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BlueCross BlueShield of Tennessee
HDHP
In-Network Out-of-Network
Calendar Year Deductible

Individual $5,000 $10,000
Family $10,000 $20,000
Out-of-Pocket Maximum
Individual $6,000 $18,000
Family $12,000 $36,000
Physician Oice Visits
Preventive Care Covered at 100% 60% after deductible
Primary Care Visit 80% after deductible 60% after deductible
Specialist Visit 60% after deductible 60% after deductible
Urgent Care 80% after deductible 60% after deductible
PhysicianNow Telemedicine $38 applies to deductible, N/A
then 80% after deductible
Hospital Services
Inpatient 80% after deductible 60% after deductible
Outpatient 80% after deductible 60% after deductible
Emergency Room 80% after deductible 80% after deductible
Retail (per 30-day supply)*, or Home Delivery Network (per 90-day supply)
Generic 80% after deductible 60% after deductible
Preferred Brand Formulary 80% after deductible 60% after deductible
Non-Preferred Brand 80% after deductible 60% after deductible
Formulary
Specialty 80% after deductible Not covered
Preventive Drugs**
Generic $10 copay 60% after deductible
Preferred Brand Formulary $35 copay 60% after deductible
Non-Preferred Brand $60 copay 60% after deductible
Formulary

* See the BCBS of TN 2019 preferred formulary for full details on prior authorization
requirements, step therapy, quantity limits, and exclusions.
** Medications listed on the BCBS of TN preventive drug list

Medical Contributions
Medical

Pre-Tax Weekly Contributions
Basic
Employee $0 .00
Employee/Spouse $77 .79
Employee/Child(ren) $58.69
Family $143 .90

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