BlueCross IndividualBronzeGoldPlatinumForms PDF

SERFF Tracking #: BCTN-129004734
State Tracking #: H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
H16I Individual Health - Major Medical/H16I.005A Individual - Preferred Provider (PPO)
Filing Company:
BlueCross BlueShield of Tennessee
Product Name:
BlueCross Bronze, BlueCross Gold, BlueCross Platinum, BlueCross MSP PPO Plan (Excluding MSP PPO Plan Silver Plans
S09P & S11P)
Project Name/Number: /
Filing at a Glance
Company:
Product Name:
State:
TOI:
Sub-TOI:
Filing Type:
Date Submitted:
SERFF Tr Num:
SERFF Status:
State Tr Num:
State Status:
Co Tr Num:
Implementation
Date Requested:
Author(s):
Reviewer(s):
Disposition Date:
Disposition Status:
Implementation Date:

BlueCross Bronze, BlueCross Gold, BlueCross Platinum, BlueCross MSP PPO Plan
(Excluding MSP PPO Plan Silver Plans S09P & S11P)
Tennessee
H16I Individual Health - Major Medical
H16I.005A Individual - Preferred Provider (PPO)
Form
04/30/2013
BCTN-129004734
Closed-Approved
H-130554
Approved
01/01/2014
Alisa Swann, Christina Hart
Vicky Stotzer (primary), Brian Hoffmeister, Melissa Merritt
07/31/2013
Approved
01/01/2014
State Filing Description:

I HIX Sched
Individual EHB ? Marketplace B01-AI1E
individual health insurance exchange plans
PDF Pipeline for SERFF Tracking Number BCTN-129004734 Generated 07/31/2013 02:57 PM
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:
S09P & S11P)
General Information
Project Name:
Project Number:
Requested Filing Mode: Review & Approval
Explanation for Combination/Other:
Submission Type: New Submission
Overall Rate Impact:
Deemer Date:
Submitted By: Alisa Swann
Status of Filing in Domicile: Pending

Date Approved in Domicile:
Domicile Status Comments: Tennessee is the state of domicile
Market Type: Individual
Individual Market Type: Individual
Filing Status Changed: 07/31/2013
State Status Changed: 07/31/2013
Created By: Alisa Swann
Corresponding Filing Tracking Number:
PPACA: Non-Grandfathered Immed Mkt Reforms
PPACA Notes: null

Some of these policy forms are intended to be sold on the
Tennessee Federally Facilitated Exchange
Exchange Intentions:
Filing Description:
This filing contains the forms for Bronze, Gold, and Platinum Individual Plans to be sold on the Tennessee Federally Facilitated
Exchange (MarketPlace), for outside the Tenessee Federally Facilitated Exchage (Non-Marketplace) and on the Office of
Personnel Management Multi-State Plan Program.
Forms for all individual non-grandfathered market silver plans (including the cost sharing variations) are in filing BCTN129004725
Rates for all the individual non-grandfathered market plans are in filing BCTN-129006109
Company and Contact

Filing Contact Information
Christina Hart, Assoc Contract Dev Analyst Christina_Hart@BCBST.com
1 Cameron Hill CIrcle
423-535-3344 [Phone]
Chattanooga, TN 37402
423-535-1984 [FAX]
Filing Company Information
BlueCross BlueShield of
Tennessee
1 Cameron Hill Circle
(423) 535-5600 ext. [Phone]
CoCode: 54518
Group Code: 3498
Group Name:
FEIN Number: 62-0427913
State of Domicile: Tennessee

Company Type:
State ID Number:
Filing Fees
Fee Required?
No
Retaliatory?
No
Fee Explanation:
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:
BlueCross Bronze, BlueCross Gold, BlueCross Platinum, BlueCross MSP PPO Plan (Excluding MSP PPO Plan Silver Plans S09P & S11P)
Project Name/Number:
Correspondence Summary
Dispositions
Status
Created By
Created On
Date Submitted
Approved
Vicky Stotzer
07/31/2013
07/31/2013
Objection Letters and Response Letters

Objection Letters
Response Letters
Status
Created By
Created On
Date Submitted
Responded By
Created On
Date Submitted
Pending
Company
Response
Melissa Merritt
05/28/2013
05/28/2013
Christina Hart
06/26/2013
06/26/2013
Amendments
Schedule
Schedule Item Name
Created By
Created On
Date Submitted
Form
Gold Schedules Network P G01 G02 and G03
Christina Hart
07/31/2013
07/31/2013
Form
Gold Schedules Network P G04 G05 G06 and G07
Christina Hart
07/31/2013
07/31/2013
Form
Gold Schedules Network S G01 G02 and G03
Christina Hart
07/31/2013
07/31/2013
Form
Gold Schedules Network S G04 G05 G06 and G07
Christina Hart
07/31/2013
07/31/2013
Supporting
Document
BCBST Individual Benefits Template
Alisa Swann
07/17/2013
07/17/2013
Form
Bronze Schedules Network E
Christina Hart
05/23/2013
05/23/2013
Form
Bronze Schedules Network P
Christina Hart
05/23/2013
05/23/2013
Form
Bronze Schedules Network S
Christina Hart
05/23/2013
05/23/2013
Form
Gold Schedules Network E G01 and G02
Christina Hart
05/23/2013
05/23/2013
Form
Christina Hart
05/23/2013
05/23/2013
Form
Christina Hart
05/23/2013
05/23/2013
Form
Christina Hart
05/23/2013
05/23/2013
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:
Amendments
Schedule
Schedule Item Name
Created By
Created On
Date Submitted
Form
Christina Hart
05/23/2013
05/23/2013
Form
Christina Hart
05/23/2013
05/23/2013
Form
Platinum Schedules Network E
Christina Hart
05/23/2013
05/23/2013
Form
Platinum Schedules Network P
Christina Hart
05/23/2013
05/23/2013
Form
Platinum Schedules Network S
Christina Hart
05/23/2013
05/23/2013
Form
Gold Schedules Network E G08 G10 and G11
Christina Hart
05/23/2013
05/23/2013
Form
Christina Hart
05/23/2013
05/23/2013
Form
Christina Hart
05/23/2013
05/23/2013
Supporting
Document
Letter of Explanation of Changes
Christina Hart
05/23/2013
05/23/2013
Form
Individual Policy
Christina Hart
04/30/2013
04/30/2013
Filing Notes
Subject
Note Type
Created By
Created On
Date Submitted
Benefit template
Note To Filer
Vicky Stotzer
07/17/2013
07/17/2013
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:
Disposition
Disposition Date: 07/31/2013
Implementation Date: 01/01/2014
Status: Approved
HHS Status: HHS Approved
State Review: Reviewed by Actuary
Comment:
Rate data does NOT apply to filing.
Schedule
Schedule Item
Schedule Item Status
Public Access
Supporting Document
Cover Letter Accident & Health
Approved
Yes
Supporting Document
Description of Variables
Approved
Yes
Supporting Document
Filing Fees
Approved
Yes
Supporting Document
Readability Certification
Approved
Yes
Supporting Document
Third Party Authorization
Approved
Yes
Supporting Document
Rates - All NEW Forms Require RATES
Approved
Yes
Supporting Document
PPACA Uniform Compliance Summary
Approved
Yes
Supporting Document
Approved
Yes
Supporting Document (revised)
Approved
Yes
Supporting Document
Replaced
Yes
Form (revised)
Approved
Yes
Form (revised)
Approved
Yes
Form (revised)
Approved
Yes
Form (revised)
Approved
Yes
Form (revised)
Approved
Yes
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:
Schedule
Schedule Item
Public Access
Form (revised)
Approved
Yes
Form (revised)
Approved
Yes
Form
Replaced
Yes
Form (revised)
Approved
Yes
Form
Replaced
Yes
Form (revised)
Approved
Yes
Form (revised)
Approved
Yes
Form
Replaced
Yes
Form (revised)
Approved
Yes
Form
Replaced
Yes
Form (revised)
Approved
Yes
Form (revised)
Approved
Yes
Form (revised)
Approved
Yes
Form (revised)
Approved
Yes
Form (revised)
Individual Policy
Approved
Yes
Form
Replaced
Yes
Form
Replaced
Yes
Form
Replaced
Yes
Form
Replaced
Yes
Form
Replaced
Yes
Form
Replaced
Yes
Form
Replaced
Yes
Form
Replaced
Yes
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:
Schedule
Schedule Item
Public Access
Form
Replaced
Yes
Form
Replaced
Yes
Form
Replaced
Yes
Form
Replaced
Yes
Form
Replaced
Yes
Form
Replaced
Yes
Form
Replaced
Yes
Form
Replaced
Yes
Form
Replaced
Yes
Form
Replaced
Yes
Form
Individual Policy
Replaced
Yes
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:
S09P & S11P)
Objection Letter
Objection Letter Status
Objection Letter Date
Submitted Date
Respond By Date
Pending Company Response

05/28/2013
05/28/2013
Dear Christina Hart,
Introduction:
I have reviewed your filing and conclude the above referenced submission cannot be approved for use in the State of
Tennessee for the following reasons:
Objection 1
Comments: Is this policy the same as the one filed under the other form filing? If so, please correct or remove the form.
Objection 2
Comments: Please provide the shortened benefit templates in pdf or xls format.
Conclusion:
It is unlawful, in accordance with Section 56-26-102, T.C.A. for you to utilize these forms and/or rates in Tennessee until you receive
approval. This is a notice of disapproval. Your filing will be held in suspense for one hundred and twenty (120) days. If no response is
received from you within this time period, your filing will be considered "disapproved" for the above stated reasons. If you have any
questions, please phone Victoria Stotzer, primary reviewer, at (615) 741-6259 or through e-mail at victoria.stotzer@tn.gov.
Sincerely,
Melissa Merritt
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:
Response Letter
Response Letter Status
Response Letter Date
Submitted Date
Submitted to State
06/26/2013
06/26/2013
Dear Vicky Stotzer,
Introduction:
Thank you for your review of our filing. I have answered the objections below. In addition, I have attached a handful of corrected schedules. The ones that have been
revised are: Individual EHB Marketplace G08-AI1E, Individual EHB MSP G08-AI1P, Individual EHB Marketplace G08-AI1S, Individual EHB Marketplace G08-AI2E,
Individual EHB MSP G08-AI2P, Individual EHB Marketplace G08-AI2S, Individual EHB Marketplace G08E, Individual EHB MSP G08P, Individual EHB NonMarketplace G08P, Individual EHB Marketplace G08S, Individual EHB Non-Marketplace G08S.
We identified additional plans that would qualify as HSA-eligible HDHPs with a small tweak to the Hospice benefit provided under the plan. These plans are the ones listed
above. The Hospice benefit was adjusted to pay standard coinsurance subject to deductible in order to meet the HDHP requirements by not providing first-dollar coverage other
than for the mandated preventive benefits.
Response 1
Comments:
It is the same policy. I have removed from this filing.
Related Objection 1
Comments: Is this policy the same as the one filed under the other form filing? If so, please correct or remove the form.
Changed Items:
Supporting Document Schedule Item Changes

Satisfied - Item:
Comments:
Attachment(s):
BCBST Individual Benefits Template (Abbreviated for TDCI Filing).xlsx
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:
Form Schedule Item Changes

Item
No.
Form
Name
Form
Number
Form
Type
Form
Action
Action Specific Readability

Data
Score
Gold Schedules
Network E G08
G10 and G11
see attached
footers
POLA
Initial
42.600
Gold Schedules Date Submitted:

Network E G08 06/26/2013
G10 and G11 rev By: Christina Hart
2.pdf
Gold Schedules
Network E G08
G10 and G11
see attached
footers
POLA
Initial
42.600
Gold Schedules
Network E G08
G10 and G11
rev.pdf
Gold Schedules
Network E G08
G10 and G11
see attached
footers
POLA
Initial
42.600

Network E G08 04/30/2013
G10 and G11.pdf By: Alisa Swann
Gold Schedules
Network P G08
G10 and G11
see attached
footers
POLA
Initial
42.600

Network P G08 06/26/2013
2.pdf
Gold Schedules
Network P G08
G10 and G11
see attached
footers
POLA
Initial
42.600
Gold Schedules
Network P G08
G10 and G11
rev.pdf
Gold Schedules
Network P G08
G10 and G11
see attached
footers
POLA
Initial
42.600

Network P G08 04/30/2013
Attachments
Submitted
Previous Version
1
Date Submitted:
05/23/2013
By:
Previous Version
Previous Version
2
Date Submitted:
05/23/2013
By:
Previous Version
2
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:

Item
No.
Form
Name
Form
Number
Form
Type
Form
Action

Data
Score
Gold Schedules
Network E G08
G10 and G11
see attached
footers
POLA
Initial
42.600

Network E G08 06/26/2013
2.pdf
Gold Schedules
Network S G08
G10 and G11
see attached
footers
POLA
Initial
42.600

Network S G08 06/26/2013
2.pdf
Gold Schedules
Network S G08
G10 and G11
see attached
footers
POLA
Initial
42.600
Gold Schedules
Network S G08
G10 and G11
rev.pdf
Gold Schedules
Network S G08
G10 and G11
see attached
footers
POLA
Initial
42.600

Network S G08 04/30/2013
Individual Policy
BCBST-INDVONOFFEX rev.
04/2013
POLA
Initial
44.100
Attachments
Submitted
Previous Version
3
Date Submitted:
05/23/2013
By:
Previous Version
Previous Version
Date Submitted:
06/26/2013
By: Christina Hart
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:

Item
No.
Form
Name
Form
Number
Form
Type
Form
Action

Data
Score
Gold Schedules
Network E G08
G10 and G11
see attached
footers
POLA
Initial
42.600

Network E G08 06/26/2013
2.pdf
Individual Policy
04/2013
POLA
Initial
44.100
Individual Policy Date Submitted:

Language Core 4 04/30/2013
1 and
By:
Exchange_Final
Version rev
043013.pdf
No Rate/Rule Schedule items changed.
Response 2
Comments:
I have attached the shortened benefit template in xls format under Supporting Documentation.
Related Objection 2
Comments: Please provide the shortened benefit templates in pdf or xls format.
Changed Items:

Satisfied - Item:
Comments:
Attachment(s):
Attachments
Submitted
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:

Item
No.
Form
Name
Form
Number
Form
Type
Form
Action

Data
Score
Gold Schedules
Network E G08
G10 and G11
see attached
footers
POLA
Initial
42.600

Network E G08 06/26/2013
2.pdf
Gold Schedules
Network E G08
G10 and G11
see attached
footers
POLA
Initial
42.600
Gold Schedules
Network E G08
G10 and G11
rev.pdf
Gold Schedules
Network E G08
G10 and G11
see attached
footers
POLA
Initial
42.600

Network E G08 04/30/2013
Gold Schedules
Network P G08
G10 and G11
see attached
footers
POLA
Initial
42.600

Network P G08 06/26/2013
2.pdf
Gold Schedules
Network P G08
G10 and G11
see attached
footers
POLA
Initial
42.600
Gold Schedules
Network P G08
G10 and G11
rev.pdf
Gold Schedules
Network P G08
G10 and G11
see attached
footers
POLA
Initial
42.600

Network P G08 04/30/2013
Attachments
Submitted
Previous Version
1
Date Submitted:
05/23/2013
By:
Previous Version
Previous Version
2
Date Submitted:
05/23/2013
By:
Previous Version
2
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:

Item
No.
Form
Name
Form
Number
Form
Type
Form
Action

Data
Score
Gold Schedules
Network E G08
G10 and G11
see attached
footers
POLA
Initial
42.600

Network E G08 06/26/2013
2.pdf
Gold Schedules
Network S G08
G10 and G11
see attached
footers
POLA
Initial
42.600

Network S G08 06/26/2013
2.pdf
Gold Schedules
Network S G08
G10 and G11
see attached
footers
POLA
Initial
42.600
Gold Schedules
Network S G08
G10 and G11
rev.pdf
Gold Schedules
Network S G08
G10 and G11
see attached
footers
POLA
Initial
42.600

Network S G08 04/30/2013
Individual Policy
04/2013
POLA
Initial
44.100
Attachments
Submitted
Previous Version
3
Date Submitted:
05/23/2013
By:
Previous Version
Previous Version
Date Submitted:
06/26/2013
By: Christina Hart
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:

Item
No.
Form
Name
Form
Number
Form
Type
Form
Action

Data
Score
Gold Schedules
Network E G08
G10 and G11
see attached
footers
POLA
Initial
42.600

Network E G08 06/26/2013
2.pdf
Individual Policy
04/2013
POLA
Initial
44.100

1 and
By:
Exchange_Final
Version rev
043013.pdf
No Rate/Rule Schedule items changed.
Conclusion:
Thank you again for your review of the filing. Please let me know if you have any questions or concerns.
Sincerely,
Christina Hart
Attachments
Submitted
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:
Amendment Letter
Submitted Date:
07/31/2013
Comments:
Thank you for your review of our filing. Weve had to update a few of our schedules for those plans with a Brand Rx Deductible. The changes to the Schedule were
limited to the Specialty Rx benefit for both Self-administered and Provider-administered Specialty drugs. These benefits were originally set up with a $120 Copayment
per Prescription after the Brand Deductible; however, we determined in the configuration process that these were filed in error and should not be subject to the Brand
Deductible. Therefore, weve updated the following schedules to accurately reflect the plan benefits: G03S_NMP, G03P_NMP, G05S_NMP, and G05P_NMP. Thank
you for your consideration.
Changed Items:
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:

Item
No.
Form
Name
Form
Number
Form
Type
Form
Action
Gold Schedules
Network P G01
G02 and G03
see attached
footers
POLA
Initial
Gold Schedules
Network P G01
G02 and G03
see attached
footers
POLA
Gold Schedules
Network P G01
G02 and G03
see attached
footers
Gold Schedules
Network P G04
G05 G06 and
G07
Gold Schedules
Network P G04
G05 G06 and
G07

Data
Score
Attachments
Submitted
42.600
Gold Schedules
Network P G01
G02 and G03
rev2.pdf
Date Submitted:
07/31/2013
By:
Initial
42.600
Gold Schedules
Network P G01
G02 and G03
rev.pdf
Date Submitted:
05/23/2013
By:
POLA
Initial
42.600

Network P G01 04/30/2013
see attached
footers
POLA
Initial
42.600
Gold Schedules
Network P G04
G05 G06 and
G07 rev2.pdf
Date Submitted:
07/31/2013
By:
see attached
footers
POLA
Initial
42.600
Gold Schedules
Network P G04
G05 G06 and
G07 rev.pdf
Date Submitted:
05/23/2013
By:
Previous Version
1
Previous Version
Previous Version
2
Previous Version
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:

Item
No.
Form
Name
Form
Number
Form
Type
Form
Action
Gold Schedules
Network P G04
G05 G06 and
G07
see attached
footers
POLA
Initial
Gold Schedules
Network S G01
G02 and G03
see attached
footers
POLA
Gold Schedules
Network S G01
G02 and G03
see attached
footers
Gold Schedules
Network S G01
G02 and G03

Data
Score
Attachments
Submitted
42.600
Gold Schedules
Network P G04
G05 G06 and
G07.pdf
Date Submitted:
04/30/2013
By: Alisa Swann
Initial
42.600
Gold Schedules
Network S G01
G02 and G03
rev2.pdf
Date Submitted:
07/31/2013
By:
POLA
Initial
42.600
Gold Schedules
Network S G01
G02 and G03
rev.pdf
Date Submitted:
05/23/2013
By:
see attached
footers
POLA
Initial
42.600

Network S G01 04/30/2013
Gold Schedules
Network S G04
G05 G06 and
G07
see attached
footers
POLA
Initial
42.600
Gold Schedules
Network S G04
G05 G06 and
G07 rev2.pdf
Date Submitted:
07/31/2013
By:
Gold Schedules
Network S G04
G05 G06 and
G07
see attached
footers
POLA
Initial
42.600
Gold Schedules
Network S G04
G05 G06 and
G07 rev.pdf
Date Submitted:
05/23/2013
By:
Previous Version
3
Previous Version
Previous Version
4
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:

Item
No.
Form
Name
Form
Number
Form
Type
Form
Action
Gold Schedules
Network S G04
G05 G06 and
G07
see attached
footers
POLA
Initial

Data
Score
Attachments
Submitted
Gold Schedules
Network S G04
G05 G06 and
G07.pdf
Date Submitted:
04/30/2013
By: Alisa Swann
Previous Version
4
42.600
No Rate Schedule Items Changed.

No Supporting Documents Changed.
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:
Amendment Letter
Submitted Date:
07/17/2013
Comments:
I am attaching an .xls version of the simplified benefit template. Please let me know if you have any difficulty opening it - if so I can upload a .pdf version of the file.
Changed Items:
No Form Schedule Items Changed.

Satisfied - Item:
Comments:
A simplified version of the plan and benefit timplate is attached.
Attachment(s):
BCBST Individual Benefits Template (Abbreviated for TDCI Filing)_20130618.xls
Previous Version
Satisfied - Item:
Comments:
Attachment(s):
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:
Amendment Letter
Submitted Date:
05/23/2013
Comments:
I believe Dakasha verified it was okay to submit corrected schedules. I have also attached a letter explaining what the changes are under "supporting documentation."
Thanks,
Christie
Changed Items:
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:

Item
No.
Form
Name
Form
Number
Form
Type
Form
Action

Data
Score
Bronze
Schedules
Network E
See attached
footers
POLA
Initial
42.600
Bronze
Date Submitted:
Schedules
05/23/2013
Network E rev.pdf By:
Bronze
Schedules
Network E
See attached
footers
POLA
Initial
42.600
Bronze
Schedules
Network E.pdf
Bronze
Schedules
Network P
see attached
footers
POLA
Initial
42.600
Bronze
Date Submitted:
Schedules
05/23/2013
Network P rev.pdf By:
Bronze
Schedules
Network P
see attached
footers
POLA
Initial
42.600
Bronze
Schedules
Network P.pdf
Date Submitted:
04/30/2013
By: Alisa Swann
Bronze
Schedules
Network S
see attached
footers
POLA
Initial
42.600
Bronze
Schedules
Network S rev
2.pdf
Date Submitted:
05/23/2013
By:
Bronze
Schedules
Network S
see attached
footers
POLA
Initial
42.600
Bronze
Schedules
Network S
revised.pdf
Date Submitted:
04/30/2013
By: Alisa Swann
Attachments
Submitted
Previous Version
Date Submitted:
04/30/2013
By: Alisa Swann
Previous Version
Previous Version
3
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:

Item
No.
Form
Name
Form
Number
Form
Type
Form
Action
Gold Schedules
Network E G01
and G02
see attached
footers
POLA
Initial
Gold Schedules
Network E G01
and G02
see attached
footers
POLA
Gold Schedules
Network E G04
and G06
see attached
footers
Gold Schedules
Network E G04
and G06

Data
Score
Attachments
Submitted
42.600
Gold Schedules
Network E G01
and G02 rev.pdf
Date Submitted:
05/23/2013
By:
Initial
42.600
Gold Schedules
Network E G01
and G02.pdf
Date Submitted:
04/30/2013
By: Alisa Swann
POLA
Initial
42.600
Gold Schedules
Network E G04
and G06 rev.pdf
Date Submitted:
05/23/2013
By:
see attached
footers
POLA
Initial
42.600
Gold Schedules
Network E G04
and G06.pdf
Date Submitted:
04/30/2013
By: Alisa Swann
Gold Schedules
Network P G01
G02 and G03
see attached
footers
POLA
Initial
42.600
Gold Schedules
Network P G01
G02 and G03
rev.pdf
Date Submitted:
05/23/2013
By:
Gold Schedules
Network P G01
G02 and G03
see attached
footers
POLA
Initial
42.600

Network P G01 04/30/2013
Previous Version
Previous Version
Previous Version
6
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:

Item
No.
Form
Name
Form
Number
Form
Type
Form
Action
Gold Schedules
Network P G04
G05 G06 and
G07
see attached
footers
POLA
Initial
Gold Schedules
Network P G04
G05 G06 and
G07
see attached
footers
POLA
Gold Schedules
Network S G01
G02 and G03
see attached
footers
Gold Schedules
Network S G01
G02 and G03

Data
Score
Attachments
Submitted
42.600
Gold Schedules
Network P G04
G05 G06 and
G07 rev.pdf
Date Submitted:
05/23/2013
By:
Initial
42.600
Gold Schedules
Network P G04
G05 G06 and
G07.pdf
Date Submitted:
04/30/2013
By: Alisa Swann
POLA
Initial
42.600
Gold Schedules
Network S G01
G02 and G03
rev.pdf
Date Submitted:
05/23/2013
By:
see attached
footers
POLA
Initial
42.600

Network S G01 04/30/2013
Gold Schedules
Network S G04
G05 G06 and
G07
see attached
footers
POLA
Initial
42.600
Gold Schedules
Network S G04
G05 G06 and
G07 rev.pdf
Date Submitted:
05/23/2013
By:
Gold Schedules
Network S G04
G05 G06 and
G07
see attached
footers
POLA
Initial
42.600
Gold Schedules
Network S G04
G05 G06 and
G07.pdf
Date Submitted:
04/30/2013
By: Alisa Swann
Previous Version
Previous Version
Previous Version
9
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:

Item
No.
Form
Name
Form
Number
Form
Type
Form
Action

Data
Score
10
Platinum
Schedules
Network E
see attached
footers
POLA
Initial
42.600
Platinum
Date Submitted:
Schedules
05/23/2013
Network E rev.pdf By:
10
Platinum
Schedules
Network E
see attached
footers
POLA
Initial
42.600
Platinum
Schedules
Network E.pdf
11
Platinum
Schedules
Network P
see attached
footers
POLA
Initial
42.600
Platinum
Date Submitted:
Schedules
05/23/2013
Network P rev.pdf By:
11
Platinum
Schedules
Network P
see attached
footers
POLA
Initial
42.600
Platinum
Schedules
Network P.pdf
12
Platinum
Schedules
Network S
see attached
footers
POLA
Initial
42.600
Platinum
Date Submitted:
Schedules
05/23/2013
Network S rev.pdf By:
12
Platinum
Schedules
Network S
see attached
footers
POLA
Initial
42.600
Platinum
Schedules
Network S.pdf
Date Submitted:
04/30/2013
By: Alisa Swann
13
Gold Schedules
Network E G08
G10 and G11
see attached
footers
POLA
Initial
42.600
Gold Schedules
Network E G08
G10 and G11
rev.pdf
Date Submitted:
05/23/2013
By:
Attachments
Submitted
Previous Version
Date Submitted:
04/30/2013
By: Alisa Swann
Previous Version
Date Submitted:
04/30/2013
By: Alisa Swann
Previous Version
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:

Item
No.
Form
Name
Form
Number
Form
Type
Form
Action

Data
Score
13
Gold Schedules
Network E G08
G10 and G11
see attached
footers
POLA
Initial
42.600

Network E G08 04/30/2013
14
Gold Schedules
Network P G08
G10 and G11
see attached
footers
POLA
Initial
42.600
Gold Schedules
Network P G08
G10 and G11
rev.pdf
14
Gold Schedules
Network P G08
G10 and G11
see attached
footers
POLA
Initial
42.600

Network P G08 04/30/2013
15
Gold Schedules
Network S G08
G10 and G11
see attached
footers
POLA
Initial
42.600
Gold Schedules
Network S G08
G10 and G11
rev.pdf
Gold Schedules
Network S G08
G10 and G11
see attached
footers
POLA
Initial
42.600

Network S G08 04/30/2013
Attachments
Submitted
Previous Version
Date Submitted:
05/23/2013
By:
Previous Version
Date Submitted:
05/23/2013
By:
Previous Version
15
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:

Satisfied - Item:
Comments:
Attachment(s):
Individual DOI letter May 2013.pdf
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:
Amendment Letter
Submitted Date:
04/30/2013
Comments:
We are adding the policy. Thanks.
Changed Items:

Item
No.
Form
Name
Form
Number
Form
Type
Form
Action
Individual Policy
04/2013
POLA
Initial

Data
Score
44.100

No Supporting Documents Changed.
Attachments
Submitted

1 and
By:
Exchange_Final
Version rev
043013.pdf
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:
S09P & S11P)
Note To Filer
Created By:
Vicky Stotzer on 07/17/2013 02:16 PM
Last Edited By:

Vicky Stotzer
Submitted On:
07/17/2013 02:16 PM
Subject:
Benefit template
Comments:
The benefit template is an xlsx file not an xls file.
Vicky
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:
Form Schedule
Lead Form Number:
Item
No.
Schedule Item
Status
Form
Name
Form
Number
Form
Type
Form
Action
Action Specific
Data
Approved
07/31/2013
Bronze Schedules
Network E
See
attached
footers
POLA
Initial
42.600
Bronze Schedules
Network E rev.pdf
Approved
07/31/2013
Bronze Schedules
Network P
see
attached
footers
POLA
Initial
42.600
Bronze Schedules
Network P rev.pdf
Approved
07/31/2013
Bronze Schedules
Network S
see
attached
footers
POLA
Initial
42.600
Bronze Schedules
Network S rev
2.pdf
Approved
07/31/2013
Gold Schedules
Network E G01 and
G02
see
attached
footers
POLA
Initial
42.600
Gold Schedules
Network E G01
and G02 rev.pdf
Approved
07/31/2013
Gold Schedules
Network E G04 and
G06
see
attached
footers
POLA
Initial
42.600
Gold Schedules
Network E G04
and G06 rev.pdf
Approved
07/31/2013
Gold Schedules
Network E G08 G10
and G11
see
attached
footers
POLA
Initial
42.600
Gold Schedules
Network E G08
G10 and G11 rev
2.pdf
Approved
07/31/2013
Gold Schedules
Network P G01 G02
and G03
see
attached
footers
POLA
Initial
42.600
Gold Schedules
Network P G01
G02 and G03
rev2.pdf
Readability
Score
Attachments
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:
Lead Form Number:

Item
No.
Schedule Item
Status
Form
Name
Form
Number
Form
Type
Form
Action
Action Specific
Data
Approved
07/31/2013
Gold Schedules
Network P G04 G05
G06 and G07
see
attached
footers
POLA
Initial
42.600
Gold Schedules
Network P G04
G05 G06 and G07
rev2.pdf
Approved
07/31/2013
Gold Schedules
Network P G08 G10
and G11
see
attached
footers
POLA
Initial
42.600
Gold Schedules
Network P G08
G10 and G11 rev
2.pdf
10
Approved
07/31/2013
Gold Schedules
Network S G01 G02
and G03
see
attached
footers
POLA
Initial
42.600
Gold Schedules
Network S G01
G02 and G03
rev2.pdf
11
Approved
07/31/2013
Gold Schedules
Network S G04 G05
G06 and G07
see
attached
footers
POLA
Initial
42.600
Gold Schedules
Network S G04
G05 G06 and G07
rev2.pdf
12
Approved
07/31/2013
Gold Schedules
Network S G08 G10
and G11
see
attached
footers
POLA
Initial
42.600
Gold Schedules
Network S G08
G10 and G11 rev
2.pdf
13
Approved
07/31/2013
Platinum Schedules
Network E
see
attached
footers
POLA
Initial
42.600
Platinum
Schedules
Network E rev.pdf
14
Approved
07/31/2013
Platinum Schedules
Network P
see
attached
footers
POLA
Initial
42.600
Platinum
Schedules
Network P rev.pdf
Readability
Score
Attachments
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:
Lead Form Number:

Item
No.
Schedule Item
Status
Form
Name
Form
Number
Form
Type
Form
Action
Action Specific
Data
Readability
Score
15
Approved
07/31/2013
Platinum Schedules
Network S
see
attached
footers
POLA
Initial
42.600
16
Approved
07/31/2013
Individual Policy
BCBSTPOLA
INDVONOFFEX
rev. 04/2013
Initial
44.100
Form Type Legend:

ADV
Advertising
AEF
Application/Enrollment Form
CER
Certificate
CERA
Certificate Amendment, Insert Page, Endorsement or

Rider
DDP
Data/Declaration Pages
FND
Funding Agreement (Annuity, Individual and Group)
MTX
Matrix
NOC
Notice of Coverage
OTH
Other
OUT
Outline of Coverage
PJK
Policy Jacket
POL
Policy/Contract/Fraternal Certificate
POLA
Policy/Contract/Fraternal Certificate: Amendment,

Insert Page, Endorsement or Rider
SCH
Schedule Pages
Attachments
Platinum
Schedules
Network S rev.pdf
ATTACHMENT C: SCHEDULE OF BENEFITS

Product Name: B01-AI1
Network: E
PLEASE READ THIS IMPORTANT STATEMENT: Network Benefits apply to services received from Network
Providers and Non-Contracted Providers. Out-of-Network benefit percentages apply to BlueCross
Maximum Allowable Charge, not to the Providers billed charge. When using Out-of-Network Providers,
the Member must pay the difference between the Providers price and the Maximum Allowable Charge.
This amount can be substantial. For more information, please refer to the definitions of Coinsurance and
Maximum Allowable Charge in the Definitions section of this Policy.
Covered Services
Network Benefits for

Covered Services
received from Network
Providers
Out-of-Network Benefits
for Covered Services
received from Out-ofNetwork Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Preventive/Well Care Services
Includes:
Preventive health exam for child or adult
Well woman exam
Screenings (includes screenings with an A or
B recommendation by the United States
Preventive Services Task Force (USPSTF),
Bright Futures recommendations for infants,
children and adolescents supported by the
Health Resources and Services
Administration (HRSA), and screening for
women as provided in the guidelines
supported by HRSA). Examples include but
are not limited to screening for breast
cancer, cervical cancer, prostate cancer,
colorectal cancer, high cholesterol, sexually
transmitted infections.
Immunizations recommended by the
Advisory Committee on Immunization
Practices (ACIP) that have been adopted by
the Centers for Disease Control and
Prevention (CDC).
Preventive counseling services (Alcohol
misuse and tobacco use counseling limited
to eight (8) visits annually; must be provided
in the primary care setting) (Dietary
counseling for adults with hyperlipidemia,
hypertension, Type 2 diabetes, coronary
artery disease and congestive heart failure
limited to six (6) visits annually.)
Lactation counseling by a trained provider during
pregnancy or in the post-partum period. Limited to
one (1) visit per pregnancy.
Individual EHB Marketplace B01-AI1E
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services
Manual breast pump, limited to one (1) per

pregnancy
FDA-approved contraceptive methods, sterilization
procedures and counseling for women with
reproductive capacity.
Screening colonoscopy or screening flexible
sigmoidoscopy
For non-screening colonoscopy or sigmoidoscopy
benefits, see Office Surgery under Practitioner
Office Visits section or Outpatient Facility Services
Outpatient Surgery
Practitioner Office Visits (except for Preventive Care)

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
Diagnosis and treatment of illness or injury
100%
Maternity care
100%
Allergy testing
100%
Allergy injections and allergy extract
100%
Provider-Administered Specialty Drugs
100%
All other medicine injections, excluding Specialty

Drugs
For surgery injections, please see Office Surgery.
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2
Office Surgery, including anesthesia, performed in

and billed by the Practitioners office
Some procedures require Prior Authorization. Call
Our consumer advisors to determine if Prior
Authorization is required. If Prior Authorization is
required and not obtained, and services are
Medically Necessary, benefits may be reduced to
40% for Out-of-Network Providers[ and for Network
Providers outside Tennessee (BlueCard PPO
Providers)]. If the reduction to 40% results in
liability to the Member greater than$2,500 above
what the Member would have paid had Prior
Authorization been obtained, then the Member may
contact customer service to have the claim reviewed
and adjusted and the reduction will be limited to
$2,500. (Services that are determined to not be
Medically Necessary are not Covered.) Network
Providers[ in Tennessee] are responsible for
obtaining Prior Authorization; Member is not
responsible for penalty when[ Tennessee] Network
Providers do not obtain Prior Authorization.
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Surgeries include incisions, excisions, biopsies,

injection treatments, fracture treatments,
applications of casts and splints, sutures, and
invasive diagnostic services (e.g., colonoscopy,
sigmoidoscopy and endoscopy).
Non-routine treatments:
Includes renal dialysis, radiation therapy,
chemotherapy and infusions.
Does not apply to Specialty Drugs. See Provider
Administered Specialty Drugs section for applicable
benefit.
Supplies
Services Received at a Facility
Prior Authorization required for Inpatient Hospital stays (except maternity), Inpatient Behavioral Health
Services, Skilled Nursing Facility or Rehabilitation Facility Stays and for certain Outpatient Facility procedures.
Call Our consumer advisors to determine if Prior Authorization is required before receiving Outpatient Facility
services. Benefits will be reduced to 40% for Out-of-Network Providers [and for Network Providers outside
Tennessee (BlueCard PPO Providers) ]when Prior Authorization is not obtained and services are Medically
Necessary. If the reduction to 40% results in liability to the Member greater than $2,500 above what the
Member would have paid had Prior Authorization been obtained, then the Member may contact Our
Page 3
consumer advisors to have the claim reviewed and adjusted and the reduction will be limited to $2,500.
(Services that are determined to not be Medically Necessary are not Covered.) Network Providers [in
Tennessee ]are responsible for obtaining Prior Authorization; Member is not responsible for penalty when[
Tennessee] Network Providers do not obtain Prior Authorization.
Inpatient Hospital Stays, including Behavioral Health Services and maternity stays:
Facility charges
Practitioner charges (including global
maternity delivery charges billed as inpatient
service)
Skilled Nursing or Rehabilitation Facility stays:
(Limited to sixty (60) days combined per calendar year)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
Practitioner charges
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
Outpatient Facility Services

Outpatient Surgery
Surgeries include invasive diagnostic services (e.g., colonoscopy, sigmoidoscopy).
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Other Outpatient procedures, services, or supplies

Supplies
100%
Provider Administered Specialty Drugs
100%
All Other services received at an outpatient

facility, including chemotherapy, radiation
therapy, renal dialysis and sleep studies
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4
Hospital Emergency Care services

Emergency Room charges
An observation stay that occurs in
conjunction with an ER visit will be subject to
member cost share under the Outpatient
Facility Services section, above, in addition to
member cost share for the ER visit.
Advanced Radiological Imaging Services
100%
100% of the Maximum

Allowable Charge
Includes CAT scans, CT scans, MRIs, PET

scans, nuclear medicine and other similar
technologies.
100%
100% of the Maximum

Allowable Charge
All Other Hospital Charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
Other Services (Any Place of Service)

Advanced Radiological Imaging
Includes CAT scans, CT scans, MRIs, PET scans,
nuclear medicine and other similar technologies.
Advanced Radiological Imaging services require
Prior Authorization, except when performed as part
of an Emergency Care visit. If Prior Authorization is
not obtained, and services are Medically Necessary,
benefits may be reduced to 40% for Out-of-Network
Providers[ and for Network Providers outside
Tennessee (BlueCard PPO Providers)]. If the
reduction to 40% results in liability to the Member
greater than $2,500 above what the Member would
have paid had Prior Authorization been obtained,
then the Member may contact Our consumer
advisors to have the claim reviewed and adjusted
and the reduction will be limited to $2,500.
(Services that are determined to not be Medically
Necessary are not Covered.) Network Providers[ in
Tennessee] are responsible for obtaining Prior
Authorization; Member is not responsible for
Penalty when [Tennessee ]Network Providers do not
obtain Prior Authorization.
All Other Diagnostic Services for illness, injury or
maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
Physical, speech, occupational, and manipulative
therapy limited to twenty (20) visits per therapy type
per calendar year; Cardiac and pulmonary rehab
therapy limited to thirty-six (36) visits per therapy
type per calendar year
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Hearing Aids for Members under age eighteen (18)

Limited to one (1) per ear every three (3) years
100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge
An office visit Copayment may apply to evaluation

and management claims filed by a therapy provider.
Please refer to Practitioner Office Visits section of
this schedule.
Home Health Care Services,
including home infusion therapy
Prior Authorization is required for skilled nurse visits
in the home, including those for home infusion
therapy. Physical, speech, occupational or
habilitative therapy provided in the home does not
require Prior Authorization.
Home Health Care is limited to sixty (60) visits per
calendar year
Durable Medical Equipment, Orthotics and
Prosthetics
Prior Authorization may be required for certain
Durable Medical Equipment, Orthotics, or
Prosthetics
Page 6
Organ Transplant Services

Organ Transplant Services, all transplants
except kidney
All Organ Transplants require Prior
Authorization. Benefits will be denied
without Prior Authorization. Transplant
Network Providers are different from
Network Providers for other services. Call
Our consumer advisors before any pretransplant evaluation or other transplant
service is performed to request
Authorization, and to obtain information
about Transplant Network Providers.
Network Providers that are not in the
Transplant Network may balance bill the
Member for amounts over TMAC not
Covered by the Plan.
Organ Transplant Services, kidney transplants
Transplant
Network
benefits:
100%
Network Providers
not in Our Transplant
Network
(Network Providers
not in our Transplant
Network include
Network Providers in
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

without Prior Authorization. Call Us at the
number on the back of Your Member ID
Card before any pre-transplant evaluation or
other transplant service is performed to
begin the Authorization process.
Pharmacy Prescription Drug Program for retail and mail order Prescriptions
Prescription Drugs 1
Out-of-Network Providers:
100% of Maximum Allowable
Charge (MAC), Out-of Network
Out-of- Pocket Maximum
applies; amounts over MAC do
not apply to the Out-of-Pocket
and are not Covered.
Generic Drug / Preferred Brand Drug / Non-Preferred Brand Drug
Retail network up to 30 days
100%
Mail Order Network and Select90

