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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