Sevier County School System

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

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

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