Network up to 90 days
100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
Network Out-ofPocket Maximum
applies, amounts
over MAC do not
apply to the Outof-Pocket and are
not Covered.
100% of the Maximum Allowable Charge
Specialty Drugs - You have a distinct network for Specialty Drugs: the Preferred Specialty Pharmacy
Network. To receive benefits for self-administered Specialty Drugs, You must use a Preferred Specialty
Pharmacy Network Provider. (Please refer to Your Policy for information on benefits for ProviderAdministered Specialty Drugs.)
Specialty Drugs are limited to a thirty (30) day supply per Prescription.
Page 7
Specialty Drugs 1
Specialty Pharmacy Network
Self-administered Specialty
Drugs, as indicated on Our
Specialty Drug list.
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
Out-of-Network Dentist
Coverage A Diagnostic and Preventive

Services; Exams Cleanings and X-rays
100%
100% of the Maximum

Allowable Charge
Coverage B Basic and Restorative

Services; Basic Restorative Basic
Endodontics Oral Surgery Basic
Periodontics
100%
100% of the Maximum

Allowable Charge
Coverage C Major Restorative and

Prosthodontic Services; Major
Restorative Major Endodontics Major
Periodontics Implants
100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Exam with Dilation as Necessary
Network
Out-of-Network
$0 Copayment

Charge
Contact Lens Fit and Follow-Up:

(Contact lens fit and two follow-up visits are
available once a comprehensive eye exam has been
completed.)
Standard Contact Lens Fit and Follow-Up:
$0 Copayment
Premium Contact Lens Fit and Follow-Up:
$0 Copayment
Frames:
100% coverage for provider

designated frames or frame
equivalent

Charge
Charge
Charge
Designated available frame at provider location

Standard Lenses (Glass or Plastic)
Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
Standard Progressive Lens
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
Tint (Fashion & Gradient & Glass-Grey)
$0 Copayment
Standard Plastic Scratch Coating
$0 Copayment
Standard Polycarbonate
$0 Copayment
Photocromatic / Transitions Plastic
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge

designated contact lenses or
contact lens equivalent:
(Contact lens includes materials only)

Extended Wear and Extended Wear Disposables
Up to 6 months supply of
monthly or 2 week disposable,
single vision spherical or toric
contact lenses

Charge
Page 9
Daily Wear / Disposables
Deductible
Individual
Family
Up to 3 months supply of daily

disposable, single vision
spherical contact lenses

Charge
In-Network Services
Providers
Out-of-Network Services
received from Out-of-Network
Providers
$0
$0 per Member, not to
exceed $0 for all Covered
Family Members
$0
$0 per Member, not to exceed
$0 for all Covered Family
Members
$0
Family Members.
$0
Members.
Out-of-Pocket Maximum
Individual
Family
Some products may be subject to Quantity Limits, Step Therapy, and Prior Authorizations specified
by the Plans P & T Committee.
2. If You have a Prescription filled at an Out-of-Network Pharmacy, You must pay all expenses and file a
claim for reimbursement with Us. Reimbursement is based on the Maximum Allowable Charge, less
any applicable Out-of-Network Deductible, Coinsurance, and/or Drug Copayment amount.
1.
When services that require Prior Authorization are received from Out-of-Network Providers, [and
Network Providers outside Tennessee, ]You are responsible for obtaining Prior Authorization. Benefits
may be reduced to 40% for Out-of-Network Providers[ and Network Providers outside Tennessee]
when Prior Authorization is not obtained
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Allowable Charge after
Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
Services received received from
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
50% after
Deductible
Maternity care
50% after
Deductible
100%
Allergy testing
50% after
Deductible
100%
50% after
Deductible
100%
50% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

50% after
Deductible

50% after
Deductible

benefit.
Supplies
50% after
Deductible
Page 3

Facility charges
50% after
Deductible
100%

service)
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
50% after
Deductible
100%
50% after
Deductible
100%

50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
50% after
Deductible
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
50% after
Deductible
50% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
50% after
Deductible
Page 6

50% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
50% after
Deductible

50% after
Deductible
100%
Ambulance
50% after
Deductible
100%
Hospice Care
50% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
apply to the Out-ofPocket Maximum and
are not Covered.
Network Providers:
50% after Network
Deductible; Network Out-ofPocket Maximum applies.
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
(MAC), after Outof-Network
Deductible, Outof Network Outof- Pocket
Maximum
applies, amounts
over MAC do not
not Covered.
Charge (MAC), after Out-ofNetwork Deductible, Out-of
Network Out-of- Pocket
Maximum applies; amounts
over MAC do not apply to the
Out-of-Pocket and are not
Covered.
50% after Deductible

Indian Health Provider Network
100%
Page 8
Out-of-Network 2
50% of the Maximum Allowable Charge after Deductible
Specialty Drugs 1
50% per Prescription after the Plan Deductible
Indian Health Provider

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,500
$5,000
$2,500 per Member, not to
exceed $5,000 for all
exceed $10,000 for all Covered
Covered Family Members
Family Members
Individual
Family
$6,350
$19,050
$6,350 per Member, not to $19,050 per Member, not to
Covered Family Members.
Family Members.
1.
Page 11
TTACHMENT C: SCHEDULE OF BENEFITS

Product Name: B01
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Individual EHB Marketplace B01E
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,500
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
50% after
Deductible
Maternity care
50% after
Deductible
100%
Allergy testing
50% after
Deductible
100%
50% after
Deductible
100%
50% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

50% after
Deductible

50% after
Deductible

benefit.
Supplies
50% after
Deductible
Page 3

Facility charges
50% after
Deductible
100%

service)
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
50% after
Deductible
100%
50% after
Deductible
100%

50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
50% after
Deductible
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
50% after
Deductible
50% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
50% after
Deductible
Page 6

50% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
50% after
Deductible

50% after
Deductible
100%
Ambulance
50% after
Deductible
100%
Hospice Care
50% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 11

Product Name: B02
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
80% after
Deductible
Maternity care
80% after
Deductible
100%
Allergy testing
80% after
Deductible
100%
80% after
Deductible
100%
80% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

80% after
Deductible

80% after
Deductible

benefit.
Supplies
80% after
Deductible
Page 3

Facility charges
80% after
Deductible
100%

service)
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
80% after
Deductible
100%
80% after
Deductible
100%

80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
80% after
Deductible
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% after
Deductible
100%
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
80% after
Deductible
80% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
80% after
Deductible
Page 6

80% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
80% after
Deductible

80% after
Deductible
100%
Ambulance
80% after
Deductible
100%
Hospice Care
80% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
80% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 11

Product Name: B03
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
100% after
Deductible
Maternity care
100% after
Deductible
100%
Allergy testing
100% after
Deductible
100%
100% after
Deductible
100%
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
Deductible

100% after
Deductible

benefit.
Supplies
100% after
Deductible
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
Hospice Care
100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$5,300
$10,600
Family Members
Individual
Family
$5,300
$15,900
Family Members.
1.
Page 11

Product Name: B04
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$5,300
$10,600
Family Members
Individual
Family
$5,300
$15,900
Family Members.
1.
Page 10

Product Name: B01
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Individual EHB Non-Marketplace B01P
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,500
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Product Name: B02
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Product Name: B03
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Network: P
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Individual EHB MSP B04-AI1P
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
100% after
Deductible
Maternity care
100% after
Deductible
100%
Allergy testing
100% after
Deductible
100%
100% after
Deductible
100%
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
Deductible

100% after
Deductible

benefit.
Supplies
100% after
Deductible
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
Hospice Care
100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$5,300
$10,600
Family Members
Individual
Family
$5,300
$15,900
Family Members.
1.
Page 11

Product Name: B04
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Individual EHB MSP B04P
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$5,300
$10,600
Family Members
Individual
Family
$5,300
$15,900
Family Members.
1.
Page 10

Product Name: B04
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$5,300
$10,600
Family Members
Individual
Family
$5,300
$15,900
Family Members.
1.
Page 10

Product Name: B05
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$6,250
$12,500
Family Members
Individual
Family
$6,250
$18,750
Family Members.
1.
Page 10

Product Name: B06
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing
$500 Copayment per

Prescription

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
Prescription Drugs 1,2
One month supply

Two months supply
Three months supply
(31 to 60 days)
(61 to 90 days)
(Up to 30 days)
Generic Drug /
Generic Drug /
Generic Drug /
Preferred Brand Drug /
Non-Preferred Brand Drug3 Non-Preferred Brand Drug3 Non-Preferred Brand Drug3
Retail network
$3/$75/$250
N/A
N/A
Mail Order Network and

Select90 Network
$3/$75/$250
$6/$150/$500
$9/$225/$750
Page 7
Out-of-Network 4
Specialty Drugs 1,2
$500 Copayment per Prescription
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$6,350
$12,700
Family Members
Individual
Family
$6,350
$19,050
Family Members.
If You or the prescribing physician choose a Non-Preferred Brand Drug when a Generic Drug
equivalent is available, You will be financially responsible for the amount by which the cost of the
Non-Preferred Brand Drug exceeds the Generic Drug cost plus the required Generic Drug
Copayment.
2. Some products may be subject to Quantity Limits, Step Therapy, and Prior Authorizations specified
3. If You choose a Non-Preferred Brand Drug when a Generic Equivalent is available, You must pay the
cost difference between the Non-Preferred Brand Drug and Generic Equivalent.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Individual EHB Marketplace B01-AI1S
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
50% after
Deductible
Maternity care
50% after
Deductible
100%
Allergy testing
50% after
Deductible
100%
50% after
Deductible
100%
50% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

50% after
Deductible

50% after
Deductible

benefit.
Supplies
50% after
Deductible
Page 3

Facility charges
50% after
Deductible
100%

service)
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
50% after
Deductible
100%
50% after
Deductible
100%

50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
50% after
Deductible
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
50% after
Deductible
50% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
50% after
Deductible
Page 6

50% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
50% after
Deductible

50% after
Deductible
100%
Ambulance
50% after
Deductible
100%
Hospice Care
50% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,500
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 11

Product Name: B01
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Individual EHB Marketplace B01S
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,500
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Product Name: B01
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Individual EHB Non-Marketplace B01S
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,500
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
50% after
Deductible
Maternity care
50% after
Deductible
100%
Allergy testing
50% after
Deductible
100%
50% after
Deductible
100%
50% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

50% after
Deductible

50% after
Deductible

benefit.
Supplies
50% after
Deductible
Page 3

Facility charges
50% after
Deductible
100%

service)
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
50% after
Deductible
100%
50% after
Deductible
100%

50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
50% after
Deductible
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
50% after
Deductible
50% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
50% after
Deductible
Page 6

50% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
50% after
Deductible

50% after
Deductible
100%
Ambulance
50% after
Deductible
100%
Hospice Care
50% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 11

Product Name: B02
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Product Name: B02
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
80% after
Deductible
Maternity care
80% after
Deductible
100%
Allergy testing
80% after
Deductible
100%
80% after
Deductible
100%
80% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

80% after
Deductible

80% after
Deductible

benefit.
Supplies
80% after
Deductible
Page 3

Facility charges
80% after
Deductible
100%

service)
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
80% after
Deductible
100%
80% after
Deductible
100%

80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
80% after
Deductible
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% after
Deductible
100%
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
80% after
Deductible
80% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
80% after
Deductible
Page 6

80% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
80% after
Deductible

80% after
Deductible
100%
Ambulance
80% after
Deductible
100%
Hospice Care
80% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
80% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 11

Product Name: B03
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Product Name: B03
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
100% after
Deductible
Maternity care
100% after
Deductible
100%
Allergy testing
100% after
Deductible
100%
100% after
Deductible
100%
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
Deductible

100% after
Deductible

benefit.
Supplies
100% after
Deductible
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
Hospice Care
100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$5,300
$10,600
Family Members
Individual
Family
$5,300
$15,900
Family Members.
1.
Page 11

Product Name: B04
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$5,300
$10,600
Family Members
Individual
Family
$5,300
$15,900
Family Members.
1.
Page 10

Product Name: B04
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$5,300
$10,600
Family Members
Individual
Family
$5,300
$15,900
Family Members.
1.
Page 10

Product Name: B05
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$6,250
$12,500
Family Members
Individual
Family
$6,250
$18,750
Family Members.
1.
Page 10

Product Name: B06
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing
$500 Copayment per

Prescription

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply

Two months supply
Three months supply
(31 to 60 days)
(61 to 90 days)
(Up to 30 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$3/$75/$250
N/A
N/A

Select90 Network
$3/$75/$250
$6/$150/$500
$9/$225/$750
Page 7
Out-of-Network 4
Specialty Drugs 1,2
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$6,350
$12,700
Family Members
Individual
Family
$6,350
$19,050
Family Members.
Copayment.
1.
Page 10

Product Name: G01-AI1
Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Individual EHB Marketplace G01-AI1E
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
65% after
Deductible
Maternity care
65% after
Deductible
100%
Allergy testing
65% after
Deductible
100%
65% after
Deductible
100%
65% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
65% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

65% after
Deductible

65% after
Deductible

benefit.
Supplies
65% after
Deductible
Page 3

Facility charges
65% after
Deductible
100%

service)
65% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
65% after
Deductible
100%
65% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
65% after
Deductible
100%
65% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
65% after
Deductible
100%
65% after
Deductible
100%

65% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
65% after
Deductible
65% after
Deductible
100%
65% of the
Maximum
Allowable Charge
after Deductible
100%
65% of the
Maximum
Allowable Charge
after Deductible
65% after
Deductible
100%
65% after
Deductible
100%
65% of the
Maximum
Allowable Charge
after Deductible
65% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
65% after
Deductible
65% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
65% after
Deductible
Page 6

65% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
65% after
Deductible

65% after
Deductible
100%
Ambulance
65% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
65% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
65% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
65% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
65% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$5,250
$15,750
Family Members.
1.
Page 11

Product Name: G01
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Individual EHB Marketplace G01E
Page 1
Covered Services

pregnancy

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs

sigmoidoscopy
Outpatient Surgery
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
65% of the Maximum

Deductible
65% of the Maximum

Deductible
65% of the Maximum

Deductible
65% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
65% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
65% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
65% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
65% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$5,250
$15,750
Family Members.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
75% after
Deductible
Maternity care
75% after
Deductible
100%
Allergy testing
75% after
Deductible
100%
75% after
Deductible
100%
75% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

75% after
Deductible

75% after
Deductible

benefit.
Supplies
75% after
Deductible
Page 3

Facility charges
75% after
Deductible
100%

service)
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
75% after
Deductible
100%
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
75% after
Deductible
100%
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
75% after
Deductible
100%
75% after
Deductible
100%

75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
75% after
Deductible
75% after
Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
75% after
Deductible
100%
75% after
Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
75% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
75% after
Deductible
75% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
75% after
Deductible
Page 6

75% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
75% after
Deductible

75% after
Deductible
100%
Ambulance
75% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
75% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
75% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 11

Product Name: G02
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
75% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
75% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$0 Copayment
N/A
N/A

Select90 Network
$0 Copayment
$0 Copayment
$0 Copayment
Out-of-Network 4
Page 7
Specialty Drugs 1,2
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
Copayment.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1

Covered Services
Providers
Covered Services

pregnancy
100%

sigmoidoscopy
Outpatient Surgery
Covered Services
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Benefits for
Benefits for
Covered Services
Covered Services
Covered Services
received from
received from
received from
Indian Health
Network Providers
Out-of-Network
Providers
Providers

Primary Care Practitioner types (Internal
Medicine, General Practice, Family Medicine,
Pediatrics, Obstetrics & Gynecology, Physician
Assistant, Nurse Practitioner)
100% after
$35 Copayment
All other Practitioners
100% after $50

Copayment
100%
Maternity care
100% after
$35 Copayment
100%
Allergy testing
100%
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

All other medicine injections, excluding
Specialty Drugs
For surgery injections, please see Office
Surgery.
Office Surgery, including anesthesia, performed
in and billed by the Practitioners office
$120 Copayment per

Prescription
100%
100%
100%
Some procedures require Prior Authorization.

Call Our consumer advisors to determine if
Prior Authorization is required. If Prior
Authorization is required and not obtained, and
services are Medically Necessary, benefits may
be reduced to 40% for Out-of-Network
reduction to 40% results in liability to the
Member greater than$2,500 above what the
Member would have paid had Prior
Authorization been obtained, then the Member
may contact customer service to have the claim 80% after Deductible
reviewed and adjusted and the reduction will
be limited to $2,500. (Services that are
determined to not be Medically Necessary are
not Covered.) Network Providers[ in
penalty when[ Tennessee] Network Providers
do not obtain Prior Authorization.
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
$50 Copayment

Administered Specialty Drugs section for
applicable benefit.
Supplies
100%
Page 3

Facility charges
80% after
Deductible
100%

service)
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
80% after
Deductible
100%
80% after
Deductible
100%

80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
80% after
Deductible
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% after
Deductible
100%
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
80% after
Deductible
100%
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
80% after
Deductible
Page 6

80% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
80% after
Deductible

80% after
Deductible
100%
Ambulance
80% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
80% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply
(Up to 30 days)
Generic Drug /
Non-Preferred Brand
Drug3
Two months supply

(31 to 60 days)
Generic Drug /
Non-Preferred Brand
Drug3
Three months supply

(61 to 90 days)
Generic Drug /
Non-Preferred Brand
Drug3
Retail network
$8/$35/$60
N/A
N/A

Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 8
Out-of-Network 4
100%
Specialty Drugs 1,2

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,000
$2,000
Family Members
Individual
Family
$4,000
$12,000
Family Members.
Copayment.
1.
Page 11

Product Name: G04
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Primary Care Practitioner types (Internal Medicine,

General Practice, Family Medicine, Pediatrics,
Obstetrics & Gynecology, Physician Assistant, Nurse
Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Network Out-ofPocket applies.
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
80% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Deductible; Outof-Pocket
Maximum applies
and amounts
over MAC do not
not Covered.
Charge (MAC), after Out-ofNetwork Deductible; Out-ofPocket Maximum applies and
amounts over MAC do not
apply to the Out-of-Pocket
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
Self-administered Specialty Drugs,
as indicated on Our Specialty Drug
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,000
$2,000
Family Members
Individual
Family
$4,000
$12,000
Family Members.
Copayment.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$0 Copayment
N/A
N/A

Select90 Network
$0 Copayment
$0 Copayment
$0 Copayment
Out-of-Network 4
Page 7
Specialty Drugs 1,2
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
Copayment.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1

Covered Services
Providers
Covered Services

pregnancy
100%

sigmoidoscopy
Outpatient Surgery
Covered Services
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Benefits for
Benefits for
Covered Services
Covered Services
Covered Services
received from
received from
received from
Indian Health
Network Providers
Out-of-Network
Providers
Providers

100% after
$35 Copayment
100% after $50

Copayment
100%
Maternity care
100% after
$35 Copayment
100%
Allergy testing
100%
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Specialty Drugs
Surgery.
$120 Copayment per

Prescription
100%
100%
100%

50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
$50 Copayment

applicable benefit.
Supplies
100%
Page 3

Facility charges
80% after
Deductible
100%

service)
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
80% after
Deductible
100%
80% after
Deductible
100%

80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
80% after
Deductible
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% after
Deductible
100%
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
80% after
Deductible
100%
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
80% after
Deductible
Page 6

80% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
80% after
Deductible

80% after
Deductible
100%
Ambulance
80% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
80% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply
(Up to 30 days)
Generic Drug /
Non-Preferred Brand
Drug3
Two months supply

(31 to 60 days)
Generic Drug /
Non-Preferred Brand
Drug3
Three months supply

(61 to 90 days)
Generic Drug /
Non-Preferred Brand
Drug3
Retail network
$8/$35/$60
N/A
N/A

Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 8
Out-of-Network 4
100%
Specialty Drugs 1,2

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,500
$3,000
Family Members
Individual
Family
$4,500
$13,500
Family Members.
Copayment.
1.
Page 11

Product Name: G06
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
80% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,500
$3,000
Family Members
Individual
Family
$4,500
$13,500
Family Members.
Copayment.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
100% after
Deductible
Maternity care
100% after
Deductible
100%
Allergy testing
100% after
Deductible
100%
100% after
Deductible
100%
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
Deductible

100% after
Deductible

benefit.
Supplies
100% after
Deductible
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
Hospice Care
100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,100
$4,200
Family Members
Individual
Family
$2,100
$6,300
Family Members.
1.
Page 11

Product Name: G08
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,100
$4,200
Family Members
Individual
Family
$2,100
$6,300
Family Members.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
100%
Maternity care
100% after
$35 Copayment
100%
Allergy testing
100%
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
$100 Copayment
per Prescription
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
$50 Copayment

benefit.
Supplies
100%
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
100% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
50% per Prescription

100%
Page 8
Out-of-Network 2
Specialty Drugs 1
Specialty Network Pharmacy

list.
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
1.
Page 11

Product Name: G10
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$100 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Deductible
50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
100% after Network


Select90 Network up to
90 days
Retail network up to 30
days
Out-of-Network 2
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$0 Copayment
N/A
N/A

Select90 Network
$0 Copayment
$0 Copayment
$0 Copayment
Out-of-Network 4
Page 7
Specialty Drugs 1,2
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
Copayment.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1

Covered Services
Providers
Covered Services

pregnancy
100%

sigmoidoscopy
Outpatient Surgery
Covered Services
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Benefits for
Benefits for
Covered Services
Covered Services
Covered Services
received from
received from
received from
Indian Health
Network Providers
Out-of-Network
Providers
Providers

100% after
$35 Copayment
100% after $50

Copayment
100%
Maternity care
100% after
$35 Copayment
100%
Allergy testing
100%
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Specialty Drugs
Surgery.
may contact customer service to have the claim
$120 Copayment per

Prescription
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
$50 Copayment

applicable benefit.
Supplies
100%
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
100% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply
(Up to 30 days)
Generic Drug /
Non-Preferred Brand
Drug3
Two months supply

(31 to 60 days)
Generic Drug /
Non-Preferred Brand
Drug3
Three months supply

(61 to 90 days)
Generic Drug /
Non-Preferred Brand
Drug3
Retail network
$8/$35/$60
N/A
N/A

Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 8
Out-of-Network 4
100%
Specialty Drugs 1,2

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
Copayment.
1.
Page 11

Product Name: G11
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Deductible
50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
100% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Covered Services
Periodontics
Network Dentist
100%
100% of the Maximum

Deductible
80%
80% of the Maximum

Deductible
50%
50% of the Maximum

Deductible
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
Copayment.
1.
Page 10

Product Name: G01
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Individual EHB Non-Marketplace G01P
Page 1
Covered Services

pregnancy

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs

sigmoidoscopy
Outpatient Surgery
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
65% of the Maximum

Deductible
65% of the Maximum

Deductible
65% of the Maximum

Deductible
65% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
65% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
65% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
65% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
65% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$5,250
$15,750
Family Members.
1.
Page 10

Product Name: G02
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
75% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
75% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Product Name: G03
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply

Two months supply
Three months supply
(31 to 60 days)
(61 to 90 days)
(Up to 30 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60 after
$500 Brand Deductible
N/A
N/A

Select90 Network
$8/$35/$60 after
$16/$70/$120 after
$24/$105/$180 after
Page 7
Out-of-Network 4
Specialty Drugs 1,2

list.
Out-of-Network
Not Covered
Pediatric Dental
Covered Services
Periodontics
Network Dentist
100%
100% of the Maximum

Deductible
80%
80% of the Maximum

Deductible
50%
50% of the Maximum

Deductible
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,000
$2,000
Family Members
Individual
Family
$4,000
$12,000
Family Members.
Copayment.
1.
Page 10

Product Name: G04
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
80% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,000
$2,000
Family Members
Individual
Family
$4,000
$12,000
Family Members.
Copayment.
1.
Page 10

Product Name: G05
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply

Two months supply
Three months supply
(31 to 60 days)
(61 to 90 days)
(Up to 30 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60 after
N/A
N/A

Select90 Network
$8/$35/$60 after
$16/$70/$120 after
$24/$105/$180 after
Page 7
Out-of-Network 4
Specialty Drugs 1,2

list.
Out-of-Network
Not Covered
Pediatric Dental
Covered Services
Periodontics
Network Dentist
100%
100% of the Maximum

Deductible
80%
80% of the Maximum

Deductible
50%
50% of the Maximum

Deductible
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,500
$3,000
Family Members
Individual
Family
$4,500
$13,500
Family Members.
Copayment.
1.
Page 10

Product Name: G06
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
80% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,500
$3,000
Family Members
Individual
Family
$4,500
$13,500
Family Members.
Copayment.
1.
Page 10

Product Name: G07
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
100% after
$10 Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$10 Copayment
Allergy testing
100%
100%

sigmoidoscopy
Outpatient Surgery

Drugs
$100 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$10 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% after
$250 Copayment
100% of the Maximum

$250 Copayment
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
80% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$3/$25/$50
N/A
N/A

Select90 Network
$3/$25/$50
$6/$50/$100
$9/$75/$150
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,000
$4,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
Copayment.
1.
Page 10

Network: P
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Individual EHB MSP G08-AI1P
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
100% after
Deductible
Maternity care
100% after
Deductible
100%
Allergy testing
100% after
Deductible
100%
100% after
Deductible
100%
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
Deductible

100% after
Deductible

benefit.
Supplies
100% after
Deductible
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
Hospice Care
100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,100
$4,200
Family Members
Individual
Family
$2,100
$6,300
Family Members.
1.
Page 11

Product Name: G08
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Individual EHB MSP G08P
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,100
$4,200
Family Members
Individual
Family
$2,100
$6,300
Family Members.
1.
Page 10

Product Name: G08
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,100
$4,200
Family Members
Individual
Family
$2,100
$6,300
Family Members.
1.
Page 10

Product Name: G10
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$100 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Deductible
50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
100% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
days

90 days
Out-of-Network 2
Page 7
Specialty Drugs 1
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
1.
Page 10

Network: P
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$0 Copayment
N/A
N/A

Select90 Network
$0 Copayment
$0 Copayment
$0 Copayment
Out-of-Network 4
Page 7
Specialty Drugs 1,2
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
Copayment.
1.
Page 10

Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1

Covered Services
Providers
Covered Services

pregnancy
100%

sigmoidoscopy
Outpatient Surgery
Covered Services
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Benefits for
Benefits for
Covered Services
Covered Services
Covered Services
received from
received from
received from
Indian Health
Network Providers
Out-of-Network
Providers
Providers

100% after
$35 Copayment
100% after $50

Copayment
100%
Maternity care
100% after
$35 Copayment
100%
Allergy testing
100%
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Specialty Drugs
Surgery.
$120 Copayment per

Prescription
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
$50 Copayment

applicable benefit.
Supplies
100%
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
100% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply
(Up to 30 days)
Generic Drug /
Non-Preferred Brand
Drug3
Two months supply

(31 to 60 days)
Generic Drug /
Non-Preferred Brand
Drug3
Three months supply

(61 to 90 days)
Generic Drug /
Non-Preferred Brand
Drug3
Retail network
$8/$35/$60
N/A
N/A

Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 8
Out-of-Network 4
100%
Specialty Drugs 1,2

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
Copayment.
1.
Page 11

Product Name: G11
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Deductible
50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
100% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Covered Services
Periodontics
Network Dentist
100%
100% of the Maximum

Deductible
80%
80% of the Maximum

Deductible
50%
50% of the Maximum

Deductible
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
Copayment.
1.
Page 10

Product Name: G11
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Deductible
50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
100% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Covered Services
Periodontics
Network Dentist
100%
100% of the Maximum

Deductible
80%
80% of the Maximum

Deductible
50%
50% of the Maximum

Deductible
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
Copayment.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Individual EHB Marketplace G01-AI1S
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
65% after
Deductible
Maternity care
65% after
Deductible
100%
Allergy testing
65% after
Deductible
100%
65% after
Deductible
100%
65% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
65% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

65% after
Deductible

65% after
Deductible

benefit.
Supplies
65% after
Deductible
Page 3

Facility charges
65% after
Deductible
100%

service)
65% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
65% after
Deductible
100%
65% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
65% after
Deductible
100%
65% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
65% after
Deductible
100%
65% after
Deductible
100%

65% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
65% after
Deductible
65% after
Deductible
100%
65% of the
Maximum
Allowable Charge
after Deductible
100%
65% of the
Maximum
Allowable Charge
after Deductible
65% after
Deductible
100%
65% after
Deductible
100%
65% of the
Maximum
Allowable Charge
after Deductible
65% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
65% after
Deductible
65% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
65% after
Deductible
Page 6

65% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
65% after
Deductible

65% after
Deductible
100%
Ambulance
65% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
65% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
65% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
65% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
65% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$5,250
$15,750
Family Members.
1.
Page 11

Product Name: G01
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Individual EHB Marketplace G01S
Page 1
Covered Services

pregnancy

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs

sigmoidoscopy
Outpatient Surgery
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
65% of the Maximum

Deductible
65% of the Maximum

Deductible
65% of the Maximum

Deductible
65% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
65% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
65% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
65% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
65% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$5,250
$15,750
Family Members.
1.
Page 10

Product Name: G01
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Individual EHB Non-Marketplace G01S
Page 1
Covered Services

pregnancy

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs

sigmoidoscopy
Outpatient Surgery
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
65% of the Maximum

Deductible
65% of the Maximum

Deductible
65% of the Maximum

Deductible
65% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
65% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
65% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
65% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
65% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$5,250
$15,750
Family Members.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
75% after
Deductible
Maternity care
75% after
Deductible
100%
Allergy testing
75% after
Deductible
100%
75% after
Deductible
100%
75% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

75% after
Deductible

75% after
Deductible

benefit.
Supplies
75% after
Deductible
Page 3

Facility charges
75% after
Deductible
100%

service)
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
75% after
Deductible
100%
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
75% after
Deductible
100%
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
75% after
Deductible
100%
75% after
Deductible
100%

75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
75% after
Deductible
75% after
Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
75% after
Deductible
100%
75% after
Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
75% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
75% after
Deductible
75% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
75% after
Deductible
Page 6

75% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
75% after
Deductible

75% after
Deductible
100%
Ambulance
75% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
75% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
75% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 11

Product Name: G02
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
75% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
75% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Product Name: G02
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
75% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
75% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Product Name: G03
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply

Two months supply
Three months supply
(31 to 60 days)
(61 to 90 days)
(Up to 30 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60 after
N/A
N/A

Select90 Network
$8/$35/$60 after
$16/$70/$120 after
$24/$105/$180 after
Page 7
Out-of-Network 4
Specialty Drugs 1,2

list.
Out-of-Network
Not Covered
Pediatric Dental
Covered Services
Periodontics
Network Dentist
100%
100% of the Maximum

Deductible
80%
80% of the Maximum

Deductible
50%
50% of the Maximum

Deductible
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,000
$2,000
Family Members
Individual
Family
$4,000
$12,000
Family Members.
Copayment.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$0 Copayment
N/A
N/A

Select90 Network
$0 Copayment
$0 Copayment
$0 Copayment
Out-of-Network 4
Page 7
Specialty Drugs 1,2
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
Copayment.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1

Covered Services
Providers
Covered Services

pregnancy
100%

sigmoidoscopy
Outpatient Surgery
Covered Services
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Benefits for
Benefits for
Covered Services
Covered Services
Covered Services
received from
received from
received from
Indian Health
Network Providers
Out-of-Network
Providers
Providers

100% after
$35 Copayment
100% after $50

Copayment
100%
Maternity care
100% after
$35 Copayment
100%
Allergy testing
100%
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Specialty Drugs
Surgery.
$120 Copayment per

Prescription
100%
100%
100%

50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
$50 Copayment

applicable benefit.
Supplies
100%
Page 3

Facility charges
80% after
Deductible
100%

service)
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
80% after
Deductible
100%
80% after
Deductible
100%

80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
80% after
Deductible
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% after
Deductible
100%
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
80% after
Deductible
100%
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
80% after
Deductible
Page 6

80% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
80% after
Deductible

80% after
Deductible
100%
Ambulance
80% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
80% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply
(Up to 30 days)
Generic Drug /
Non-Preferred Brand
Drug3
Two months supply

(31 to 60 days)
Generic Drug /
Non-Preferred Brand
Drug3
Three months supply

(61 to 90 days)
Generic Drug /
Non-Preferred Brand
Drug3
Retail network
$8/$35/$60
N/A
N/A

Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 8
Out-of-Network 4
100%
Specialty Drugs 1,2

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,000
$2,000
Family Members
Individual
Family
$4,000
$12,000
Family Members.
Copayment.
1.
Page 11

Product Name: G04
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
80% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,000
$2,000
Family Members
Individual
Family
$4,000
$12,000
Family Members.
Copayment.
1.
Page 10

Product Name: G04
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
80% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,000
$2,000
Family Members
Individual
Family
$4,000
$12,000
Family Members.
Copayment.
1.
Page 10

Product Name: G05
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply

Two months supply
Three months supply
(31 to 60 days)
(61 to 90 days)
(Up to 30 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60 after
N/A
N/A

Select90 Network
$8/$35/$60 after
$16/$70/$120 after
$24/$105/$180 after
Page 7
Out-of-Network 4
Specialty Drugs 1,2

list.
Out-of-Network
Not Covered
Pediatric Dental
Covered Services
Periodontics
Network Dentist
100%
100% of the Maximum

Deductible
80%
80% of the Maximum

Deductible
50%
50% of the Maximum

Deductible
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,500
$3,000
Family Members
Individual
Family
$4,500
$13,500
Family Members.
Copayment.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$0 Copayment
N/A
N/A

Select90 Network
$0 Copayment
$0 Copayment
$0 Copayment
Out-of-Network 4
Page 7
Specialty Drugs 1,2
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
Copayment.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1

Covered Services
Providers
Covered Services

pregnancy
100%

sigmoidoscopy
Outpatient Surgery
Covered Services
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Benefits for
Benefits for
Covered Services
Covered Services
Covered Services
received from
received from
received from
Indian Health
Network Providers
Out-of-Network
Providers
Providers

100% after
$35 Copayment
100% after $50

Copayment
100%
Maternity care
100% after
$35 Copayment
100%
Allergy testing
100%
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Specialty Drugs
Surgery.
$120 Copayment per

Prescription
100%
100%
100%

50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
$50 Copayment

applicable benefit.
Supplies
100%
Page 3

Facility charges
80% after
Deductible
100%

service)
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
80% after
Deductible
100%
80% after
Deductible
100%

80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
80% after
Deductible
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% after
Deductible
100%
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
80% after
Deductible
100%
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
80% after
Deductible
Page 6

80% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
80% after
Deductible

80% after
Deductible
100%
Ambulance
80% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
80% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply
(Up to 30 days)
Generic Drug /
Non-Preferred Brand
Drug3
Two months supply

(31 to 60 days)
Generic Drug /
Non-Preferred Brand
Drug3
Three months supply

(61 to 90 days)
Generic Drug /
Non-Preferred Brand
Drug3
Retail network
$8/$35/$60
N/A
N/A

Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 8
Out-of-Network 4
100%
Specialty Drugs 1,2

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,500
$3,000
Family Members
Individual
Family
$4,500
$13,500
Family Members.
Copayment.
1.
Page 11

Product Name: G06
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
80% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,500
$3,000
Family Members
Individual
Family
$4,500
$13,500
Family Members.
Copayment.
1.
Page 10

Product Name: G06
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
80% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,500
$3,000
Family Members
Individual
Family
$4,500
$13,500
Family Members.
Copayment.
1.
Page 10

Product Name: G07
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
100% after
$10 Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$10 Copayment
Allergy testing
100%
100%

sigmoidoscopy
Outpatient Surgery

Drugs
$100 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$10 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% after
$250 Copayment
100% of the Maximum

$250 Copayment
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
80% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$3/$25/$50
N/A
N/A

Select90 Network
$3/$25/$50
$6/$50/$100
$9/$75/$150
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,000
$4,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
Copayment.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
100% after
Deductible
Maternity care
100% after
Deductible
100%
Allergy testing
100% after
Deductible
100%
100% after
Deductible
100%
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
Deductible

100% after
Deductible

benefit.
Supplies
100% after
Deductible
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
Hospice Care
100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,100
$4,200
Family Members
Individual
Family
$2,100
$6,300
Family Members.
1.
Page 11

Product Name: G08
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,100
$4,200
Family Members
Individual
Family
$2,100
$6,300
Family Members.
1.
Page 10

Product Name: G08
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,100
$4,200
Family Members
Individual
Family
$2,100
$6,300
Family Members.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
100%
Maternity care
100% after
$35 Copayment
100%
Allergy testing
100%
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
$100 Copayment
per Prescription
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
$50 Copayment

benefit.
Supplies
100%
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
100% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

list.
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
1.
Page 11

Product Name: G10
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$100 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Deductible
50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
100% after Network


90 days
days
Out-of-Network 2
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
1.
Page 10

Product Name: G10
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$100 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Deductible
50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
100% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
days

90 days
Out-of-Network 2
Page 7
Specialty Drugs 1
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$0 Copayment
N/A
N/A

Select90 Network
$0 Copayment
$0 Copayment
$0 Copayment
Out-of-Network 4
Page 7
Specialty Drugs 1,2
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
Copayment.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1

Covered Services
Providers
Covered Services

pregnancy
100%

sigmoidoscopy
Outpatient Surgery
Covered Services
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Benefits for
Benefits for
Covered Services
Covered Services
Covered Services
received from
received from
received from
Indian Health
Network Providers
Out-of-Network
Providers
Providers

100% after
$35 Copayment
100% after $50

Copayment
100%
Maternity care
100% after
$35 Copayment
100%
Allergy testing
100%
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Specialty Drugs
Surgery.
$120 Copayment per

Prescription
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
$50 Copayment

applicable benefit.
Supplies
100%
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
100% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply
(Up to 30 days)
Generic Drug /
Non-Preferred Brand
Drug3
Two months supply

(31 to 60 days)
Generic Drug /
Non-Preferred Brand
Drug3
Three months supply

(61 to 90 days)
Generic Drug /
Non-Preferred Brand
Drug3
Retail network
$8/$35/$60
N/A
N/A

Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 8
Out-of-Network 4
100%
Specialty Drugs 1,2

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
Copayment.
1.
Page 11

Product Name: G11
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Deductible
50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
100% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Covered Services
Periodontics
Network Dentist
100%
100% of the Maximum

Deductible
80%
80% of the Maximum

Deductible
50%
50% of the Maximum

Deductible
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
Copayment.
1.
Page 10

Product Name: G11
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Deductible
50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
100% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Covered Services
Periodontics
Network Dentist
100%
100% of the Maximum

Deductible
80%
80% of the Maximum

Deductible
50%
50% of the Maximum

Deductible
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
Copayment.
1.
Page 10

Product Name: P01-AI1
Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Individual EHB Marketplace P01-AI1E
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$0 Copayment
N/A
N/A

Select90 Network
$0 Copayment
$0 Copayment
$0 Copayment
Out-of-Network 4
Page 7
Specialty Drugs 1,2
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
Copayment.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1

Covered Services
Providers
Covered Services

pregnancy
100%

sigmoidoscopy
Outpatient Surgery
Covered Services
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Benefits for
Benefits for
Covered Services
Covered Services
Covered Services
received from
received from
received from
Indian Health
Network Providers
Out-of-Network
Providers
Providers

100% after
$20 Copayment
100% after $40

Copayment
100%
Maternity care
100% after
$20 Copayment
100%
Allergy testing
100%
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Specialty Drugs
Surgery.
$100 Copayment per

Prescription
100%

100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
$40 Copayment

applicable benefit.
Supplies
100%
Page 3

Facility charges
50% after
Deductible
100%

service)
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
50% after
Deductible
100%
50% after
Deductible
100%

50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
50% after
Deductible
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
50% after
Deductible
100%
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
50% after
Deductible
Page 6

50% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
50% after
Deductible

50% after
Deductible
100%
Ambulance
50% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply
(Up to 30 days)
Generic Drug /
Non-Preferred Brand
Drug3
Two months supply

(31 to 60 days)
Generic Drug /
Non-Preferred Brand
Drug3
Three months supply

(61 to 90 days)
Generic Drug /
Non-Preferred Brand
Drug3
Retail network
$3/$25/$50
N/A
N/A

Network
$3/$25/$50
$6/$50/$100
$9/$75/$150
Page 8
Out-of-Network 4
100%
Specialty Drugs 1,2

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$1,800
$5,400
Family Members.
Copayment.
1.
Page 11

Product Name: P01
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Individual EHB Marketplace P01E
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$20 Copayment
100% after $40

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$20 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$100 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$40 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
50% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$3/$25/$50
N/A
N/A

Select90 Network
$3/$25/$50
$6/$50/$100
$9/$75/$150
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$1,800
$5,400
Family Members.
Copayment.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
75% after
Deductible
Maternity care
75% after
Deductible
100%
Allergy testing
75% after
Deductible
100%
75% after
Deductible
100%
75% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

