Page 5 - Tender Greens Benefit Guide Sample

MEDICAL OPTIONS

Plan Features BLUE SHIELD PPO

In-Network Non-Network
Lifetime Maximum Unlimited
Deductible (Annual)
- Individual / Family $500 / $1,500 $1,000 / $3,000
Co-Insurance (Plan Pays) 80% 60%

Physician Office Visit $20 copay 40%
Out of Pocket Maximum
- Individual / Family $3,500 / $10,000 $9,000 / $27,000
Hospital Benefits $500/admit, 20% $500/admit, 40%
Emergency $150 copay (waived if admitted), 20%
Urgent Care $25 copay
Wellness Exams 100% 40%

Chiropractic
(20 visits/year maximum) $20 copay 40%
Mental Health/Substance Abuse
- Inpatient $500/admit, 20% $500/admit, 40%
- Outpatient $20 copay 40%
Prescription Drugs - Copay 30-day supply
- Generic Formulary (Tier 1) $10

- Brand (Tier 2) $20 Not covered
- Non-Formulary (Tier 3) $40
- Deductible none
- Mail Order (90 day supply) $20 / $40 / $80

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