UL - 2023-24 Benefits Guide (FINAL 11.1.2023) SP
6 • 2023 Gerresheimer Salary Benefits Bulletin
HEALTH PLAN OPTIONS
2023 MEDICAL PLAN COMPARISON Administered by Horizon Blue Cross Blue Shield
Website: http://www.horizonblue.com Phone: 1-800-355-BLUE (2583)
MEDICAL BENEFITS
GOLD PLAN
HIGH DEDUCTIBLE HEALTHCARE PLAN
SERVICES
IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK
Calendar Year Deductible Individual / Family
$800 / $1,600
$1,200 / $2,400
$3,000 / $6,000*
$4,500 / $9,000*
Maximum Out-of-Pocket (includes deductible) Individual / Family
$10,000 / $20,000
$5,000 / $10,000
$5,500 / $11,000 $11,000 / $22,000
Doctor Visits - General / Family Practitioner
$30 co-pay
60% after ded.
70% after ded.
50% after ded.
Specialist Visits
$60 co-pay
60% after ded.
70% after ded.
50% after ded.
Well-Baby Care
100%
60% after ded.
100%
50% after ded.
Routine Gynecological Exam
100%
60% after ded.
100%
50% after ded.
Preventive: Annual Routine Physical Immunizations, PAP Smear, Mammograms, Prostate Exam
100%
60% after ded.
100%
50% after ded.
Emergency Room Treatment
$300 for true emergency
70% after ded.
Hospitalization: Inpatient Services Room & Board (Semi-Private Room)
$300, then 80% after ded.
$500, then 60% after ded.
70% after ded.
50% after ded.
In-Hospital Doctor Visits (Including Consultations)
80% after ded.
60% after ded.
70% after ded.
50% after ded.
Pre-Admission Tests
100%
60% after ded.
70% after ded.
50% after ded.
Second Surgical Opinion
100%
100%
70% after ded.
50% after ded.
Surgery
80% after ded.
60% after ded.
70% after ded.
50% after ded.
Outpatient Surgery
80% after ded.
60% after ded.
70% after ded.
50% after ded.
Anesthesia
80% after ded.
60% after ded.
70% after ded.
50% after ded.
Routine Laboratory Tests
100%
60% after ded.
70% after ded.
50% after ded.
Routine X-Rays
100%
60% after ded.
70% after ded.
50% after ded.
Chiropractic Care
$60 co-pay
60% after ded.
70% after ded.
50% after ded.
Mental Health/Substance Abuse Inpatient
70% after ded.
50% after ded.
$500, then 60% after ded. 60% after ded.
$300, then 80% after ded. $60 co-pay
70% after ded.
50% after ded.
Outpatient
This summary is for descriptive purposes only and should not be relied upon to fully determine coverage. It is not an agreement or a contract. * Entire family deductible must be satisfied before any benefits begin to be paid by the plan.
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