75% after
Deductible

75% after
Deductible

benefit.
Supplies
75% after
Deductible
Page 3

Facility charges
75% after
Deductible
100%

service)
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
75% after
Deductible
100%
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
75% after
Deductible
100%
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
75% after
Deductible
100%
75% after
Deductible
100%

75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
75% after
Deductible
75% after
Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
75% after
Deductible
100%
75% after
Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
75% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
75% after
Deductible
75% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
75% after
Deductible
Page 6

75% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
75% after
Deductible

75% after
Deductible
100%
Ambulance
75% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
75% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
75% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
$1,500
$4,500
Family Members.
Individual
Family
1.
Page 11

Product Name: P02
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
75% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
75% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
$1,500
$4,500
Family Members.
Individual
Family
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$0 Copayment
N/A
N/A

Select90 Network
$0 Copayment
$0 Copayment
$0 Copayment
Out-of-Network 4
Page 7
Specialty Drugs 1,2
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
Copayment.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1

Covered Services
Providers
Covered Services

pregnancy
100%

sigmoidoscopy
Outpatient Surgery
Covered Services
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Benefits for
Benefits for
Covered Services
Covered Services
Covered Services
received from
received from
received from
Indian Health
Network Providers
Out-of-Network
Providers
Providers

100% after
$10 Copayment
100% after $40

Copayment
100%
Maternity care
100% after
$10 Copayment
100%
Allergy testing
100%
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Specialty Drugs
Surgery.
$100 Copayment per

Prescription
100%

100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
$40 Copayment

applicable benefit.
Supplies
100%
Page 3

Facility charges
75% after
Deductible
100%

service)
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
75% after
Deductible
100%
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
75% after
Deductible
100%
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
75% after
Deductible
100%
75% after
Deductible
100%

75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
75% after
Deductible
75% after
Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
75% after
Deductible
100%
75% after
Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
75% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
75% after
Deductible
100%
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
75% after
Deductible
Page 6

75% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
75% after
Deductible

75% after
Deductible
100%
Ambulance
75% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
75% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
75% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply
(Up to 30 days)
Generic Drug /
Non-Preferred Brand
Drug3
Two months supply

(31 to 60 days)
Generic Drug /
Non-Preferred Brand
Drug3
Three months supply

(61 to 90 days)
Generic Drug /
Non-Preferred Brand
Drug3
Retail network
$3/$25/$50
N/A
N/A

Network
$3/$25/$50
$6/$50/$100
$9/$75/$150
Page 8
Out-of-Network 4
100%
Specialty Drugs 1,2

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$3,000
$9,000
Family Members.
Copayment.
1.
Page 11

Product Name: P03
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$10 Copayment
100% after $40

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$10 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$100 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$40 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
75% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
75% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$3/$25/$50
N/A
N/A

Select90 Network
$3/$25/$50
$6/$50/$100
$9/$75/$150
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$3,000
$9,000
Family Members.
Copayment.
1.
Page 10

Product Name: P01
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Individual EHB Non-Marketplace P01P
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$20 Copayment
100% after $40

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$20 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$100 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$40 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
50% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$3/$25/$50
N/A
N/A

Select90 Network
$3/$25/$50
$6/$50/$100
$9/$75/$150
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$1,800
$5,400
Family Members.
Copayment.
1.
Page 10

Product Name: P02
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
75% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
75% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
$1,500
$4,500
Family Members.
Individual
Family
1.
Page 10

Product Name: P03
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$10 Copayment
100% after $40

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$10 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$100 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$40 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
75% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
75% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$3/$25/$50
N/A
N/A

Select90 Network
$3/$25/$50
$6/$50/$100
$9/$75/$150
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$3,000
$9,000
Family Members.
Copayment.
1.
Page 10

Product Name: P04
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
100% after
$10 Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$10 Copayment
Allergy testing
100%
100%

sigmoidoscopy
Outpatient Surgery

Drugs
$100 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$10 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
100% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$3/$25/$50
N/A
N/A

Select90 Network
$3/$25/$50
$6/$50/$100
$9/$75/$150
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Covered Services
Periodontics
Network Dentist
100%
100% of the Maximum

Deductible
80%
80% of the Maximum

Deductible
50%
50% of the Maximum

Deductible
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,500
$3,000
Family Members
$1,500
$4,500
Family Members.
Individual
Family
Copayment.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Individual EHB Marketplace P01-AI1S
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$0 Copayment
N/A
N/A

Select90 Network
$0 Copayment
$0 Copayment
$0 Copayment
Out-of-Network 4
Page 7
Specialty Drugs 1,2
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
Copayment.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1

Covered Services
Providers
Covered Services

pregnancy
100%

sigmoidoscopy
Outpatient Surgery
Covered Services
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Benefits for
Benefits for
Covered Services
Covered Services
Covered Services
received from
received from
received from
Indian Health
Network Providers
Out-of-Network
Providers
Providers

100% after
$20 Copayment
100% after $40

Copayment
100%
Maternity care
100% after
$20 Copayment
100%
Allergy testing
100%
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Specialty Drugs
Surgery.
$100 Copayment per

Prescription
100%

100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
$40 Copayment

applicable benefit.
Supplies
100%
Page 3

Facility charges
50% after
Deductible
100%

service)
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
50% after
Deductible
100%
50% after
Deductible
100%

50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
50% after
Deductible
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
50% after
Deductible
100%
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
50% after
Deductible
Page 6

50% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
50% after
Deductible

50% after
Deductible
100%
Ambulance
50% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply
(Up to 30 days)
Generic Drug /
Non-Preferred Brand
Drug3
Two months supply

(31 to 60 days)
Generic Drug /
Non-Preferred Brand
Drug3
Three months supply

(61 to 90 days)
Generic Drug /
Non-Preferred Brand
Drug3
Retail network
$3/$25/$50
N/A
N/A

Network
$3/$25/$50
$6/$50/$100
$9/$75/$150
Page 8
Out-of-Network 4
100%
Specialty Drugs 1,2

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$1,800
$5,400
Family Members.
Copayment.
1.
Page 11

Product Name: P01
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Individual EHB Marketplace P01S
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$20 Copayment
100% after $40

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$20 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$100 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$40 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
50% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$3/$25/$50
N/A
N/A

Select90 Network
$3/$25/$50
$6/$50/$100
$9/$75/$150
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$1,800
$5,400
Family Members.
Copayment.
1.
Page 10

Product Name: P01
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Individual EHB Non-Marketplace P01S
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$20 Copayment
100% after $40

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$20 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$100 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$40 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
50% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$3/$25/$50
N/A
N/A

Select90 Network
$3/$25/$50
$6/$50/$100
$9/$75/$150
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$1,800
$5,400
Family Members.
Copayment.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
75% after
Deductible
Maternity care
75% after
Deductible
100%
Allergy testing
75% after
Deductible
100%
75% after
Deductible
100%
75% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

75% after
Deductible

75% after
Deductible

benefit.
Supplies
75% after
Deductible
Page 3

Facility charges
75% after
Deductible
100%

service)
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
75% after
Deductible
100%
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
75% after
Deductible
100%
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
75% after
Deductible
100%
75% after
Deductible
100%

75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
75% after
Deductible
75% after
Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
75% after
Deductible
100%
75% after
Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
75% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
75% after
Deductible
75% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
75% after
Deductible
Page 6

75% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
75% after
Deductible

75% after
Deductible
100%
Ambulance
75% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
75% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
75% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
$1,500
$4,500
Family Members.
Individual
Family
1.
Page 11

Product Name: P02
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
75% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
75% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
$1,500
$4,500
Family Members.
Individual
Family
1.
Page 10

Product Name: P02
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
75% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
75% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
$1,500
$4,500
Family Members.
Individual
Family
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$0 Copayment
N/A
N/A

Select90 Network
$0 Copayment
$0 Copayment
$0 Copayment
Out-of-Network 4
Page 7
Specialty Drugs 1,2
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
Copayment.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1

Covered Services
Providers
Covered Services

pregnancy
100%

sigmoidoscopy
Outpatient Surgery
Covered Services
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Benefits for
Benefits for
Covered Services
Covered Services
Covered Services
received from
received from
received from
Indian Health
Network Providers
Out-of-Network
Providers
Providers

100% after
$10 Copayment
100% after $40

Copayment
100%
Maternity care
100% after
$10 Copayment
100%
Allergy testing
100%
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Specialty Drugs
Surgery.
$100 Copayment per

Prescription
100%

100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
$40 Copayment

applicable benefit.
Supplies
100%
Page 3

Facility charges
75% after
Deductible
100%

service)
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
75% after
Deductible
100%
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
75% after
Deductible
100%
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
75% after
Deductible
100%
75% after
Deductible
100%

75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
75% after
Deductible
75% after
Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
75% after
Deductible
100%
75% after
Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
75% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
75% after
Deductible
100%
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
75% after
Deductible
Page 6

75% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
75% after
Deductible

75% after
Deductible
100%
Ambulance
75% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
75% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
75% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply
(Up to 30 days)
Generic Drug /
Non-Preferred Brand
Drug3
Two months supply

(31 to 60 days)
Generic Drug /
Non-Preferred Brand
Drug3
Three months supply

(61 to 90 days)
Generic Drug /
Non-Preferred Brand
Drug3
Retail network
$3/$25/$50
N/A
N/A

Network
$3/$25/$50
$6/$50/$100
$9/$75/$150
Page 8
Out-of-Network 4
100%
Specialty Drugs 1,2

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$3,000
$9,000
Family Members.
Copayment.
1.
Page 11

Product Name: P03
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$10 Copayment
100% after $40

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$10 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$100 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$40 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
75% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
75% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$3/$25/$50
N/A
N/A

Select90 Network
$3/$25/$50
$6/$50/$100
$9/$75/$150
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$3,000
$9,000
Family Members.
Copayment.
1.
Page 10

Product Name: P03
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$10 Copayment
100% after $40

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$10 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$100 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$40 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
An office visit Copaymentment may apply to

evaluation and management claims filed by a
therapy provider. Please refer to Practitioner Office
Visits section of this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
75% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
75% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$3/$25/$50
N/A
N/A

Select90 Network
$3/$25/$50
$6/$50/$100
$9/$75/$150
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$3,000
$9,000
Family Members.
Copayment.
1.
Page 10

Product Name: P04
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
100% after
$10 Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$10 Copayment
Allergy testing
100%
100%

sigmoidoscopy
Outpatient Surgery

Drugs
$100 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Deductible
50% of the Maximum

Deductible
100% after
$10 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
100% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$3/$25/$50
N/A
N/A

Select90 Network
$3/$25/$50
$6/$50/$100
$9/$75/$150
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Covered Services
Periodontics
Network Dentist
100%
100% of the Maximum

Deductible
80%
80% of the Maximum

Deductible
50%
50% of the Maximum

Deductible
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,500
$3,000
Family Members
$1,500
$4,500
Family Members.
Individual
Family
Copayment.
1.
Page 10
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:
Supporting Document Schedules

Satisfied - Item:
Cover Letter Accident & Health
Comments:
Cover letter is attached
Attachment(s):
Combined DOI letter and Drug List.pdf
Item Status:
Approved
Status Date:
07/31/2013
Satisfied - Item:
Description of Variables
Comments:
Variables are denoted by brackets: " [ ] ".
Attachment(s):
Item Status:
Approved
Status Date:
07/31/2013
Bypassed - Item:
Filing Fees
Bypass Reason:
No filing fees required
Attachment(s):
Item Status:
Approved
Status Date:
07/31/2013
Satisfied - Item:
Readability Certification
Comments:
Readability certificate is attached
Attachment(s):
Readability Certification.pdf
Item Status:
Approved
Status Date:
07/31/2013
Bypassed - Item:
Third Party Authorization
Bypass Reason:
No Third Party involvement
Attachment(s):
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:
Item Status:
Approved
Status Date:
07/31/2013
Satisfied - Item:
Rates - All NEW Forms Require RATES
Rate tables from the QHP application are in the rate filing accompanying this form filing.
Comments:
SERFF Tracking number BCTN-129006109
Attachment(s):
Item Status:
Approved
Status Date:
07/31/2013
Satisfied - Item:
Comments:
Uniform compliance summary is attached
Attachment(s):
IU65_PPACA_UniformComplianceSummary.pdf
Item Status:
Approved
Status Date:
07/31/2013
Satisfied - Item:
Comments:
Attachment(s):
Individual DOI letter May 2013.pdf
Item Status:
Approved
Status Date:
07/31/2013
Satisfied - Item:
Comments:
A simplified version of the plan and benefit timplate is attached.
Attachment(s):
BCBST Individual Benefits Template (Abbreviated for TDCI Filing)_20130618.xls
Item Status:
Approved
Status Date:
07/31/2013
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:
Attachment BCBST Individual Benefits Template (Abbreviated for TDCI Filing)_20130618.xls is not a
PDF document and cannot be reproduced here.

www.bcbst.com
April 29, 2013
Ms. Victoria Stotzer
Tennessee Department of Commerce and Insurance
Actuarial Section, 4th Floor
500 James Robertson Parkway
Nashville, Tennessee 37243-1130
RE: BCBST INDV ONOFFEX Rev 04-2013 and related schedules
Dear Ms. Stotzer:
The above-mentioned Policy and schedules are enclosed for your review and approval. The Policy
will be used with each of the attached schedules.
We are filing the Policy and schedules for use in the individual market beginning January 1, 2014.
The Policy is for use both on- and off-exchange.
The policy number has a letter in it which indicates whether the coverage level is bronze, silver, gold
or platinum. All Network S and Network P plans will be offered in each of the eight service areas
across the state. Network E plan offerings, which are limited to the Exchange, will only be offered in
four of the eight service areas identified by the State those service areas include the Knoxville,
Chattanooga, Nashville and Memphis metropolitan areas.
You will notice the schedules contain variables regarding BlueCard PPO Providers. Historically,
members using BlueCard PPO Providers outside of Tennessee have been held to different prior
authorization requirements than members using BlueCard PPO Providers inside the state. In an effort
to remedy this difference, the BlueCross BlueShield Association is working with all Blues plans to
require that members will not be held to different prior authorization requirements when using
BlueCard PPO Providers outside of the home state, or Tennessee for our purposes. This
requirement is scheduled to be implemented by the end of the first quarter of 2014. We added the
variable to prevent the need to refile all of our schedules next year.
We certify that the health benefit plans prescription drug benefit complies with the final rule on
Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation. A list of drugs
covered is included.
Rates are provided for these new products.
A certificate of readability is enclosed. Please let us know if the forms meet with your approval.
Your prompt attention is appreciated. If you have any questions or need additional information,
please e-mail Christina_Hart@bcbst.com or call (423) 535-3344.
Sincerely,
Christina Hart
Associate Contract Development Analyst
RXCui
207073
242679
544412
544412
544412
352307
352307
352307
352308
352308
352308
615172
615172
615172
352309
352309
352309
352310
352310
352310
404602
404602
404602
643021
643021
643021
643023
643023
643023
1299203
1300006
1300014
1300016
1053651
1053654
1053657
1053660
1053663
1053666
885133
199150
200132
199149
261313
211776
352052
Label Name
8-MOP 10 MG CAPSULE
ABACAVIR 300 MG TABLET
ABILIFY 1 MG/ML SOLUTION
ABILIFY 10 MG TABLET
ABILIFY 2 MG TABLET
ABILIFY 2 MG TABLET
ABILIFY 2 MG TABLET
ABILIFY 5 MG TABLET
ABILIFY 5 MG TABLET
ABILIFY 5 MG TABLET
ABILIFY DISCMELT 10 MG TABLET
ABSORICA 10 MG CAPSULE
ABSTRAL 100 MCG TAB SUBLINGUAL
ACANYA GEL PUMP
ACARBOSE 100 MG TABLET
ACCOLATE 10 MG TABLET
ACCOLATE 20 MG TABLET
ACCUNEB 0.63 MG/3 ML INH SOLN
Strength
10000
300000
1000
1000
1000
10000
10000
10000
15000
15000
15000
2000
2000
2000
20000
20000
20000
30000
30000
30000
5000
5000
5000
10000
10000
10000
15000
15000
15000
10000
20000
30000
40000
100
200
300
400
600
800
1200
100000
25000
50000
10000
20000
210
Unit
MG
MG
MG/ML
MG/ML
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
MG
MG
MG
MG
MG/ML
352051
207892
207893
207895
207891
809854
809858
882559
998689
998685
854986
854990
854927
993770
993781
993890
993755
197426
213525
313786
197303
197304
562524
307707
197305
307718
307719
855476
855482
207484
858749
751970
751970
261109
261110
261106
262219
261107
261108
1359125
1359128
905030
905034
905026
905093
905101
905043
ACCUNEB 1.25 MG/3 ML INH SOLN

ACCUPRIL 10 MG TABLET
ACCURETIC 10-12.5 MG TABLET
ACCURETIC 20-12.5 MG TABLET
ACCURETIC 20-25 MG TABLET
ACEBUTOLOL 200 MG CAPSULE
ACEBUTOLOL 400 MG CAPSULE
ACEON 2 MG TABLET
ACEON 4 MG TABLET
ACEON 8 MG TABLET
ACETAMINOPHEN-COD #2 TABLET
ACETAMINOPHEN-CODEINE ELIXIR
ACETAMINOPHN-BUTALBITAL 325-50
ACETASOL HC EAR DROPS
ACETASOL HC EAR DROPS
ACETAZOLAMIDE 125 MG TABLET
ACETAZOLAMIDE 250 MG TABLET
ACETAZOLAMIDE ER 500 MG CAP
ACETIC ACID 0.25% IRRIG SOLN
ACETIC ACID 2% EAR SOLUTION
ACETYLCYSTEINE 10% VIAL
ACETYLCYSTEINE 20% VIAL
ACLOVATE 0.05% CREAM
ACLOVATE 0.05% OINTMENT
ACTICIN 5% CREAM
ACTIGALL 300 MG CAPSULE
ACTIMMUNE 2 MILLION UNIT VIAL
ACTIMMUNE 2 MILLION UNIT VIAL
ACTIQ 1,200 MCG LOZENGE
ACTIQ 1,600 MCG LOZENGE
ACTIQ 200 MCG LOZENGE
ACTIVELLA 0.5-0.1 MG TABLET
ACTIVELLA 1 MG-0.5 MG TABLET
ACTONEL 150 MG TABLET
ACTONEL 5 MG TABLET
420
10000
20000
40000
5000
10000
20000
25000
200000
400000
2000
4000
8000
15000
30000
60000
12000
325000
1000
1000
125000
250000
500000
250
2000
10000
20000
50
50
5000
300000
3000
3000
1200
1600
200
400
600
800
500
1000
150000
30000
35000
35000
35000
5000
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG
%
%
MG
MG
MG
%
%
%
%
%
%
%
MG
MMU
MMU
MCG
MG
MCG
MCG
MCG
MCG
MG
MG
MG
MG
MG
MG
MG
MG
905095
861785
861824
899993
900000
261266
261267
261268
540517
860109
860105
858366
197310
307730
197311
197313
701858
672916
672917
672918
313852
307731
849866
541894
687045
577960
577962
541365
541879
1009147
861222
861224
861226
861228
861233
861238
730065
730065
891437
891438
313967
896185
896190
896193
896212
896229
896243
ACTONEL WITH CALCIUM TABLET

ACTOPLUS MET 15 MG-500 MG TAB
ACTOPLUS MET 15 MG-850 MG TAB
ACTOPLUS MET XR 15-1,000 MG TB
ACTOPLUS MET XR 30-1,000 MG TB
ACTOS 15 MG TABLET
ACTOS 30 MG TABLET
ACTOS 45 MG TABLET
ACUFLEX CAPLET
ACULAR 0.5% EYE DROPS
ACULAR LS 0.4% OPHTH SOL
ACUVAIL 0.45% OPHTH SOLUTION
ACYCLOVIR 200 MG CAPSULE
ACYCLOVIR 200 MG/5 ML SUSP
ACYCLOVIR 400 MG TABLET
ACYCLOVIR 800 MG TABLET
ACZONE 5% GEL
ADALAT CC 30 MG TABLET
ADAPALENE 0.1% CREAM
ADAPALENE 0.1% GEL
ADCIRCA 20 MG TABLET
ADDERALL 10 MG TABLET
ADDERALL 12.5 MG TABLET
ADDERALL 7.5 MG TABLET
ADDERALL XR 10 MG CAPSULE
ADOXA 150 MG CAPSULE
ADOXA 150 MG CAPSULE
ADRENACLICK 0.15 MG AUTO-INJCT
ADRENACLICK 0.3 MG AUTO-INJECT
ADRENALIN 1:1,000 NASAL SOLN
ADVAIR 100-50 DISKUS
ADVAIR HFA 115-21 MCG INHALER
500000
500000
850000
1000000
1000000
15000
30000
45000
55000
500
400
450
200000
200000
400000
800000
5000
30000
60000
90000
100
100
20000
10000
12500
15000
20000
30000
5000
7500
10000
15000
20000
25000
30000
5000
150000
150000
150
300
0
100
250
250
250
500
115
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
%
MG
MG
MG
MG
%
MG
MG
MG
%
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
0
MCG
MCG
MCG
MG
MG
MCG
896245
896271
896273
896235
896237
1367955
1367967
1367946
1367942
1368056
1368058
1367938
1368050
1368065
1367973
1367978
791834
791846
791838
791842
828929
1101857
755092
318272
672920
672921
845512
998191
845518
1119402
1362082
597857
1363779
1363653
602517
998183
1046613
206213
1298352
1011703
754944
206347
828252
996623
1236095
854914
206026

ADVATE 1,201-1,800 UNITS VIAL
ADVATE 200-400 UNITS VIAL
ADVATE 801-1,200 UNITS VIAL
ADVATE 801-1,200 UNITS VIAL
ADVICOR 1,000 MG-20 MG TABLET
ADVICOR 1,000 MG-40 MG TABLET
ADVICOR 500 MG-20 MG TABLET
ADVICOR 750 MG-20 MG TABLET
AEROBID-M AEROSOL WITH ADAPTER
AEROHIST CAPLET
AEROKID SYRUP
AF-ASPIRIN 81 MG TAB CHEW
AFEDITAB CR 30 MG TABLET
AFEDITAB CR 60 MG TABLET
AFINITOR 10 MG TABLET
AFINITOR 2.5 MG TABLET
AFINITOR 5 MG TABLET
AFINITOR 7.5 MG TABLET
AGGRENOX 25 MG-200 MG CAPSULE
AGRYLIN 0.5 MG CAPSULE
AH-CHEW D TABLET CHEW
AH-CHEW II CHEWABLE TABLET
AHIST 12 MG TABLET
AIRACOF LIQUID
AK-CON 0.1% EYE DROPS
AKNE-MYCIN 2% OINTMENT
AK-PENTOLATE 1% EYE DROPS
AKTEN 3.5% GEL DROPS
ALACOL DM SYRUP
ALA-CORT 1% CREAM
ALAGESIC LQ ORAL SOLUTION
ALA-HIST AC LIQUID
ALAHIST DHC LIQUID
ALAMAST 0.1% DROPS
ALA-QUIN 3-0.5% CREAM
115
230
230
45
45
1500000
1500000
1800000
3000000
250000
250000
4000000
500000
500000
1000000
1000000
1000000
1000000
500000
750000
0
0
10000
81000
30000
60000
10000
2500
5000
7500
25000
500
10000
15000
12000
12500
100
2000
1000
3500
0
1000
40000
0
0
100
1000
MCG
MCG
MCG
MCG
MCG
IU
IU
IU
IU
AHFU
AHFU
IU
IU
IU
IU
IU
MG
MG
MG
MG
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
%
%
%
%
ML
%
MG
0
0
%
%
884077
211148
630208
245314
351137
351136
755497
582498
197316
197318
359144
359145
1191026
855480
855474
797544
1191394
208112
208116
200825
200820
200817
226734
656773
904419
904396
904405
904425
904431
861132
753095
999496
404419
540617
105562
1251353
754933
1293472
349249
997422
997493
997502
997484
997512
997515
1046276
995478
ALA-SCALP 2% LOTION
ALBENZA 200 MG TABLET
ALBUTEROL 0.083% INHAL SOLN
ALBUTEROL 5 MG/ML SOLUTION
ALBUTEROL SUL 0.63 MG/3 ML SOL
ALBUTEROL SUL 1.25 MG/3 ML SOL
ALBUTEROL SULF 2 MG/5 ML SYRUP
ALBUTEROL SULF HFA 90 MCG INH
ALBUTEROL SULFATE 2 MG TAB
ALBUTEROL SULFATE 4 MG TAB
ALBUTEROL SULFATE ER 4 MG TAB
ALBUTEROL SULFATE ER 8 MG TAB
ALCAINE 0.5% EYE DROPS
ALCLOMETASONE DIPR 0.05% OINT
ALCLOMETASONE DIPRO 0.05% CRM
ALCOHOL PREP SWABS
ALCORTIN A GEL
ALDACTAZIDE 25-25 TABLET
ALDACTAZIDE 50-50 TABLET
ALDACTONE 100 MG TABLET
ALDARA 5% CREAM
ALDEX DM SUSPENSION
ALENDRONATE SODIUM 10 MG TAB
ALENDRONATE SODIUM 5 MG TABLET
ALFUZOSIN HCL ER 10 MG TABLET
ALICLEN 6% SHAMPOO
ALI-FLEX TABLET
ALINIA 100 MG/5 ML SUSPENSION
ALINIA 500 MG TABLET
ALKERAN 2 MG TABLET
ALLANHIST PDX DROPS
ALLANHIST PDX SYRUP
ALLANTAN PEDIATRIC ORAL SUSP
ALLANVAN-S SUSPENSION
ALLEGRA 180 MG TABLET
ALLEGRA 30 MG/5 ML SUSPENSION
ALLEGRA 60 MG TABLET
ALLEGRA ODT 30 MG TABLET
ALLEGRA-D 12 HOUR TABLET
ALLEGRA-D 24 HOUR TABLET
ALLERSOL 0.1% EYE DROPS
ALLFEN CD TABLET
2000
200000
830
5000
210
420
2000
0
2000
4000
4000
8000
500
50
50
0
2000
0
50000
100000
25000
50000
5000
15000
10000
35000
40000
5000
70000
10000
6000
50000
100000
500000
2000
3000
50000
5000
0
180000
30000
60000
30000
0
240000
100
400000
%
MG
MG/ML
MG
MG/ML
MG/ML
MG/5ML
0
MG
MG
MG
MG
%
%
%
0
%
MG
MG
MG
MG
MG
%
MG
MG
MG
MG
MG
MG
MG
%
MG
MG/5ML
MG
MG
MG/ML
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
996727
197319
197320
897294
762390
762390
206792
858370
486155
310173
1149645
310180
861206
861210
1297400
979442
979450
979456
308047
308048
197321
308050
197322
433798
433800
433799
433801
485413
485415
485414
485416
237212
213262
997024
704858
845489
260333
104384
104385
1006065
997006
997007
884383
1093291
1087593
799037
799040
ALLFEN CDX TABLET

ALLOPURINOL 100 MG TABLET
ALLOPURINOL 300 MG TABLET
ALOCRIL 2% EYE DROPS
ALODOX CONVENIENCE KIT
ALODOX CONVENIENCE KIT
ALOMIDE 0.1% EYE DROPS
ALOQUIN GEL
ALORA 0.025 MG PATCH
ALORA 0.05 MG PATCH
ALORA 0.075 MG PATCH
ALORA 0.1 MG PATCH
ALPHAGAN P 0.1% DROPS
ALPHAGAN P 0.15% EYE DROPS
ALPHANATE 1,500-600 UNIT VIAL
ALPHANINE SD 1,000 UNITS VIAL
ALPHANINE SD 1,500 UNITS VIAL
ALPHANINE SD 500 UNITS VIAL
ALPRAZOLAM 0.25 MG TABLET
ALPRAZOLAM 0.5 MG TABLET
ALPRAZOLAM 1 MG TABLET
ALPRAZOLAM 1 MG/ML ORAL CONC
ALPRAZOLAM 2 MG TABLET
ALPRAZOLAM ER 0.5 MG TABLET
ALPRAZOLAM ER 1 MG TABLET
ALPRAZOLAM ODT 0.25 MG TAB
ALPRAZOLAM ODT 0.5 MG TAB
ALPRAZOLAM ODT 1 MG TAB
ALPRAZOLAM ODT 2 MG TAB
ALPROSTADIL 500 MCG/ML VIAL
ALREX 0.2% EYE DROPS
ALSUMA 6 MG/0.5 ML AUTO-INJECT
ALTABAX 1% OINTMENT
ALTACE 1.25 MG CAPSULE
ALTACE 10 MG CAPSULE
ALTACE 2.5 MG CAPSULE
ALTACE 5 MG CAPSULE
ALTAVERA-28 TABLET
ALTOPREV 20 MG TABLET
ALUVEA 39% CREAM
ALUVEA 40% CREAM
ALVESCO 160 MCG INHALER
ALVESCO 80 MCG INHALER
400000
100000
300000
2000
20000
20000
100
12500
25
50
75
100
100
150
1500000
1000000
1500000
500000
250
500
1000
1000
2000
500
1000
2000
3000
250
500
1000
2000
500
200
12000
1000
1250
10000
2500
5000
150
20000
40000
60000
39000
40000
160
80
MG
MG
MG
%
MG
MG
%
%
MG
MG
MG
MG
%
%
UNITS
U
U
U
MG
MG
MG
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MCG/ML
%
MG/ML
%
MG
MG
MG
MG
MG
MG
MG
MG
%
%
MG
MG
1242786
1242787
849389
849389
849395
849395
849385
849385
153843
153591
153845
790451
854875
854878
854882
854896
1089060
996716
1300022
1089057
996712
197327
199041
197328
213211
213212
1112687
1244632
1112715
540540
754890
211465
977880
977883
618977
312548
476271
582299
197351
211848
313794
308119
833528
834348
617768
794641
856783
ALYACEN 1-35-28 TABLET

ALYACEN 7-7-7-28 TABLET
AMANTADINE 100 MG CAPSULE
AMANTADINE 100 MG CAPSULE
AMANTADINE 100 MG TABLET
AMANTADINE 100 MG TABLET
AMANTADINE 50 MG/5 ML SYRUP
AMANTADINE 50 MG/5 ML SYRUP
AMARYL 1 MG TABLET
AMARYL 2 MG TABLET
AMARYL 4 MG TABLET
AMBI 10PEH-400GFN-20DM TABLET
AMBIEN 10 MG TABLET
AMBIEN 5 MG TABLET
AMBIEN CR 12.5 MG TABLET
AMBIEN CR 6.25 MG TABLET
AMBIFED CD TABLET
AMBIFED CDX TABLET
AMBIFED TABLET
AMBIFED-G CD TABLET
AMBIFED-G CDX TABLET
AMCINONIDE 0.1% CREAM
AMCINONIDE 0.1% LOTION
AMCINONIDE 0.1% OINTMENT
AMERGE 1 MG TABLET
AMERGE 2.5 MG TABLET
AMETHIA 0.15-0.03-0.01 MG TAB
AMETHIA LO TABLET
AMETHYST 90-20 MCG TABLET
AMICAR 1,000 MG TABLET
AMICAR 25% SOLUTION
AMICAR 500 MG TABLET
AMILORIDE HCL 5 MG TABLET
AMILORIDE HCL-HCTZ 5-50 MG TAB
AMINOBENZOATE POT 500 MG CAP
AMINOBENZOATE POT ENVULE 2 GM
AMINOCAPROIC ACID 1,000 MG TAB
AMINOCAPROIC ACID 25% SOLUTION
AMINOCAPROIC ACID 500 MG TAB
AMINO-CERV CREAM
AMINOPHYLLINE 100 MG TABLET
AMINOPHYLLINE 200 MG TABLET
AMIODARONE HCL 200 MG TABLET
AMIODARONE HCL 400 MG TABLET
AMITIZA 24 MCG CAPSULES
AMITIZA 8 MCG CAPSULE
AMITRIPTYLINE HCL 10 MG TAB
1000
777000
100000
100000
100000
100000
50000
50000
1000
2000
4000
0
10000
5000
12500
6250
30000
30000
400000
20000
20000
100
100
100
1000
2500
150
0
0
1000000
250000
500000
5000
0
500000
2000000
1000000
250000
500000
0
100000
200000
200000
400000
24
8
10000
MG
MG
MG
MG
MG
MG
MG/5ML
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
%
MG
MG
MG
MG
MG
MG
MG/ML
MG
MG
MG
MG
MG
MG
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
856762
856773
856834
856845
856853
308135
308136
197361
597987
597967
597990
404013
597971
597974
597993
597977
597980
597984
404011
898342
898346
898350
898353
898356
898359
543460
197362
404058
404061
404064
617309
617423
562251
617322
617316
617430
617296
617993
562508
197363
197364
197365
197366
308177
313797
308181
313850

AMLODIPINE BESYLATE 10 MG TAB
AMLODIPINE BESYLATE 2.5 MG TAB
AMLODIPINE BESYLATE 5 MG TAB
AMLODIPINE-ATORVAST 10-10 MG
AMLODIPINE-ATORVAST 2.5-10 MG
AMLODIPINE-BENAZEPRIL 10-20 MG
AMLODIPINE-BENAZEPRIL 2.5-10
AMMONIUM LACTATE 12% CREAM
AMMONIUM LACTATE 12% LOTION
AMNESTEEM 10 MG CAPSULE
AMOX TR-K CLV 200-28.5 TAB CHW
AMOX TR-K CLV 200-28.5/5 SUSP
AMOX TR-K CLV 250-125 MG TAB
AMOX TR-K CLV 400-57 TAB CHEW
AMOX TR-K CLV 400-57/5 SUSP
AMOXAPINE 100 MG TABLET
AMOXICILLIN 125 MG TAB CHEW
AMOXICILLIN 125 MG/5 ML SUSP
100000
150000
25000
50000
75000
10000
2500
5000
10000
10000
10000
10000
2500
2500
2500
5000
5000
5000
5000
10000
40000
2500
10000
20000
5000
12000
12000
10000
20000
40000
200000
200000
250000
250000
400000
400000
500000
600000
875000
100000
150000
25000
50000
125000
125000
200000
200000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
MG
MG
MG
MG
MG/5ML
MG
MG/5ML
MG
MG/5ML
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG/5ML
MG
MG/5ML
308182
598025
628676
239191
308188
308189
308191
308192
308194
617995
541892
687043
577957
577961
541363
541878
1009145
313799
308210
313800
308212
897025
828359
828355
1050802
1050805
1050808
1050811
1050814
1192860
1192862
577307
1037274
208221
91792
857299
857303
857307
597850
597852
1360954
1360954
1362211
1362211
1360956
1360956
1012574
AMOXICILLIN 250 MG CAPSULE

AMOXICILLIN 500 MG CAPSULE
AMOXICILLIN 500 MG TABLET
AMOXICILLIN 875 MG TABLET
AMOXICILLIN-CLAV ER 1,000-62.5
AMPHETAMINE SALTS 10 MG TAB
AMPHETAMINE SALTS 12.5 MG TB
AMPHETAMINE SALTS 20 MG TABLET
AMPHETAMINE SALTS 7.5 MG TAB
AMPICILLIN 125 MG/5 ML SUSP
AMPICILLIN 250 MG/5 ML SUSP
AMPICILLIN TR 250 MG CAPSULE
AMPICILLIN TR 500 MG CAPSULE
AMPYRA ER 10 MG TABLET
AMRIX ER 15 MG CAPSULE
AMRIX ER 30 MG CAPSULE
AMTURNIDE 150-5-12.5 MG TAB
AMTURNIDE 300-10-25 MG TAB
AMTURNIDE 300-5-25 MG TAB
AMVISC 12 MG/ML SYRINGE
AMVISC PLUS 16 MG/ML SYRINGE
AMYL NITRITE AMPUL
ANABAR CAPLET
ANACAINE OINTMENT
ANADROL-50 TABLET
ANAFRANIL 25 MG CAPSULE
ANAGRELIDE HCL 0.5 MG CAPSULE
ANAGRELIDE HCL 1 MG CAPSULE
ANALPRAM HC 1% CREAM
ANALPRAM HC 1% CREAM
ANALPRAM HC 2.5% CREAM
ANALPRAM HC 2.5% CREAM
ANALPRAM HC 2.5% LOTION
ANALPRAM HC 2.5% LOTION
ANAMANTLE HC CREAM
250000
250000
250000
250000
400000
400000
500000
500000
875000
1000000
10000
12500
15000
20000
30000
5000
7500
125000
250000
250000
500000
10000
15000
30000
150000
300000
300000
300000
300000
12000
16000
0
0
10000
50000
25000
50000
75000
500
1000
1000
1000
2500
2500
2500
2500
0
MG
MG
MG
MG/5ML
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/ML
MG/ML
0
MG
%
MG
MG
MG
MG
MG
MG
%
%
%
%
%
%
0
1012574
1012569
1012569
849400
849438
1048056
1048056
199224
207125
207127
349281
1190955
261192
1190957
261193
285015
1100711
731526
692688
1301615
1301604
1193120
1193046
205626
210628
210716
578797
578799
244309
995626
995668
995688
1291101
1291101
260318
260318
1291103
1291103
213092
213091
966609
966820
351712
803194
847261
855858
308345
ANAMANTLE HC CREAM
ANAMANTLE HC FORTE CREAM KIT
ANAMANTLE HC FORTE CREAM KIT
ANAPROX 275 MG TABLET
ANAPROX DS 550 MG TABLET
ANASPAZ 0.125 MG TABLET ODT
ANASPAZ 0.125 MG TABLET ODT
ANASTROZOLE 1 MG TABLET
ANCOBON 250 MG CAPSULE
ANCOBON 500 MG CAPSULE
ANDEHIST NR SYRUP
ANDRODERM 2 MG/24HR PATCH
ANDRODERM 2.5 MG/24HR PATCH
ANDROGEL 1%(2.5G) GEL PACKET
ANDROGEL 1.62%(2.5G) GEL PCKT
ANDROID 10 MG CAPSULE
ANDROXY 10 MG TABLET
ANGELIQ 0.25 MG-0.5 MG TABLET
ANGELIQ 0.5 MG-1 MG TABLET
ANIMI-3 CAPSULE
ANIMI-3 WITH VITAMIN D CAPSULE
ANSAID 100 MG TABLET
ANTABUSE 250 MG TABLET
ANTABUSE 500 MG TABLET
ANTARA 130 MG CAPSULE
ANTARA 43 MG CAPSULE
ANTIPYRINE-BENZOCAINE EAR DROP
ANTIVERT 12.5 MG TABLET
ANTIVERT 25 MG TABLET
ANTIVERT 50 MG TABLET
ANUCORT-HC 25 MG SUPPOSITORY
ANUCORT-HC 25 MG SUPPOSITORY
ANUSOL-HC 2.5% CREAM
ANUSOL-HC 2.5% CREAM
ANUSOL-HC 25 MG SUPPOSITORY
ANUSOL-HC 25 MG SUPPOSITORY
ANZEMET 100 MG TABLET
ANZEMET 50 MG TABLET
APEXICON 0.05% OINTMENT
APEXICON E 0.05% CREAM
APHTHASOL 5% PASTE
APIDRA 100 UNITS/ML VIAL
APIDRA SOLOSTAR 100 UNITS/ML
APOKYN 30 MG/3 ML CARTRIDGE
APRACLONIDINE HCL 0.5% DROPS
0
1000
1000
275000
550000
125
125
1000
250000
500000
45000
2000
2500
4000
5000
25000
40500
10000
10000
250
1000
0
500000
100000
250000
500000
130000
43000
0
12500
25000
50000
25000
25000
2500
2500
25000
25000
100000
50000
50
50
5000
100000
100000
10000
500
0
%
%
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG
MG
MG
MG/HR
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
0
MG
MG
MG
MG
MG
%
%
MG
MG
MG
MG
%
%
%
U/ML
U/ML
MG/ML
%
753482
825134
805515
603378
1116760
750267
730046
352047
731231
731235
352048
731245
352044
731229
352262
731227
352045
731241
731250
352046
213377
213379
1094010
1093300
763457
1114333
351974
997224
1100187
997230
997222
997228
151124
861358
861362
861364
861366
208544
208544
208534
208534
208547
208547
208549
208549
208535
208535
APRI 28 DAY TABLET

