 30% after deductibleYou pay 50% after deductibleYou pay 20% after deductible ($150 facility copay per incident)You pay 40% after deductible ($150 facility copay per incident)Inpatient costs(Professional and facility)You pay 30% after deductibleYou pay 20% after deductibleYou pay 30% after deductibleYou pay 50% after deductible ($500 facility per day maximum)You pay 20% after deductible ($150 facility copay per day)You pay 40% after deductible ($500 facility per day maximum)24 www.bcbstx.com/trsactivecare