Page 4 - Tender Greens Benefit Guide Sample

MEDICAL OPTIONS

Plan Features Narrow HMO HMO HMO
BLUE SHIELD BLUE SHIELD Blue Shield
Narrow Network Only Network Only Network Only
Lifetime Maximum Unlimited Unlimited Unlimited

Deductible (Annual)
- Individual / Family $0 / $0 $0 / $0 $0 / $0

Co-Insurance (Plan Pays) N/A N/A N/A
Physician Office Visit $10 copay $10 copay $10 copay
Out of Pocket Maximum
- Individual / Family $1,000 / $2,000 $1,000 / $2,000 $1,500 / $3,000
Hospital Benefits No charge No charge No charge

Emergency Room $100 copay $100 copay $100 copay
(copay waived if admitted)

Urgent Care $25 copay $25 copay $10 copay
Wellness Exams No charge No charge No charge
$15 copay
Chiropractic $10 copay $10 copay
20 visits/year maximum 20 visits/year maximum 30 visits/year
maximum
Mental Health/Substance Abuse
- Inpatient No charge No charge No charge
- Outpatient $10 copay $10 copay $10 copay

Prescription Drugs - Copay 30-day supply 30-day supply 30-day supply
- Generic Formulary (Tier 1) $10 $10 $15
- Brand (Tier 2) $20 $20 $35
- Non-Formulary (Tier 3) $40 $40 n/a
- Deductible none none none
- Mail Order (90 day supply) $20 / $40 / $80 $20 / $40 / $80 $30/$70 (100-day)

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