APRISO ER 0.375 GRAM CAPSULE
APTIVUS 100 MG/ML SOLUTION
APTIVUS 250 MG CAPSULE
ARALEN PHOSPHATE 500 MG TAB
ARANELLE 28 TABLET
ARANESP 100 MCG/0.5 ML SYRINGE
ARANESP 100 MCG/ML VIAL
ARANESP 25 MCG/0.42 ML SYRING
ARANESP 500 MCG/1 ML SYRINGE
ARAVA 10 MG TABLET
ARAVA 20 MG TABLET
ARBINOXA 4 MG TABLET
ARBINOXA 4 MG/5 ML LIQUID
ARCALYST 220 MG INJECTION
ARCAPTA NEOHALER 75 MCG CAP
ARESTIN 1 MG MICROSPHERE
ARICEPT 10 MG TABLET
ARICEPT 23 MG TABLET
ARICEPT 5 MG TABLET
ARICEPT ODT 10 MG TABLET
ARICEPT ODT 5 MG TABLET
ARIMIDEX 1 MG TABLET
ARIXTRA 10 MG SYRINGE
ARIXTRA 2.5 MG SYRINGE
ARIXTRA 5 MG SYRINGE
ARIXTRA 7.5 MG SYRINGE
ARMOUR THYROID 120 MG TABLET
150
375
100000
250000
500000
0
100
100
150
100
200
25
25
300
300
40
40
500
60
60
10000
20000
4000
4000
220000
75
1000
10000
23000
5000
10000
5000
1000
10000
2500
5000
7500
120000
120000
15000
15000
180000
180000
240000
240000
30000
30000
MG
MG
MG
MG
MG
MG
MG/0.5
MG/ML
MCG
MG/0.5
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/.3M
MG/ML
MG
MG
MG
MG/5ML
MG
MCG
MG
MG
MG
MG
MG
MG
MG
MG/0.8
MG/0.5
MG/0.4
MG/0.6
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
208551
208551
208540
208540
208543
208543
261317
1359107
1359109
104112
849383
994239
790284
746811
746813
746815
746804
212033
308417
243670
308416
1293665
860798
862042
860803
544864
639539
639543
577785
577787
805863
805859
805855
1020066
197379
197380
197381
197383
197382
206821
104719
206828
617312
617310
617311
259255
864675

AROMASIN 25 MG TABLET
ARTHROTEC 50 MG-200 MCG TAB
ARTHROTEC 75 MG-200 MCG TAB
ASACOL EC 400 MG TABLET
ASACOL HD DR 800 MG TABLET
ASCOMP WITH CODEINE CAPSULE
ASMANEX TWISTHALER 110 MCG #30
ASMANEX TWISTHALR 220 MCG #120
ASPIRIN 325 MG TABLET
ASPIRIN 975 MG TABLET EC
ASPIRIN EC 81 MG TABLET
ASPIRIN EC 81 MG TABLET
ASPIR-LOW EC 81 MG TABLET
ASTELIN 137 MCG NASAL SPRAY
ASTEPRO 0.15% NASAL SPRAY
ASTEPRO 137 MCG NASAL SPRAY
ASTRINGYN SOLUTION
ATACAND 16 MG TABLET
ATACAND 32 MG TABLET
ATACAND 4 MG TABLET
ATACAND 8 MG TABLET
ATACAND HCT 16-12.5 MG TAB
ATACAND HCT 32-12.5 MG TAB
ATACAND HCT 32-25 MG TABLET
ATELVIA DR 35 MG TABLET
ATENOLOL 100 MG TABLET
ATENOLOL-CHLORTHAL 50-25 TB
ATENOLOL-CHLORTHALIDONE 100-25
ATIVAN 0.5 MG TABLET
ATIVAN 1 MG TABLET
ATIVAN 2 MG TABLET
ATORVASTATIN 10 MG TABLET
ATOVAQUONE-PROGUANIL 250-100
300000
300000
60000
60000
90000
90000
250000
50000
75000
400000
800000
30000
110
220
220
220
220
325000
975000
81000
81000
81000
0
150
0
259000
16000
32000
4000
8000
16000
32000
32000
35000
100000
25000
50000
50000
100000
500
1000
2000
10000
20000
40000
80000
250000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MCG
MCG
MCG
MCG
MCG
MG
MG
MG
MG
MG
0
%
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
864681
749329
643070
643070
1190655
1190570
836372
836364
836368
668995
1310531
1310535
617333
824186
617339
824174
824190
824194
618028
861689
214040
1148595
214041
584503
1305268
1305269
823934
823938
823942
861762
861808
861765
861818
847716
847712
847708
847720
847724
261241
261242
261243
153666
153667
153665
1005767
1000672
1006105
ATOVAQUONE-PROGUANIL 62.5-25
ATRALIN 0.05% GEL
ATRIPLA TABLET
ATRIPLA TABLET
ATROPINE 1% EYE DROPS
ATROPINE 1% EYE OINTMENT
ATROVENT 0.03% SPRAY
ATROVENT 0.06% SPRAY
ATROVENT HFA INHALER
ATUSS DS SUSPENSION
AUBAGIO 14 MG TABLET
AUBAGIO 7 MG TABLET
AUGMENTIN 125-31.25 MG/5 ML
AUGMENTIN 250-125 TABLET
AUGMENTIN 250-62.5 MG/5 ML
AUGMENTIN 250-62.5 TAB CHEW
AUGMENTIN ES-600 SUSPENSION
AUGMENTIN XR 1,000-62.5 TAB
AURALGAN EAR DROPS
AURAX OTIC SOLUTION
AURODEX OTIC SOLUTION
AUROGUARD OTIC SOLUTION
AUVI-Q 0.15 MG AUTO-INJECTOR
AUVI-Q 0.3 MG AUTO-INJECTOR
AVALIDE 150-12.5 MG TABLET
AVALIDE 300-12.5 MG TABLET
AVALIDE 300-25 MG TABLET
AVANDAMET 2 MG-1,000 MG TAB
AVANDAMET 2 MG-500 MG TABLET
AVANDAMET 4 MG-1,000 MG TABLET
AVANDAMET 4 MG-500 MG TABLET
AVANDARYL 4 MG-1 MG TABLET
AVANDIA 2 MG TABLET
AVANDIA 4 MG TABLET
AVANDIA 8 MG TABLET
AVAPRO 150 MG TABLET
AVAPRO 300 MG TABLET
AVAPRO 75 MG TABLET
AVAR CLEANSER
AVAR GEL
AVAR LS CLEANSER
62500
50
200000
200000
1000
1000
30
60
17
30000
14000
7000
125000
250000
250000
250000
500000
875000
600000
1000000
5000
5500
0
0
150
300
150000
300000
25000
1000000
2000
0
4000
1000
2000
4000
8000
8000
2000
4000
8000
150000
300000
75000
0
10000
10000
MG
%
MG
MG
%
%
%
%
MCG
MG
MG
MG
MG/5ML
MG
MG/5ML
MG
MG
MG
MG/5ML
MG
%
%
0
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
0
%
%
1005835
1000736
208435
261339
794246
750268
830605
830605
846101
892299
892299
892344
892344
1190284
1190284
892351
892351
1086310
1086310
892357
892357
208327
208332
352118
153324
727816
284589
284588
582620
104096
1000407
404476
404475
706872
197388
860805
860796
1043753
637218
637185
861416
308459
141963
308460
749783
248656
749780
AVAR-E EMOLLIENT CREAM

AVAR-E LS CREAM
AVC 15% CREAM
AVELOX 400 MG TABLET
AVELOX ABC PACK 400 MG TAB
AVIANE-28 TABLET
AVIDOXY 100 MG TABLET
AVIDOXY 100 MG TABLET
AVIDOXY DK KIT
AVINZA 120 MG CAPSULE
AVITA 0.025% CREAM
AVITA 0.025% GEL
AVODART 0.5 MG SOFTGEL
AVONEX ADMIN PACK 30 MCG VL
AVONEX PEN 30 MCG/0.5 ML
AXERT 12.5 MG TABLET
AXERT 6.25 MG TABLET
AXID 15 MG/ML ORAL SOLUTION
AXID 150 MG PULVULE
AYGESTIN 5 MG TABLET
AZASAN 100 MG TABLET
AZASAN 75 MG TABLET
AZASITE 1% EYE DROPS
AZATHIOPRINE 50 MG TABLET
AZELASTINE HCL 0.05% DROPS
AZELASTINE HCL 0.1% NASAL SPRY
AZELEX 20% CREAM
AZILECT 0.5 MG TABLET
AZILECT 1 MG TABLET
AZITHROMYCIN 1 GM PWD PACKET
AZITHROMYCIN 100 MG/5 ML SUSP
AZITHROMYCIN 200 MG/5 ML SUSP
AZITHROMYCIN 250 MG TABLET
10000
10000
15000
400000
400000
0
100000
100000
100000
120000
120000
30000
30000
45000
45000
60000
60000
75000
75000
90000
90000
25
25
500
30
30
12500
6250
15000
150000
5000
100000
75000
1000
50000
500
137
20000
500
1000
1000000
100000
200000
250000
250000
500000
500000
%
%
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
MG
MCG
MCG
MG
MG
MG
MG
MG
MG
MG
%
MG
%
MG
%
MG
MG
GM
MG/5ML
MG/5ML
MG
MG
MG
MG
204844
213272
744624
744628
744632
744636
208437
724154
831872
308508
308511
308511
197391
197392
208416
208416
849580
849580
213182
103570
108758
754943
806392
806396
885857
1236083
1095362
824299
1092360
824303
607579
578457
578459
637477
901649
825181
211874
825180
310520
1233622
966547
999394
312104
312104
312107
312107
1046815

AZOPT 1% EYE DROPS
AZOR 10-20 MG TABLET
AZOR 10-40 MG TABLET
AZOR 5-20 MG TABLET
AZOR 5-40 MG TABLET
AZULFIDINE 500 MG TABLET
AZULFIDINE ENTAB 500 MG
AZURETTE 28 DAY TABLET
BACITRACIN 500 UNIT/GM OINTMNT
BACITRACIN-POLYMYXIN EYE OINT
BACITRACIN-POLYMYXIN EYE OINT
BACLOFEN 10 MG TABLET
BACLOFEN 20 MG TABLET
BACTRIM 400-80 MG TABLET
BACTRIM 400-80 MG TABLET
BACTRIM DS TABLET
BACTRIM DS TABLET
BACTROBAN 2% CREAM
BACTROBAN 2% OINTMENT
BACTROBAN NASAL 2% OINTMENT
BALACALL DM SYRUP
BALANCED SALT SOLUTION
BALANCED SALT SOLUTION
BALSALAZIDE DISODIUM 750 MG CP
BALTUSSIN SYRUP
BALZIVA 28 TABLET
BANZEL 200 MG TABLET
BANZEL 40 MG/ML SUSPENSION
BANZEL 400 MG TABLET
BARACLUDE 0.05 MG/ML SOLUTION
BARACLUDE 0.5 MG TABLET
BARACLUDE 1 MG TABLET
BASE, PCCA POLOXAMER 407 GEL
BAYCADRON 0.5 MG/5 ML ELIXIR
BAYER ADULT LOW STRENGTH ASA
BAYER ASPIRIN 325 MG GELCAP
BAYER CHILDREN'S ASPIRIN
BD GLUCOSE 5 G TABLET CHEWABLE
BEBULIN VH IMMU 200-1,200 UNIT
BECONASE AQ 0.042% SPRAY
BEFLEX CAPLET
BELLADONNA-OPIUM 16.2-30 SUPP
BELLADONNA-PHENOBARBITAL TAB
600000
1000
10000
10000
5000
5000
500000
500000
0
500000
0
0
10000
20000
400000
400000
800000
800000
2000
2000
2000
0
0
0
750000
20000
35
200000
40000
400000
50
500
1000
20000
500
81000
325000
81000
0
700000
0
500000
30000
30000
60000
60000
0
MG
%
MG
MG
MG
MG
MG
MG
0
U/G
MG
MG
MG
MG
MG
MG
MG
MG
%
%
%
ML
0
0
MG
MG/5ML
MCG
MG
MG/ML
MG
MG/ML
MG
MG
%
MG/5ML
MG
MG
MG
MG
U
0
MG
MG
MG
MG
MG
MG
1046815
1049634
898687
898690
898719
898723
898362
898367
898372
898378
826015
826019
826023
1236206
826011
352200
352201
352199
847060
847055
847042
1312997
991063
991084
991088
208502
845977
208482
845978
284544
1049278
213082
1099800
866058
1049682
1302433
1302437
1020047
846031
604583
727465
197397
283417
809322
845836
389122
797678
BELLADONNA-PHENOBARBITAL TAB
BENADRYL 50 MG/ML VIAL
BENAZEPRIL HCL 10 MG TABLET
BENAZEPRIL-HCTZ 10-12.5 MG TAB
BENAZEPRIL-HCTZ 20-25 MG TAB
BENEFIX 1,000 UNIT KIT
BENEFIX 250 UNIT KIT
BENEFIX 500 UNIT KIT
BENICAR 20 MG TABLET
BENICAR 40 MG TABLET
BENICAR 5 MG TABLET
BENICAR HCT 20-12.5 MG TABLET
BENICAR HCT 40-12.5 MG TABLET
BENICAR HCT 40-25 MG TABLET
BENSAL HP OINTMENT
BENTYL 10 MG CAPSULE
BENTYL 10 MG/5 ML SYRUP
BENTYL 20 MG TABLET
BENZAC AC 10% GEL
BENZAC AC 10% GEL
BENZAC AC 5% GEL
BENZAC W WASH 5% LIQUID
BENZACLIN CAREKIT
BENZALKONIUM CL 17% SOLUTION
BENZAMYCINPAK GEL
BENZASHAVE 10% CREAM
BENZEFOAM 5.3% EMOLLIENT FOAM
BENZEFOAM ULTRA 9.8% FOAM
BENZEPRO 5.3% EMOLLIENT FOAM
BENZEPRO 9.8% FOAM
BENZIQ 5.25% GEL
BENZIQ 5.25% WASH
BENZIQ LS 2.75% GEL
BENZOIN COMPOUND TINCTURE
BENZONATATE 100 MG CAPSULE
BENZONATATE 200 MG CAPSULE
BENZOYL PEROX 8% CREAMY WASH
BENZOYL PEROXIDE 2.5% WASH
BENZOYL PEROXIDE 3% CLEANSER
BENZOYL PEROXIDE 3% PAD
0
50000
10000
20000
40000
5000
10000
12500
25000
5000
1000000
2000000
250000
3000000
500000
20000
40000
5000
20000
40000
25000
0
10000
10000
20000
10000
10000
5000
5000
1000
17000
5000
10000
5300
9800
5300
9800
5250
5250
2750
0
100000
200000
8000
2500
3000
3000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
IU
IU
IU
IU
IU
MG
MG
MG
MG
MG
MG
0
MG
MG/5ML
MG
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
0
MG
MG
%
%
%
%
866054
847131
797704
828534
420071
797710
1049680
885219
885213
885209
863042
867381
850309
1149663
1150834
1150838
238920
240209
197405
848180
848176
848208
848178
197407
197408
197409
1244634
904569
904581
904591
904603
207059
1297753
1297757
308720
857321
857328
857336
857340
208560
208561
213729
1013630
205857
205863
205860
205866
BENZOYL PEROXIDE 5.3% FOAM

BENZOYL PEROXIDE 8.5% CLEANSER
BENZOYL PEROXIDE 9.8% FOAM
BENZTROPINE MES 0.5 MG TAB
BENZTROPINE MES 1 MG TABLET
BENZTROPINE MES 2 MG TABLET
BEPREVE 1.5% EYE DROPS
BERINERT 500 UNIT KIT
BESIVANCE 0.6% SUSP
BETADINE 5% EYE SOLUTION
BETAGAN 0.25% EYE DROPS
BETAGAN 0.5% EYE DROPS
BETAMETHASONE DP 0.05% CRM
BETAMETHASONE DP 0.05% LOT
BETAMETHASONE DP 0.05% OINT
BETAMETHASONE DP 0.05% OINT
BETAMETHASONE DP AUG 0.05% CRM
BETAMETHASONE DP AUG 0.05% GEL
BETAMETHASONE DP AUG 0.05% LOT
BETAMETHASONE VA 0.1% CREAM
BETAMETHASONE VA 0.1% LOTION
BETAMETHASONE VALER 0.1% OINTM
BETAMETHASONE VALER 0.12% FOAM
BETAPACE 120 MG TABLET
BETAPACE AF 80 MG TABLET
BETASERON 0.3 MG KIT
BETAXOLOL 10 MG TABLET
BETAXOLOL 20 MG TABLET
BETAXOLOL HCL 0.5% EYE DROP
BETHANECHOL 10 MG TABLET
BETIMOL 0.25% EYE DROPS
BETIMOL 0.5% EYE DROPS
BETOPTIC S 0.25% EYE DROPS
BEYAZ 28 TABLET
BIAXIN 125 MG/5 ML SUSPENSION
BIAXIN 250 MG TABLET
BIAXIN 250 MG/5 ML SUSPENSION
BIAXIN 500 MG TABLET
5300
6000
6000
8500
9000
9000
9800
500
1000
2000
1500
500000
600
5000
250
500
50
50
50
50
50
50
50
100
100
100
0
120000
160000
240000
80000
300
10000
20000
500
10000
25000
5000
50000
250
500
250
3000
125000
250000
250000
500000
%
%
%
%
%
%
%
MG
MG
MG
%
U
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
MG
MG
MG
MG
MG
MG
MG
%
MG
MG
MG
MG
%
%
%
MG
MG/5ML
MG
MG/5ML
MG
685543
835342
1113013
199123
905379
978680
208975
1248083
1246604
1246599
1246606
854901
854905
854908
854916
854919
1006122
1012017
1011987
904934
545144
1307630
1307635
1000720
845988
1000861
1088805
1307147
1014469
707348
809220
308691
809212
308697
749880
211329
1094543
1116639
861200
861208
979529
1020510
1358993
578018
404375
197411
197412
BIAXIN XL 500 MG TABLET

BICALUTAMIDE 50 MG TABLET
BIDIL TABLET
BIFERA RX TABLET
BILTRICIDE 600 MG TABLET
BINOSTO 70 MG TABLET EFF
BIONECT 0.2% CREAM
BIONECT 0.2% GEL
BIONECT 0.2% SPRAY
BISOPROLOL FUMARATE 10 MG TAB
BISOPROLOL FUMARATE 5 MG TAB
BISOPROLOL-HCTZ 10-6.25 MG TAB
BISOPROLOL-HCTZ 2.5-6.25 MG TB
BISOPROLOL-HCTZ 5-6.25 MG TAB
BLEPH-10 10% EYE DROPS
BLEPHAMIDE EYE DROPS
BLEPHAMIDE EYE OINTMENT
BONIVA 150 MG TABLET
BOROFAIR EAR DROPS
BOSULIF 100 MG TABLET
BOSULIF 500 MG TABLET
BP 10-1 WASH
BP 7% WASH
BP CLEANSING WASH
BP FOLINATAL PLUS B TABLET
BP NEW ALLERGY DM SUSPENSION
BP POLY-650 TABLET
BP-50% UREA EMULSION
BPO 4% CREAMY WASH PACK
BPO 4% GEL
BPO 8% CREAMY WASH PACK
BPO 8% GEL
BREVICON 28 TABLET
BREVOXYL-8 GEL
BRIELLYN TABLET
BRILINTA 90 MG TABLET
BRIMONIDINE 0.2% EYE DROP
BRIMONIDINE TARTRATE 0.15% DRP
BROMAX 11 MG TABLET
BROMDAY 0.09% EYE DROP TWINPAK
BROMFED DM COUGH SYRUP
BROMFENAC SODIUM 0.09% EYE DRP
BROMHIST PEDIATRIC DROPS
BROMOCRIPTINE 2.5 MG TABLET
BROMOCRIPTINE 5 MG CAPSULE
500000
500000
500000
50000
20000
22000
600000
70000
200
200
200
10000
5000
10000
2500
5000
10000
200
200
150000
2000
100000
500000
10000
7000
10000
0
30000
650000
50000
4000
4000
8000
8000
500
8000
35
90000
200
150
11000
90
10000
90
15000
2500
5000
MG
MG
MG
MG
MG
MG
MG
MG
%
%
%
MG
MG
MG
MG
MG
%
%
%
MG
%
MG
MG
0
%
%
MG
MG/5ML
MG
%
%
%
%
%
MG
%
MCG
MG
%
%
MG
%
ML
%
MG/ML
MG
MG
695935
1356865
1304107
1304535
1356814
1356868
1356834
1304971
993505
993505
993520
993520
993542
993542
993559
993559
349094
351109
1244211
197417
197418
197419
210085
213196
984107
351264
351265
351267
351266
993524
993687
993687
993691
993691
993503
993503
993536
993536
993541
993541
993557
993557
993518
993518
866096
866083
866018
BROVANA 15 MCG/2 ML SOLUTION

BROVEX ADT SUSPENSION
BROVEX PB DM TABLET
BROVEX PD SUSPENSION
BROVEX PSE DM TABLET
BROVEX PSE TABLET
BROVEX SR CAPSULE
BUCALSEP SOLUTION
BUDEPRION SR 100 MG TABLET
BUDEPRION XL 150 MG TABLET
BUDESONIDE 0.25 MG/2 ML SUSP
BUDESONIDE 0.5 MG/2 ML SUSP
BUDESONIDE EC 3 MG CAPSULE
BUMETANIDE 0.5 MG TABLET
BUMETANIDE 1 MG TABLET
BUMETANIDE 2 MG TABLET
BUPAP TABLET
BUPHENYL 500 MG TABLET
BUPHENYL POWDER
BUPRENORPHINE 2 MG TABLET SL
BUPRENORPHINE 8 MG TABLET SL
BUPRENORPHIN-NALOXON 8-2 MG TB
BUPRENORPHN-NALOXN 2-0.5 MG TB
BUPROBAN 150 MG TABLET
BUPROPION HCL 100 MG TABLET
BUPROPION HCL SR 100 MG TABLET
BUPROPION HCL SR 100 MG TABLET
BUPROPION HCL SR 200 MG TAB
BUPROPION HCL SR 200 MG TAB
BUPROPION HCL XL 150 MG TABLET
BUPROPION SR 150 MG TABLET
BUPROPION SR 150 MG TABLET
BUSPAR 5 MG TABLET
BUSPIRONE HCL 10 MG TABLET
15
10000
4000
30000
20000
40000
90000
0
100000
100000
150000
150000
150000
150000
300000
300000
250
500
3000
500
1000
2000
650000
500000
0
2000
8000
8000
2000
150000
100000
100000
75000
75000
100000
100000
200000
200000
150000
150000
300000
300000
150000
150000
5000
10000
15000
MCG
MG/5ML
MG
MG/5ML
MG
MG
MG
0
MG
MG
MG
MG
MG
MG
MG
MG
MG/2ML
MG/2ML
MG
MG
MG
MG
MG
MG
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
866090
866094
866111
238154
240093
993943
238153
994237
238135
238134
1251616
1251629
1251623
886634
904874
904878
904882
1242968
847913
847917
751616
751620
827075
751623
199703
750199
750203
750207
750211
750223
750219
750215
750227
750231
750235
750239
849930
1293506
849928
1250496
1250508
897667
897685
901468
897676
897680
313921

BUSPIRONE HCL 7.5 MG TABLET
BUTALB-ACETAMIN-CAFF 50-325-40
BUTALB-ACETAMIN-CAFF 50-500-40
BUTALB-CAFF-ACETAMINOPH-CODEIN
BUTALBIT-ACETAMINOPHEN-CAFF CP
BUTALBITAL COMP-CODEINE #3 CAP
BUTALBITAL COMPOUND TABLET
BUTALBITAL-ASA-CAFFEINE CAP
BUTISOL SODIUM 30 MG TABLET
BUTISOL SODIUM 30 MG/5 ML ELX
BUTISOL SODIUM 50 MG TABLET
BUTORPHANOL 10 MG/ML SPRAY
BUTRANS 10 MCG/HR PATCH
BYDUREON 2 MG VIAL
BYETTA 10 MCG DOSE PEN INJ
BYETTA 5 MCG DOSE PEN INJ
BYSTOLIC 10 MG TABLET
BYSTOLIC 2.5 MG TABLET
CABERGOLINE 0.5 MG TABLET
CADUET 10 MG-10 MG TABLET
CADUET 2.5 MG-10 MG TABLET
CAFCIT 20 MG/ML ORAL SOLN
CAFERGOT TABLET
CAFFEINE CIT 60 MG/3 ML ORAL
CAFGESIC CAPSULE
CAFGESIC FORTE TABLET
CALAN 120 MG TABLET
CALAN 80 MG TABLET
CALAN SR 120 MG CAPLET
CALCIPOTRIENE 0.005% CREAM
30000
5000
7500
325000
500000
30000
0
30000
0
325000
30000
30000
50000
10000
10
20
5
2000
10
5
10000
250
20000
5000
500
10000
10000
10000
10000
2500
2500
2500
5000
5000
5000
5000
20000
0
20000
250000
500000
120000
80000
120000
180000
240000
5
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG
MG/ML
MG
MG
MG
MG
MCG
MCG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/ML
MG
MG/ML
MG
MG
MG
MG
MG
MG
MG
%
198373
308865
313919
1013636
308867
308867
308868
308868
313932
313932
388517
359296
197433
748962
967897
835728
1149667
1235267
583257
578325
578330
802749
104044
1100907
1042693
1191267
993767
1114074
1114096
308962
308963
317173
308964
197436
197437
197438
197439
284539
208097
905394
308973
308973
308976
308976
308979
308979
388311
CALCIPOTRIENE 0.005% OINTMENT

CALCIPOTRIENE 0.005% SOLUTION
CALCITONIN-SALMON 200 UNITS SP
CALCITRENE 0.005% OINTMENT
CALCITRIOL 0.25 MCG CAPSULE
CALCITRIOL 1 MCG/ML SOLUTION
CALCITRIOL 1 MCG/ML SOLUTION
CALCITRIOL 3 MCG/G OINTMENT
CALCIUM ACETATE 667 MG CAPSULE
CALCIUM ACETATE 667 MG TABLET
CAMILA TABLET
CAMPRAL 333 MG DOSE PAK
CAMPRAL DR 333 MG TABLET
CAMRESE 0.15-0.03-0.01 MG TAB
CAMRESE LO TABLET
CANASA 1,000 MG SUPPOSITORY
CANDESARTAN-HCTZ 16-12.5 MG TB
CANDESARTAN-HCTZ 32-12.5 MG TB
CANDESARTAN-HCTZ 32-25 MG TAB
CANTIL 25 MG TABLET
CAPACET CAPSULE
CAPCOF LIQUID
CAPEX SHAMPOO
CAPITAL WITH CODEINE SUSP
CAPRELSA 100 MG TABLET
CAPRELSA 300 MG TABLET
CAPTOPRIL 100 MG TABLET
CAPTOPRIL 12.5 MG TABLET
CAPTOPRIL-HCTZ 25-15 MG TABLET
CARAC CREAM
CARAFATE 1 GM TABLET
CARBAGLU 200 MG DISPER TABLET
CARBAMAZEPINE 100 MG TAB CHEW
CARBAMAZEPINE 100 MG TAB CHEW
CARBAMAZEPINE 100 MG/5 ML SUSP
CARBAMAZEPINE 100 MG/5 ML SUSP
CARBAMAZEPINE 200 MG TABLET
CARBAMAZEPINE 200 MG TABLET
CARBAMAZEPINE ER 100 MG CAP
5
5
200000
5
250
250
500
500
1
1
0
667000
667000
350
333000
333000
150
0
1000000
16000
32000
32000
25000
50000
2000
10
12000
100000
300000
100000
12500
25000
50000
15000
25000
50000
0
500
1000000
200000
100000
100000
100000
100000
200000
200000
100000
%
%
U/DOSE
%
MCG
MCG
MCG
MCG
MCG
MCG
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
ML
%
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
MG
MG
MG
MG/5ML
MG/5ML
MG
MG
MG
200133
402505
402505
200131
402506
402506
404742
404742
308977
308977
313931
313931
1101952
726004
755311
483090
476399
197444
476515
308988
308989
197443
197445
403851
810083
403852
730988
403850
810090
1010696
1012904
1037164
1012789
858589
858583
858595
831055
833219
834393
831137
830863
830847
830839
830803
830798
830876
830878

CARBAMAZEPINE ER 200 MG TABLET
CARBAMAZEPINE ER 200 MG TABLET
CARBAMAZEPINE XR 400 MG TABLET
CARBAMAZEPINE XR 400 MG TABLET
CARBATROL ER 100 MG CAPSULE
CARBATUSS SYRUP
CARBATUSS-CL LIQUID
CARBA-XP LIQUID
CARBIDOPA-LEVO 10-100 MG ODT
CARBIDOPA-LEVO 25-100 TAB
CARBIDOPA-LEVO ER 25-100 TAB
CARBIDOPA-LEVO ER 50-200 TAB
CARBIDOPA-LEVODOPA 10-100 TAB
CARBIDOPA-LEVODOPA 25-250 TAB
CARBIDOPA-LEVODOPA-ENTA 100 MG
CARBINOXAMINE 4 MG/5 ML LIQUID
CARBINOXAMINE MALEATE 4 MG TAB
CARBOFED DM SYRUP
CARDEC-DM SYRUP
CARDENE SR 30 MG CAPSULE
CARDIZEM 120 MG TABLET
CARDIZEM CD 120 MG CAPSULE
CARDIZEM LA 120 MG TABLET
200000
200000
200000
300000
400000
400000
100000
100000
200000
200000
300000
300000
0
100000
100000
10000
25000
25000
250000
100000
200000
10000
250000
100000
125000
150000
200000
50000
75000
4000
4000
15000
4000
30000
45000
60000
120000
30000
60000
90000
120000
180000
240000
300000
360000
120000
180000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG
MG/5ML
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
830880
830883
830898
830902
104367
104367
104368
104368
104369
104369
205544
205544
1242404
1242408
730794
197446
197447
994226
1006689
352077
1250486
1250486
904620
206343
206343
206346
206346
978573
831226
831255
831309
831338
200032
200033
686924
200031
108828
855944
884175
884187
884191
998673
998677
998681
645459
901614
834768

CARDURA 1 MG TABLET
CARDURA 1 MG TABLET
CARDURA 2 MG TABLET
CARDURA 2 MG TABLET
CARDURA 4 MG TABLET
CARDURA 4 MG TABLET
CARDURA 8 MG TABLET
CARDURA 8 MG TABLET
CARDURA XL 4 MG TABLET
CARDURA XL 8 MG TABLET
CARISOPRODOL 250 MG TABLET
CARISOPRODOL 350 MG TABLET
CARISOPRODOL COMPOUND TAB
CARISOPRODOL CPD-CODEINE TAB
CARMOL 10% SCALP LOTION
CARMOL 40 LOTION
CARMOL HC 1% CREAM
CARMOL HC 1% CREAM
CARMOL SCALP TREATMENT KIT
CARNITOR 100 MG/ML ORAL SOLN
CARNITOR 100 MG/ML ORAL SOLN
CARNITOR 330 MG TABLET
CARNITOR 330 MG TABLET
CARTEOLOL HCL 1% EYE DROPS
CARTIA XT 120 MG CAPSULE
CARVEDILOL 12.5 MG TABLET
CARVEDILOL 25 MG TABLET
CASODEX 50 MG TABLET
CATAFLAM 50 MG TABLET
CATAPRES 0.1 MG TABLET
CATAPRES-TTS 1 PATCH
CAVIRINSE ORAL RINSE
CAYSTON 75 MG INHAL SOLUTION
CAZIANT 28 DAY TABLET
240000
300000
360000
420000
1000
1000
2000
2000
4000
4000
8000
8000
4000
8000
250000
350000
0
0
10000
40000
1000
1000
10000
100000
100000
330000
330000
1000
120000
180000
240000
300000
12500
25000
3125
6250
50000
50000
100
200
300
100
200
300
200
75000
777000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
%
%
%
MG/ML
MG/ML
MG
MG
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/24H
MG/24H
MG
%
MG/ML
MG
897288
108395
581580
206794
206796
206795
309044
309045
313888
309042
197449
309043
309047
309048
309049
105171
309054
476576
200346
351127
847360
309076
309077
309078
309079
309080
197452
309081
197453
581583
211974
581584
211979
309096
309097
309098
213468
213469
352314
686381
670086
284591
213344
213345
616444
616444
616447
CEDAX 180 MG/5 ML SUSPENSION

CEDAX 400 MG CAPSULE
CEDAX 90 MG/5 ML SUSPENSION
CEENU 10 MG CAPSULE
CEENU 100 MG CAPSULE
CEENU 40 MG CAPSULE
CEFACLOR 125 MG/5 ML SUSP
CEFACLOR 250 MG CAPSULE
CEFACLOR 250 MG/5 ML SUSP
CEFACLOR 375 MG/5 ML SUSPEN
CEFACLOR 500 MG CAPSULE
CEFACLOR ER 500 MG TABLET
CEFADROXIL 1 GM TABLET
CEFADROXIL 250 MG/5 ML SUSP
CEFADROXIL 500 MG CAPSULE
CEFADROXIL 500 MG/5 ML SUSP
CEFDINIR 125 MG/5 ML SUSP
CEFDINIR 250 MG/5 ML SUSP
CEFDINIR 300 MG CAPSULE
CEFDITOREN PIVOXIL 200 MG TAB
CEFDITOREN PIVOXIL 400 MG TAB
CEFPODOXIME 100 MG TABLET
CEFPODOXIME 100 MG/5 ML SUSP
CEFPODOXIME 200 MG TABLET
CEFPODOXIME 50 MG/5 ML SUSP
CEFPROZIL 125 MG/5 ML SUSP
CEFPROZIL 250 MG TABLET
CEFPROZIL 250 MG/5 ML SUSP
CEFPROZIL 500 MG TABLET
CEFTIN 125 MG/5 ML ORAL SUSP
CEFTIN 250 MG TABLET
CEFTIN 250 MG/5 ML ORAL SUSP
CEFTIN 500 MG TABLET
CEFUROXIME 125 MG/5 ML SUSP
CEFUROXIME AXETIL 250 MG TAB
CEFUROXIME AXETIL 500 MG TAB
CELEBREX 100 MG CAPSULE
CELESTONE 0.6 MG/5 ML SOLUTION
CELEXA 10 MG TABLET
CELEXA 20 MG TABLET
CELEXA 40 MG TABLET
CELLCEPT 200 MG/ML ORAL SUSP
CELLCEPT 200 MG/ML ORAL SUSP
CELLCEPT 250 MG CAPSULE
180000
400000
90000
10000
100000
40000
125000
250000
250000
375000
500000
500000
1000000
250000
500000
500000
125000
250000
300000
200000
400000
100000
100000
200000
50000
125000
250000
250000
500000
125000
250000
250000
500000
125000
250000
500000
100000
200000
400000
50000
600
10000
20000
40000
200000
200000
250000
MG/5ML
MG
MG/5ML
MG
MG
MG
MG/5ML
MG
MG/5ML
MG/5ML
MG
MG
MG
MG/5ML
MG
MG/5ML
MG/5ML
MG/5ML
MG
MG
MG
MG
MG/5ML
MG
MG/5ML
MG/5ML
MG
MG/5ML
MG
MG/5ML
MG
MG/5ML
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG/5ML
MG
MG
MG
MG/ML
MG/ML
MG
616447
616435
616435
207088
1242631
352233
540391
261220
261221
261371
404070
1042784
1088459
210086
309110
309112
309115
309113
309114
197454
999608
584444
584446
104885
761973
209969
1014673
309140
637188
795735
637190
795737
1364848
207949
877417
995993
755618
755550
856769
856792
905369
905495
905516
889614
889614
834127
834206
CELLCEPT 250 MG CAPSULE

CELLCEPT 500 MG TABLET
CELLCEPT 500 MG TABLET
CELONTIN 300 MG KAPSEAL
CEM-UREA 45% PRE-FILLED APPL
CENESTIN 0.3 MG TABLET
CENTANY 2% OINTMENT
CENTERGY DM PEDIATRIC DROPS
CENTERGY PEDIATRIC DROPS
CEPHADYN TABLET
CEPHALEXIN 125 MG/5 ML SUSP
CEPHALEXIN 250 MG CAPSULE
CEPHALEXIN 250 MG TABLET
CEPHALEXIN 250 MG/5 ML SUSP
CEPHALEXIN 500 MG CAPSULE
CEPHALEXIN 500 MG TABLET
CERISA WASH
CEROVEL 40% GEL
CEROVEL 40% LOTION
CESAMET 1 MG CAPSULE
CESIA 28 DAY TABLET
CETACAINE SPRAY
CETIRIZINE HCL 1 MG/ML SYRUP
CEVIMELINE HCL 30 MG CAPSULE
CHANTIX 0.5 MG TABLET
CHANTIX 1 MG CONT MONTH PAK
CHANTIX 1 MG TABLET
CHANTIX STARTING MONTH PAK
CHATEAL-28 TABLET
CHEMET 100 MG CAPSULE
CHENODAL 250 MG TABLET
CHERATUSSIN DAC SYRUP
CHLORAL HYDRATE 500 MG/5 ML
CHLORDEX GP SYRUP
CHLORDIAZEPO-AMITRIPTYL 5-12.5
CHLORDIAZEPOX-AMITRIPTYL 10-25
CHLORDIAZEPOXIDE 10 MG CAPSULE
CHLORDIAZEPOXIDE-CLIDINIUM CAP
CHLORDIAZEPOXIDE-CLIDINIUM CAP
CHLORHEXIDINE 0.12% RINSE
CHLORHEXIDINE GLUC 20% SOLN
250000
500000
500000
300000
45000
300
450
625
900
1250
2000
3000
2000
650000
125000
250000
250000
250000
500000
500000
10000
40000
40000
1000
777000
0
1000
30000
500
1000
1000
500
150
100000
250000
10000
500000
0
5000
10000
10000
25000
5000
0
0
120
0
MG
MG
MG
MG
%
MG
MG
MG
MG
MG
%
MG/ML
MG/ML
MG
MG/5ML
MG
MG
MG/5ML
MG
MG
0
%
%
MG
MG
0
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
0
MG
MG
MG
MG
MG
MG
MG
%
0
1086475
1117531
1116758
197475
197476
991039
991044
991188
991194
991336
197495
197496
197499
197500
197502
848943
309271
309272
313892
309273
762660
1300064
1100057
309289
313941
309290
250344
309291
242461
242462
103943
213307
197506
212787
197507
197508
849599
809871
213226
205769
213224
205770
205771
213320
847488
899122
404630
CHLOR-MAL-PHENYLEPHRINE HCL TB
CHLOROQUINE PH 250 MG TABLET
CHLOROQUINE PH 500 MG TABLET
CHLOROTHIAZIDE 250 MG TABLET
CHLOROTHIAZIDE 500 MG TABLET
CHLORPROMAZINE 10 MG TABLET
CHLORPROPAMIDE 100 MG TABLET
CHLORPROPAMIDE 250 MG TABLET
CHLORTHALIDONE 25 MG TABLET
CHLORTHALIDONE 50 MG TABLET
CHLORZOXAZONE 500 MG TABLET
CHOLESTYRAMINE POWDER
CHOLINE MAG TRISAL 1 GM TAB
CHOLINE MAG TRISAL 500 MG TB
CHOLINE MAG TRISAL 750 MG TB
CHOLINE MAG TRISAL LIQUID
CIALIS 2.5 MG TABLET
CICLODAN 0.77% CREAM
CICLODAN 8% SOLUTION
CICLOPIROX 0.77% CREAM
CICLOPIROX 0.77% GEL
CICLOPIROX 0.77% TOPICAL SUSP
CICLOPIROX 1% SHAMPOO
CICLOPIROX 8% SOLUTION
CILOSTAZOL 100 MG TABLET
CILOSTAZOL 50 MG TABLET
CILOXAN 0.3% EYE DROPS
CILOXAN 0.3% OINTMENT
CIMETIDINE 300 MG TABLET
CIMETIDINE 300 MG/5 ML SOLN
CIMZIA 200 MG/ML SYRINGE KIT
CINRYZE 500 UNIT VIAL
CIPRO 10% SUSPENSION
CIPRO 250 MG TABLET
CIPRO 5% SUSPENSION
CIPRO 500 MG TABLET
CIPRO 750 MG TABLET
CIPRO HC OTIC SUSPENSION
CIPRO XR 1,000 MG TABLET
CIPRO XR 500 MG TABLET
CIPRODEX OTIC SUSPENSION
20000
250000
500000
250000
500000
10000
100000
200000
25000
50000
100000
250000
25000
50000
500000
0
1000000
500000
750000
0
2500
770
8000
770
770
770
1000
8000
100000
50000
300
300
300000
300000
400000
800000
400000
500000
500000
250000
250000
500000
750000
200
1000000
500000
300
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
0
MG
MG
MG
0
MG
%
%
%
%
%
%
%
MG
MG
%
%
MG
MG/ML
MG
MG
MG/2
U
MG/5ML
MG
MG/5ML
MG
MG
%
MG
MG
%
848956
309307
403921
359383
199370
197511
309309
197512
283672
309313
200371
309314
1100471
404059
404062
643488
404065
1005855
755661
608692
637548
352086
1112250
1112260
1000921
240741
197516
309322
197517
359385
999477
857430
857461
1189036
1005771
882533
882536
748743
748746
748748
748750
804978
804973
797450
804975
310170
404656
CIPROFLOXACIN 0.2% OTIC SOLN

