Page 12 - Tender Greens EE Guide 01-20 Non-CA.pub

Medical Plan Highlights

Blue Shield Blue Shield
Plan Name PPO HDHP PPO

1
Network Name PPO Non-Network 1 PPO Non-Network
Plan Differences

Network   
- Network Size  
- In-Network Benefits  
- Non-Network Benefits  
Team Member Premiums $ $$$

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

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

Emergency Services Ded, $150 Copay, 20% $150 Copay, 20%
Chiropractic Ded, 20% Ded, 40% $25 Copay Ded, 40%
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