Page 12 - Tender Greens EE Guide 01-20

Blue Shield Blue Shield Blue Shield
Plan Name HMO PPO HDHP PPO
Narrow Network: SaveNet Non- Non-
1
1
Network Name Full Network: Access+ PPO Network PPO Network
Plan Differences SaveNet Access+
Network
- Network Size    
- In-Network Benefits ✓ ✓ ✓
- Non-Network Benefits ✓ ✓
Team Member Premiums $ $$ $ $$$

Health Savings Account
- Employer Funded ✓
- Team Member Funded ✓
Team Member Cost Contribution, Copay Contribution, Deductible, Contribution, Deductible,
Sharing Coinsurance Copay, Coinsurance
Access to Providers Managed by Your PCP Managed by You Managed by You

Health Benefits
Lifetime Max Benefit Unlimited Unlimited Unlimited

Deductible (Calendar Year)
- Individual $0 $3,000 $750 $2,250
2
- Family $0 $6,000 $2,250 $6,750
Out-of-Pocket Maximum
- Individual $2,500 $5,500 $10,000 $5,250 $9,500
2
- Family $5,000 $11,000 $20,000 $10,500 $19,000
Coinsurance (You Pay) N/A 20% 40% 20% 40%
Office Visit Copay
- Preventive Care No Charge No Charge Not Covered No Charge Not Covered
- PCP $25 Copay Ded, 20% Ded, 40% $25 Copay Ded, 40%
- Specialist $40 Copay Ded, 20% Ded, 40% $25 Copay Ded, 40%
- Urgent Care $25 Copay Ded, 20% Ded, 40% $25 Copay Ded, 40%
- Virtual Visits (Teladoc) $5 Copay $45 Copay N/A $5 Copay N/A
- House Calls (Heal) Not Covered Ded, 20% N/A $25 Copay N/A
Hospitalization
- Inpatient $750 Copay Per Admit Ded, 20% Ded, 40% Ded, 20% Ded, 40%
- Outpatient Surgery $100-$400 Copay Ded, 20% Ded, 40% Ded, 10%-25% Ded, 40%
Lab and X-Ray
- Diagnostic No Charge Ded, 20% Ded, 40% $25-$50 Copay Ded, 40%
- Complex No Charge Ded, 20%-30% Ded, 40% Ded, 20%-30% Ded, 40%

Emergency Services $150 Copay Ded, $150 Copay, 20% $150 Copay, 20%
Chiropractic $10 Copay Ded, 20% Ded, 40% $25 Copay Ded, 40%
Max 30 Visits/Year Max 20 Visits/Year Max 20 Visits/Year
1 Limitations apply. See SBC for details.
2 Individual members within a family are protected at the individual amount.

12 Team Member Benefits