Page 6 - 2018 CareHere Enrollment

2018 Benefits Enrollment

Plan Details*

BCBST BCBST
Option 1—TN Only Option 2
Network S Network P

Calendar Year Deductible
Individual $2,600 $2,600
Family $5,000 $5,000
Out-of-Pocket Maximum
Individual $4,000 $4,000
Family $8,000 $8,000
Physician Ofice Visits
Wellness/Preventive Covered at 100% Covered at 100%
Primary Care 20% after deductible 20% after deductible
Specialist 20% after deductible 20% after deductible
Urgent Care 20% after deductible 20% after deductible
Chiropractice Care— 20% after deductible 20% after deductible
30 Visits
Hospital Services
Inpatient 20% after deductible 20% after deductible
Outpatient 20% after deductible 20% after deductible
Emergency Room 20% after deductible 20% after deductible

* In-network beneits are shown here. For out-of-network coverage details, please refer to your
summary plan description (SPD) or an oficial plan document.

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