CIPROFLOXACIN 0.3% EYE DROP
CIPROFLOXACIN ER 1,000 MG TAB
CIPROFLOXACIN ER 500 MG TABLET
CIPROFLOXACIN HCL 100 MG TAB
CITALOPRAM HBR 10 MG TABLET
CITALOPRAM HBR 10 MG/5 ML SOLN
CITRANATAL B-CALM COMBO PACK
CLARAVIS 10 MG CAPSULE
CLARIFOAM EF EMOLLIENT FOAM
CLARINEX 0.5 MG/ML (2.5 MG/5)
CLARINEX 2.5 MG REDITABS
CLARINEX 5 MG REDITABS
CLARINEX 5 MG TABLET
CLARINEX-D 12 HOUR TABLET
CLARINEX-D 24 HOUR TABLET
CLARIS CLARIFYING WASH
CLARITHROMYCIN 125 MG/5 ML SUS
CLARITHROMYCIN 250 MG TABLET
CLARITHROMYCIN 250 MG/5 ML SUS
CLARITHROMYCIN 500 MG TABLET
CLARITHROMYCIN ER 500 MG TAB
CLEANSE AND TREAT PADS
CLEMASTINE 0.5 MG/5 ML SYRUP
CLEMASTINE FUM 2.68 MG TAB
CLENIA EMOLLIENT CREAM
CLENIA FOAMING WASH
CLEOCIN 100 MG VAGINAL OVULE
CLEOCIN 2% VAGINAL CREAM
CLEOCIN 75 MG/5 ML GRANULES
CLEOCIN HCL 150 MG CAPSULE
CLEOCIN T 1% GEL
CLEOCIN T 1% LOTION
CLEOCIN T 1% PLEDGETS
CLEOCIN T 1% SOLUTION
CLIMARA 0.025 MG/DAY PATCH
200
300
1000000
500000
100000
250000
500000
750000
10000
10000
20000
40000
20000
10000
20000
30000
40000
10000
2500
2500
5000
5000
120000
240000
10000
125000
250000
250000
500000
500000
2000
670
2680
0
0
100000
2000
75000
150000
300000
75000
1000
1000
1000
1000
25
37
%
%
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
%
MG/5ML
MG
MG
MG
MG
MG
%
MG/5ML
MG
MG/5ML
MG
MG
%
MG/5ML
MG
0
0
MG
%
MG/5ML
MG
MG
MG
%
%
%
%
MG
MG
310174
404657
310178
310181
402252
259256
358917
1091339
351330
309337
562266
197518
284215
309329
309332
309333
797274
904326
197519
477451
830205
890923
105944
1006558
1014379
1014379
1043389
1043389
861434
861448
861490
861487
861505
861495
861353
861492
861513
861506
206048
857297
857301
857305
349194
349195
349198
197527
349196

CLIMARA 0.06/MG DAY PATCH
CLIMARA PRO PATCH
CLINAC BPO 7% GEL
CLIND PH-BENZOYL PEROX 1.2-5%
CLINDACIN P 1% PLEDGETS
CLINDAGEL 1% GEL
CLINDAMYCIN 2% VAGINAL CREAM
CLINDAMYCIN 75 MG/5 ML SOLN
CLINDAMYCIN HCL 150 MG CAPSULE
CLINDAMYCIN PH 1% GEL
CLINDAMYCIN PH 1% SOLUTION
CLINDAMYCIN PHOS 1% PLEDGET
CLINDAMYCIN PHOS 1% PLEDGET
CLINDAMYCIN PHOSP 1% LOTION
CLINDAMYCIN PHOSPHATE 1% FOAM
CLINDAREACH 1% KIT
CLINDESSE 2% VAGINAL CREAM
CLINORIL 200 MG TABLET
CLINPRO 5000 1.1% TOOTHPASTE
CLOBETA + PLUS KIT
CLOBETA + PLUS KIT
CLOBETA + PLUS KIT
CLOBETA + PLUS KIT
CLOBETASOL 0.05% GEL
CLOBETASOL 0.05% OINTMENT
CLOBETASOL 0.05% SHAMPOO
CLOBETASOL 0.05% SOLUTION
CLOBETASOL 0.05% TOPICAL LOTN
CLOBETASOL EMOLLIENT 0.05% CRM
CLOBETASOL PROP 0.05% FOAM
CLOBEX 0.05% SHAMPOO
CLOBEX 0.05% SPRAY
CLOBEX 0.05% TOPICAL LOTION
CLODERM 0.1% CREAM
CLOMIPRAMINE 25 MG CAPSULE
CLONAZEPAM 0.125 MG DIS TAB
CLONAZEPAM 0.25 MG ODT
CLONAZEPAM 0.5 MG DIS TABLET
CLONAZEPAM 0.5 MG TABLET
CLONAZEPAM 1 MG DIS TABLET
50
60
75
100
45
7000
1000
1000
1000
2000
75000
150000
300000
75000
1000
1000
1000
1000
1000
1000
1000
2000
200000
1100
50
50
50
50
50
50
50
50
50
50
50
50
50
50
100
25000
50000
75000
125
250
500
500
1000
MG/24H
MG
MG
MG
MG
%
%
%
%
%
MG/5ML
MG
MG
MG
%
%
%
%
%
%
%
%
MG
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
MG
MG
MG
MG
MG
MG
MG
MG
197528
349197
197529
998671
998675
998679
884173
884185
884189
749196
309362
197464
197465
197466
884196
884202
884207
309370
309371
309367
308714
308715
197535
309374
197536
429212
476177
721773
476179
104776
104775
847217
204837
847734
1297363
1297359
1012160
1114002
1145972
1114030
997170
997287
1297649
997296
857360
885859
197541
CLONAZEPAM 1 MG TABLET
CLONAZEPAM 2 MG ODT
CLONAZEPAM 2 MG TABLET
CLONIDINE 0.1 MG/DAY PATCH
CLONIDINE HCL 0.1 MG TABLET
CLOPIDOGREL 300 MG TABLET
CLOPIDOGREL 75 MG TABLET
CLORAZEPATE 15 MG TABLET
CLORAZEPATE 3.75 MG TABLET
CLORAZEPATE 7.5 MG TABLET
CLORPRES 0.1-15 TABLET
CLOTRIMAZOLE 1% SOLUTION
CLOTRIMAZOLE 10 MG TROCHE
CLOTRIMAZOLE AF 1% CRM
CLOTRIMAZOLE-BETAMETHASONE CRM
CLOTRIMAZOLE-BETAMETHASONE LOT
CLOZAPINE 100 MG TABLET
CLOZAPINE ODT 100 MG TABLET
CLOZAPINE ODT 12.5 MG TABLET
CLOZAPINE ODT 25 MG TABLET
CLOZARIL 100 MG TABLET
CLOZARIL 25 MG TABLET
CNL 8 NAIL KIT
COAL TAR SOLUTION
COARTEM TABLETS
COCAINE 10% SOLUTION
COCAINE 4% SOLUTION
COCET TABLET
CODAR AR LIQUID
CODAR D LIQUID
CODAR GF LIQUID
CODEINE SULFATE 15 MG TABLET
CODEINE SULFATE 30 MG/5 ML SOL
CO-GESIC 5-500 TABLET
COLAZAL 750 MG CAPSULE
COLCHICINE 0.6 MG TABLET
1000
2000
2000
100
200
300
100
200
300
300000
75000
15000
3750
7500
100
200
300
1000
10000
1000
0
0
100000
200000
25000
50000
100000
12500
25000
100000
25000
8000
0
20000
10000
4000
650000
2000
30000
200000
15000
30000
30000
60000
5000
750000
600
MG
MG
MG
MG/24H
MG/24H
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
%
MG
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
MG
%
%
MG
MG/ML
MG/ML
MG/5ML
MG
MG
MG
MG
MG
MG
MG
858071
1048447
1048452
1048445
1048450
802059
802059
854995
967014
861637
1251495
1251501
836366
1190225
213088
213088
213088
1049591
1363410
1363408
1364581
404421
404422
1147337
1147337
1304511
261318
1314672
1091157
1091172
1091187
1091212
351750
582929
544452
895464
1111642
645949
352337
833530
205610
797697
898420
212389
212390
686926
212388
COLCRYS 0.6 MG TABLET

COLESTID 1 GM TABLET
COLESTID FLAVORED GRANULES
COLESTIPOL HCL 1 GM TABLET
COLESTIPOL HCL GRANULES PACKET
COLOCORT 100 MG ENEMA
COLOCORT 100 MG ENEMA
COLY-MYCIN S EAR DROPS
COLYTE WITH FLAVOR PACKETS
COMBIGAN EYE DROPS
COMBIPATCH 0.05-0.14 MG PTCH
COMBIPATCH 0.05-0.25 MG PTCH
COMBIVENT INHALER
COMBIVENT RESPIMAT INHAL SPRAY
COMBIVIR TABLET
COMBIVIR TABLET
COMBIVIR TABLET
COMBUNOX TABLET
COMETRIQ 100 MG DAILY-DOSE PK
COMETRIQ 140 MG DAILY-DOSE PK
COMETRIQ 60 MG DAILY-DOSE PACK
COMMIT 2 MG LOZENGE
COMMIT 4 MG LOZENGE
COMPLERA TABLET
COMPLERA TABLET
COMPLETE-RF PRENATAL TABLET
COMTAN 200 MG TABLET
CONCEPT OB CAPSULE
CONCERTA ER 18 MG TABLET
CONDYLOX 0.5% GEL
CONDYLOX 0.5% TOPICAL SOLN
CONSTULOSE 10 GM/15 ML SOLN
CONTROL RX CREAM
COPAXONE 20 MG INJECTION KIT
COPD TABLET
COPEGUS 200 MG TABLET
CORDARONE 200 MG TABLET
CORDRAN 0.05% LOTION
CORDRAN 4 MCG/SQ CM TAPE
CORDRAN SP 0.05% CREAM
COREG 12.5 MG TABLET
COREG 25 MG TABLET
600
1000000
0
1000000
0
100000
100000
0
0
2000
50
250
0
0
300000
300000
300000
5000
100000
140000
60000
2000
4000
200000
200000
0
200000
85000
18000
27000
36000
54000
500
500
0
1100
20000
200000
200000
200000
50
4000
50
12500
25000
3125
6250
MG
GM
0
GM
0
MG
MG
0
0
%
MG
MG
0
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
0
%
MG
MG
MG
MG
%
MCG/CM
%
MG
MG
MG
MG
860512
860518
860524
860534
206961
201337
201338
1095283
861449
861526
1293943
1293876
208712
208816
208680
102250
102250
106948
106948
828248
206400
206511
825186
688704
688704
854997
206522
863832
863825
1012097
208003
208029
213280
995213
995216
994014
855290
855298
855304
855314
855320
855326
855334
855340
855346
705921
705919
COREG CR 10 MG CAPSULE
CORGARD 20 MG TABLET
CORIFACT KIT
CORMAX 0.05% OINTMENT
CORMAX 0.05% SOLUTION
CORTANE-B LOTION
CORTANE-B OTIC DROPS
CORTEF 10 MG TABLET
CORTEF 20 MG TABLET
CORTEF 5 MG TABLET
CORTENEMA 100 MG ENEMA
CORTENEMA 100 MG ENEMA
CORTIFOAM 10% AEROSOL
CORTIFOAM 10% AEROSOL
CORTISONE 25 MG TABLET
CORTISPORIN CREAM
CORTISPORIN EAR SOLUTION
CORTISPORIN EAR SUSPENSION
CORTISPORIN OINTMENT
CORTISPORIN OINTMENT
CORTISPORIN-TC EAR SUSP
CORTOMYCIN EAR SUSPENSION
CORZALL LIQUID
CORZALL PLUS LIQUID
CORZALL-PE LIQUID
CORZIDE 40-5 TABLET
CORZIDE 80-5 TABLET
COSOPT PF EYE DROPS
COTAB A TABLET
COTAB AX TABLET
COTABFLU TABLET
COUMADIN 1 MG TABLET
COUMADIN 2.5 MG TABLET
COUMADIN 7.5 MG TABLET
COVARYX H.S. TABLET
COVARYX TABLET
10000
20000
40000
80000
20000
40000
80000
1000000
50
50
0
0
10000
20000
5000
100000
100000
10000
10000
25000
0
0
0
0
0
0
1000
20000
7500
1000
0
0
2000
4000
4000
4000
1000
10000
2000
2500
3000
4000
5000
6000
7500
1250
2500
MG
MG
MG
MG
MG
MG
MG
EA
%
%
0
0
MG
MG
MG
MG
MG
%
%
MG
0
0
0
MG
MG
0
%
MG
ML
ML
MG
MG
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
901522
901525
979482
979487
979494
1251039
359361
863841
863829
1113046
863836
859749
859753
859421
859426
583265
153579
541058
153127
153128
831111
831246
831109
831261
750265
1037383
207369
895697
895989
895991
999965
198683
309594
1047040
1047041
761974
828348
828320
828299
828358
828353
1298366
1298356
1298364
1298360
1298066
1298070
COVERA-HS ER 180 MG TABLET

COVERA-HS ER 240 MG TABLET
COZAAR 100 MG TABLET
COZAAR 25 MG TABLET
COZAAR 50 MG TABLET
C-PHEN DM DROPS
CPM 8-PE 20-MSC 1.25 MG TAB
CREON DR 12,000 UNITS CAPSULE
CRESTOR 10 MG TABLET
CRESTOR 5 MG TABLET
CRESYLATE EAR DROPS
CRINONE 4% GEL
CRIXIVAN 100 MG CAPSULE
CROLOM 4% EYE DROPS
CROMOLYN 20 MG/2 ML NEB SOLN
CROMOLYN 4% EYE DROPS
CROMOLYN SODIUM 100 MG/5 ML
CRYSELLE-28 TABLET
C-TAN D SUSPENSION
CUPRIMINE 250 MG CAPSULE
CUTIVATE 0.005% OINTMENT
CUTIVATE 0.05% CREAM
CUTIVATE 0.05% LOTION
CUVPOSA 1 MG/5 ML SOLUTION
CVS GLUCOSE 40% GEL
CYANOCOBALAMIN 1,000 MCG/ML
CYCLAFEM 1-35-28 TABLET
CYCLAFEM 7-7-7-28 TABLET
CYCLESSA 28 DAY TABLET
CYCLOBENZAPRINE 10 MG TABLET
CYCLOBENZAPRINE 5 MG TABLET
CYCLOBENZAPRINE 7.5 MG TABLET
CYCLOBENZAPRINE ER 15 MG CAP
CYCLOBENZAPRINE ER 30 MG CAP
CYCLOGYL 0.5% EYE DROPS
CYCLOGYL 1% EYE DROPS
CYCLOGYL 2% EYE DROPS
CYCLOMYDRIL EYE DROPS
CYCLOPENTOLATE 1% EYE DROPS
CYCLOPENTOLATE HCL 2% DROPS
181000
241000
100000
25000
50000
3000
20000
60000000
1.2E+08
3000000
30000000
10000
20000
40000
5000
0
4000
100000
200000
400000
4000
20000
4000
20000
0
5000
250000
50
50
50
1000
40000
1000
1000
777000
777000
10000
5000
7500
15000
30000
500
1000
2000
0
1000
2000
MG
MG
MG
MG
MG
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
ML
%
MG
MG
MG
%
MG/2ML
%
MG/ML
MG
MG/5ML
MG
%
%
%
MG
%
MCG/ML
MG
MG
MG
MG
MG
MG
MG
MG
%
%
%
0
%
%
197549
197550
197551
859081
328160
328160
309632
309632
835886
835886
197553
197553
835925
835925
241834
241834
835894
835894
1298358
596928
596928
596928
596932
596932
596932
615186
615186
615186
866021
866144
404539
209788
209789
903699
903458
903705
209177
104098
543018
828618
209304
861674
1091843
579442
754836
759487
1359121
CYCLOPHOSPHAMIDE 25 MG TAB
CYCLOPHOSPHAMIDE 50 MG TABLET
CYCLOSERINE 250 MG CAPSULE
CYCLOSET 0.8 MG TABLET
CYCLOSPORINE 100 MG CAPSULE
CYCLOSPORINE 100 MG/ML SOLN
CYCLOSPORINE 50 MG SOFTGEL
CYCLOSPORINE 50 MG SOFTGEL
CYCLOSPORINE MODIFIED 100 MG
CYLATE 1% EYE DROPS
CYMBALTA 20 MG CAPSULE
CYPROHEPTADINE 2 MG/5 ML SYRUP
CYPROHEPTADINE 4 MG TABLET
CYSTADANE POWDER
CYSTAGON 150 MG CAPSULE
CYSTAGON 50 MG CAPSULE
CYTOMEL 25 MCG TABLET
CYTOTEC 100 MCG TABLET
CYTOTEC 200 MCG TABLET
CYTRA-2 ORAL SOLUTION
CYTRA-3 SYRUP
CYTRA-K ORAL SOLUTION
D.H.E.45 1 MG/ML AMPUL
DALIRESP 500 MCG TABLET
DALLERGY CAPLET SA
DALLERGY DM SYRUP
DALLERGY PE SYRUP
DALLERGY PSE ER TABLET
25000
50000
250000
800
100000
100000
100000
100000
100000
100000
25000
25000
50000
50000
100000
100000
25000
25000
1000
20000
20000
20000
30000
30000
30000
60000
60000
60000
2000
4000
0
150000
50000
25
5
50
100
200
0
0
0
1000
500
2500
15000
2000
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG
0
MG
MG
MG
MG
MG
MG
MG
ML
ML
ML
MG
MG
MG
ML
ML
0
755224
1235566
831865
831862
884520
884532
884535
197554
197555
197556
856654
856658
856662
856652
856656
856660
197557
197558
201912
827750
1300538
1235867
207243
753437
753439
753442
753443
849508
849522
849517
849524
849503
880450
1369589
1053620
1053590
835811
206620
206715
206813
1051006
1050074
1368960
208076
208080
208081
208082
DALLERGY SYRUP
DALLERGY TABLET
DALLERGY-JR CAPSULE
DALLERGY-JR SUSPENSION
D-AMPHETAMINE ER 10 MG CAPSULE
DANAZOL 100 MG CAPSULE
DANTRIUM 100 MG CAPSULE
DANTROLENE SODIUM 100 MG CAP
DAPSONE 100 MG TABLET
DAPSONE 25 MG TABLET
DARAPRIM 25 MG TABLET
DARVON 65 MG PULVULE
DASETTA 1-35-28 TABLET
DASETTA 7/7/7-28 TABLET
DAYPRO 600 MG CAPLET
DAYTRANA 10 MG/9 HR PATCH
DAYTRANA 15 MG/9 HR PATCH
DAYTRANA 20 MG/9 HOUR PATCH
DAYTRANA 30 MG/9 HOUR PATCH
DDAVP 0.01% NASAL SPRAY
DDAVP 0.01% SOLUTION
DDAVP 0.1 MG TABLET
DDAVP 0.2 MG TABLET
DDAVP 4 MCG/ML VIAL
DEBACTEROL SOLUTION
DEBACTEROL SWABSTICK
DECONAMINE SYRUP DYE-FREE
DECONAMINE TABLET DYE-FREE
DELATESTRYL 200 MG/ML VIAL
DELESTROGEN 10 MG/ML VIAL
DELOS 3.5% CLEANSER
DELOS 3.5% LOTION
DELZICOL DR 400 MG CAPSULE
DEMADEX 10 MG TABLET
DEMADEX 5 MG TABLET
625
0
20000
20000
10000
15000
5000
100000
200000
50000
100000
25000
50000
100000
25000
50000
100000
25000
25000
65000
1000
777000
600000
10000
15000
20000
30000
100
100
100
200
4
0
30000
30000
60000
200000
10000
20000
40000
3500
3500
400000
10000
100000
20000
5000
MG/5ML
MG
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/ML
MG/ML
MG
MG
MCG/ML
0
%
MG
MG
MG/ML
MG/ML
MG/ML
MG/ML
%
%
MG
MG
MG
MG
MG
905341
905347
861517
861525
201388
211343
630196
1101938
542214
542214
1099683
1099683
1099689
1099689
1099689
1099598
1099598
1099598
1099871
1099871
1099871
1099626
1099626
1099626
1099679
1099679
1099679
1099565
1099565
1099565
1099571
1099571
1099571
207370
206417
1000154
1000128
1000133
1000158
835831
835842
1191309
208982
706547
351706
1191301
1099288
DEMECLOCYCLINE 150 MG TABLET

DEMECLOCYCLINE 300 MG TABLET
DEMEROL 100 MG TABLET
DEMEROL 50 MG TABLET
DEMSER 250 MG CAPSULE
DENAVIR 1% CREAM
DENTA 5000 PLUS CREAM
DENTAGEL 1.1% GEL
DEPADE 50 MG TABLET
DEPADE 50 MG TABLET
DEPAKENE 250 MG CAPSULE
DEPAKENE 250 MG CAPSULE
DEPAKENE 250 MG/5 ML SOLUTION
DEPAKOTE 125 MG SPRINKLE CAP
DEPAKOTE DR 500 MG TABLET
DEPAKOTE EC 125 MG TABLET
DEPAKOTE ER 250 MG TABLET
DEPEN 250 MG TITRATAB
DEPO-ESTRADIOL 5 MG/ML VIAL
DEPO-PROVERA 150 MG/ML SYRN
DEPO-PROVERA 150 MG/ML VIAL
DEPO-PROVERA 400 MG/ML VIAL
DEPO-SUBQ PROVERA 104 SYRINGE
DEPO-TESTOSTERONE 100 MG/ML VL
DEPO-TESTOSTERONE 200 MG/ML
DERMA-SMOOTHE-FS ECZEMA OIL
DERMATOP 0.1% CREAM
DERMATOP 0.1% OINTMENT
DERMAZENE CREAM
DERMOTIC OIL 0.01% EAR DROPS
DESIPRAMINE 10 MG TABLET
150000
300000
100000
50000
250000
1000
1100
1100
50000
50000
250000
250000
250000
250000
250000
125000
125000
125000
500000
500000
500000
125000
125000
125000
250000
250000
250000
250000
250000
250000
500000
500000
500000
250000
5000
150000
150000
400000
104000
100000
200000
10
100
100
1000
10
10000
MG
MG
MG
MG
MG
%
%
%
MG
MG
MG
MG
MG/5ML
MG/5ML
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
%
%
%
%
%
MG
1099292
1099296
1099300
1099304
1099316
577080
403841
349420
849506
849520
849501
849515
833008
753367
692757
349351
197572
204135
1112788
1112785
205529
205534
205530
197573
315059
141850
197574
197575
977861
856379
855180
855195
855184
855191
1147021
1147993
226343
197577
309686
343033
197579
197580
197581
197582
197583
309684
702220

DESLORATADINE 2.5 MG ODT
DESLORATADINE 5 MG ODT
DESLORATADINE 5 MG TABLET
DESMOPRESSIN 0.01% SPRAY
DESMOPRESSIN 0.1 MG/ML SOL
DESMOPRESSIN AC 4 MCG/ML AMPUL
DESMOPRESSIN ACETATE 0.1 MG TB
DESMOPRESSIN ACETATE 0.2 MG TB
DESOGEN 28 DAY TABLET
DESONATE 0.05% GEL
DESONIDE 0.05% CREAM
DESONIDE 0.05% LOTION
DESONIL + PLUS COMBO PACK
DESONIL COMBO PACK
DESONIL CREAM COMBO PACK
DESOWEN 0.05% CREAM KIT
DESOWEN 0.05% LOTION KIT
DESOWEN 0.05% OINTMENT
DESOXIMETASONE 0.05% CREAM
DESOXIMETASONE 0.05% GEL
DESOXIMETASONE 0.05% OINTMENT
DESOXIMETASONE 0.25% CREAM
DESOXIMETASONE 0.25% OINTMENT
DESOXYN 5 MG TABLET
DESYREL 50 MG TABLET
DETROL 1 MG TABLET
DETROL 2 MG TABLET
DETROL LA 2 MG CAPSULE
DETROL LA 4 MG CAPSULE
DEX4 GLUCOSE BITS TABLET CHEW
DEX4 GLUCOSE TABLET CHEW
DEXAMETHASONE 0.1% EYE DROP
DEXAMETHASONE 0.5 MG TABLET
DEXAMETHASONE 0.5 MG/5 ML ELX
DEXAMETHASONE 1 MG TABLET
DEXAMETHASONE INTENSOL 1MG/1ML
DEXCHLORPHEN 2 MG/5 ML SYRUP
100000
150000
25000
50000
75000
2500
5000
5000
100
100
4
100
200
150
50
50
50
50
50
50
50
50
50
50
50
0
250
250
5000
50000
1000
2000
2000
4000
1000000
0
100
500
500
750
1000
1500
2000
4000
6000
1000
2000
MG
MG
MG
MG
MG
MG
MG
MG
MG/ML
MG/ML
MCG/ML
MG
MG
MG
%
%
%
%
%
%
%
%
%
%
%
%
%
%
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG/ML
MG/5ML
309709
884528
884534
884537
902624
899548
899557
899518
797022
797023
847225
861221
861223
861225
861227
861232
861237
884385
884386
996565
205872
205875
205879
826865
876439
800061
800064
800003
800474
800115
800074
801958
801966
801962
197589
197590
801957
801965
197591
309843
309844
801961
861404
992076
669093
854801
855942
DEXCHLORPHENIRAMINE 6 MG TAB
DEXEDRINE SPANSULE 10 MG
DEXILANT DR 30 MG CAPSULE
DEXMETHYLPHENIDATE 10 MG TAB
DEXMETHYLPHENIDATE 2.5 MG TAB
DEXMETHYLPHENIDATE 5 MG TAB
DEXPAK 10 DAY 1.5 MG TABLET
DEXTROAMP-AMPHET ER 10 MG CAP
DEXTROAMPHETAMINE 10 MG TAB
DEXTROAMPHETAMINE 5 MG TAB
DEX-TUSS LIQUID
DIABETA 1.25 MG TABLET
DIABETA 2.5 MG TABLET
DIABETA 5 MG TABLET
DIALYVITE 800 WITH IRON TAB
DIAMOX SEQUELS ER 500 MG CAP
DIANEAL PD-2 WITH 1.5% DEXT
DIANEAL WITH 1.5% DEXTROSE
DIASTAT 2.5 MG PEDI SYSTEM
DIASTAT ACUDIAL 12.5-15-20 MG
DIASTAT ACUDIAL 5-7.5-10 MG KT
DIAZEPAM 10 MG TABLET
DIAZEPAM 2.5 MG RECTAL GEL
DIAZEPAM 20 MG RECTAL GEL
DIAZEPAM 5 MG/5 ML SOLUTION
DIAZEPAM 5 MG/ML ORAL CONC
DIAZEPAM 5-7.5-10 MG GEL KIT
DIBENZYLINE 10 MG CAPSULE
DICEL DM SUSPENSION
DICEL SUSPENSION
DICLOFENAC 0.1% EYE DROPS
DICLOFENAC POT 50 MG TABLET
6000
10000
15000
5000
30000
10000
2500
5000
1500
1500
1500
10000
15000
20000
25000
30000
5000
10000
5000
300000
1250
2500
5000
800
500000
0
0
0
344000
395000
483000
2500
20000
10000
10000
2000
2500
20000
5000
1000
5000
10000
10000
25000
75000
100
50000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG
ML
ML
ML
MOSM/L
MOSM/L
MOSM/L
MG
MG
MG
MG
MG
MG
MG
MG
MG/ML
MG/ML
MG
MG
MG
MG/5ML
%
MG
855906
855926
855664
855657
857706
1359105
197595
197596
991061
991082
991086
284183
284185
284184
284988
904549
284420
153183
905387
722113
1111110
830614
404749
966577
966607
201900
207107
207108
207112
201901
207106
197603
998728
998728
197604
309888
1245443
197606
1245373
393245
1113417
861672
831224
831254
831305
855673
1313884
DICLOFENAC SOD 50 MG TAB EC

DICLOFENAC SOD DR 75 MG TAB
DICLOFENAC SOD EC 25 MG TAB
DICLOFENAC SOD ER 100 MG TAB
DICLOFENAC-MISOPROST 50-0.2 TB
DICLOFENAC-MISOPROST 75-0.2 TB
DICLOXACILLIN 250 MG CAPSULE
DICLOXACILLIN 500 MG CAPSULE
DICYCLOMINE 10 MG CAPSULE
DICYCLOMINE 10 MG/5 ML SYRUP
DICYCLOMINE 20 MG TABLET
DIDANOSINE DR 125 MG CAPSULE
DIDRONEL 400 MG TABLET
DIFFERIN 0.1% CREAM
DIFFERIN 0.1% GEL
DIFFERIN 0.1% LOTION
DIFFERIN 0.3% GEL
DIFICID 200 MG TABLET
DIFIL-G 400 TABLET
DIFIL-G TABLET
DIFLORASONE 0.05% CREAM
DIFLORASONE 0.05% OINTMENT
DIFLUCAN 10 MG/ML SUSPENSION
DIFLUCAN 100 MG TABLET
DIFLUCAN 40 MG/ML SUSPENSION
DIFLUNISAL 500 MG TABLET
DIGEX NF CAPSULE
DIGEX NF CAPSULE
DIGOXIN 125 MCG TABLET
DIGOXIN 50 MCG/ML SOLUTION
DIHISTINE DH LIQUID
DIHYDROERGOTAMINE 1 MG/ML AM
DILACOR XR 120 MG CAPSULE
DILANTIN 100 MG KAPSEAL
DILANTIN 125 MG/5 ML SUSP
50000
75000
25000
100000
50000
75000
250000
500000
10000
10000
20000
125000
200000
250000
400000
400000
100
100
100
300
200000
400000
300000
50
50
50000
100000
150000
200000
200000
50000
500000
0
0
125
125
125
250
250
50
0
1000
120000
180000
240000
100000
125000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG
MG
%
%
%
%
MG
MG
MG
%
%
MG/5ML
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MCG
MCG
MG
MG
MG
MG/ML
ML
MG
MG
MG
MG
MG
MG/5ML
855871
1313887
891870
897658
897698
897704
897712
755351
578649
831215
831252
831285
831337
831209
831250
831302
831054
830861
830845
830837
830801
830877
830879
830882
833217
831103
831102
830872
830865
830869
830795
831359
848524
833703
833704
833705
833706
351762
352001
352274
351761
809018
809022
809026
809030
809014
905164
DILANTIN 30 MG KAPSEAL
DILANTIN 50 MG INFATAB
DILATRATE-SR 40 MG CAPSULE
DILAUDID 1 MG/ML LIQUID
DILAUDID 2 MG TABLET
DILEX-G 200 SYRUP
DILEX-G 400 TABLET
DILT XR 120 MG CAPSULE
DILT-CD ER 300 MG CAPSULE
DILTIA XT 120 MG CAPSULE
DILTIAZEM 120 MG TABLET
DILTIAZEM 24HR CD 120 MG CAP
DILTIAZEM 24HR ER 180 MG TAB
DILTIAZEM ER 120 MG 12-HR CAP
DILTIAZEM HCL ER 360 MG CAP
DILTIAZEM HCL ER 420 MG CAP
DILTZAC ER 120 MG CAPSULE
DIOVAN 160 MG TABLET
DIOVAN 320 MG TABLET
DIOVAN 40 MG TABLET
DIOVAN 80 MG TABLET
DIOVAN HCT 160-12.5 MG TAB
DIOVAN HCT 160-25 MG TABLET
DIOVAN HCT 320-12.5 MG TAB
DIOVAN HCT 320-25 MG TABLET
DIOVAN HCT 80-12.5 MG TABLET
DIPENTUM 250 MG CAPSULE
30000
50000
40000
5000
2000
4000
8000
200000
400000
120000
0
240000
300000
120000
180000
240000
120000
120000
180000
240000
300000
180000
240000
300000
30000
60000
90000
120000
60000
90000
360000
420000
120000
180000
240000
300000
360000
160000
320000
40000
80000
160000
160000
320000
320000
80000
250000
MG
MG
MG
MG/5ML
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
1020477
1049289
1049633
1190568
1190572
848197
848200
848195
309952
197622
309955
309958
636794
309960
197623
197624
863622
863630
863638
213439
1099625
1099625
1099625
1099678
1099678
1099678
1099870
1099870
1099870
1099563
1099563
1099563
1099569
1099569
1099569
1099596
1099596
1099596
723526
688711
540468
1088761
864708
864720
1236122
759613
755175
DIPHENHYDRAMINE 50 MG CAPSULE
DIPHENHYDRAMINE 50 MG/ML SYN
DIPHENHYDRAMINE 50 MG/ML VIAL
DIPHENOXYLATE-ATROPINE LIQ
DIPHENOXYLATE-ATROPINE TABLET
DIPROLENE 0.05% LOTION
DIPROLENE 0.05% OINTMENT
DIPROLENE AF 0.05% CREAM
DIPYRIDAMOLE 25 MG TABLET
DISOPYRAMIDE 100 MG CAPSULE
DISOPYRAMIDE 150 MG CAP SA
DISOPYRAMIDE 150 MG CAPSULE
DISULFIRAM 250 MG TABLET
DISULFIRAM 500 MG TABLET
DITROPAN XL 10 MG TABLET
DIURIL 250 MG/5 ML ORAL SUSP
DIVALPROEX SOD DR 125 MG TAB
DIVALPROEX SOD ER 250 MG TAB
DIVALPROEX SODIUM 125 MG CAP
DIVIGEL 0.25 MG GEL PACKET
DOLGIC PLUS TABLET
DOLOGESIC CAPLET
DOLOGESIC LIQUID
DOLOPHINE HCL 10 MG TABLET
DOLOPHINE HCL 5 MG TABLET
DONATUSS DC SYRUP
DONATUSSIN DM SYRUP
DONATUSSIN SYRUP
50000
50000
50000
2500
2500
0
50
50
25000
50000
75000
100000
150000
150000
250000
500000
10000
15000
5000
250000
125000
125000
125000
250000
250000
250000
500000
500000
500000
250000
250000
250000
500000
500000
500000
125000
125000
125000
250
750000
500000
0
10000
5000
7500
150000
15000
MG
MG/ML
MG
MG/5ML
MG
%
%
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
ML
MG
MG
MG
MG/ML
MG/5ML
997223
997229
997220
997226
1046924
1046924
1046999
1046999
1046978
1046978
207889
310015
313954
108959
212443
197625
197625
197626
197626
197627
197627
197628
197628
1000048
1000048
1000054
1000054
1000058
1000058
1000064
1000064
1000070
1000070
1000076
1000076
1000097
1000097
348869
348869
434018
434018
799048
799048
406524
406524
199026
199026
DONEPEZIL HCL 10 MG TABLET

DONEPEZIL HCL 5 MG TABLET
DONEPEZIL HCL ODT 10 MG TABLET
DONEPEZIL HCL ODT 5 MG TABLET
DONNATAL ELIXIR
DONNATAL ELIXIR
DONNATAL EXTENTABS
DONNATAL EXTENTABS
DONNATAL TABLET
DONNATAL TABLET
DORAL 15 MG TABLET
DORZOLAMIDE HCL 2% EYE DROPS
DORZOLAMIDE-TIMOLOL EYE DROPS
DOVONEX 0.005% CREAM
DOVONEX 0.005% SOLUTION
DOXAZOSIN MESYLATE 1 MG TAB
DOXEPIN 10 MG CAPSULE
DOXEPIN 10 MG/ML ORAL CONC
DOXEPIN 10 MG/ML ORAL CONC
DOXYCYCLINE HYC DR 100 MG CAP
DOXYCYCLINE HYC DR 100 MG CAP
DOXYCYCLINE HYC DR 100 MG TAB
DOXYCYCLINE HYCLATE 100 MG CAP
10000
5000
10000
5000
0
0
0
0
0
0
15000
2000
2000
5
5
1000
1000
2000
2000
4000
4000
8000
8000
10000
10000
10000
10000
100000
100000
150000
150000
25000
25000
50000
50000
75000
75000
100000
100000
100000
100000
150000
150000
75000
75000
100000
100000
MG
MG
MG
MG
ML
ML
MG
MG
MG
MG
MG
%
%
%
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/ML
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
197633
197633
283535
283535
199027
199027
728207
728207
597808
597808
310029
310029
700408
700408
359465
359465
1101457
1367416
205494
205483
197634
197635
197636
748800
213282
213283
213284
899257
351958
731463
731457
1246310
1246313
835905
998711
806501
1250986
262071
583490
261184
261185
261186
1090655
804547
213823
866455
866464
DOXYCYCLINE HYCLATE 100 MG TAB

DOXYCYCLINE MONO 150 MG CAP
DOXYCYCLINE MONO 150 MG CAP
DOXYCYCLINE MONO 150 MG TABLET
DOXYCYCLINE MONO 75 MG CAPSULE
DOXYCYCLINE MONO 75 MG CAPSULE
DOXYTEX 2.5 MG/2.5 ML LIQUID
DRISDOL 50,000 UNITS CAPSULE
DRITHOCREME HP 1% CREAM
DRITHO-SCALP 0.5% CREAM
DRONABINOL 10 MG CAPSULE
DRONABINOL 2.5 MG CAPSULE
DRONABINOL 5 MG CAPSULE
DROSPIRENONE-ETH ESTRADIOL TAB
DROXIA 200 MG CAPSULE
DRYMAX SYRUP
DUAC 1.2-5% GEL
DUETACT 30-2 MG TABLET
DUETACT 30-4 MG TABLET
DULERA 100 MCG/5 MCG INHALER
DULERA 200 MCG/5 MCG INHALER
DUONEB 0.5 MG-3 MG/3 ML SOLN
DURABAC CAPSULE
DURABAC FORTE TABLET
DURADRYL SYRUP
DURAGESIC 100 MCG/HR PATCH
DURAXIN CAPSULE
DUREZOL 0.05% EYE DROPS
DURICEF 500 MG CAPSULE
DUTOPROL 100-12.5 MG TABLET
100000
100000
20000
20000
50000
50000
150000
150000
150000
150000
50000
50000
75000
75000
75000
75000
1000
50000000
1000
500
10000
2500
5000
0
200000
300000
400000
30000
1000
2000
4000
100
200
0
250000
500000
1250
100
12
25
50
75
0
500
500000
100000
25000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/ML
IU
%
%
MG
MG
MG
MG
MG
MG
MG
ML
%
MG
MG
MG
MG
0
MG
MG
ML
MCG
MCG
MG
MCG
MCG
MG
%
MG
MG
MG
866475
208124
209135
310045
207355
404094
583282
262221
404528
885733
885735
197639
241063
208674
208675
1297521
1094214
863603
863606
206789
608793
857366
209004
209004
212086
1189781
1001476
707680
1091650
1091654
1235150
1235157
1363293
1251905
998706
1048058
1048058
1102277
1111267
1111263
1088774
208850
208850
208851
208851
208853
729931

DYAZIDE 37.5-25 CAPSULE
DYFLEX-G TABLET
DY-G LIQUID
DYNACIN 100 MG CAPSULE
DYNACIN 100 MG TABLET
DYNACIN 75 MG CAPSULE
DYNACIRC CR 10 MG TABLET
DYNACIRC CR 5 MG TABLET
DYPHYLLINE GG TABLET
DYPHYLLINE-GG ELIXIR
DYRENIUM 100 MG CAPSULE
DYRENIUM 50 MG CAPSULE
DYTAN 25 MG TABLET CHEWABLE
DYTUSS COUGH SYRUP
E.E.S. 200 MG/5 ML GRANULES
E.E.S. 400 FILMTAB
EASPRIN 975 MG TABLET EC
EC-NAPROSYN EC 375 MG TABLET
ECONAZOLE NITRATE 1% CREAM
ECONOPRED PLUS 1% EYE DROPS
ECONOPRED PLUS 1% EYE DROPS
ECOTRIN EC 325 MG TABLET
ECOTRIN EC 81 MG TABLET
ECPIRIN EC 325 MG TABLET
ED CHLORPED D PEDIATRIC DROPS
EDARBI 40 MG TABLET
EDARBI 80 MG TABLET
EDARBYCLOR 40-12.5 MG TABLET
EDARBYCLOR 40-25 MG TABLET
ED-CHLOR-TAN CAPLET
EDECRIN 25 MG TABLET
ED-FLEX CAPSULE
ED-SPAZ 0.125 MG ODT
ED-SPAZ 0.125 MG ODT
EDURANT 25 MG TABLET
EFFER-K 10 MEQ TABLET EFF
EFFEXOR 37.5 MG TABLET
EFFEXOR 37.5 MG TABLET
EFFEXOR 50 MG TABLET
EFFEXOR XR 150 MG CAPSULE
50000
25000
0
100000
100000
100000
50000
75000
75000
10000
5000
0
0
100000
50000
25000
12500
200000
400000
975000
375000
1000
1000
1000
325000
81000
325000
10000
40000
80000
12500
25000
8000
25000
0
125
125
25000
750000
1500000
25000
37500
37500
50000
50000
75000
150000
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
ML
MG
MG
MG
MG/5ML
MG/5ML
MG
MG
MG
%
%
%
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MEQ
MG
MG
MG
MG
MG
MG
729931
729932
729932
729929
729929
855816
855820
213045
213268
859188
860656
706467
352085
207485
1305089
830642
1364441
1364447
756226
1005928
211140
92582
92583
92584
213204
863847
863847
863849
863849
863851
863851
863853
863853
863855
863855
863857
863857
205562
404466
644278
404465
754509
206726
1091828
865216
865208
865212

