Page 8 - HutsonWood-2023-24-Benefit Guide

Medical and Pharmacy Coverage

This chart compares the basic provisions of the three medical plan options offered through BlueCross BlueShield of Tennessee. Network providers can be
found at www.bcbst.com.

$2,500 PPO $4,000 HDHP $6,900 HDHP
Medical Plan Provisions In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Company contribution to HSA (Individual/Family) None $500/$1,000 $500/$1,000
Annual Deductible (Individual/Family) $2,500/$5,000 $5,000/$10,000 $4,000/$8,000 $7,000/$16,000 $6,900/$13,800 $13,800/$27,600
Out-of-Pocket Maximum (Includes Deductible) $7,000/$14,000 $13,200/$28,000 $7,000/$13,100 $13,100/$26,200 $6,900/$13,800 $13,800/$27,600
Preventive Care Covered at 100% 60%* Covered at 100% 60%* Covered at 100% 100%*
Primary Care Provider Office Visit $25 copay 60%* 80%* 60%* Covered at 100%* 100%*
Specialist Office Visit $50 copay 60%* 80%* 60%* Covered at 100%* 100%*
X-Ray and Lab Covered at 100% 60%* 80%* 60%* Covered at 100%* 100%*
Inpatient Hospital Services 80%* 60%* 80%* 60%* Covered at 100%* 100%*
Outpatient Hospital Services 80%* 60%* 80%* 60%* Covered at 100%* 100%*
Urgent Care $50 copay 60%* 80%* 60%* Covered at 100%* 100%*
Emergency Room $300 copay 80%* Covered at 100%*
Pharmacy Provisions
Prescription Drug Deductible (Individual/Family) None None None
Retail Pharmacy (30-day supply)
Generic $10 copay 60%* 80%* 60%* Covered at 100%* 100%*
Brand Preferred $40 copay 60%* 80%* 60%* Covered at 100%* 100%*
Brand Non-Preferred $60 copay 60%* 80%* 60%* Covered at 100%* 100%*
Specialty 25% (max of $200) Not covered 80%* Not covered Covered at 100%* Not covered
Mail Order Pharmacy or Plus90 Network (up to a 90-day supply)
Generic $25 copay 60%* 80%* 60%* Covered at 100%* 100%*
Brand Preferred $100 copay 60%* 80%* 60%* Covered at 100%* 100%*
Brand Non-Preferred $150 copay 60%* 80%* 60%* Covered at 100%* 100%*
Preventive Drugs (30-day supply)
Generic $10 copay $5 copay 60%* $5 copay 100%*
Brand Preferred $40 copay $25 copay 60%* $25 copay 100%*
Brand Non-Preferred $60 copay $50 copay 60%* $50 copay 100%*

*After deductible is met
Note: This is a summary only of your coverage. In-network services are based on negotiated charges; out-of-network services are based on reasonable and customary (R&C) charges.

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