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Bus Driver Comparison Plan

Sevier County Wellness Clinic

Sevier County
Wellness Clinic		 Base Plan
In Network		 Base Plan
Out of Network		 Standard Plan
In Network		 Standard Plan
Out of Network		 Premium Plan
In Network		 Premium Plan
Out of Network

Office Visits

  • Primary Care Visit/Sick Visit

Prescription Drugs

Labwork

 No Charge No Charge No Charge No Charge No Charge No Charge

 

Preventative Care Base Plan
In Network		 Base Plan
Out of Network		 Standard Plan
In Network		 Standard Plan
Out of Network		 Premium Plan
In Network		 Premium Plan
Out of Network

Office Visits

  • Well child Care/Well Woman Exam
  • Mammogram/Cervical and Prostate Screening
  • Other Well Care Screenings
  • Immunizations

Other

  • FDA-approved contraceptive methods for women
 No Charge Not Covered No Charge Not Covered No Charge Not Covered

 

Practitioner's Office Service Base Plan
In Network		 Base Plan
Out of Network		 Standard Plan
In Network		 Standard Plan
Out of Network		 Premium Plan
In Network		 Premium Plan
Out of Network

Primary Care Office Visits

  • Family/General/Internal Medicine Practice
  • Surgery in Office Setting
  • Maternity Visit (co-pay first visit only)
 $50 Copay 60% After Deductible $30 Copay 50% After Deductibe $25 Copay 40% After Deductibe

Specialist Office Visit

  • Specialist Visit
  • Surgery in Office Setting
 $80 Copay 60% After Deductible $60 Copay 50% After Deductible $50 Copay 40% After Deductibe

Diagnostic Services (X-Ray, Labwork, etc)

  • Allergy Testing/Injections
  • Maternity Care Diagnostic
 No Additional Copay 60% After Deductible No Additional Copay 50% After Deductible No Additional Copay 40% After Deductible
Non-Routine Diagnostic Service (MRI/CAT/PET) $50 Copay 60% After Deductible $20 Copay 50% After Deductible $25 Copay 40% After Deductible
All Other Diagnostic Services for Illness or Injury No Additional Copay 60% After Deductible  No Additional Copay  50% After Deductible No Additional Copay  40% After Deductible
Chiropractor Services (25 visits) 40% After Deductible 60% After Deductible $60 Copay  50% After Deductible $50 Copay 40% After Deductible

 

Pharmacy Base Plan
In Network		 Base Plan
Out of Network		 Standard Plan
In Network		 Standard Plan
Out of Network		 Premium Plan
In Network		 Premium Plan
Out of Network
30 Day Supply

$200 Brand Only Deductible

Generic:  $20 Copay

Preferred:  $60 Copay

Non-Prefered:  $110 Copay

Speciality:  $350

$200 Brand Only Deductible

 

Reimbursement Varies

Generic:  $15 Copay

Preferred:  $45 Copay

Non-Prefered:  $100 Copay

Specialty:  $300

 Reimbursement Varies

Generic:  $10 Copay

Preferred:  $35 Copay

Non-Prefered:  $90 Copay

Specialty:  $250

 Reimbursement Varies

 

Convenience Clinics/Urgent Care Base Plan
In Network		 Base Plan
Out of Network		 Standard Plan
In Network		 Standard Plan
Out of Network		 Premium Plan
In Network		 Premium Plan
Out of Network
Convenience Clinic $50 Copay 60% After Deductible $30 Copay 50% After Deductible $25 Copay 40% After Deductible
Urgent Care Facility $80 Copay 60% After Deductible $60 Copay 50% After Deductible $50 Copay 40% After Deductible

 

Emergency Room Base Plan
In Network		 Base Plan
Out of Network		 Standard Plan
In Network		 Standard Plan
Out of Network		 Premium Plan
In Network		 Premium Plan
Out of Network
Emergency Room Visit 40% After Deductible 40% After Deductible $300 Copay $300 Copay $250 Copay $250 Copay

 

Outpatient Services Base Plan
In Network		 Base Plan
Out of Network		 Standard Plan
In Network		 Standard Plan
Out of Network		 Premium Plan
In Network		 Premium Plan
Out of Network
Outpatient Surgery Facility/Practioner 40% After Deductible 60% After Deductible 30% After Deductible 50% After Deductible 20% After Deductible 40% After Deductible

Outpatient Diagnostic Services

  • Non-Routine Diagnositc Service (MRI/CAT/PET)
 40% After Deductible 60% After Deductible 30% After Deductible 50% After Deductible 20% After Deductible 40% After Deductible

Outpatient Diagnostic Services

  • All Other Diagnostic Services for Illness or Injury
 No Additional Charge 60% After Deductible No Additional Charge 50% After Deductible No Additional Charge 40% After Deductible

Other Outpatient Procedures and Services

  • Therapy Services
  • All Other Services
 40% After Deductible 60% After Deductible 30% After Deductible 50% After Deductible 20% After Deductible 40% After Deductible

 

Inpatient Facility Services Base Plan
In Network		 Base Plan
Out of Network		 Standard Plan
In Network		 Standard Plan
Out of Network		 Premium Plan
In Network		 Premium Plan
Out of Network
Facility Charges 40% After Deductible 60% After Deductible 30% After Deductible 50% After Deductible 20% After Deductible 40% After Deductible
Practioner Charges (including maternity) 40% After Deductible 60% After Deductible 30% After Deductible 50% After Deductible 20% After Deductible 40% After Deductible

 

Other Services Base Plan
In Network		 Base Plan
Out of Network		 Standard Plan
In Network		 Standard Plan
Out of Network		 Premium Plan
In Network		 Premium Plan
Out of Network
Ambulance 40% After Deductible 60% After Deductible 30% After Deductible 50% After Deductible 20% After Deductible 40% After Deductible
Outpatient Hospice 40% Coinsurance 60% Coinsurance 30% Coinsurance 50% After Deductible 20% Coinsurance 40% After Deductible

 

Deductible Base Plan
In Network		 Base Plan
Out of Network		 Standard Plan
In Network		 Standard Plan
Out of Network		 Premium Plan
In Network		 Premium Plan
Out of Network
Individual $3,000 $6,000 $1,500 $3,000 $1,000 $2,000
Family $6,000 $12,000 $3,000 $6,000 $2,000 $4,000

 

Out of Pocket Maximum Base Plan
In Network		 Base Plan
Out of Network		 Standard Plan
In Network		 Standard Plan
Out of Network		 Premium Plan
In Network		 Premium Plan
Out of Network
Individual $7,000 $14,000 $5,000 $10,000 $3,500 $7,000
Family $14,000 $28,000 $10,000 $20,000 $7,000 $14,000