EFFEXOR XR 37.5 MG CAPSULE
EFFEXOR XR 37.5 MG CAPSULE
EFFIENT 10 MG TABLET
EFFIENT 5 MG TABLET
EFUDEX 5% CREAM
EFUDEX 5% SOLUTION
ELDEPRYL 5 MG CAPSULE
ELESTAT 0.05% EYE DROPS
ELESTRIN 0.06% GEL
ELIDEL 1% CREAM
ELIMITE 5% CREAM
ELINEST-28 TABLET
ELIPHOS 667 MG TABLET
ELIQUIS 2.5 MG TABLET
ELIQUIS 5 MG TABLET
ELIXOPHYLLIN 80 MG/15 ML ELIX
ELLA 30 MG TABLET
ELMIRON 100 MG CAPSULE
ELOCON 0.1% CREAM
ELOCON 0.1% LOTION
ELOCON 0.1% OINTMENT
EMADINE 0.05% EYE DROPS
EMBEDA 100-4 MG CAPSULE
EMBEDA 20-0.8 MG CAPSULE
EMCYT 140 MG CAPSULE
EMEND 125 MG CAPSULE
EMEND 40 MG CAPSULE
EMEND 80 MG CAPSULE
EMEND TRIFOLD PACK
EMLA CREAM
EMOQUETTE 28 DAY TABLET
EMSAM 12 MG/24 HOURS PATCH
150000
37500
37500
75000
75000
10000
5000
5000
5000
5000
50
8700
1000
5000
0
667000
2500
5000
80000
30000
100000
100
100
100
50
100000
100000
20000
20000
30000
30000
50000
50000
60000
60000
80000
80000
140000
125000
40000
80000
0
2500
150
12000
6000
9000
MG
MG
MG
MG
MG
MG
MG
%
%
MG
%
G
%
%
MG
MG
MG
MG
MG/15M
MG
MG
%
%
%
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
MG
MG
MG
616148
404587
543021
543027
858817
858804
858810
858813
858828
858824
261105
809159
802652
995864
996655
1049227
1049235
848928
1090669
630720
630724
630726
730880
630729
1358205
854248
854245
854252
854228
854255
854235
854238
854241
761977
317094
801731
1244213
644165
884664
755470
404200
404200
830648
999476
999479
999494
904783
EMTRIVA 10 MG/ML SOLUTION

EMTRIVA 200 MG CAPSULE
ENABLEX 15 MG TABLET
ENABLEX 7.5 MG TABLET
ENALAPRIL MALEATE 10 MG TAB
ENALAPRIL MALEATE 2.5 MG TAB
ENALAPRIL MALEATE 20 MG TAB
ENALAPRIL MALEATE 5 MG TABLET
ENALAPRIL-HCTZ 10-25 MG TABLET
ENALAPRIL-HCTZ 5-12.5 MG TAB
ENBREL 25 MG KIT
ENBREL 25 MG/0.5 ML SYRINGE
ENBREL 50 MG/ML SURECLICK SYR
ENCORA COMBO PACK
ENDACOF-DC LIQUID
ENDOCET 7.5-325 MG TABLET
ENDOCET 7.5-500 MG TABLET
ENDODAN 4.83-325 MG TABLET
ENFOLAST-N TABLET
ENJUVIA 0.3 MG TABLET
ENOVARX-CYCLOBENZAPRINE 2% CRM
ENOXAPARIN 100 MG/ML SYR
ENOXAPARIN 120 MG/0.8 ML SYR
ENOXAPARIN 150 MG/ML SYR
ENOXAPARIN 300 MG/3 ML VIAL
ENPRESSE-28 TABLET
ENTACAPONE 200 MG TABLET
ENTEREG 12 MG CAPSULE
ENTOCORT EC 3 MG CAPSULE
ENTRE-COUGH SUSPENSION
ENTRE-S SUSPENSION
ENULOSE 10 GM/15 ML SOLUTION
EPIDRIN CAPSULE
EPIDRIN CAPSULE
EPIDUO GEL
EPIFLUR 0.25 MG TABLET CHEW
EPIFLUR 0.5 MG TABLET CHEWABLE
EPIFLUR 1 MG TABLET CHEWABLE
EPIFOAM FOAM
10000
200000
15000
7500
10000
2500
20000
5000
10000
5000
25000
25000
50000
400000
30000
7500
7500
4835
600000
300
450
625
900
1250
2000
100000
120000
150000
30000
300000
40000
60000
80000
0
200000
12000
3000
175000
30000
0
0
0
0
250
500
1000
1000
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
0
MG
MG
0
MG
MG
MG
%
904783
994225
860654
727373
727410
727345
310132
727347
727386
211817
211817
152932
152931
352230
213483
213484
351256
351257
205917
205912
212218
205921
205923
213474
562501
562502
310140
602395
602395
602395
198030
672908
672910
672909
1367410
318179
1293864
1293504
1242998
831533
580294
798133
686402
686420
206075
206080
206078
EPIFOAM FOAM
EPIKLOR 20 MEQ PACKET
EPINASTINE HCL 0.05% EYE DROPS
EPINEPHRINE 0.1 MG/ML SYRINGE
EPINEPHRINE 0.15 MG AUTO-INJCT
EPINEPHRINE 0.3 MG AUTO-INJECT
EPINEPHRINE 1 MG/ML AMPUL
EPIPEN 0.3 MG AUTO-INJECTOR
EPIPEN JR 2-PAK 0.15 MG INJCTR
EPITOL 200 MG TABLET
EPITOL 200 MG TABLET
EPIVIR 10 MG/ML ORAL SOLN
EPIVIR 150 MG TABLET
EPIVIR 300 MG TABLET
EPIVIR HBV 100 MG TABLET
EPIVIR HBV 25 MG/5 ML SOLN
EPLERENONE 25 MG TABLET
EPLERENONE 50 MG TABLET
EPOGEN 2,000 UNITS/ML VIAL
EPOGEN 20,000 UNITS/2 ML VIAL
EPOPROSTENOL SODIUM 0.5 MG VL
EPOPROSTENOL SODIUM 1.5 MG VL
EPROSARTAN MESYLATE 600 MG TAB
EPZICOM TABLET
EPZICOM TABLET
EPZICOM TABLET
EQ NICOTINE 21 MG/24HR PATCH
EQUETRO 100 MG CAPSULE
ERGOCALCIFEROL 1.25 MG CAPSULE
ERGOLOID MESYLATES 1 MG TAB
ERGOMAR 2 MG TABLET SL
ERGOTAMINE-CAFFEINE TABLET
ERIVEDGE 150 MG CAPSULE
ERRIN 0.35 MG TABLET
ERTACZO 2% CREAM
ERY 2% PADS
ERYPED 100 MG/2.5 ML DROPS
ERYPED 400 MG/5 ML GRANULES
ERY-TAB 250 MG TABLET EC
ERY-TAB 500 MG TABLET EC
ERY-TAB EC 333 MG TABLET
1000
20000
50
100
150
300
1000
300
150
200000
200000
10000
150000
300000
100000
25000
25000
50000
2000000
10000000
20000000
3000000
4000000
40000000
500
500
600000
600000
600000
600000
21000
100000
200000
300000
50000000
1000
2000
0
150000
350
2000
2000
40000
400000
250000
500000
333000
%
MEQ
%
MG/ML
MG
MG
MG/ML
MG
MG
MG
MG
MG/ML
MG
MG
MG
MG/5ML
MG
MG
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
IU
MG
MG
MG
MG
MG
%
%
MG/ML
MG/5ML
MG
MG
MG
686355
686406
750841
310152
797452
318202
686400
598006
197650
310154
686405
310149
750839
244374
686383
686383
895384
895384
349332
349332
351250
351250
351249
351249
351285
351285
211189
211161
211499
205733
197653
197654
890918
205909
206101
206241
310175
310182
197657
197658
310189
197659
242333
403922
238003
403923
241527
ERYTHROCIN 250 MG FILMTAB

ERYTHROMYCIN 2% GEL
ERYTHROMYCIN 2% PLEDGETS
ERYTHROMYCIN 2% SOLUTION
ERYTHROMYCIN 200 MG/5 ML GRAN
ERYTHROMYCIN 250 MG FILMTAB
ERYTHROMYCIN 500 MG FILMTAB
ERYTHROMYCIN EC 250 MG CAP
ERYTHROMYCIN ES 400 MG TAB
ERYTHROMYCIN EYE OINTMENT
ERYTHROMYCIN ST 250 MG TAB
ERYTHROMYCIN-BENZOYL GEL
ERYTHROMYCIN-SULFISOX SUSP
ESCITALOPRAM 10 MG TABLET
ESCITALOPRAM OXALATE 5 MG/5 ML
ESCITALOPRAM OXALATE 5 MG/5 ML
ESGIC 50-325-40 MG TABLET
ESGIC CAPSULE
ESGIC PLUS CAPSULE
ESGIC-PLUS 50-500-40 MG TABLET
ESTAZOLAM 1 MG TABLET
ESTAZOLAM 2 MG TABLET
ESTRACE 0.01% CREAM
ESTRACE 0.5 MG TABLET
ESTRACE 1 MG TABLET
ESTRACE 2 MG TABLET
ESTRADERM 0.05 MG PATCH
ESTRADERM 0.1 MG PATCH
ESTRADIOL 0.5 MG TABLET
ESTRADIOL 1 MG TABLET
ESTRADIOL 10 MG/ML VIAL
ESTRADIOL 2 MG TABLET
ESTRADIOL TDS 0.025 MG/DAY
250000
500000
500000
2000
2000
2000
200000
250000
500000
250000
400000
500
250000
5000
0
0
0
0
10000
10000
20000
20000
5000
5000
5000
5000
0
0
500000
500000
1000
2000
10
500
1000
2000
50
100
500
1000
10000
2000
25
37
50
60
75
MG
MG
MG
%
%
%
MG/5ML
MG
MG
MG
MG
%
MG
%
ML
ML
ML
ML
MG
MG
MG
MG
MG
MG
MG/5ML
MG/5ML
MG
MG
MG
MG
MG
MG
%
MG
MG
MG
MG
MG
MG
MG
MG/ML
MG
MG
MG
MG
MG
MG
238004
310190
310191
1359124
1359127
688509
848330
581549
197670
238006
310212
310213
310215
1359133
995599
995607
197682
251322
1049615
1049615
616810
315097
904535
904547
197684
197685
197686
199390
310245
359500
310247
197687
207864
207894
728122
213171
544741
261361
999685
863843
866081
996552
208117
208118
226665
1308571
285017

ESTRADIOL VALERATE 20 MG/ML VL
ESTRADIOL VALERATE 40 MG/ML VL
ESTRADIOL-NORETH 0.5-0.1 MG TB
ESTRADIOL-NORETH 1-0.5 MG TAB
ESTRASORB PACKET
ESTRING 2 MG VAGINAL RING
ESTROGEL 0.06% GEL
ESTROGEN-METHYLTESTOS F.S. TAB
ESTROGEN-METHYLTESTOS H.S. TAB
ESTROPIPATE 0.625(0.75 MG) TAB
ESTROPIPATE 1.25(1.5 MG) TAB
ESTROPIPATE 2.5(3 MG) TAB
ESTROSTEP FE-28 TABLET
ETHAMBUTOL HCL 100 MG TABLET
ETHAMBUTOL HCL 400 MG TABLET
ETHOSUXIMIDE 250 MG CAPSULE
ETHOSUXIMIDE 250 MG/5 ML SYRP
ETH-OXYDOSE 20 MG/ML SOLUTION
ETH-OXYDOSE 20 MG/ML SOLUTION
ETHYL ALCOHOL 200 PROOF
ETHYL CHLORIDE SPRAY
ETIDRONATE DISODIUM 200 MG TAB
ETIDRONATE DISODIUM 400 MG TAB
ETODOLAC 200 MG CAPSULE
ETODOLAC 300 MG CAPSULE
ETODOLAC 400 MG TABLET
ETODOLAC 500 MG TABLET
ETODOLAC ER 400 MG TABLET
ETOPOSIDE 50 MG CAPSULE
EURAX 10% CREAM
EURAX 10% LOTION
EVAMIST 1.53 MG/SPRAY
EVISTA 60 MG TABLET
EVOCLIN 1% FOAM
EVOXAC 30 MG CAPSULE
EXACTACAIN SPRAY
EXALL LIQUID
EXALL-D LIQUID
EXECLEAR-C SYRUP
EXELDERM 1% CREAM
EXELDERM 1% SOLUTION
EXELON 1.5 MG CAPSULE
EXELON 13.3 MG/24HR PATCH
EXELON 2 MG/ML ORAL SOLUTION
100
20000
40000
500
1000
750
2000
750
2500
1250
750
1500
3000
0
100000
400000
250000
250000
20000
20000
0
0
200000
400000
200000
300000
400000
500000
400000
500000
600000
50000
10000
10000
1530
60000
1000
30000
0
100000
30000
10000
1000
1000
1500
13300
2000
MG
MG/ML
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG/ML
MG/ML
%
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
MG
MG
%
MG
0
MG/5ML
MG
MG/5ML
%
%
MG
MG
2MG/ML
226666
226667
751302
226668
725105
310261
724879
724887
724891
724895
848134
848155
848139
848144
848149
616159
616161
616163
404536
1294246
895264
860244
729768
1100746
636528
637562
644787
1304988
199192
199193
198382
284245
310274
108852
201219
206853
848726
848730
848734
848738
848742
848746
848750
848752
152880
542977
721775
EXELON 3 MG CAPSULE
EXELON 4.5 MG CAPSULE
EXELON 6 MG CAPSULE
EXEMESTANE 25 MG TABLET
EXFORGE 10-160 MG TABLET
EXFORGE HCT 10-160-12.5 MG TAB
EXFORGE HCT 10-160-25 MG TAB
EXFORGE HCT 5-160-12.5 MG TAB
EXJADE 125 MG TABLET
EXODERM LOTION
EXOTIC-HC EAR DROP
EXPECTUSS LIQUID
EXTAVIA 0.3 MG KIT
EXTINA 2% FOAM
EXTRANEAL ICODEXTRIN DIAL SOLN
FABB TABLET
FACTIVE 320 MG TABLET
FA-CYANCOBA-PYRIDOXINE TAB
FALMINA-28 TABLET
FAMCICLOVIR 125 MG TABLET
FAMOTIDINE 40 MG TABLET
FAMOTIDINE 40 MG/5 ML SUSP
FAMVIR 125 MG TABLET
FANAPT 1 MG TABLET
FANAPT 10 MG TABLET
FANAPT 12 MG TABLET
FANAPT 2 MG TABLET
FANAPT 4 MG TABLET
FANAPT 6 MG TABLET
FANAPT 8 MG TABLET
FANAPT TITRATION PACK
FARESTON 60 MG TABLET
FAZACLO 100 MG TABLET
FAZACLO 12.5 MG ODT
3000
4500
4600
6000
9500
250000
10000
10000
5000
5000
10000
10000
10000
5000
5000
125000
250000
500000
25000
0
75000
300
2000
3500
1000
320000
0
0
125000
250000
500000
40000
40000
125000
250000
500000
1000
10000
12000
2000
4000
6000
8000
1000
60000
100000
12500
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
0
MG/5ML
MG
%
MEQ
MG
MG
0
MG
MG
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
1006803
996923
543013
1087414
968904
968900
198358
198359
310285
209026
209027
209028
105929
105930
402695
402698
402696
1243480
153124
1244908
1251325
1251335
1251327
1251337
848333
848343
602452
602457
602461
310288
477560
349287
310289
477562
351133
200311
860880
860886
763250
763252
310291
245136
577057
245134
245135
197696
310293
FAZACLO 150 MG ODT

FAZACLO 200 MG ODT
FAZACLO 25 MG TABLET
FE C PLUS TABLET
FEIBA NF 1,750-3,250 UNIT VIAL
FEIBA VH IMMUNO 400-650 UNITS
FELBAMATE 400 MG TABLET
FELBAMATE 600 MG TABLET
FELBAMATE 600 MG/5 ML SUSP
FELBATOL 400 MG TABLET
FELBATOL 600 MG TABLET
FELBATOL 600 MG/5 ML SUSP
FELDENE 10 MG CAPSULE
FELDENE 20 MG CAPSULE
FELODIPINE ER 10 MG TABLET
FELODIPINE ER 2.5 MG TABLET
FELODIPINE ER 5 MG TABLET
FEM PH VAGINAL JELLY
FEMARA 2.5 MG TABLET
FEMCON FE TABLET
FEMHRT 0.5 MG-2.5 MCG TABLET
FEMHRT 0.5 MG-2.5 MCG TABLET
FEMHRT 1-5 TABLET
FEMHRT 1-5 TABLET
FEMRING 0.05 MG VAGINAL RING
FEMRING 0.10 MG VAGINAL RING
FEMTRACE 0.45 MG TABLET
FENOFIBRATE 134 MG CAPSULE
FENOFIBRATE 145 MG TABLET
FENOFIBRIC ACID 105 MG TABLET
FENOFIBRIC ACID 35 MG TABLET
FENOGLIDE 120 MG TABLET
FENOGLIDE 40 MG TABLET
FENOPROFEN 600 MG TABLET
FENTANYL 100 MCG/HR PATCH
FENTANYL CIT OTFC 1,200 MCG
150000
200000
25000
100000
1750000
400000
400000
600000
600000
400000
600000
600000
10000
20000
10000
2500
5000
0
2500
35
500
500
5
5
50
100
450
900
1800
134000
145000
160000
200000
48000
54000
67000
105000
35000
120000
40000
600000
100
12
25
50
75
1200
MG
MG
MG
MG
U
U
MG
MG
MG/5ML
MG
MG
MG/5ML
MG
MG
MG
MG
MG
%
MG
MCG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MCG
MCG
MCG
MCG
MCG
MCG
310294
310295
310297
313992
313993
668622
668624
668626
668628
668630
995613
999803
1087218
836270
1087238
1190357
999805
251156
310316
828301
997488
997501
997415
997406
860884
860888
1043748
200172
310346
211190
993945
211310
211333
994277
1148145
283900
283896
1248009
1248067
1247404
1248074
1248037
1247406
360172
207287
687211
207290
FENTANYL CIT OTFC 1,600 MCG

FENTANYL CITRATE OTFC 200 MCG
FENTORA 100 MCG BUCCAL TABLET
FER-IN-SOL 15 MG/ML DROPS
FEROTRIN CAPSULE
FEROTRINSIC CAPSULE
FERRALET 90 DUAL-IRON TABLET
FERRAPLUS 90 TABLET
FERRIPROX 500 MG TABLET
FERROGELS FORTE SOFTGEL
FERROUS SULF 15 MG IRON/ML DRP
FERROUS SULF 75 (15) MG/0.6 ML
FEXMID 7.5 MG TABLET
FEXOFENADINE HCL 30 MG TABLET
FEXOFENADINE HCL 60 MG TABLET
FEXOFENADINE-PSE ER 180-240 TB
FEXOFENADINE-PSE ER 60-120 TAB
FIBRICOR 105 MG TABLET
FIBRICOR 35 MG TABLET
FINACEA 15% GEL
FINASTERIDE 1 MG TABLET
FINASTERIDE 5 MG TABLET
FIORICET 50-325-40 MG TABLET
FIORICET-COD 30-50-325-40 CAP
FIORINAL 50-325-40 MG CAPSULE
FIORINAL 50-325-40 MG CAPSULE
FIORINAL WITH CODEINE #3 CAP
FIRAZYR 30 MG/3 ML SYRINGE
FIRST 2% TESTOSTERONE OINT
FIRST HYDROCORT 10% GEL
FIRST-BXN MOUTHWASH
FIRST-DUKE'S MOUTHWASH
FIRST-LANSOPRAZOLE 3 MG/ML
FIRST-MARY'S MOUTHWASH
FIRST-MOUTHWASH BLM SUSPENSION
FIRST-OMEPRAZOLE 2 MG/ML SUSP
FIRST-TESTOSTERONE MC 2% CR
FLAGYL 250 MG TABLET
FLAGYL 375 CAPSULE
FLAGYL 500 MG TABLET
1600
200
400
600
800
100
200
400
600
800
125000
0
0
0
0
500000
460000
15000
125000
7500
30000
60000
240000
0
105000
35000
15000
1000
5000
0
30000
325000
325000
30000
10000
2000
10000
1600
600
3000
1200
0
2000
2000
250000
375000
500000
MG
MCG
MCG
MCG
MCG
MCG
MCG
MCG
MCG
MCG
MG/ML
MG
MG
MG
MG
MG
MG
MG/ML
MG/ML
MG
MG
MG
MG
MG
MG
MG
%
MG
MG
MG
MG
MG
MG
MG
MG/ML
0
%
G
G
MG/ML
G
0
MG/ML
0
MG
MG
MG
687204
1249631
1095229
886666
886671
886662
855628
828350
828322
998715
999416
999423
211199
211200
863671
896323
803308
896023
896027
896019
896001
896006
895996
310352
197698
197699
197700
310353
197701
197702
197703
313979
856607
1313826
752376
1191302
1191307
1191310
1191315
1191256
1191299
103456
310362
103457
310364
861717
1098478
FLAGYL ER 750 MG TABLET

FLAREX 0.1% EYE DROPS
FLAVOXATE HCL 100 MG TABLET
FLECAINIDE ACETATE 100 MG TAB
FLECTOR 1.3% PATCH
FLEXERIL 10 MG TABLET
FLEXERIL 5 MG TABLET
FLEXTRA PLUS CAPSULE
FLEXTRA-650 TABLET
FLEXTRA-DS TABLET
FLOLAN 0.5 MG VIAL
FLOLAN 1.5 MG VIAL
FLOMAX 0.4 MG CAPSULE
FLONASE 0.05% NASAL SPRAY
FLO-PRED 16.7(15) MG/5 ML SUSP
FLOVENT 100 MCG DISKUS
FLOVENT HFA 110 MCG INHALER
FLUCONAZOLE 10 MG/ML SUSP
FLUCONAZOLE 100 MG TABLET
FLUCONAZOLE 40 MG/ML SUSP
FLUCYTOSINE 250 MG CAPSULE
FLUCYTOSINE 500 MG CAPSULE
FLUDROCORTISONE 0.1 MG TABLET
FLUMADINE 100 MG TABLET
FLUNISOLIDE 0.025% SPRAY
FLUNISOLIDE 29 MCG-0.025% SPR
FLUOCINOLONE 0.01% CREAM
FLUOCINOLONE 0.01% SCALP OIL
FLUOCINOLONE 0.01% SOLUTION
FLUOCINOLONE 0.025% CREAM
FLUOCINOLONE 0.025% OINTMENT
FLUOCINOLONE OIL 0.01% EAR DRP
FLUOCINONIDE 0.05% CREAM
FLUOCINONIDE 0.05% GEL
FLUOCINONIDE 0.05% OINTMENT
FLUOCINONIDE 0.05% SOLUTION
FLUORABON 0.25 MG/0.6 ML DROPS
FLUOR-A-DAY 0.25 MG TAB CHEW
750000
100
100000
100000
150000
50000
1300
10000
5000
425000
650000
50000
500
1500
400
50
15000
100
250
50
110
220
44
50000
100000
150000
200000
200000
50000
250000
500000
100
100000
0
25
10
10
10
25
25
10
50
50
50
50
416
250
MG
%
MG
MG
MG
MG
%
MG
MG
MG
MG
MG
MG
MG
MG
%
MG/5ML
MCG
MCG
MCG
MCG
MCG
MCG
MG/5ML
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG
0
%
%
%
%
%
%
%
%
%
%
%
MG/ML
MG
1098483
1098490
630475
617624
636724
861724
861728
310377
92752
310379
105583
310380
310386
313995
310384
313990
310385
248642
313989
1190110
865117
859841
865123
859835
860918
861848
1098924
1298088
1298091
1243585
197724
197725
197726
895487
895987
895990
896321
310404
310405
903884
903887
903891
208420
545243
856935
899549
899559
FLUOR-A-DAY 0.5 MG TAB CHEW

FLUOR-A-DAY 1 MG TABLET CHEW
FLUOR-A-DAY 2.5 MG/ML DROPS
FLUORIDEX SENSITIVITY 1.1% GEL
FLUORITAB 0.25 MG/DRP DROPS
FLUORITAB 0.5 MG TABLET CHEW
FLUORITAB 1 MG TABLET CHEW
FLUOROMETHOLONE 0.1% DROPS
FLUOROPLEX 1% CREAM
FLUOROURACIL 2% TOPICAL SOLN
FLUOROURACIL 5% CREAM
FLUOROURACIL 5% TOP SOLUTION
FLUOXETINE 20 MG/5 ML SOLUTION
FLUOXETINE DR 90 MG CAPSULE
FLUOXETINE HCL 10 MG CAPSULE
FLUOXETINE HCL 10 MG TABLET
FLUPHENAZINE 1 MG TABLET
FLUPHENAZINE 2.5 MG TABLET
FLUPHENAZINE 2.5 MG/5 ML ELIX
FLUPHENAZINE 5 MG/ML CONC
FLURA-DROPS 0.25 MG/DROP
FLURAZEPAM 15 MG CAPSULE
FLURAZEPAM 30 MG CAPSULE
FLURBIPROFEN 0.03% EYE DROP
FLURBIPROFEN 100 MG TABLET
FLURBIPROFEN 50 MG TABLET
FLUTAMIDE 125 MG CAPSULE
FLUTICASONE PROP 0.005% OINT
FLUTICASONE PROP 0.05% CREAM
FLUTICASONE PROP 0.05% LOTION
FLUTICASONE PROP 50 MCG SPRAY
FLUVASTATIN SODIUM 20 MG CAP
FLUVASTATIN SODIUM 40 MG CAP
FLUVOXAMINE MALEATE 100 MG TAB
FML FORTE 0.25% EYE DROPS
FML LIQUIFILM 0.1% EYE DROP
FML S.O.P. 0.1% OINTMENT
FOCALIN 10 MG TABLET
FOCALIN 2.5 MG TABLET
500
1000
2500
1100
5000
500
1000
100
1000
2000
5000
5000
20000
90000
10000
10000
20000
20000
40000
60000
1000
10000
2500
500
5000
5000
5000
15000
30000
30
100000
50000
125000
50
50
50
50
20000
40000
100000
25000
50000
250
100
100
10000
2500
MG
MG
MG/ML
%
MG/ML
MG
MG
%
%
%
%
%
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/ML
MG
MG/ML
MG/ML
MG
MG
%
MG
MG
MG
%
%
%
%
MG
MG
MG
MG
MG
%
%
%
MG
MG
899519
899441
899463
899487
1101928
899497
1101934
1006610
899513
1043300
999472
198640
310410
198641
1305135
542045
861356
861360
861363
861365
1246328
205686
310416
205689
860998
861002
847907
688596
904421
904399
904427
904450
904433
904495
904465
857169
857183
857187
857166
857174
603112
542465
603122
978757
978760
978741
978745
FOCALIN 5 MG TABLET
FOCALIN XR 10 MG CAPSULE
FOLCAL DHA CAPSULE
FOLCAPS TABLET
FOLIC ACID 0.4 MG TABLET
FOLIC ACID 1 MG TABLET
FOLIC ACID 800 MCG TABLET
FOLIVANE-PRX DHA NF CAPSULE
FOLTRATE TABLET
FONDAPARINUX 10 MG/0.8 ML SYR
FONDAPARINUX 2.5 MG/0.5 ML SYR
FONDAPARINUX 5 MG/0.4 ML SYR
FONDAPARINUX 7.5 MG/0.6 ML SYR
FORADIL AEROLIZER 12 MCG CAP
FORMADON 10% SOLUTION
FORMALDEHYDE 10% SOLUTION
FORMA-RAY 20% SOLUTION
FORTAMET ER 1,000 MG TABLET
FORTAMET ER 500 MG TABLET
FORTEO 750 MCG/3 ML PEN
FORTICAL 200 UNITS NASAL SPRAY
FOSAMAX 10 MG TABLET
FOSAMAX 5 MG TABLET
FOSAMAX 70 MG ORAL SOLUTION
FOSAMAX PLUS D 70 MG-2,800 IU
FOSAMAX PLUS D 70 MG-5,600 IU
FOSINOPRIL SODIUM 10 MG TAB
FOSINOPRIL-HCTZ 10-12.5 MG TAB
FOSINOPRIL-HCTZ 20-12.5 MG TAB
FOSRENOL 1,000 MG TABLET CHEW
FOSRENOL 500 MG TABLET CHEW
FOSRENOL 750 MG TABLET CHEW
FRAGMIN 10,000 UNITS SYRINGE
FRAGMIN 10,000 UNITS/ML VIAL
5000
10000
15000
20000
25000
30000
35000
40000
5000
27000
0
400
1000
800
30000
0
10000
2500
5000
7500
12
10000
10000
20000
1000000
500000
750
200000
10000
35000
5000
70000
70000
70000
70000
10000
20000
40000
10000
20000
1000000
500000
750000
10000000
10000000
12500000
15000000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
0
MG
MG
MG
MG
0
MG/0.8
MG/0.5
MG/0.4
MG/0.6
MCG
%
%
%
MG
MG
MCG
U/DOSE
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
U/ML
U/ML
U/.5ML
U/.6ML
978747
978727
978778
978735
978737
540434
352058
1364460
1114356
207790
197730
310429
313988
197731
197732
404460
310430
283523
310431
310432
310433
310434
1299967
1299971
1299973
1299978
860901
860695
860707
860715
579148
310436
310437
213049
213050
314007
200206
1046301
1046307
998726
998726
831269
643783
1364477
967023
967012
979099

FRAGMIN 25,000 UNITS/ML VIAL
FRENADOL TABLET
FROVA 2.5 MG TABLET
FULYZAQ 125 MG DR TABLET
FUMATINIC ER CAPSULE
FURADANTIN 25 MG/5 ML SUSP
FUROSEMIDE 10 MG/ML SOLUTION
FUROSEMIDE 20 MG TABLET
FUROSEMIDE 40 MG/5 ML SOLN
FUZEON CONVENIENCE KIT
GABAPENTIN 100 MG CAPSULE
GABAPENTIN 250 MG/5 ML SOLN
GABAPENTIN 600 MG TABLET
GABAPENTIN 800 MG TABLET
GABITRIL 12 MG TABLET
GALANTAMINE 4 MG/ML ORAL SOLN
GALANTAMINE ER 16 MG CAPSULE
GALANTAMINE HBR 12 MG TABLET
GALZIN 25 MG CAPSULE
GALZIN 50 MG CAPSULE
GANCICLOVIR 250 MG CAPSULE
GANCICLOVIR 500 MG CAPSULE
GARAMYCIN 3 MG/GM EYE OINT
GARAMYCIN 3 MG/ML EYE DROPS
GASTRINEX NF CAPSULE
GASTRINEX NF CAPSULE
GASTROCROM 100 MG/5 ML CONC
GASTROMARK 175 MCG/ML SUSP
GATTEX 5 MG ONE-VIAL KIT
GAVILYTE-C SOLUTION
GAVILYTE-G SOLUTION
GAVILYTE-N SOLUTION
18000000
2500000
25000000
5000000
7500000
600000
2500
125000
0
25000
10000
20000
40000
40000
80000
90000
100000
250000
300000
400000
600000
800000
12000
16000
2000
4000
4000
16000
24000
8000
12000
4000
8000
25000
50000
250000
500000
300
300
625
625
20000
175
5000
0
0
0
U/.72M
U/.2ML
U/ML
U/.2ML
U/.3ML
MG
MG
MG
MG
MG/5ML
MG/ML
MG
MG
MG/5ML
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
MCG
MCG
MG/ML
MCG
MG
0
0
0
750100
864820
1250565
310459
1099897
544455
1293874
835835
835835
835892
835892
835896
835896
545236
205797
197735
310465
310466
310467
205798
285127
285127
284548
284548
284549
284549
284550
284550
1114604
748798
993804
1243583
1367691
1358777
1359029
1359024
1358764
1012899
404588
404589
199245
199246
199247
310488
310490
315107
310489
GEL-KAM 0.63% DENTAL RINSE

GELNIQUE 10% GEL SACHETS
GELNIQUE 3% GEL
GEMFIBROZIL 600 MG TABLET
GENERESS FE CHEWABLE TABLET
GENERLAC 10 GM/15 ML SOLUTION
GENEXOTIC HC EAR DROPS
GENGRAF 100 MG CAPSULE
GENGRAF 100 MG/ML SOLUTION
GENGRAF 100 MG/ML SOLUTION
GENTAK 3 MG/GM EYE OINTMENT
GENTAK 3 MG/ML EYE DROPS
GENTAMICIN 0.1% CREAM
GENTAMICIN 0.1% OINTMENT
GENTAMICIN 3 MG/GM EYE OINT
GENTAMICIN 3 MG/ML EYE DROPS
GENTASOL 3 MG/ML EYE DROPS
GEODON 20 MG CAPSULE
GESTICARE DHA COMBO PACK
GIANVI 3 MG-0.02 MG TABLET
GIANVI 3 MG-0.02 MG TABLET
GIAZO 1.1 GM TABLET
GILDAGIA 0.4 MG-0.035 MG TAB
GILDESS 1 MG-20 MCG TABLET
GILDESS 1.5 MG-30 MCG TABLET
GILDESS FE 1.5-30 TABLET
GILDESS FE 1-20 TABLET
GILENYA 0.5 MG CAPSULE
GLEEVEC 100 MG TABLET
GLEEVEC 400 MG TABLET
GLIMEPIRIDE 1 MG TABLET
GLIPIZIDE 10 MG TABLET
GLIPIZIDE 5 MG TABLET
GLIPIZIDE ER 10 MG TABLET
GLIPIZIDE ER 2.5 MG TABLET
630
10000
3000
600000
800
0
0
100000
100000
100000
100000
25000
25000
300
300
100
100
300
300
300
20000
20000
40000
40000
60000
60000
80000
80000
0
0
0
1100000
35
0
1500
1500
1000
500
100000
400000
1000
2000
4000
10000
5000
10000
2500
%
%
%
MG
MG
0
0
MG
MG
MG
MG
MG
MG
%
%
%
%
%
%
%
MG
MG
MG
MG
MG
MG
MG
MG
0
MG
MG
MG
MCG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
314006
861731
861736
861740
153095
310497
861006
861008
861012
860977
860983
616103
205830
205828
865568
865571
865573
861752
861757
861015
861018
1038787
197737
310534
310537
314000
310536
310539
861748
861753
861743
310571
240548
197738
197739
881407
881409
881411
213487
213485
213486
966916
966922
210074
238636
310599
763507
GLIPIZIDE ER 5 MG TABLET
GLIPIZIDE-METFORMIN 2.5-250 MG
GLIPIZIDE-METFORMIN 2.5-500 MG
GLIPIZIDE-METFORMIN 5-500 MG
GLUCAGEN 1 MG HYPOKIT
GLUCAGON 1 MG EMERGENCY KIT
GLUCOPHAGE 1,000 MG TABLET
GLUCOPHAGE 500 MG TABLET
GLUCOPHAGE 850 MG TABLET
GLUCOPHAGE XR 500 MG TAB
GLUCOPHAGE XR 750 MG TAB
GLUCOSE 40% GEL
GLUCOTROL 10 MG TABLET
GLUCOTROL 5 MG TABLET
GLUCOTROL XL 10 MG TABLET
GLUCOTROL XL 2.5 MG TABLET
GLUCOTROL XL 5 MG TABLET
GLUCOVANCE 2.5-500 MG TABLET
GLUCOVANCE 5-500 MG TABLET
GLUMETZA ER 1,000 MG TABLET
GLUMETZA ER 500 MG TABLET
GLUTOSE 15 GEL
GLYBURIDE 1.25 MG TABLET
GLYBURIDE 2.5 MG TABLET
GLYBURIDE 5 MG TABLET
GLYBURIDE MICRO 1.5 MG TAB
GLYBURIDE MICRO 3 MG TABLET
GLYBURIDE MICRO 6 MG TABLET
GLYBURIDE-METFORMIN 2.5-500 MG
GLYBURIDE-METFORMIN 5-500 MG
GLYBURID-METFORMIN 1.25-250 MG
GLYCINE 1.5% IRRIGATION
GLYCOLIC ACID 70% SOLUTION
GLYCOPYRROLATE 1 MG TABLET
GLYCOPYRROLATE 2 MG TABLET
GLYNASE 1.5 MG PRESTAB
GLYNASE 3 MG PRESTAB
GLYNASE 6 MG PRESTAB
GLYSET 100 MG TABLET
GLYSET 25 MG TABLET
GLYSET 50 MG TABLET
GOLYTELY PACKET
GOLYTELY SOLUTION
GORDOFILM SOLUTION
GORDO-UREA 40% OINTMENT
GRANISETRON HCL 1 MG TABLET
GRANISOL 2 MG/10 ML SOLUTION
5000
250000
500000
5000
1000
1000
1000000
500000
850000
500000
750000
40000
10000
5000
10000
2500
5000
2500
5000
1000000
500000
40000
1250
2500
5000
1500
3000
6000
2500
5000
1250
1500
70000
1000
2000
1500
3000
6000
100000
25000
50000
0
0
0
40000
1000
1000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
MG
MG
MG
MG
MG
MG
MG
MG
0
0
0
%
MG
MG/5ML
211226
205915
239238
310600
242831
239239
205904
205906
995868
995872
995450
197743
197744
197745
197746
1298099
996462
995983
890783
1053854
1053854
208681
826847
1000480
198477
211822
211835
977990
977978
206546
206548
1005905
1005905
1005908
1005908
310670
310671
314035
314034
197754
310672
141935
977836
1235241
1235241
1235243
1235243
GRANULEX SPRAY
GRIFULVIN V 500 MG TABLET
GRISEOFULVIN 125 MG/5 ML SUSP
GRISEOFULVIN MICRO 500 MG TAB
GRISEOFULVIN ULTRA 125 MG TAB
GRISEOFULVIN ULTRA 250 MG TAB
GRIS-PEG 125 MG TABLET
GRIS-PEG 250 MG TABLET
GUAIFENESIN AC COUGH SYRUP
GUAIFENESIN-CODEINE LIQUID
GUAIFENESIN-CODEINE TABLET
GUANABENZ ACETATE 4 MG TAB
GUANABENZ ACETATE 8 MG TAB
GUANFACINE 1 MG TABLET
GUANFACINE 2 MG TABLET
GUANIDINE HCL 125 MG TABLET
GUIATUSS AC SYRUP
GUIATUSS DAC SYRUP
GYNAZOLE-1 CREAM
HALAC COMBO KIT
HALAC COMBO KIT
HALCION 0.25 MG TABLET
HALFLYTELY-BISACODYL BOWEL KIT
HALFLYTELY-BISACODYL BOWEL KIT
HALFPRIN EC 162 MG TABLET
HALOBETASOL PROP 0.05% CREAM
HALOBETASOL PROP 0.05% OINTMNT
HALOG 0.1% CREAM
HALOG 0.1% OINTMENT
HALONATE COMBO PACK
HALONATE COMBO PACK
HALONATE PAC COMBO PACK
HALONATE PAC COMBO PACK
HALOPERIDOL 0.5 MG TABLET
HALOPERIDOL 1 MG TABLET
HALOPERIDOL LAC 2 MG/ML CONC
HEATHER TABLET
HECORIA 0.5 MG CAPSULE
HECORIA 0.5 MG CAPSULE
HECORIA 1 MG CAPSULE
0
500000
125000
500000
125000
250000
125000
250000
10000
10000
10000
4000
8000
1000
2000
125000
10000
10000
2000
50
50
250
0
5000
162000
162000
81000
50
50
100
100
50
50
50
50
500
1000
10000
2000
20000
5000
2000
350
500
500
1000
1000
0
MG
MG/5ML
MG
MG
MG
MG
MG
MG/5ML
MG/5ML
MG
MG
MG
MG
MG
MG
MG/5ML
MG
%
%
%
MG
0
MG
MG
MG
MG
%
%
%
%
%
%
%
%
MG
MG
MG
MG
MG
MG
MG/ML
MG
MG
MG
MG
MG
1235245
1235245
540687
858264
261247
758020
1367961
1367950
1367963
1367959
999749
999783
1087410
1087399
404084
1368083
1368089
1368063
1291090
1291090
1362024
1362026
1362027
1362029
1362030
1361029
1361044
1362048
1362052
1362054
1362055
1366636
1361219
1362057
1362060
1362062
1361226
1362831
1361574
1361853
1361615
1361050
881343
153473
992152
1363013
902753
HECTOROL 0.5 MCG CAPSULE
HECTOROL 1 MCG CAPSULE
HECTOROL 2.5 MCG CAPSULE
HELIDAC THERAPY
HELIXATE FS 2,000 UNIT VIAL
HELIXATE FS 250 UNIT VIAL
HELIXATE FS 3,000 UNITS VIAL
HELIXATE FS 500 UNIT VIAL
HEMATOGEN FA SOFTGEL
HEMATOGEN FORTE SOFTGEL
HEMAX CAPLET
HEMOCYTE PLUS CAPSULE
HEMOCYTE-F TABLET
HEMOFIL M 220-400 UNITS VIAL
HEMOFIL M 401-800 UNITS VIAL
HEMOFIL M 801-1,700 UNITS VIAL
HEMRIL-30 30 MG SUPPOSITORY
HEMRIL-30 30 MG SUPPOSITORY
HEPARIN IV FLUSH 1 UNIT/ML SYR
HEPARIN LOCK FLUSH 10 UNITS/ML
HEPARIN LOCK FLUSH 100 UNIT/ML
HEPARIN NA 1,000 UNITS/ML VIAL
HEPARIN SOD 10,000 UNIT/ML VL
HEPARIN SOD 20,000 UNIT/ML VL
HEPARIN SOD 5,000 UNIT/0.5 ML
HEPARIN SOD 5,000 UNIT/ML SYR
HEP-LOCK 100 UNITS/ML VIAL
HEPSERA 10 MG TABLET
HEXALEN 50 MG CAPSULE
HIPREX 1 GM TABLET
HISTEX SR CAPLET
HIZENTRA 4 GRAM/20 ML VIAL
5000
5000
500
100
2500
0
1800000
250000
3000000
500000
200000
460000
1000
106000
0
850000
0
0
30000
30000
1000
1000
1000
1000
1000
10000
10000
10000
10000
10000
10000
10000
100000
10000
10000
10000
1000000
10000000
20000000
10000000
5000000
100000
10000
50000
1000000
120000
4000
MG
MG
MCG
MCG
MCG
0
IU
UNITS
IU
UNITS
MG
MG
MG
MG
MG
UNITS
0
0
MG
MG
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
MG
MG
MG
MG
GM
582901
992759
992819
1101337
1040025
847209
865098
847213
731281
847254
752388
826584
826315
763565
727705
825170
847189
847199
311026
311036
351859
748738
748740
856942
992671
992660
905199
905222
905225
905395
105602
849650
728546
199903
429503
310798
197770
857391
857111
856992
857005
857118
857083
833036
856987
857002
856903
HM ISOPROPYL ALCOHOL 91%

