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BlueCross BlueShield of Tennessee
Family Coverage— HDHP
Embedded In-Network Out-of-Network
Deductibles and Calendar Year Deductible $5,000 $10,000
Individual
Out-of-Pocket Family $10,000 $20,000
Maximums Out-of-Pocket Maximum
Embedded deductibles means your Individual $6,000 $18,000
plan has an individual deductible Family $12,000 $36,000
for each family member as well Physician Oice Visits
as a maximum family deductible. Preventive Care Covered at 100% 60% after deductible
When a family member meets his
or her individual deductible, the Primary Care Visit 80% after deductible 60% after deductible
plan will begin sharing healthcare Specialist Visit 60% after deductible 60% after deductible
costs for this family member. Urgent Care 80% after deductible 60% after deductible
The rest of the family still has to PhysicianNow Telemedicine $38 applies to deductible, N/A
satisfy their individual deductible. then 80% after deductible
However, all individual expenses Hospital Services
for each family member count Inpatient 80% after deductible 60% after deductible
toward the family deductible. Once
the family deductible is met (by Outpatient 80% after deductible 60% after deductible
more than one family member), Emergency Room 80% after deductible 80% after deductible
the plan will share costs for all Retail (per 30-day supply)*, or Home Delivery Network (per 90-day supply)
family members for the rest of the Generic 80% after deductible 60% after deductible
plan year. The same applies to the Preferred Brand Formulary 80% after deductible 60% after deductible
out-of-pocket maximum. 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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Family Coverage— HDHP
Embedded In-Network Out-of-Network
Deductibles and Calendar Year Deductible $5,000 $10,000
Individual
Out-of-Pocket Family $10,000 $20,000
Maximums Out-of-Pocket Maximum
Embedded deductibles means your Individual $6,000 $18,000
plan has an individual deductible Family $12,000 $36,000
for each family member as well Physician Oice Visits
as a maximum family deductible. Preventive Care Covered at 100% 60% after deductible
When a family member meets his
or her individual deductible, the Primary Care Visit 80% after deductible 60% after deductible
plan will begin sharing healthcare Specialist Visit 60% after deductible 60% after deductible
costs for this family member. Urgent Care 80% after deductible 60% after deductible
The rest of the family still has to PhysicianNow Telemedicine $38 applies to deductible, N/A
satisfy their individual deductible. then 80% after deductible
However, all individual expenses Hospital Services
for each family member count Inpatient 80% after deductible 60% after deductible
toward the family deductible. Once
the family deductible is met (by Outpatient 80% after deductible 60% after deductible
more than one family member), Emergency Room 80% after deductible 80% after deductible
the plan will share costs for all Retail (per 30-day supply)*, or Home Delivery Network (per 90-day supply)
family members for the rest of the Generic 80% after deductible 60% after deductible
plan year. The same applies to the Preferred Brand Formulary 80% after deductible 60% after deductible
out-of-pocket maximum. 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
8
