b'Benefits for 2022MedicalSUMMARY OF COVERAGEPlan Features BCBS SB PPO $500 BCBS SB PPO $1500 BCBS SB PPO $3000IN NETWORKCalendar Year$500 / $1,000 $1,500 / $3,000 $3,000 / $6,000Deductibles (Individual / Family)In regards to deductible, no member will spend more than the single deductibleCoinsurance Max (Individual / Family) $2,500 / $5,000 $2,500 / $5,000 $2,500 / $5,000Preventive Care 100% covered 100% covered 100% coveredPrimary Care Visit $40 $40 $40Virtual Visit $40 $40 $40Specialist Visit $60 $60 $60Diagnostic Exam 20% after deductible 20% after deductible 20% after deductibleX-Rays 20% after deductible 20% after deductible 20% after deductibleComplex Images 20% after deductible 20% after deductible 20% after deductibleOutpatient Procedure 20% after deductible 20% after deductible 20% after deductibleInpatient Visit 20% after deductible 20% after deductible 20% after deductibleEmergency Room $250(waived if admitted) $250(waived if admitted) $250(waived if admitted)Urgent Care $60 $60 $60Tier1 Generic RX (30 Day Supply) $10 $10 $10Tier 2 Formulary RX (30 DaySupply) $40 $40 $40Tier 3 Non-Formulary RX(30 Day Supply) $80 $80 $80Calendar Year$6,350 / $12,700 $6,350 / $12,700 $6,850 / $13,700Out-of-Pocket Max (Individual / Family)To locate a provider participating in the BCBSM PPO network go to www.bcbsm.com and click on Find a Doctor. For Out of Network benefits please refer to the benefit summaries.2022 Employee Benefit Guide This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance7carrier or providers contract.'