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BUSINESS SERVICES CORPORATION D/B/A BENEFIT CHOICES SMALL GROUP PLANS10/30/2023 12:20 PM2024 HIGHMARK BLUESHIELD OF NORTHEASTERN NEW YORK - Small Business 2 to 100 RATES SHOWN COVER REGION 1METAL TIER PRODUCT TIERMONTHLY RATEAggregate / EmbeddedDEDUCTIBLE (SINGLE/FAMILY)COINSURANCEOOP MAX (SINGLE/FAMILY)OFFICE VISITSPECIALIST VISITLAB SERVICESINPATIENT HOSPITALOUTPATIENT SURGERYERURGENT CAREPRESCRIPTION DRUGSPLATINUM POS CLASSIC DISCONTINUED 2024 CURRENT SUBSCRIBERS MAP TO PLATINUM RADIUS PLUSIndividual Empl/Spouse Parent/Child(ren) FamilyPLATINUM RADIUS Plus **Individual Empl/Spouse Parent/Child(ren) Family$1,056.15 $2,112.31 $1,795.46 $3,010.04N/A N/A N/A $7,000/$14,000 Embedded$15 $30 $30 $500 $100 $150 (CHANGE FOR 2024)$75 (CHANGE FOR 2024)$10/$35/$100GOLD POS CLASSIC DISCONTINUED 2024 CURRENT SUBSCRIBERS MAP TO GOLD BLENDED RADIUSIndividual Empl/Spouse Parent/Child(ren) Family$787.64 $1,575.29 $1,338.99 $2,244.78GOLD BLENDED RADIUSIndividual Empl/Spouse Parent/Child(ren) Family$897.91 $1,795.82 $1,526.45 $2,559.05 N/A $1,250/$2,500 30% FS $9,100/$18,200 Embedded$25 not subject to deductible$50 not subject to deductible$50 not subject to deductible30% after deductible30% after deductible$350 not subject to deductible$100 not subject to deductible$10/$35/$100 not subject to deductibleGOLD EPO HIGH Individual Empl/Spouse Parent/Child(ren) Family$1,118.84 $2,237.67 $1,902.02 $3,188.68N/A N/A N/A $9,100/$18,200 Embedded$30 $50 $50 $1000 $250 (CHANGE FOR 2024) $300 $75 $10/$50/$100 (CHANGE FOR 2024)GOLD RADIUS HIGH **Individual Empl/Spouse Parent/Child(ren) Family$978.90 $1,957.80 $1,664.13 $2,789.87N/A N/A N/A $9,100/$18,200 Embedded$30 $50 $50 $1,000 $250 (CHANGE FOR 2024)$300 $75 $10/$50/$100 (CHANGE FOR 2024)SILVERSILVER EPO 7000 (HSA QUALIFIED)Individual Empl/Spouse Parent/Child(ren) Family$865.67 $1,731.33 $1,471.63 $2,467.15True Family * $3,500/$7,000 AggregateN/A $7,500/$15,000 Embedded (CHANGE FOR 2024)$30 after deductible (CHANGE FOR 2024)$50 after deductible (CHANGE FOR 2024)$50 after deductible (CHANGE FOR 2024)$1,000 after deductible$350 after deductible$250 after deductible$75 After deductible$10/$35/$100 After deductibleINN In Network OON Out of NetworkALL RATES COVER BLUE SHIELD REGION 1.ALL RATES ARE DEPENDENT TO AGE 26.ALL PLANS INCLUDE ONE $250 WELLNESS DEBIT CARD PER CONTRACT - RENEWS ANNUALLYAGGREGATE: For any policy with two or more members, the deductible must be met by any one or any combination of members before the plan makes payments.EMBEDDED: Each member must meet their individual deductible before plan pays. Individual deductible also applies to family deductible level. Once family deductible is met, plan begins payment of services for all contract members.* TRUE FAMILY DEDUCTIBLE: Unlike embedded deductible plans, there is no limit to the amount one member can pay toward the family deductible. For both types of deductibles, once the deductible is met, you will pay copays or coinsurance when you receive covered services.** THIS PLAN INCLUDES "AWAY FROM HOME CARE@" GUEST MEMBERSHIP. Please contact Highmark Blue Shield to register for away from home care. To ensure coverage by a network provider, confirm on www.bsneny.org Find a Doctor link PEDIATRIC DENTAL is now embedded in medical plans at no extra charge; Members show their medical card to their dentist for pediatric dental care.NOTE: In case of a discrepancy in the display of these plan details and rates, The carrier's actual plan details and rates prevail.PLATINUMGOLD