Page 10 - AESC 2019 Benefits Gudie

BlueCross BlueShield of Tennessee
Savings (HSA) Plan Reimbursement (HRA) Plan Sharing (EPO) Plan
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Skilled Nursing Care
100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible
Limitations 60 days/CY 60 days/CY 60 days/CY N/A
Home Health Care
100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible
Chiropractic Care
100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible
Limitations $1,000/CY; $2,000 per family $1,000/CY; $2,000 per family $1,000/CY; $2,000 per family
Hospice Care
100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible
Outpatient Therapies
Physical Therapy 100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible
Speech Therapy 100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible
Occupational Therapy 100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible
Pulmonary Therapy 100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible
Cardiac Therapy 100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible
Acupuncture
100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible
Limitations $1,000/CY; $2,000 per family $1,000/CY; $2,000 per family $1,000/CY; $2,000 per family
Bariatric Surgery
100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible
Limitations Limited to Centers of Excellence Limited to Centers of Excellence Limited to Centers of Excellence
Routine Foot Care
100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible
Limitations Covered; limited to 1 orthotic/CY Covered; limited to 1 orthotic/CY Covered; limited to 1 orthotic/CY
Hearing Aids
100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible
Limitations 1 hearing aid/3 years; no $ limit 1 hearing aid/3 years; no $ limit 1 hearing aid/3 years; no $ limit
(supplies not included) (supplies not included) (supplies not included)
For more coverage details, please refer to your summary plan description (SPD) or an official plan document .

Family Coverage—Embedded Deductibles and Out-of-Pocket Maximums Embedded deductibles means your
plan has an individual deductible for each family member as well as a maximum family deductible . When a
family member meets his or her individual deductible, the plan will begin sharing healthcare costs for this family
member . The rest of the family still has to satisfy their individual deductible . However, all individual expenses for
each family member count toward the family deductible . Once the family deductible is met (by more than one
family member) the plan will share costs for all family members for the rest of the plan year . The same applies to
the out-of-pocket maximum .

10 2019 Benefits Enrollment