HOMATROPAIRE 5% EYE DROPS
HOMATROPINE HBR 5% EYE DROP
HORIZANT ER 600 MG TABLET
HP ACTHAR GEL 80 UNIT/ML VIAL
HUMALOG 100 UNITS/ML CARTRIDGE
HUMALOG 100 UNITS/ML VIAL
HUMALOG MIX 50-50 KWIKPEN
HUMALOG MIX 50-50 VIAL
HUMALOG MIX 75-25 KWIKPEN
HUMALOG MIX 75-25 VIAL
HUMATE-P 2,400 UNIT VWF:RCO
HUMATE-P 600 UNIT VWF:RCO
HUMIRA 20 MG/0.4 ML SYRINGE
HUMIRA 40 MG/0.8 ML SYRINGE
HUMIRA CROHN'S STARTER PACK
HUMULIN 70-30 PEN
HUMULIN N 100 UNITS/ML PEN
HUMULIN N 100 UNITS/ML VIAL
HUMULIN R 100 UNITS/ML VIAL
HUMULIN R 500 UNITS/ML VIAL
HYCAMTIN 0.25 MG CAPSULE
HYCAMTIN 1 MG CAPSULE
HYCET 7.5 MG-325 MG/15 ML SOL
HYCODAN SYRUP
HYCODAN TABLET
HYDRALAZINE 10 MG TABLET
HYDREA 500 MG CAPSULE
HYDRO 35 FOAM
HYDRO 40 FOAM
HYDROCHLOROTHIAZIDE 12.5 MG CP
HYDROCHLOROTHIAZIDE 12.5 MG TB
HYDROCHLOROTHIAZIDE 25 MG TAB
HYDROCHLOROTHIAZIDE 50 MG TAB
HYDROCODON-ACETAMINOPH 2.5-325
HYDROCODON-ACETAMINOPHEN 5-300
91000
5000
5000
600000
80000
100000
100000
50000
50000
75000
75000
2400000
500000
20000
40000
40000
100000
100000
100000
100000
500000
250
1000
2500
0
0
10000
100000
25000
50000
500000
35000
40000
12500
12500
25000
50000
2500
2500
7500
7500
500000
650000
7500
5000
5000
5000
%
%
%
MG
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
UNITS
AHFU
MG/0.4
MG/0.8
MG/0.8
U/ML
U/ML
U/ML
U/ML
U/ML
MG
MG
MG/5ML
0
MG
MG
MG
MG
MG
MG
%
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
856980
856999
857107
857383
856908
856892
856940
856944
857099
1087459
992668
992656
859315
858770
858778
858798
1370767
197782
310878
310878
310891
197785
103401
197783
1291085
1291085
197787
1291082
1291082
604449
604449
1370758
1370754
1370750
310870
1234506
1234506
1246538
1246538
1246586
1246586
1235049
1235049
1294025
1294025
992675
897696
HYDROCODON-ACETAMINOPHN 10-300
HYDROCODONE-ACETAMINOPHEN SOLN
HYDROCODONE-CHLORPHENIRAM SUSP
HYDROCODONE-HOMATROPINE SYRUP
HYDROCODONE-HOMATROPINE TABLET
HYDROCODONE-IBUPROFEN 10-200
HYDROCODONE-IBUPROFEN 2.5-200
HYDROCODONE-IBUPROFEN 5-200 MG
HYDROCODONE-IBUPROFEN 7.5-200
HYDROCORTISONE 0.1% SOLN
HYDROCORTISONE 10 MG TABLET
HYDROCORTISONE 100 MG ENEMA
HYDROCORTISONE 100 MG ENEMA
HYDROCORTISONE 2.5% CREAM
HYDROCORTISONE 2.5% LOTION
HYDROCORTISONE 2.5% OINTMENT
HYDROCORTISONE 30 MG SUPP
HYDROCORTISONE 30 MG SUPP
HYDROCORTISONE AC 25 MG SUPP
HYDROCORTISONE AC 25 MG SUPP
HYDROCORTISONE ACETATE 2% GEL
HYDROCORTISONE ACETATE 2% GEL
HYDROCORTISONE BUTYR 0.1% OINT
HYDROCORTISONE VAL 0.2% CREAM
HYDROCORTISONE VAL 0.2% OIN
HYDROCORTISONE-IODOQUINOL CRM
HYDROCORTISONE-PRAMOXINE CREAM
HYDROCORTISONE-PRAMOXINE CREAM
HYDROCORT-PRAM 2.5%-1% CRM KIT
HYDROCORT-PRAMOXINE 1%-1% CRM
HYDROCORT-PRAMOXINE 1%-1% CRM
HYDROCORT-PRAMOXINE 2.5%-1% CM
HYDROCORT-PRAMOXINE 2.5%-1% CM
HYDROMET SYRUP
HYDROMORPHONE 2 MG TABLET
10000
325000
500000
10001
660000
750000
2500
0
0
10000
0
5000
10000
0
5000
200000
100
10000
100000
100000
2500
2500
2500
20000
30000
30000
5000
25000
25000
2000
2000
100
200
200
1000
2500
2500
2500
2500
2500
2500
1000
1000
2500
2500
0
2000
MG
MG
MG
MG
MG
MG
MG/5ML
ML
ML
MG/5ML
ML
MG
MG
0
MG
MG
%
MG
MG
MG
%
%
%
MG
MG
MG
MG
MG
MG
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
ML
MG
897749
897702
897657
897710
979092
197797
995241
995241
995218
995218
995258
995258
995281
995232
995232
995253
995253
995278
995278
1098158
1244204
1098159
1098163
1048052
1048052
1037236
1046985
1046985
1046982
1046982
1047881
1047881
1047895
1047895
1046770
1046770
1047905
1047905
1245026
707347
208471
208471
208467
208467
208470
208470
979466
HYDROMORPHONE 3 MG SUPPOS
HYDROMORPHONE 5 MG/5 ML SOLN
HYDROXYCHLOROQUINE 200 MG TAB
HYDROXYUREA 500 MG CAPSULE
HYDROXYZINE 10 MG/5 ML SYRUP
HYDROXYZINE 10 MG/5 ML SYRUP
HYDROXYZINE HCL 10 MG TABLET
HYDROXYZINE PAM 100 MG CAP
HYGEL 0.2% GEL
HYLASE WOUND GEL
HYLIRA 0.2% GEL
HYLIRA HYDRATING LOTION
HYOMAX-SL 0.125 MG TABLET SL
HYOMAX-SL 0.125 MG TABLET SL
HYOPHEN TABLET
HYOSCYAMINE 0.125 MG ODT
HYOSCYAMINE 0.125 MG ODT
HYOSCYAMINE 0.125 MG TAB SL
HYOSCYAMINE 0.125 MG TAB SL
HYOSCYAMINE 0.125 MG/5 ML ELIX
HYOSCYAMINE 0.125 MG/5 ML ELIX
HYOSCYAMINE 0.125 MG/ML DROP
HYOSCYAMINE 0.125 MG/ML DROP
HYOSCYAMINE ER 0.375 MG TAB
HYOSCYAMINE ER 0.375 MG TAB
HYOSCYAMINE SULF 0.125 MG TAB
HYOSCYAMINE SULF 0.125 MG TAB
HYPER-SAL 3.5% VIAL
HYPER-SAL 7% VIAL
HYTRIN 10 MG CAPSULE
HYTRIN 10 MG CAPSULE
HYTRIN 2 MG CAPSULE
HYTRIN 2 MG CAPSULE
HYTRIN 5 MG CAPSULE
HYTRIN 5 MG CAPSULE
HYZAAR 100-12.5 TABLET
3000
4000
1000
8000
200000
500000
10000
10000
10000
10000
25000
25000
50000
100000
100000
25000
25000
50000
50000
200
2500
200
100
125
125
81600
125
125
125
125
125
125
125
125
375
375
125
125
3500
7000
10000
10000
2000
2000
5000
5000
100000
MG
MG
MG/ML
MG
MG
MG
MG/5ML
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
%
%
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG/5ML
MG/ML
MG/ML
MG
MG
MG
MG
%
%
MG
MG
MG
MG
MG
MG
MG
979473
979470
904932
859317
858780
197805
206905
197806
206913
197807
206917
1111197
1087418
1364358
1364362
1087438
1365866
206035
206858
211616
901478
835593
835564
835568
835591
835589
835577
835572
310982
284460
582328
208450
758523
582330
209169
860088
208452
105611
1102282
197815
197816
856462
856483
856537
856571
206971
206969
HYZAAR 100-25 TABLET

HYZAAR 50-12.5 TABLET
IBANDRONATE SODIUM 150 MG TAB
IBUDONE 10-200 MG TABLET
IBUDONE 5-200 MG TABLET
IBUPROFEN 400 MG TABLET
ICAR-C PLUS SR CAPSULE
ICAR-C PLUS TABLET
ICLUSIG 15 MG TABLET
ICLUSIG 45 MG TABLET
IFEREX 150 FORTE CAPSULE
ILEVRO 0.3% OPHTH DROPS
ILOTYCIN 0.5% EYE OINTMENT
IMDUR ER 120 MG TABLET
IMIPRAMINE HCL 10 MG TABLET
IMIPRAMINE PAMOATE 100 MG CAP
IMIQUIMOD 5% CREAM PACKET
IMITREX 100 MG TABLET
IMITREX 20 MG NASAL SPRAY
IMITREX 4 MG/0.5 ML PEN INJECT
IMITREX 5 MG NASAL SPRAY
IMITREX 6 MG/0.5 ML PEN INJECT
IMITREX 6 MG/0.5 ML SYRNG KIT
IMURAN 50 MG TABLET
INCIVEK 375 MG TABLET
INDAPAMIDE 1.25 MG TABLET
INDAPAMIDE 2.5 MG TABLET
INDERAL LA 120 MG CAPSULE SA
INDOCIN 25 MG/5 ML SUSPENSION
INDOCIN 50 MG SUPPOSITORY
100000
50000
150000
10000
5000
400000
400000
600000
600000
800000
800000
100000
100000
15000
45000
1000
300
500
120000
30000
60000
10000
25000
50000
100000
125000
150000
75000
5000
100000
20000
25000
4000
5000
50000
12000
12000
50000
375000
1250
2500
120000
160000
60000
80000
25000
50000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
MG
MG
MG/.5M
MG
MG
MG/ML
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG
197817
197818
310992
213084
1243010
1243014
978715
856471
856576
797819
883810
798502
856441
402106
402105
999826
758555
1052660
1250723
545293
545293
1251596
1251596
207035
207035
207029
207029
1020155
862010
862015
862021
862027
866105
686441
686443
686445
859861
859865
798049
687059
108896
211020
835903
836292
836281
836358
545122
INDOMETHACIN 25 MG CAPSULE
INDOMETHACIN 50 MG CAPSULE
INDOMETHACIN ER 75 MG CAPSULE
INFERGEN 9 MCG/0.3 ML VIAL
INLYTA 1 MG TABLET
INLYTA 5 MG TABLET
INNOHEP 20,000 UNIT/ML VIAL
INNOPRAN XL 120 MG CAPSULE
INNOPRAN XL 80 MG CAPSULE
INOVA 4% EASY PAD
INOVA 4-1 EASY PAD
INOVA 8% EASY PAD
INOVA 8-2 EASY PAD
INSPRA 25 MG TABLET
INSPRA 50 MG TABLET
INTEGRA F CAPSULE
INTELENCE 100 MG TABLET
INTRON A 10 MILLION UNIT/ML
INTRON A 10 MILLION UNIT/ML
INTRON A 18 MILLION UNITS VIAL
INTRON A 6 MILLION UNIT/ML VL
INTRON A 6 MILLION UNIT/ML VL
INTROVALE 0.15-0.03 MG TABLET
INTUNIV ER 1 MG TABLET
INVEGA ER 1.5 MG TABLET
INVEGA ER 3 MG TABLET
INVIRASE 200 MG CAPSULE
INVIRASE 500 MG TABLET
IODOFLEX PAD
IODOSORB GEL
IOPIDINE 0.5% EYE DROPS
IOPIDINE 1% EYE DROPS
IPRAT-ALBUT 0.5-3(2.5) MG/3 ML
IPRATROPIUM 0.03% SPRAY
IPRATROPIUM 0.06% SPRAY
IPRATROPIUM BR 0.02% SOLN
IQUIX 1.5% EYE DROPS
25000
50000
75000
900
1000
5000
20000000
120000
80000
4000
1000
8000
2000
25000
50000
0
100000
200000
25000
10000
10000
18000
18000
50000
50000
6000
6000
15
1000
2000
3000
4000
1500
3000
6000
9000
200000
500000
0
0
500
1000
0
30
60
20
1500
MG
MG
MG
MCG/ML
MG
MG
U/ML
MG
MG
%
%
%
%
MG
MG
MG
MG
MG
MG
MMU
MMU
MMU
MMU
MMU
MMU
MMU
MMU
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
0
0
%
%
0
%
%
%
%
200095
200096
200094
310792
310793
402091
1102207
1235591
1235595
744846
201427
351381
979541
824485
824485
606947
606947
631357
311166
197832
105292
402481
901435
897700
897714
1190664
211198
211237
1000656
1000870
1000903
992749
992761
208123
793872
793873
381056
197838
206842
197839
314055
197841
311194
311192
311197
311196
317110
IRBESARTAN 150 MG TABLET

IRBESARTAN-HCTZ 150-12.5 MG TB
IRBESARTAN-HCTZ 300-12.5 MG TB
IRESSA 250 MG TABLET
IROSPAN 24/6 TABLET
ISENTRESS 100 MG TABLET CHEW
ISENTRESS 25 MG TABLET CHEW
ISENTRESS 400 MG TABLET
ISMO 20 MG TABLET
ISOCHRON 40 MG TABLET SA
ISODITRATE ER 40 MG TABLET
ISOMETHEPT-CAFF-ACETAMINOPH TB
ISOMETHEPT-CAFF-ACETAMINOPH TB
ISOMETHEPT-DICHLORALP-ACETAMIN
ISOMETHEPT-DICHLORALP-ACETAMIN
ISONARIF CAPSULE
ISONIAZID 100 MG TABLET
ISONIAZID 300 MG TABLET
ISONIAZID 50 MG/5 ML SOLUTION
ISOPROPYL ALCOHOL 99%
ISOPTIN SR 120 MG TABLET
ISOPTO ATROPINE 1% EYE DROPS
ISOPTO CARBACHOL 1.5% DROPS
ISOPTO CARBACHOL 3% DROPS
ISOPTO CARPINE 1% EYE DROPS
ISOPTO HOMATROPINE 2% DROPS
ISOPTO HOMATROPINE 5% DROPS
ISOPTO HYOSCINE 0.25% DROPS
ISORDIL 40 MG TABLET
ISORDIL TITRADOSE 5 MG TAB
ISOSORBIDE DN 10 MG TABLET
ISOSORBIDE DN 2.5 MG TAB SL
ISOSORBIDE DN 5 MG TABLET SL
ISOSORBIDE DN ER 40 MG TABLET
ISOSORBIDE MN 10 MG TABLET
ISOSORBIDE MN 20 MG TABLET
ISOSORBIDE MN ER 120 MG TAB
ISOSORBIDE MN ER 30 MG TABLET
150000
300000
75000
150000
300000
250000
65000
100000
25000
400000
20000
40000
40000
130000
130000
0
0
0
100000
300000
50000
99000
120000
180000
240000
1000
1500
3000
1000
2000
4000
2000
5000
250
40000
5000
10000
2500
20000
30000
5000
5000
40000
10000
20000
120000
30000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
%
MG
MG
MG
%
%
%
%
%
%
%
%
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
353538
1298834
1298799
197848
197849
542512
311204
1193337
1193345
1193349
1193353
1193341
996101
855292
855300
855306
855316
855322
855328
855336
855342
855348
861771
861821
1243833
1243843
1243848
665036
665040
665044
755737
1234972
1243026
1243033
1243040
1116552
1090996
1236169
762663
757594
762986
1037379
1367219
1359030
1358780
1358765
1359025
ISOSORBIDE MN ER 60 MG TABLET
ISOXSUPRINE 10 MG TABLET
ISOXSUPRINE 20 MG TABLET
ISRADIPINE 2.5 MG CAPSULE
ISRADIPINE 5 MG CAPSULE
ISTALOL 0.5% EYE DROPS
ITRACONAZOLE 100 MG CAPSULE
JAKAFI 10 MG TABLET
JAKAFI 15 MG TABLET
JAKAFI 20 MG TABLET
JAKAFI 25 MG TABLET
JAKAFI 5 MG TABLET
JALYN 0.5-0.4 MG CAPSULE
JANTOVEN 1 MG TABLET
JANTOVEN 2.5 MG TABLET
JANTOVEN 7.5 MG TABLET
JANUMET 50-1,000 MG TABLET
JANUMET 50-500 MG TABLET
JANUMET XR 100-1,000 MG TABLET
JANUMET XR 50-1,000 MG TABLET
JANUMET XR 50-500 MG TABLET
JANUVIA 100 MG TABLET
JAY-PHYL SYRUP
J-COF DHC LIQUID
JENTADUETO 2.5 MG-1000 MG TAB
JEVANTIQUE 1 MG-5 MCG TABLET
JINTELI 1 MG-5 MCG TABLET
J-MAX DHC LIQUID
JOLESSA 0.15 MG-0.03 MG TABLET
JOLIVETTE TABLET
J-TAN D SR TABLET
J-TAN D SUSPENSION
J-TAN D TAB CHEW
JUNEL 1.5-30 TABLET
JUNEL 1/20 TABLET
JUNEL FE 1 MG-20 MCG TABLET
JUNEL FE 1.5 MG-30 MCG TABLET
60000
10000
20000
2500
5000
500
100000
10000
15000
20000
25000
5000
500
1000
10000
2000
2500
3000
4000
5000
6000
7500
1000000
500000
100000
1000000
500000
100000
25000
50000
50000
3000
1000000
500000
850000
1000
5
100000
30
350
30000
5000
0
1500
0
0
1500
MG
MG
MG
MG
MG
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG/5ML
MG
MG
MG
MG
MG
MG/5ML
MG
MG
MG
MG/5ML
0
MG
MG
MG
MG
1189818
1189814
1189827
1312415
1312422
1312429
1364490
1364494
1364498
892176
892496
892496
892556
892556
1303731
1303731
1303733
1303733
892598
892598
892645
892645
892658
892658
1303738
1303738
894803
894803
894805
894805
1303742
1303742
894816
894816
847745
847745
847745
847741
847741
847741
847749
847749
847749
1243052
628955
762001
546627
JUVISYNC 100-10 MG TABLET

JUXTAPID 10 MG CAPSULE
K EFFERVESCENT 25 MEQ TABLET
KADIAN ER 10 MG CAPSULE
KALETRA 100-25 MG TABLET
KALETRA 400-100/5 ML ORAL SOLU
KALYDECO 150 MG TABLET
KAON-CL ER 10 MEQ TABLET
KARIVA 28 DAY TABLET
KAYEXALATE POWDER
100000
100000
100000
50000
50000
50000
10000
20000
5000
25000
10000
10000
100000
100000
130000
130000
150000
150000
20000
20000
200000
200000
30000
30000
40000
40000
50000
50000
60000
60000
70000
70000
80000
80000
25000
25000
25000
50000
50000
50000
0
0
0
150000
750000
0
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MEQ
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
0
MG
212306
212339
637175
753483
1085738
630807
404595
261335
261336
284391
807834
847673
672605
847249
543372
581901
581696
630050
607091
212332
883501
1297755
1297759
797851
866109
707352
602855
539741
1014367
203088
728550
106336
197853
1300272
359697
197855
197856
860103
860107
834022
727714
793741
1006693
206157
206159
206160
628958
KEFLEX 250 MG CAPSULE

KELNOR 1/35 28 TABLET
KENALOG AEROSOL SPRAY
KEPPRA 1,000 MG TABLET
KEPPRA 100 MG/ML ORAL SOLN
KEPPRA 250 MG TABLET
KEPPRA XR 500 MG TABLET
KEPPRA XR 750 MG TABLET
KERAFOAM 30% FOAM
KERAFOAM 42% FOAM
KERALAC CREAM
KERALAC LOTION
KERALAC NAIL GEL
KERALAC NAILSTIK
KERALAC OINTMENT
KERALYT 6% GEL
KERALYT SCALP COMPLETE KIT
KERLONE 10 MG TABLET
KERLONE 20 MG TABLET
KEROL 42% REDI-CLOTHS
KEROL AD 45% EMULSION
KEROL ZX 50% PRE-FILLED APPL
KETEK 300 MG TABLET
KETEK 400 MG TABLET
KETOCON + PLUS COMBO PACK
KETOCONAZOLE 2% CREAM
KETOCONAZOLE 2% FOAM
KETOCONAZOLE 2% SHAMPOO
KETOCONAZOLE 200 MG TABLET
KETODAN 2% FOAM
KETOPROFEN 200 MG CAPSULE SA
KETOPROFEN 50 MG CAPSULE
KETOPROFEN 75 MG CAPSULE
KETOROLAC 0.4% OPHTH SOLUTION
KETOROLAC 0.5% OPHTH SOLUTION
KETOROLAC 10 MG TABLET
KINERET 100 MG/0.67 ML SYR
KIONEX POWDER
KLARON 10% LOTION
KLONOPIN 0.5 MG TABLET
KLONOPIN 1 MG TABLET
KLONOPIN 2 MG TABLET
KLOR-CON 10 MEQ TABLET
250000
500000
750000
0
25
1000000
100000
250000
500000
750000
500000
750000
30000
42000
50000
35000
50000
50000
50000
6000
6000
10000
20000
42000
45000
50000
300000
400000
2000
2000
2000
2000
200000
2000
200000
50000
75000
400
500
10000
100000
0
10000
500
1000
2000
750000
MG
MG
MG
MG
%
MG
MG/ML
MG
MG
MG
MG
MG
%
%
%
%
%
%
%
%
%
MG
MG
%
%
%
MG
MG
%
%
%
%
MG
%
MG
MG
MG
%
%
MG
MG
MG
%
MG
MG
MG
MG
897139
832718
832731
832891
866648
1368097
1368106
1368048
1367999
1368052
1368041
1245268
209224
209223
1251241
1101778
1251192
1251196
670031
604651
1356074
1111020
103909
896758
896762
896766
543464
543812
351312
754512
847628
248332
311249
1116183
391937
1250542
105018
105018
206201
206201
108782
108782
201240
201240
105019
105019
201239
KLOR-CON 20 MEQ PACKET

KLOR-CON 8 MEQ TABLET
KLOR-CON M15 TABLET
KLOR-CON M20 TABLET
KLOR-CON-EF 25 MEQ TAB EFF
KOATE-DVI 1,000 UNITS KIT
KOATE-DVI 250 UNIT KIT
KOGENATE FS 2,000 UNIT VIAL
KOGENATE FS 250 UNIT VIAL
KOGENATE FS 3,000 UNITS VIAL
KOGENATE FS 500 UNIT VIAL
KORLYM 300 MG TABLET
K-PHOS #2 TABLET
K-PHOS M.F. TABLET
K-PHOS NEUTRAL TABLET
K-PHOS ORIGINAL TABLET
KRISTALOSE 10 GM PACKET
KRISTALOSE 20 GM PACKET
K-TAB ER 10 MEQ TABLET
KURIC 2% CREAM
KURVELO TABLET
KUVAN 100 MG TABLET
KYTRIL 1 MG TABLET
LABETALOL HCL 100 MG TABLET
LAC-HYDRIN 12% CREAM
LAC-HYDRIN 12% LOTION
LACLOTION 12% LOTION
LACRISERT 5 MG EYE INSERT
LACTATED RINGERS IRRIGATION
LACTIC ACID 10% E CREAM
LACTIC ACID 10% LOTION
LACTOCAL-F TABLET
LACTULOSE 10 GM/15 ML SOLUTION
LAGESIC CAPLET
LAMICTAL 100 MG TABLET
LAMICTAL 25 MG DISPER TABLET
20000
600000
1125000
1500000
25000
1000000
250000
1800000
250000
3000000
500000
300000
305000
155000
250000
500000
10000000
20000000
750000
2000
150
100000
1000
100000
200000
300000
12000
12000
12000
5000
0
0
10000
0
0
600000
100000
100000
150000
150000
200000
200000
25000
25000
25000
25000
5000
MEQ
MG
MG
MG
MEQ
AHFU
AHFU
IU
AHFU
IU
IU
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
MG
MG
MG
MG
MG
%
%
%
MG
0
0
%
MG
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
201239
849049
849049
849050
849050
849051
849051
849052
849052
851749
851749
851753
851753
851751
851751
795772
795772
795778
795778
795774
795774
900145
900145
900157
900157
900165
900165
1146692
1146692
1098610
1098610
900169
900169
900984
900984
900866
900866
900891
900891
199147
349491
200082
200082
200082
198427
198427
198428

LAMICTAL ODT 100 MG TABLET
LAMICTAL ODT START KIT (BLUE)
LAMICTAL ODT START KIT (BLUE)
LAMICTAL ODT START KIT (GREEN)
LAMICTAL ODT START KIT (GREEN)
LAMICTAL ODT START KT (ORANGE)
LAMICTAL ODT START KT (ORANGE)
LAMICTAL TAB START KIT (BLUE)
LAMICTAL TAB START KIT (BLUE)
LAMICTAL TAB START KIT (GREEN)
LAMICTAL TAB START KIT (GREEN)
LAMICTAL TB START KIT (ORANGE)
LAMICTAL TB START KIT (ORANGE)
LAMICTAL XR 100 MG TABLET
LAMICTAL XR START KIT (BLUE)
LAMICTAL XR START KIT (BLUE)
LAMICTAL XR START KIT (GREEN)
LAMICTAL XR START KIT (GREEN)
LAMICTAL XR START KIT (ORANGE)
LAMICTAL XR START KIT (ORANGE)
LAMIVUDINE 150 MG TABLET
LAMIVUDINE 300 MG TABLET
LAMIVUDINE-ZIDOVUDINE TABLET
LAMOTRIGINE 100 MG TABLET
5000
100000
100000
200000
200000
25000
25000
50000
50000
25000
25000
50000
50000
25000
25000
25000
25000
25000
25000
25000
25000
100000
100000
200000
200000
25000
25000
250000
250000
300000
300000
50000
50000
25000
25000
50000
50000
25000
25000
150000
300000
300000
300000
300000
100000
100000
150000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
198428
198429
198429
311264
311264
282401
751139
751139
311265
311265
850087
900156
900164
1146690
1098608
900168
751563
751563
753451
753451
309889
596843
311277
351261
351260
285018
847232
200801
200809
205732
1000089
314072
885770
1297357
1235249
1040036
1040043
824916
824917
205687
749148
205284
205285
103918
103919
687048
751885

LAMOTRIGINE 25 MG DISPER TAB
LAMOTRIGINE 25 MG DISPER TAB
LAMOTRIGINE 25 MG TB START KIT
LAMOTRIGINE 25 MG TB START KIT
LAMOTRIGINE 5 MG DISPER TABLET
LAMOTRIGINE 5 MG DISPER TABLET
LAMOTRIGINE ER 100 MG TABLET
LAMOTRIGINE TABLET STARTER KIT
LANOXIN 250 MCG TABLET
LANSOPRAZOLE DR 15 MG CAPSULE
LANSOPRAZOLE DR 30 MG CAPSULE
LANSOPRAZOLE ODT 15 MG TABLET
LANSOPRAZOLE ODT 30 MG TABLET
LANTUS 100 UNITS/ML VIAL
LANTUS SOLOSTAR 100 UNITS/ML
LASIX 20 MG TABLET
LASIX 40 MG TABLET
LASIX 80 MG TABLET
LASTACAFT 0.25% EYE DROPS
LATANOPROST 0.005% EYE DROPS
LATRIX 50% TOPICAL SUSPENSION
LATUDA 120 MG TABLET
LATUDA 20 MG TABLET
LATUDA 40 MG TABLET
LATUDA 80 MG TABLET
LAVOCLEN-4 CREAMY WASH
LAVOCLEN-8 CREAMY WASH
LAZERFORMALYDE 10% SOLUTION
LEENA 28 TABLET
LEFLUNOMIDE 10 MG TABLET
LEFLUNOMIDE 20 MG TABLET
LESCOL 20 MG CAPSULE
LESCOL 40 MG CAPSULE
LESCOL XL 80 MG TABLET
LESSINA-28 TABLET
150000
200000
200000
25000
25000
25000
25000
25000
5000
5000
100000
200000
25000
250000
300000
50000
25000
25000
25000
25000
250
15000
30000
15000
30000
100000
100000
20000
40000
80000
250
5
50000
120000
20000
40000
80000
4000
8000
10000
0
10000
20000
20000
40000
80000
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
U/ML
U/ML
MG
MG
MG
%
%
%
MG
MG
MG
MG
%
%
%
MG
MG
MG
MG
MG
MG
MG
722120
722124
200064
197860
197861
197862
197863
105553
545835
545875
349590
311286
242754
544445
211815
211816
284481
1191187
1046771
1046771
616238
847241
387003
403884
311288
311289
311290
807832
846378
1150832
1150836
315134
315134
197448
197448
855168
855172
314080
477391
199884
199885
311296
1095227
748878
751901
763088
810096
LETAIRIS 10 MG TABLET
LETAIRIS 5 MG TABLET
LETROZOLE 2.5 MG TABLET
LEUCOVORIN CALCIUM 10 MG TAB
LEUKERAN 2 MG TABLET
LEUPROLIDE 2WK 1 MG/0.2 ML KT
LEVACET CAPLET
LEVALBUTEROL 0.31 MG/3 ML SOL
LEVALBUTEROL 0.63 MG/3 ML SOL
LEVALBUTEROL CONC 1.25 MG/0.5
LEVAQUIN 25 MG/ML SOLUTION
LEVAQUIN 250 MG TABLET
LEVATOL 20 MG TABLET
LEVBID 0.375 MG TABLET SA
LEVBID 0.375 MG TABLET SA
LEVEMIR 100 UNITS/ML VIAL
LEVEMIR FLEXPEN 100 UNITS/ML
LEVETIRACETAM 1,000 MG TABLET
LEVETIRACETAM 100 MG/ML SOLN
LEVETIRACETAM 250 MG TABLET
LEVETIRACETAM ER 500 MG TABLET
LEVETIRACETAM ER 750 MG TABLET
LEVOBUNOLOL 0.25% EYE DROPS
LEVOBUNOLOL 0.5% EYE DROPS
LEVOCARNITINE 100 MG/ML SOLN
LEVOCARNITINE 100 MG/ML SOLN
LEVOCARNITINE 330 MG TABLET
LEVOCARNITINE 330 MG TABLET
LEVOCETIRIZINE 2.5 MG/5 ML SOL
LEVOCETIRIZINE 5 MG TABLET
LEVOFLOXACIN 0.5% EYE DROPS
LEVOFLOXACIN 25 MG/ML SOLUTION
LEVOFLOXACIN 250 MG TABLET
LEVONEST-28 TABLET
LEVONOR-ETH ESTRAD 0.15-0.03
LEVONOR-ETH ESTRAD 0.15-0.03
LEVONORGESTREL 0.75 MG TABLET
LEVONORG-ETH ESTRAD ETH ESTRAD
10000
5000
2500
10000
15000
25000
5000
2000
5000
0
310
630
1250
25000
250000
500000
750000
20000
375
375
100000
100000
1000000
100000
250000
500000
750000
500000
750000
250
500
100000
100000
330000
330000
2500
5000
500
25000
250000
500000
750000
0
150
30
750
0
MG
MG
MG
MG
MG
MG
MG
MG
MG/ML
0
MG/3ML
MG/3ML
MG/.5M
MG/ML
MG
MG
MG
MG
MG
MG
U/ML
U/ML
MG
MG/ML
MG
MG
MG
MG
MG
%
%
MG/ML
MG/ML
MG
MG
5ML
MG
%
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
748879
197873
966180
966180
966183
966183
966284
966284
966193
966193
966199
966199
966203
966203
966210
966210
966156
966156
966216
966216
966163
966163
966169
966169
966174
966174
892246
892246
966248
966248
966224
966224
966270
966270
966271
966271
966225
966225
966249
966249
892251
892251
966220
966220
892255
892255
966164
LEVORA-28 TABLET
LEVORPHANOL 2 MG TABLET
LEVOTHROID 100 MCG TABLET
LEVOTHYROXINE 100 MCG TABLET
0
2000
100
100
112
112
125
125
137
137
150
150
175
175
200
200
25
25
300
300
50
50
75
75
88
88
100
100
112
112
125
125
137
137
137
137
150
150
175
175
200
200
25
25
300
300
50
MG
MG
MCG
MCG
MCG
MCG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MCG
MCG
MG
MG
MCG
MCG
MCG
MCG
MCG
MCG
MCG
MCG
MCG
MCG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MCG
MCG
MG
MG
MCG
966164
966221
966221
966222
966222
966253
966253
966283
966283
966184
966184
966190
966190
966194
966194
966200
966200
966204
966204
966211
966211
966157
966157
966217
966217
966170
966170
966175
966175
1047907
1047907
1047908
1047908
762674
352272
352272
352273
352273
404408
404408
404420
404420
723827
402110
997008
686433
889616

LEVOXYL 100 MCG TABLET
LEVSIN 0.125 MG TABLET
LEVSIN 0.125 MG TABLET
LEVSIN-SL 0.125 MG TABLET SL
LEVSIN-SL 0.125 MG TABLET SL
LEVULAN KERASTICK
LEXAPRO 10 MG TABLET
LEXAPRO 5 MG TABLET
LEXAPRO 5 MG TABLET
LEXAPRO 5 MG/5 ML SOLUTION
LEXAPRO 5 MG/5 ML SOLUTION
LEXIVA 50 MG/ML SUSPENSION
LEXIVA 700 MG TABLET
LEXUSS 210 LIQUID
LIALDA DR 1.2 GM TABLET
LIBRAX CAPSULE
50
50
50
75
75
88
88
100
100
112
112
125
125
137
137
150
150
175
175
200
200
25
25
300
300
75
75
88
88
125
125
125
125
20000
10000
10000
20000
20000
5000
5000
5000
5000
50000
700000
2000
1200000
0
MCG
MCG
MCG
MCG
MCG
MCG
MCG
MCG
MCG
MCG
MCG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MCG
MCG
MG
MG
MCG
MCG
MG
MG
MG
MG
MG
MG
%
MG
MG
MG
MG
MG
MG
MG/5ML
MG/5ML
MG/ML
MG
MG
MG
MG
889616
312320
1011748
1011748
1012621
1012621
1012628
1012628
1011749
1011749
1010739
1010739
1010835
1010835
1010836
1010836
1010296
1010296
1011852
1011852
1012060
1012060
1012062
1012062
1012064
1012064
1010878
1010878
1011831
1011831
1011838
1011838
1012221
1012221
1012233
1012233
1012235
1012235
1012229
1012229
1012223
1012223
197877
1011705
1011705
1250672
856781
LIBRAX CAPSULE
LICE TREATMENT 1% CREME RINSE
LIDAMANTLE 3% CREAM
LIDAMANTLE 3% CREAM
LIDAMANTLE HC 0.5-3% CREAM
LIDAMANTLE HC 0.5-3% CREAM
LIDAMANTLE HC LOTION
LIDAMANTLE HC LOTION
LIDAMANTLE LOTION
LIDAMANTLE LOTION
LIDOCAINE 2% VISCOUS SOLN
LIDOCAINE 2% VISCOUS SOLN
LIDOCAINE 3% CREAM
LIDOCAINE 3% CREAM
LIDOCAINE 3% LOTION
LIDOCAINE 3% LOTION
LIDOCAINE 5% OINTMENT
LIDOCAINE 5% OINTMENT
LIDOCAINE HCL 2% JELLY
LIDOCAINE HCL 4% SOLUTION
LIDOCAINE-HC 2.8-0.55% GEL
LIDOCAINE-HC 2.8-0.55% GEL
LIDOCAINE-HC 2-2% CREAM KIT
LIDOCAINE-HC 3-0.5% CREAM KIT
LIDOCAINE-HC 3-0.5% CREAM KIT
LIDOCAINE-HC 3-2.5% GEL KIT
LIDOCAINE-HC 3-2.5% GEL KIT
LIDOCAINE-PRILOCAINE CREAM
LIDODERM 5% PATCH
LIDODERM 5% PATCH
LIDOVIR 4%-4% OINTMENT KIT
LIMBITROL TABLET
0
1000
3000
3000
0
0
0
0
3000
3000
2000
2000
3000
3000
3000
3000
5000
5000
2000
2000
2000
2000
2000
2000
2000
2000
4000
4000
4000
4000
4000
4000
550
550
2000
2000
0
0
1000
1000
2500
2500
2500
5000
5000
4000
5000
MG
%
%
%
0
0
0
0
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
0
0
%
%
%
%
%
%
%
%
MG
141860
197878
1307415
1307421
903697
903456
903703
617314
617318
617320
262095
702055
702169
314076
311353
314077
205326
197884
311354
197885
197886
197887
1112717
311355
197889
197890
197893
197891
756059
197892
206786
213557
861646
861650
861654
1037185
1370772
1370765
1370760
1370768
261330
582981
581539
672651
633172
1359031
1358781
LINDANE 1% LOTION
LINDANE 1% SHAMPOO
LINZESS 145 MCG CAPSULE
LINZESS 290 MCG CAPSULE
LIOTHYRONINE SOD 25 MCG TAB
LIPITOR 10 MG TABLET
LIPOFEN 150 MG CAPSULE
LIPOFEN 50 MG CAPSULE
LISINOPRIL 10 MG TABLET
LISINOPRIL 2.5 MG TABLET
LISINOPRIL-HCTZ 10-12.5 MG TAB
LISINOPRIL-HCTZ 20-12.5 MG TAB
LISINOPRIL-HCTZ 20-25 MG TAB
LITHIUM 8 MEQ/5 ML SOLUTION
LITHIUM CARBONATE 150 MG CAP
LITHIUM CARBONATE 300 MG TAB
LITHIUM CARBONATE ER 300 MG TB
LITHIUM CITRATE 8 MEQ/5 ML SOL
LITHIUM ER 450 MG TABLET
LITHOBID 300 MG TABLET SA
LITHOSTAT 250 MG TABLET
LIVALO 1 MG TABLET
LIVALO 2 MG TABLET
LIVALO 4 MG TABLET
LO LOESTRIN FE 1-10 TABLET
LOCOID 0.1% CREAM
LOCOID 0.1% LOTION
LOCOID 0.1% OINTMENT
LOCOID 0.1% SOLUTION
LODOSYN 25 MG TABLET
LODRANE 12D TABLET SA
LODRANE 24 ER CAPSULE
LODRANE 24D CAPSULE SA
LODRANE D SUSPENSION
LOESTRIN 21 1.5/30 TABLET
LOESTRIN 21 1-20 TABLET
1000
1000
145
290
25
5
50
10000
20000
40000
80000
150000
50000
10000
2500
20000
30000
40000
5000
10000
12500
25000
8000
150000
300000
300000
600000
300000
8000
450000
300000
250000
1000
2000
4000
1000
100
100
100
100
25000
45000
12000
90000
90000
1500
0
%
%
MCG
MCG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MEQ/5M
MG
MG
MG
MG
MG
MEQ/5M
MG
MG
MG
MG
MG
MG
MG
%
%
%
%
MG
MG
MG
MG
MG/5ML
MG
MG
1359118
1359026
1358770
351909
603834
351898
603836
351842
359280
359281
672838
542947
1190641
749787
978006
205751
866513
866516
866498
866502
351913
544743
197900
197901
197902
311376
857385
857387
857109
857117
857120
857105
1147709
1099026
1189098
1189100
979480
979485
979492
979464
979471
979468
810097
213263
1099503
1312627
898689
LOESTRIN 24 FE TABLET
LOESTRIN FE 1.5/30 TABLET
LOESTRIN FE 1-20 TABLET
LOFIBRA 134 MG CAPSULE
LOFIBRA 160 MG TABLET
LOFIBRA 54 MG TABLET
LOHIST 12D TABLET SA
LOHIST 12HR TABLET SA
LOHIST-DM SYRUP
LOHIST-PD DROPS
LOMOTIL TABLET
LO-OVRAL-28 TABLET
LOPERAMIDE 2 MG CAPSULE
LOPID 600 MG TABLET
LOPRESSOR 100 MG TABLET
LOPRESSOR 50 MG TABLET
LOPRESSOR HCT 100-25 TABLET
LOPRESSOR HCT 50-25 TABLET
LOPROX 0.77% GEL
LOPROX 1% SHAMPOO
LORAZEPAM 0.5 MG TABLET
LORAZEPAM 1 MG TABLET
LORAZEPAM 2 MG TABLET
LORAZEPAM 2 MG/ML ORAL CONCENT
LORCET 10-650 TABLET
LORCET PLUS TABLET
LORTAB 10-500 TABLET
LORTAB 5-500 TABLET
LORTAB 7.5-500 TABLET
LORTAB ELIXIR
LORTUSS EX LIQUID
LORYNA 3 MG-0.02 MG TABLET
LORZONE 375 MG TABLET
LORZONE 750 MG TABLET
LOSARTAN POTASSIUM 100 MG TAB
LOSARTAN-HCTZ 100-12.5 MG TAB
LOSARTAN-HCTZ 100-25 MG TAB
LOSARTAN-HCTZ 50-12.5 MG TAB
LOSEASONIQUE TABLET
LOTEMAX 0.5% EYE DROPS
LOTEMAX 0.5% EYE OINTMENT
LOTEMAX 0.5% OPHTHALMIC GEL
LOTENSIN 10 MG TABLET
0
1500
0
134000
160000
200000
54000
67000
45000
12000
0
15000
0
0
2000
600000
100000
50000
0
0
770
1000
500
1000
2000
2000
10001
650000
10000
5000
500000
167000
22500
0
375000
750000
100000
25000
50000
100000
100000
50000
0
500
500
500
10000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
ML
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
%
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
%
MG
898692
898721
898725
898366
898371
898376
898382
898344
898348
898352
898355
898358
898361
261163
213641
284515
540181
261362
197903
197904
197905
854249
854247
854253
854232
854256
854236
854239
854242
750244
314078
311385
311386
314075
206274
206278
206272
206279
1111350
901280
901288
901296
205700
93181
209125
204913
1009341
LOTENSIN HCT 10-12.5 TABLET
LOTENSIN HCT 20-25 TABLET
LOTREL 10-20 MG CAPSULE
LOTREL 2.5-10 MG CAPSULE
LOTRIMIN AF 1% SOLUTION
LOTRISONE CREAM
LOTRISONE LOTION
LOTRONEX 0.5 MG TABLET
LOTRONEX 1 MG TABLET
LOVASTATIN 10 MG TABLET
LOVENOX 100 MG PREFILLED SYR
LOVENOX 30 MG PREFILLED SYRN
LOVENOX 300 MG/3 ML VIAL
LOW-OGESTREL-28 TABLET
LOXAPINE 10 MG CAPSULE
LOXITANE 10 MG CAPSULE
LOZI-FLUR 1 MG LOZENGE
LUDENT FLUORIDE 0.25 MG TB CHW
LUDENT FLUORIDE 0.5 MG TB CHEW
LUDENT FLUORIDE 1 MG TAB CHEW
LUFYLLIN 200 MG TABLET
LUFYLLIN-400 TABLET
LUFYLLIN-GG ELIXIR
LUGOL'S SOLUTION
LUMIGAN 0.01% EYE DROPS
20000
40000
5000
10000
12500
25000
5000
10000
40000
2500
10000
20000
5000
1000
0
0
500
1000
10000
20000
40000
100000
120000
150000
30000
300000
40000
60000
80000
0
10000
25000
5000
50000
10000
25000
5000
50000
1000
250
500
1000
200000
400000
0
0
10
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
0
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
ML
ML
%
285128
540407
540409
540411
864946
543296
751884
903875
903881
1244636
751554
607018
607018
607020
607020
898718
898718
607022
607022
607024
607024
607026
607026
607028
607028
607033
607033
607038
607038
207373
883830
539712
201883
207791
201882
251575
1049253
1049259
1049262
1049269
794747
864679
864685
204119
1298857
1298861
1298870
LUMIGAN 0.03% EYE DROPS

