Cost Sharing Benefits (In Network)
Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.
Deductible (Individual) | $5,200 |
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Deductible (Family) | $10,400 |
Coinsurance | Not applicable |
Out of Pocket Maximum (Individual) | $6,400 |
Out of Pocket Maximum (Family) | $12,800 |
Doctor Visits
Primary Care Visit | 50% Coinsurance after deductible |
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Specialist Visit | 50% Coinsurance after deductible |
Inpatient Facility | 50% Coinsurance after deductible |
Inpatient Physician | 50% Coinsurance after deductible |
Emergency Room Services | 50% Coinsurance after deductible |
Tests and Imaging
Imaging (CT/PET Scans, MRIs) | 50% Coinsurance after deductible |
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Laboratory Outpatient and Professional Services | 50% Coinsurance after deductible |
X-Ray and Diagnostic Imaging | 50% Coinsurance after deductible |
Health Management Programs
Asthma | Available |
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Depression | Not available |
Diabetes | Available |
Heart Disease | Available |
High Blood Pressure / High Cholesterol | Not available |
Lower Back Pain | Not available |
Pain Management | Not available |
Pregnancy | Not available |
Weight Loss | Not available |
Other
Mental / Behavioral Health Inpatient | 50% Coinsurance after deductible |
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Mental / Behavioral Health Outpatient | 50% Coinsurance after deductible |
Rehabilitative Speech Therapy | 50% Coinsurance after deductible |
Rehabilitative Occupational & Physical Therapy | 50% Coinsurance after deductible |
Outpatient Facility | 50% Coinsurance after deductible |
Outpatient Surgery | 50% Coinsurance after deductible |
Prescription Drugs
Generic Rx | 50% Coinsurance after deductible |
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Preferred Brand Rx | 50% Coinsurance after deductible |
Non Preferred Brand Rx | 50% Coinsurance after deductible |
Specialty Drugs | 50% Coinsurance after deductible |
Other Plans in Tennessee
Plan Silver S01S, Network S | Deductible $0 | Coinsurance Not applicable | Out of Pocket $7,150 |
Plan Gold G06S, Network S | Deductible $1,500 | Coinsurance Not applicable | Out of Pocket $4,500 |
Plan Silver S04S, Network S | Deductible $2,000 | Coinsurance Not applicable | Out of Pocket $5,100 |
Plan Gold G06S, Network S | Deductible $1,500 | Coinsurance Not applicable | Out of Pocket $4,500 |
Plan Silver S04S, Network S | Deductible $2,000 | Coinsurance Not applicable | Out of Pocket $5,100 |
Plan Silver S04S, Network S | Deductible $2,000 | Coinsurance Not applicable | Out of Pocket $5,100 |
Plan Bronze B07S, Network S | Deductible $5,200 | Coinsurance Not applicable | Out of Pocket $6,400 |
Plan Silver S01S, Network S | Deductible $0 | Coinsurance Not applicable | Out of Pocket $7,150 |
Plan Silver S01S, Network S | Deductible $0 | Coinsurance Not applicable | Out of Pocket $7,150 |
Plan Gold G06S, Network S | Deductible $1,500 | Coinsurance Not applicable | Out of Pocket $4,500 |
Plan Bronze B07S, Network S | Deductible $5,200 | Coinsurance Not applicable | Out of Pocket $6,400 |
Plan Silver S01S, Network S | Deductible $0 | Coinsurance Not applicable | Out of Pocket $7,150 |
Plan Gold G06S, Network S | Deductible $1,500 | Coinsurance Not applicable | Out of Pocket $4,500 |
Plan Gold G06S, Network S | Deductible $1,500 | Coinsurance Not applicable | Out of Pocket $4,500 |
Plan Silver S04S, Network S | Deductible $2,000 | Coinsurance Not applicable | Out of Pocket $5,100 |
Plan Silver S04S, Network S | Deductible $2,000 | Coinsurance Not applicable | Out of Pocket $5,100 |
Plan Bronze B07S, Network S | Deductible $5,200 | Coinsurance Not applicable | Out of Pocket $6,400 |
Plan Bronze B07S, Network S | Deductible $5,200 | Coinsurance Not applicable | Out of Pocket $6,400 |
Plan Silver S01S, Network S | Deductible $0 | Coinsurance Not applicable | Out of Pocket $7,150 |