Page 31 - Demo

Let%u2019s see what Gary may pay to manage his diabetes with each TRS-ActiveCare plan using in-network providers, services, facilities and labs.This example includes:%u2022 hospital stay%u2022 specialist visit %u2013 1 per year%u2022 PCP visits %u2013 4 per year%u2022 prescription medicationCOST OF CARE $18,300TRS-ACTIVECARE PRIMARYTRS-ACTIVECARE PRIMARY+ TRS-ACTIVECARE HDDeductible $2,500 $1,200 $3,300Coinsurance 30% after deductible 20% after deductible 30% after deductibleCopay and coinsurance for PCP $30 $15 30% after deductibleCopay and coinsurance for specialist $70 $70 30% after deductibleHospital/facility coinsuranceBased on one night at a cost of $11,00030% after deductible 20% after deductible 30% after deductibleInsulin out-of-pocket costsBased on yearly cost of $6,000$25 for 31-day supply$75 for 60- to 90-day supply$25 for 31-day supply$75 for 60- to 90-day supply 25% after deductibleWHAT GARY MAY PAY BASED ON $18,300 TOTAL COST OF CAREDeductible $2,500 $1,200 $3,300Office copays $190 $130 No copaysInsulin copays and coinsurance $300 copays $300 copays $1,500 coinsuranceCoinsurance $2,550 $1,960 $2,680Health plan paid $12,760 $14,710 $10,820Total paid by Gary $5,540 $3,590 $7,480www.bcbstx.com/trsactivecare 31