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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
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
Other
|
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
|
$50 Copay | 60% After Deductible | $30 Copay | 50% After Deductibe | $25 Copay | 40% After Deductibe |
|
Specialist Office Visit
|
$80 Copay | 60% After Deductible | $60 Copay | 50% After Deductible | $50 Copay | 40% After Deductibe |
|
Diagnostic Services (X-Ray, Labwork, etc)
|
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
|
40% After Deductible | 60% After Deductible | 30% After Deductible | 50% After Deductible | 20% After Deductible | 40% After Deductible |
|
Outpatient Diagnostic Services
|
No Additional Charge | 60% After Deductible | No Additional Charge | 50% After Deductible | No Additional Charge | 40% After Deductible |
|
Other Outpatient Procedures and 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 |