Page 9 - AESC 2019 Benefits Gudie

Medical Plan Details

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
Calendar Year Embedded Deductible Embedded Deductible Embedded Deductible
Deductible
Individual $2,700 $5,400 $1,600 $3,200 $750 N/A
Employee + Spouse $5,400 $10,800 $2,200 $4,300 $1,000 N/A
Employee + Child(ren) $5,400 $10,800 $2,200 $4,300 $1,000 N/A
Family $5,400 $10,800 $3,200 $6,400 $1,500 N/A
Out-of-Pocket Embedded OOP Maximum Embedded OOP Maximum Embedded OOP Maximum
Maximum
Individual $2,700 $5,400 $3,200 $5,800 $4,500 N/A
Employee + Spouse $5,400 $10,800 $6,400 $11,500 $5,250 N/A
Employee + Child(ren) $5,400 $10,800 $6,400 $11,500 $5,250 N/A
Family $5,400 $10,800 $8,500 $15,400 $9,000 N/A
Physician Office Visits
Primary Care 100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible
Specialist 100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible
PhysicianNow $40 applies N/A $40 applies N/A $40 applies N/A
Telemedicine to deductible, to deductible, to deductible,
then 100% after then 80% after then 80% after
deductible deductible deductible
Wellness/Preventive
100% 100% 100% 60% after 100% N/A
no deductible or no deductible or no deductible or deductible no deductible or
copay copay copay copay
Lab, X-Ray/Radiology Services
Outpatient Facility 100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible
Outpatient Hospital 100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible
X-Ray/Radiology Services
Outpatient Facility 100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible
Outpatient Hospital 100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible
Hospital Services
Inpatient 100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible
Outpatient 100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible
Emergency Room 100% after 100% after $100 copay; $100 copay; $100 copay; N/A
deductible deductible then 80% after then 80% after then 80% after
deductible deductible deductible
Mental Health and Substance Abuse
Inpatient 100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible
Outpatient 100% after 100% after 80% after 60% after 80% after N/A
deductible deductible deductible deductible deductible

Envision AESC 9