Xpress Global Systems • 2023 Benefit Guide
MEDICAL BLUECROSS BLUESHIELD OF TN Your medical benefits are provided by BlueCross BlueShield of TN and provides coverage for both in-network and out- of-network providers. You will always have stronger benefits when visiting in-network providers. BCBST.com 800-565-9140
Medical
Traditional PPO Plan
High PPO Plan
High Deducitble Health Plan
In-network
In-Network
In-network
Annual deductible (Individual/Family)
$3,000 / $6,000
$7,500/$15,000
$5,000 / $10,000
Out-of-pocket maximum (Individual/Family)*
$6,000 / $12,000
$9,100/$18,820
$5,000 / $10,000
Preventive care
Covered at 100%
Covered at 100%
Covered at 100%
Primary physician office visit
$30 copay
30% after deductible
Subject to deductible
Specialist office visit
$50 copay
30% after deductible
Subject to deductible
Telehealth
$35 copay
$35
$50 copay
Inpatient hospital services
30% after deductible
30% after deductible
Subject to deductible
Outpatient hospital services (lab, x-ray, diagnostic)
30% after deductible
30% after deductible
Subject to deductible
Urgent care
$50 copay
30% after deductible
Subject to deductible
Emergency room care
30% after deductible
30% after deductible
Subject to deductible
Prescription drugs Retail (30-day supply) Generic
$10
$10
Subject to deductible
Brand preferred
$30
$30
Subject to deductible
Brand non-preferred
30%
Not covered
Subject to deductible
Out-of-Network OON Deductible (Individual/Maximum per Family) OON Out-of-Pocket Max (Individual / Maximum per Family)
$6,000 / $12,000
$10,000/$20,000
$10,000 / $20,000
$12,000 / $24,000
$15,000/$30,000
$15,000 / $30,000
Out-of-Network Benefits
50% after deductible
50% after deductible
20% after deductible
This is a summary of coverage; please refer to your summary plan description for the full scope of coverage. In-network services are based on negotiated charges; Out-of- network services are based on a percentage of Medicare charges.
* Includes Deductible and Copayments
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