TBS Employee Health Coverage

SILVER LEVEL

PLAN

BENEFITS PLAN BASIC INFORMATION*

Group Name: 
Group Number: 
Anniversary Date: 

Rate Effective Date: 

Product: 
Product Plan: 
Level: 

PLAN DETAILS

INN Deductible: 
INN Family Deductible: 
OON Deductible: 
OON Family Deductible: 
Coinsurance: 
PCP Copayment: 
INN Out of Pocket: 
INN Family Out of Pocket:
OON Out of Pocket:
OON Family Out of Pocket:
Drug:
Pediatric Dental:
Pediatric Vision:
Status:

 

TOTAL BUILDING SERVICES
26U22ERC
06/01

06/01/2020

GroupCare - PPO
GroupCare Copay 60/50 $4,600
Silver Level Coverage

 

 

$4,600 (In Network)
$13,800
$9,200 (Out Of Network)
$27,600
60% / 40%    
$45 (Primary Care Physician)
$8,150
$16,300
$16,300
$32,600
15/40/70/90%Sp;ST
Included
Included
Non-Grandfathered

  • Open Enrollment begins in June annually.

  • Late enrollees must wait until following June.

  • Expect 30 days for Blue Cross to process application and provide proof of coverage. 

  • TBS pays 50% of employee's monthly premium under any plan.

  • Employees pay costs for spouse and/or children.

  • Policy is effective on the 1st day of the month following 60 days of employment.
NEED TO KNOW!

COST BREAKDOWN

$640.59
$1281.18
$1185.09
$1,825.68

Employee Only:

Employee & Spouse:
Employee & Children:
Family:

$320.30
$640.59
$592.55
$912.84

$3,843.54
$7687.08
$7110.54
$10,954.08

$73.91
$147.83
$136.74
$210.66

-$320.29
-$640.59
-$592.54

-$912.84

Actual Monthly
Cost
TBS
Contributes
Employee Pays
Per- Month
Employee Pays
Per-Year
Employee Pays
Per-Week
Plans

Must be employed 60 days prior to enrollment.

Please return completed form to PO Box 358, Liberty, MS 39645.