LUNESTA 1 MG TABLET
LUNESTA 2 MG TABLET
LUNESTA 3 MG TABLET
LUSAIR LIQUID
LUSONAL LIQUID
LUTERA-28 TABLET
LUVOX CR 100 MG CAPSULE
LUVOX CR 150 MG CAPSULE
LUXIQ 0.12% FOAM
LYBREL 90-20 MCG TABLET
LYRICA 100 MG CAPSULE
LYRICA 20 MG/ML ORAL SOLUTION
LYRICA 20 MG/ML ORAL SOLUTION
LYSODREN 500 MG TABLET
LYSTEDA 650 MG TABLET
MACROBID 100 MG CAPSULE
MACRODANTIN 100 MG CAPSULE
MAFENIDE ACETATE 50 GM POWD PK
MAGNACET 10 MG-400 MG TABLET
MAGNACET 2.5 MG-400 MG TABLET
MAGNACET 5 MG-400 MG TABLET
MAGNACET 7.5 MG-400 MG TABLET
MAGNEBIND 400 RX TABLET
MALARONE 250-100 MG TABLET
MALARONE 62.5-25 MG PED TAB
MALATHION 0.5% LOTION
MAPROTILINE 25 MG TABLET
30
1000
2000
3000
200000
100000
0
100000
150000
0
0
100000
100000
150000
150000
20000
20000
200000
200000
225000
225000
25000
25000
300000
300000
50000
50000
75000
75000
500000
650000
100000
100000
25000
50000
0
10000
2500
5000
7500
0
250000
62500
500
25000
50000
75000
%
MG
MG
MG
MG
MG/5ML
MG
MG
MG
%
MG
MG
MG
MG
MG
MG/ML
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
0
MG
MG
MG
MG
MG
MG
MG
%
MG
MG
MG
994404
995443
211167
857319
205645
205641
205642
1245919
201708
209826
207588
1091632
1091629
1091635
1091638
1091623
210671
210672
210673
966812
213322
213321
828537
828536
804695
1245432
1053605
205669
856894
1089072
996724
798999
1307253
1314649
1089063
996720
1299235
1359141
1359148
995455
996708
208591
208601
93253
93252
996738
995440
MAR-COF BP LIQUID
MAR-COF CG LIQUID
MARGESIC CAPSULE
MARGESIC H 5-500 CAPSULE
MARINOL 10 MG CAPSULE
MARINOL 2.5 MG CAPSULE
MARINOL 5 MG CAPSULE
MARLISSA-28 TABLET
MARPLAN 10 MG TABLET
MARTEN-TAB 325-50 TABLET
MATULANE 50 MG CAPSULE
MATZIM LA 180 MG TABLET
MAVIK 1 MG TABLET
MAVIK 2 MG TABLET
MAVIK 4 MG TABLET
MAXAIR AUTOHALER 0.2 MG AERO
MAXALT 10 MG TABLET
MAXALT 5 MG TABLET
MAXALT MLT 10 MG TABLET
MAXALT MLT 5 MG TABLET
MAXICHLOR DM TABLET
MAXICHLOR PEH TABLET
MAXICHLOR PSE TABLET
MAXIDEX 0.1% EYE DROPS
MAXIDONE 10-750 MG TABLET
MAXIFED CD TABLET
MAXIFED CDX TABLET
MAXIFED DM TABLET
MAXIFED DMX TABLET
MAXIFED TABLET
MAXIFED-G CD TABLET
MAXIFED-G CDX TABLET
MAXIFED-G TABLET
MAXIFLU CD TABLET
MAXIFLU CDX TABLET
MAXIPHEN CD TABLET
MAXIPHEN CDX TABLET
MAXITROL EYE DROPS
MAXITROL EYE OINTMENT
MAXZIDE 37.5 MG-25 MG TABLET
MAXZIDE 75 MG-50 MG TABLET
M-CLEAR CAPSULE
M-CLEAR WC LIQUID
2000
0
0
5000
10000
2500
5000
150
10000
325000
50000
180000
240000
300000
360000
420000
1000
2000
4000
200
10000
5000
10000
5000
0
10000
60000
100
750000
60000
60000
400000
400000
400000
400000
400000
580000
40000
60000
0
10000
100
0
25000
0
200000
10000
ML
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
0
MG
MG
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
EA
MG
0
MG
%
0
MG
MG
MG
MG/5ML
206758
206753
206756
105347
995624
995666
618552
618557
749849
207138
207136
207141
834023
260330
207137
1000114
1000126
1000153
1000135
1000141
829500
835913
860227
885111
860215
860221
860225
152695
311486
597406
1190587
1244921
994291
212039
212232
212373
212464
545276
1298452
861455
861467
861479
207839
197928
197929
211947
197931
MEBARAL 100 MG TABLET

MEBENDAZOLE 100 MG TAB CHEW
MECLIZINE 12.5 MG TABLET
MECLIZINE 25 MG TABLET
MECLOFENAMATE 100 MG CAPSULE
MECLOFENAMATE 50 MG CAPSULE
MEDICARE PROXY NED
MEDROL 16 MG TABLET
MEDROL 2 MG TABLET
MEDROL 32 MG TABLET
MEDROL 4 MG DOSEPAK
MEDROL 4 MG TABLET
MEDROL 8 MG TABLET
MEDROXYPROGESTERONE 10 MG TAB
MEDROXYPROGESTERONE 150 MG/ML
MEDROXYPROGESTERONE 150 MG/ML
MEDROXYPROGESTERONE 2.5 MG TAB
MEDROXYPROGESTERONE 5 MG TAB
MEFENAMIC ACID 250 MG CAPSULE
MEFLOQUINE HCL 250 MG TABLET
MEGACE 40 MG/ML ORAL SUSP
MEGACE ES 625 MG/5 ML SUSP
MEGESTROL 20 MG TABLET
MEGESTROL 40 MG TABLET
MEGESTROL ACET 40 MG/ML SUSP
MELOXICAM 15 MG TABLET
MELOXICAM 7.5 MG TABLET
MELOXICAM 7.5 MG/5 ML SUSP
M-END MAX D LIQUID
M-END PE LIQUID
M-END WC LIQUID
MENEST 0.3 MG TABLET
MENOSTAR 14 MCG/DAY PATCH
MENTAX 1% CREAM
MEPERIDINE 100 MG TABLET
MEPERIDINE 50 MG TABLET
MEPERIDINE 50 MG/5 ML SOLUTION
MEPHYTON 5 MG TABLET
MEPROBAMATE 200 MG TABLET
MEPROBAMATE 400 MG TABLET
MEPRON 750 MG/5 ML SUSPENSION
MERCAPTOPURINE 50 MG TABLET
100000
32000
50000
100000
12500
25000
100000
50000
150
16000
2000
32000
4000
4000
8000
10000
150000
150000
2500
5000
250000
250000
40000
625000
20000
40000
40000
15000
7500
7500
667
330
1300
300
625
1250
2500
14
1000
100000
50000
50000
5000
200000
400000
750000
50000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/ML
MG/ML
MG
MG
MG
MG
MG/ML
MG/5ML
MG
MG
MG/ML
MG
MG
MG
ML
MG/5ML
ML
MG
MG
MG
MG
MCG
%
MG
MG
MG/5ML
MG
MG
MG
MG/5ML
MG
238151
994289
352210
903849
903859
903845
1091139
1091163
1091178
1091193
1091204
1091220
1091488
861738
861742
979409
979444
979475
351254
861004
861007
861010
860996
860975
860981
208592
864769
991147
864978
864761
864706
864712
864718
991149
864980
977860
197939
197940
992150
992184
996826
197941
197942
541524
197943
197944
311625
MESALAMINE 4 GM/60 ML ENEMA

MESEHIST WC LIQUID
MESNEX 400 MG TABLET
MESTINON 180 MG TIMESPAN
MESTINON 60 MG TABLET
MESTINON 60 MG/5 ML SYRUP
METADATE CD 10 MG CAPSULE
METADATE ER 20 MG TABLET
METAGLIP 2.5-500 MG TABLET
METAGLIP 5-500 MG TABLET
METAPROTERENOL 10 MG TABLET
METAPROTERENOL 10 MG/5 ML SYR
METAPROTERENOL 20 MG TABLET
METAXALONE 800 MG TABLET
METFORMIN HCL 1,000 MG TABLET
METFORMIN HCL 500 MG TABLET
METFORMIN HCL 850 MG TABLET
METFORMIN HCL ER 1,000 MG TAB
METFORMIN HCL ER 500 MG TABLET
METFORMIN HCL ER 750 MG TABLET
METHADEX EYE DROPS
METHADONE 10 MG/5 ML SOLUTION
METHADONE 10 MG/ML ORAL CONC
METHADONE 40 MG TABLET DISPR
METHADONE 5 MG/5 ML SOLUTION
METHADONE HCL 10 MG TABLET
METHADOSE 10 MG/ML ORAL CONC
METHADOSE 40 MG TABLET DISPR
METHAMPHETAMINE 5 MG TABLET
METHAZOLAMIDE 25 MG TABLET
METHAZOLAMIDE 50 MG TABLET
METHENAMINE HIPP 1 GM TABLET
METHENAMINE MD 500 MG TABLET
METHERGINE 0.2 MG TABLET
METHIMAZOLE 10 MG TABLET
METHIMAZOLE 5 MG TABLET
METHITEST 10 MG TABLET
METHOCARBAMOL 500 MG TABLET
METHOCARBAMOL 750 MG TABLET
METHOTREXATE 1 GM VIAL
4000000
1300
400000
180000
60000
60000
10000
20000
30000
40000
50000
60000
20000
500000
5000
10000
10000
20000
800000
1000000
500000
850000
1000000
500000
750000
100
10000
10000
40000
1000
10000
10000
5000
10000
40000
5000
25000
50000
1000000
500000
200
10000
5000
10000
500000
750000
1000000
GM/60M
ML
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
%
MG/5ML
MG/ML
MG
MG/ML
MG
MG
MG
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/ML
311625
105585
105585
311627
311627
314088
403914
197951
197956
197958
197963
197960
996824
1091151
1091153
1091135
1091391
1091394
1091324
1091498
1091343
1091495
1091150
1091133
1091392
1091497
1091341
1091137
1091161
1091176
1091191
1091202
1091218
1091145
1091147
1091155
1091170
1091185
1091210
1091225
328161
197971
259966
762675
197973
311665
311666
METHOTREXATE 1 GM VIAL
METHOTREXATE 2.5 MG TABLET
METHOTREXATE 2.5 MG TABLET
METHOTREXATE 50 MG/2 ML VIAL
METHOTREXATE 50 MG/2 ML VIAL
METHSCOPOLAMINE BROM 2.5 MG TB
METHSCOPOLAMINE BROM 5 MG TAB
METHYCLOTHIAZIDE 5 MG TABLET
METHYLDOPA 250 MG TABLET
METHYLDOPA 500 MG TABLET
METHYLDOPA-HCTZ 250-15 MG TAB
METHYLDOPA-HCTZ 250-25 MG TAB
METHYLERGONOVINE 0.2 MG TABLET
METHYLIN 10 MG TABLET
METHYLIN 10 MG/5 ML SOLUTION
METHYLIN 2.5 MG CHEWABLE TAB
METHYLIN 5 MG CHEWABLE TABLET
METHYLIN 5 MG/5 ML SOLUTION
METHYLIN ER 20 MG TABLET
METHYLPHENIDATE 10 MG TABLET
METHYLPHENIDATE 10 MG/5 ML SOL
METHYLPHENIDATE 5 MG/5 ML SOLN
METHYLPHENIDATE CD 10 MG CAP
METHYLPHENIDATE ER 10 MG TAB
METHYLPHENIDATE SR 20 MG TAB
METHYLPREDNISOLONE 16 MG TAB
METIPRANOLOL 0.3% EYE DROPS
METOCLOPRAMIDE 10 MG TABLET
1000000
2500
2500
25000
25000
2500
5000
5000
250000
500000
15000
25000
200
10000
10000
10000
2500
20000
5000
5000
5000
20000
10000
10000
20000
5000
5000
10000
20000
30000
40000
50000
60000
10000
10000
18000
27000
36000
54000
20000
16000
32000
4000
4000
8000
300
10000
MG/ML
MG
MG
MG/ML
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG/5ML
MG
MG
MG/5ML
MG
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
311668
104884
197978
197979
311671
105450
866412
866419
866427
866436
866511
866924
866514
866479
866491
866482
211666
605730
754766
261119
311678
242736
314106
199055
311681
311679
142046
1300483
206257
206258
1362706
1362712
1362720
261204
213570
284531
213431
213432
749833
749837
749841
992765
1359032
1359020
1359027
1358775
541140
METOCLOPRAMIDE 5 MG TABLET
METOCLOPRAMIDE 5 MG/5 ML SYRUP
METOLAZONE 10 MG TABLET
METOLAZONE 2.5 MG TABLET
METOLAZONE 5 MG TABLET
METOPIRONE 250 MG CAPSULE
METOPROLOL SUCC ER 100 MG TAB
METOPROLOL TARTRATE 100 MG TAB
METOPROLOL-HCTZ 100-25 MG TAB
METROCREAM 0.75% CREAM
METROGEL TOPICAL 1% GEL
METROGEL-VAGINAL 0.75% GEL
METROLOTION TOPICAL 0.75%
METRONIDAZOLE 0.75% CREAM
METRONIDAZOLE 0.75% LOTION
METRONIDAZOLE 250 MG TABLET
METRONIDAZOLE 375 MG CAPSULE
METRONIDAZOLE 500 MG TABLET
METRONIDAZOLE TOPICAL 0.75% GL
METRONIDAZOLE VAGINAL 0.75% GL
METVIXIA 16.8% CREAM
MEVACOR 20 MG TABLET
MEVACOR 40 MG TABLET
MEXILETINE 150 MG CAPSULE
MIACALCIN 200 UNIT NASAL SPRAY
MIACALCIN 200 UNIT/ML VIAL
MICARDIS 20 MG TABLET
MICARDIS HCT 40-12.5 MG TABLET
MICARDIS HCT 80-12.5 MG TABLET
MICARDIS HCT 80-25 MG TABLET
MICONAZOLE 3 200 MG VAG SUPP
MICROGESTIN 21 1.5-30 TAB
MICROGESTIN 21 1-20 TABLET
MICROGESTIN FE 1.5-30 TAB
MICROGESTIN FE 1-20 TABLET
MICRO-K 10 MEQ EXTENCAPS
5000
5000
10000
2500
5000
250000
100000
200000
25000
50000
100000
25000
50000
0
0
0
750
1000
750
750
750
750
250000
375000
500000
750
750
168000
20000
40000
150000
200000
250000
200000
200000
20000
40000
80000
40000
80000
80000
200000
1500
0
1500
0
750000
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
%
%
%
%
MG
MG
MG
%
%
MG/G
MG
MG
MG
MG
MG
U/DOSE
IU/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
208939
748987
211759
977882
422410
422410
993462
993466
993470
731407
731407
1293639
861670
795097
808118
1005831
1235042
1359129
208979
208979
208980
208980
208981
208981
1052678
861659
861661
861663
545278
1356979
1356997
1357007
1357009
197984
197985
314108
207364
207362
403840
197986
197987
999536
991606
859035
859042
859046
858627
MICRO-K 8 MEQ EXTENCAPS

MICRONOR 0.35 MG TABLET
MICROZIDE 12.5 MG CAPSULE
MIDAMOR 5 MG TABLET
MIDAZOLAM HCL 2 MG/ML SYRUP
MIDAZOLAM HCL 2 MG/ML SYRUP
MIDODRINE HCL 10 MG TABLET
MIDODRINE HCL 2.5 MG TABLET
MIDODRINE HCL 5 MG TABLET
MIDRIN CAPSULE
MIDRIN CAPSULE
MIGERGOT SUPPOSITORY
MIGRANAL NASAL SPRAY
MILLIPRED 10 MG/5 ML SOLUTION
MILLIPRED 5 MG TABLET
MILLIPRED DP 5 MG DOSE PACK TB
MILLIPRED DP 5 MG DOSE PACK TB
MIMVEY 1-0.5 MG TABLET
MINIPRESS 1 MG CAPSULE
MINIPRIN EC 81 MG TABLET
MINITRAN 0.1 MG/HR PATCH
MINIVELLE 0.0375 MG PATCH
MINOCYCLINE 100 MG CAPSULE
MINOCYCLINE HCL 100 MG TABLET
MINOXIDIL 10 MG TABLET
MINOXIDIL 2.5 MG TABLET
MI-OMEGA NF CAPSULE
MIOSTAT VIAL
MIRAPEX 0.125 MG TABLET
600000
350
12500
5000
10000
10000
10000
2500
5000
0
0
0
500
10000
5000
5000
5000
1000
1000
1000
2000
2000
5000
5000
81000
100
200
400
600
37
50
75
100
100000
50000
75000
100000
50000
75000
10000
2500
0
10
125
250
500
750
MG
MG
MG
MG
MG/5ML
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/HR
MG/HR
MG/HR
MG/HR
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
MG
MG
MG
859054
859050
901543
901547
901551
1114481
901557
1114487
901537
762002
283406
311725
283407
314111
283485
311726
476809
311727
317128
1298883
1298908
1298912
1298924
152697
152698
603844
753396
1299896
1299897
1299859
1299890
1299871
311753
151029
151030
584193
992770
998514
1368118
1368120
205621
205621
205619
205619
700410
700410
1362059
MIRAPEX 1 MG TABLET
MIRAPEX ER 0.375 MG TABLET
MIRAPEX ER 3 MG TABLET
MIRCETTE 28 DAY TABLET
MIRTAZAPINE 15 MG ODT
MIRTAZAPINE 15 MG TABLET
MIRTAZAPINE 7.5 MG TABLET
MISOPROSTOL 100 MCG TABLET
MISOPROSTOL 200 MCG TABLET
MOBAN 10 MG TABLET
MOBAN 25 MG TABLET
MOBAN 5 MG TABLET
MOBAN 50 MG TABLET
MOBIC 7.5 MG TABLET
MOBIC 7.5 MG TABLET
MOBIC 7.5 MG/5 ML SUSPENSION
MODICON 28 TABLET
MOEXIPRIL HCL 15 MG TABLET
MOEXIPRIL HCL 7.5 MG TABLET
MOEXIPRIL-HCTZ 15-12.5 MG TAB
MOEXIPRIL-HCTZ 15-25 MG TABLET
MOEXIPRIL-HCTZ 7.5-12.5 MG TAB
MOMETASONE FUROATE 0.1% CREAM
MOMETASONE FUROATE 0.1% OINT
MOMETASONE FUROATE 0.1% SOLN
MOMETASONE FUROATE 0.1% SOLN
MONISTAT 3 COMBO PACK
MONISTAT-DERM 2% CREAM
MONOCLATE-P 1,000 UNITS KIT
MONOCLATE-P 1,500 UNITS KIT
MONODOX 100 MG CAPSULE
MONOJECT HEPARIN 100 UNITS/ML
1000
1500
375
750
1500
2250
3000
3750
4500
0
15000
15000
30000
30000
45000
45000
7500
100
200
10000
25000
5000
50000
7500
7500
7500
500
15000
7500
15000
15000
7500
100
100
100
100
0
2000
1000000
1500000
100000
100000
50000
50000
75000
75000
100000
MG
MG
MG
MG
MG
MG
MG
MG
MG
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
%
%
0
%
UNITS
AHFU
MG
MG
MG
MG
MG
MG
U/ML
1362061
206854
206856
1365899
762003
209023
797012
200224
351246
311759
242438
808921
892516
892516
892589
892589
892625
892625
892603
892603
894780
894780
892678
892678
894807
894807
891874
891874
891881
891881
892646
892646
891888
891888
891893
891893
892554
892554
892596
892596
892345
892345
894801
894801
892352
892352
894814
MONOJECT HEPARIN 100 UNITS/ML

MONOKET 10 MG TABLET
MONOKET 20 MG TABLET
MONO-LINYAH 28 TABLET
MONONESSA 28 TABLET
MONONINE 1,000 UNITS KIT
MONONINE 500 UNITS VIAL
MONTELUKAST SOD 10 MG TABLET
MONTELUKAST SOD 4 MG GRANULES
MONTELUKAST SOD 4 MG TAB CHEW
MONTELUKAST SOD 5 MG TAB CHEW
MONUROL 3 GM SACHET
MORPHINE SULF 10 MG SUPPOS
MORPHINE SULF 10 MG/5 ML SOLN
MORPHINE SULF ER 100 MG TABLET
MORPHINE SULFATE ER 100 MG CAP
100000
10000
20000
250
250
1000000
500000
10000
4000
4000
5000
300000
10000
10000
10000
10000
20000
20000
20000
20000
20000
20000
30000
30000
5000
5000
100000
100000
15000
15000
200000
200000
30000
30000
60000
60000
100000
100000
20000
20000
30000
30000
50000
50000
60000
60000
80000
U/ML
MG
MG
MG
MG
U
U
MG
MG
MG
MG
GM
MG
MG
MG/5ML
MG/5ML
MG/ML
MG/ML
MG
MG
MG/5ML
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
894814
892582
892582
892672
892672
1190740
201142
201152
202098
800918
1047508
1047508
828703
892560
892560
892574
892574
892648
892648
894813
894813
892660
892660
762872
854859
1235389
1234482
1364854
1364855
311877
106346
207511
995605
995609
103899
199058
199058
200060
200060
1300092
208656
208659
208660
616450
616450
616449
616449

MORPHINE SULFATE IR 15 MG TAB
MOTOFEN TABLET
MOTRIN 400 MG TABLET
MOVIPREP POWDER PACKET
MOXEZA 0.5% EYE DROPS
MOXEZA 0.5% EYE DROPS
MOZOBIL 20 MG/ML VIAL
MS CONTIN 100 MG TABLET
MS CONTIN 15 MG TABLET SA
MS CONTIN 15 MG TABLET SA
MS CONTIN CR 30 MG TABLET
MS CONTIN CR 30 MG TABLET
MST 600 TABLET
MULTAQ 400 MG TABLET
MULTIVIT-FLUOR 0.25 MG TAB CHW
MULTIVIT-FLUOR 0.25 MG/ML DROP
MULTIVIT-FLUOR 0.5 MG TAB CHEW
MULTIVIT-FLUORIDE 1 MG TAB CHW
MUPIROCIN 2% CREAM
MUPIROCIN 2% OINTMENT
MUROCOLL-2 EYE DROPS
MYAMBUTOL 100 MG TABLET
MYAMBUTOL 400 MG TABLET
MYCOBUTIN 150 MG CAPSULE
MYCOPHENOLATE 250 MG CAPSULE
MYCOPHENOLATE 250 MG CAPSULE
MYCOPHENOLATE 500 MG TABLET
MYCOPHENOLATE 500 MG TABLET
MYDFRIN 2.5% EYE DROPS
MYDRAL 0.5% EYE DROPS
MYDRAL 1% EYE DROPS
MYDRIACYL 1% EYE DROPS
MYFORTIC 180 MG TABLET
80000
15000
15000
30000
30000
0
400000
600000
800000
0
500
500
0
100000
100000
15000
15000
200000
200000
60000
60000
30000
30000
600000
400000
250
250
500
1000
2000
2000
0
100000
400000
150000
250000
250000
500000
500000
2500
500
1000
1000
180000
180000
360000
360000
MG
MG
MG
MG
MG
MG
MG
MG
MG
0
%
%
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/ML
MG
MG
%
%
ML
MG
MG
MG
MG
MG
MG
MG
%
%
%
%
MG
MG
MG
MG
604664
105551
1242611
1242613
1242615
1116492
201747
207478
686922
996481
996216
1241901
311892
311893
198006
198007
198008
198000
198001
831838
249277
896112
896108
1246677
260323
858118
198011
198011
996563
996742
996574
996634
1046272
1116331
1116341
1116351
1116369
207093
105898
105914
105899
835560
311913
198013
198012
198014
603103
MYHIST-PD LIQUID
MYLERAN 2 MG TABLET
MYORISAN 10 MG CAPSULE
MYOXIN OTIC SUSPENSION
MYSOLINE 250 MG TABLET
MYSOLINE 50 MG TABLET
MYTELASE 10 MG CAPLET
MYTUSSIN AC SYRUP
MYTUSSIN DAC SYRUP
MYZILRA-28 TABLET
NABUMETONE 500 MG TABLET
NABUMETONE 750 MG TABLET
NADOLOL 20 MG TABLET
NADOLOL-BENDROFLU 40-5 MG TAB
NADOLOL-BENDROFLU 80-5 MG TAB
NAFRINSE ACIDULATED
NAFRINSE PED 0.25 MG/DROP
NAFTIN 1% CREAM
NAFTIN 1% GEL
NAFTIN 2% CREAM
NALFON 200 MG PULVULE
NALFON 400 MG CAPSULE
NALTREXONE 50 MG TABLET
NALTREXONE 50 MG TABLET
NAMENDA 10 MG TABLET
NAMENDA 10 MG/5 ML SOLUTION
NAMENDA 5 MG TABLET
NAMENDA 5-10 MG TITRATION PK
NAPHAZOLINE 0.1% EYE DROPS
NAPRELAN CR 375 MG TABLET
NAPRELAN CR DOSECRD 500-750 MG
NAPROSYN 125 MG/5 ML SUSPEN
NAPROSYN 250 MG TABLET
NAPROSYN EC 500 MG TABLET
NAPROXEN 125 MG/5 ML SUSPEN
NAPROXEN 250 MG TABLET
NAPROXEN DR 375 MG TABLET
7500
2000
10000
20000
40000
1000
250000
50000
10000
10000
10000
0
500000
750000
20000
40000
80000
0
0
20
5000
1000
1000
2000
200000
400000
50000
50000
10000
0
5000
0
100
375000
500000
750000
750000
25000
250000
375000
500000
500000
25000
250000
375000
500000
375000
MG
MG
MG
MG
MG
0
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
MG/ML
%
%
%
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
MG
MG
MG
MG/ML
MG
MG
MG
MG
MG/ML
MG
MG
MG
MG
311915
849398
849431
311918
314135
104836
670615
1085799
861115
746201
1113064
207100
1304503
978950
311919
314142
883795
1085820
1245109
1245109
351486
351486
1245111
1245111
728583
728583
1115806
1115806
728585
728585
1301874
1301874
728587
728587
1301876
1301876
1115496
1115496
728589
728589
1245113
1245113
1115802
1115802
208495
208493
208496
NAPROXEN DR 500 MG TABLET

NAPROXEN SODIUM 275 MG TAB
NAPROXEN SODIUM 550 MG TAB
NARATRIPTAN HCL 1 MG TABLET
NARATRIPTAN HCL 2.5 MG TABLET
NARDIL 15 MG TABLET
NARIZ LIQUID
NASACORT AQ NASAL SPRAY
NASCOBAL 500 MCG NASAL SPRAY
NASONEX 50 MCG NASAL SPRAY
NASOTUSS LIQUID
NATACYN EYE DROPS
NATAFORT TABLET
NATAZIA 28 TABLET
NATEGLINIDE 120 MG TABLET
NATEGLINIDE 60 MG TABLET
NATELLE ONE CAPSULE
NATROBA 0.9% TOPICAL SUSP
NATURE-THROID 113.75 MG TABLET
NATURE-THROID 130 MG TABLET
NAVANE 10 MG CAPSULE
NAVANE 2 MG CAPSULE
NAVANE 20 MG CAPSULE
500000
275000
550000
1000
2500
15000
200000
55
500
50
25000
5000
60000
3000
120000
60000
28000
900
113750
113750
129600
129600
146250
146250
16250
16250
162500
162500
194400
194400
260000
260000
32400
32400
325000
325000
48750
48750
64800
64800
81250
81250
97500
97500
10000
2000
20000
MG
MG
MG
MG
MG
MG
MG
MCG
MG
MG
ML
%
MG
MG
MG
MG
MG
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
208494
861599
1146217
751875
762005
751879
762004
750264
1098649
1098666
1098670
1098674
1098678
996636
1116150
615965
968030
995359
207120
866042
204874
204423
310687
309679
309680
310594
314124
1117090
1116154
835911
835911
835899
835899
835909
835909
750191
211680
802720
546338
1095608
1087623
206901
206912
727542
213128
727537
207052
NAVANE 5 MG CAPSULE
NEBUPENT 300 MG INHAL POWDER
NEBUSAL 6% VIAL
NECON 0.5-35-28 TABLET
NECON 10-11-28 TABLET
NECON 7-7-7-28 TABLET
NEFAZODONE HCL 100 MG TABLET
NEO AC SYRUP
NEO-BACIT-POLY-HC EYE OINTMENT
NEOBENZ MICRO 5.5% CREAM
NEOBENZ MICRO CREAM PLUS PACK
NEOBENZ MICRO WASH PLUS PACK
NEO-FRADIN 125 MG/5 ML SOLN
NEOMYCIN 500 MG TABLET
NEOMYCIN-POLY-HC EYE DROPS
NEOMYCIN-POLYMYXIN-HC EAR SOLN
NEOMYCIN-POLYMYXIN-HC EAR SUSP
NEOMYC-POLYM-DEXAMET EYE OINTM
NEOMYC-POLYM-DEXAMETH EYE DROP
NEOMYC-POLYM-GRAMICID EYE DROP
NEOMY-POLYMYXIN B 40 MG/ML AMP
NEO-POLYCIN EYE OINTMENT
NEO-POLYCIN HC EYE OINTMENT
NEORAL 100 MG GELATIN CAPSULE
NEORAL 100 MG/ML SOLUTION
NEORAL 100 MG/ML SOLUTION
NEOSPORIN EYE DROPS
NEOSPORIN GU IRR 40 MG/ML AMP
NEOTIC EAR DROPS
NEOTUSS-D LIQUID
NEPHROCAPS QT TABLET
NEPHROCAPS SOFTGEL
NEPTAZANE 25 MG TABLET
NEPTAZANE 50 MG TABLET
NEULASTA 6 MG/0.6 ML SYRINGE
NEUMEGA 5 MG VIAL
NEUPOGEN 300 MCG/0.5 ML SYR
NEUPOGEN 300 MCG/ML VIAL
5000
300000
6000
500
10000
1000
1000
777000
100000
150000
200000
250000
50000
15000
1000
5500
5500
7000
125000
500000
1500
0
1000
0
100
0
0
3500
1000
100000
100000
100000
100000
25000
25000
0
0
100
0
1000
0
25000
50000
6000
5000
300
300
MG
MG
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
%
%
%
%
MG/5ML
MG
%
%
%
0
%
0
0
MG/GM
%
MG
MG
MG/ML
MG/ML
MG
MG
0
0
%
MG
MG
MG
MG
MG
MG/.6M
MG
MCG/ML
MCG/ML
727545
1251914
722256
1251918
724142
724156
1251922
259711
105028
351973
105029
105030
261280
261281
562510
603978
199422
311943
1305143
1369746
615979
861570
1297660
606728
861576
606731
861583
1297763
854861
1303930
311944
1098135
1098142
1098144
858613
858616
351427
351429
351433
1246066
605818
748051
605820
748052
209326
968849
105071
NEUPOGEN 480 MCG/0.8 ML SYR

NEUPRO 1 MG/24 HR PATCH
NEURIN-SL TABLET SL
NEURONTIN 100 MG CAPSULE
NEURONTIN 250 MG/5 ML SOLN
NEURONTIN 600 MG TABLET
NEURONTIN 800 MG TABLET
NEUTRAL SODIUM FLUORIDE
NEVANAC 0.1% DROPTAINER
NEVIRAPINE 200 MG TABLET
NEVIRAPINE 50 MG/5 ML SUSP
NEXA SELECT CAPSULE
NEXA SELECT SOFTGEL
NEXAVAR 200 MG TABLET
NEXIUM DR 10 MG PACKET
NEXIUM DR 2.5 MG PACKET
NEXIUM DR 20 MG CAPSULE
NEXIUM DR 40 MG CAPSULE
NEXT CHOICE 0.75 MG TABLET
NEXT CHOICE ONE DOSE 1.5 MG TB
NIACOR 500 MG TABLET
NIASPAN ER 1,000 MG TABLET
NIASPAN ER 500 MG TABLET
NIASPAN ER 750 MG TABLET
NICARDIPINE 20 MG CAPSULE
NICARDIPINE 30 MG CAPSULE
NICODERM CQ 14 MG/24HR PATCH
NICOMIDE TABLET
NICORELIEF 2 MG GUM
NICORELIEF 2 MG LOZENGE
NICORELIEF 4 MG GUM
NICORELIEF 4 MG LOZENGE
NICORETTE 2 MG CHEWING GUM
NICORETTE 2 MG LOZENGE
NICORETTE 4 MG CHEWING GUM
480
1000
2000
3000
4000
6000
8000
0
100000
250000
300000
400000
600000
800000
200
100
200000
50000
29000
29000
200000
10000
2500
20000
20000
40000
40000
5000
750
1500
500000
1000000
500000
750000
20000
30000
14000
21000
7000
500
2000
2000
4000
4000
2000
2000
4000
MCG/ML
MG
MG
MG
MG
MG
MG
0
MG
MG/5ML
MG
MG
MG
MG
%
%
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
968851
1241796
198029
359817
359818
198031
892244
1189287
896103
880433
541603
880437
360394
351438
198032
198033
198034
198035
198036
284551
198037
577634
577643
577648
577651
763519
311984
763574
311985
763589
360344
790489
207273
899660
899521
899690
899607
899642
899705
311989
311992
311995
861657
486148
198038
198039
486152
NICORETTE 4 MG LOZENGE
NICOTINAMIDE-ZINC-COPPER-FA TB
NICOTINE 14 MG/24HR PATCH
NICOTINE 2 MG LOZENGE
NICOTINE 4 MG LOZENGE
NICOTINE 7 MG/24HR PATCH
NICOTINE TRANSDERMAL SYSTEM
NICOTROL CARTRIDGE INHALER
NICOTROL NS 10 MG/ML SPRAY
NIFEDIAC CC 30 MG TABLET
NIFEDICAL XL 30 MG TABLET
NIFEDICAL XL 60 MG TABLET
NIFEDIPINE 10 MG CAPSULE
NIFEDIPINE 20 MG CAPSULE
NIFEDIPINE ER 30 MG TABLET
NILANDRON 150 MG TABLET
NIMODIPINE 30 MG CAPSULE
NIRAVAM 0.25 MG ODT
NIRAVAM 0.5 MG ODT
NIRAVAM 1 MG ODT
NIRAVAM 2 MG ODT
NISOLDIPINE ER 17 MG TABLET
NISOLDIPINE ER 25.5 MG TABLET
NISOLDIPINE ER 8.5 MG TABLET
NITRO-BID 2% OINTMENT
NITRO-DUR 0.1 MG/HR PATCH
NITROFURANTOIN 25 MG/5 ML SUSP
NITROFURANTOIN MCR 100 MG CAP
NITROFURANTOIN MCR 50 MG CAP
NITROGLYCERIN 0.1 MG/HR PATCH
NITROGLYCERIN 0.3 MG TAB SL
NITROGLYCERIN 0.4 MG TABLET SL
4000
500
14000
2000
4000
7000
21000
10000
10000
30000
60000
90000
30000
60000
10000
20000
30000
60000
90000
150000
30000
250
500
1000
2000
17000
20000
25500
30000
34000
40000
8500
2000
100
200
300
400
600
800
25000
100000
50000
100
200
300
400
400
MG
MG
MG
MG
MG
MG
MG
MG
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
MG/HR
MG/HR
MG/HR
MG/HR
MG/HR
MG/HR
MG/5ML
MG
MG
MG/HR
MG/HR
MG
MG
MG/HR
198040
486146
312013
312018
312020
705129
995019
705133
207331
207346
207361
763066
476872
312025
198041
108329
206978
201896
1308442
748977
857001
857004
857007
748886
847348
849851
847247
847245
546407
748961
1000405
749784
749786
749860
749881
749882
213120
804982
1242215
209288
209066
209692
902648
902652
1099290
1099294
1099298
NITROGLYCERIN 0.6 MG TAB SL

NITROGLYCERIN ER 2.5 MG CAP
NITROGLYCERIN ER 6.5 MG CAP
NITROGLYCERIN ER 9 MG CAPSULE
NITROGLYCERIN LINGUAL 0.4 MG
NITROLINGUAL 0.4 MG SPRAY
NITROMIST 400 MCG SPRAY
NITROSTAT 0.3 MG TABLET SL
NIX 1% CREME RINSE LIQUID
NIZATIDINE 15 MG/ML SOLUTION
NIZATIDINE 150 MG CAPSULE
NIZATIDINE 300 MG CAPSULE
NIZORAL 2% CREAM
NIZORAL 2% SHAMPOO
NIZORAL 200 MG TABLET
NOHIST-A LIQUID
NORA-BE TABLET
NORCO 10-325 TABLET
NORCO 5-325 TABLET
NORCO 7.5-325 TABLET
NORDETTE-28 TABLET
NORDITROPIN FLEXPRO 10 MG/1.5
NORDITROPIN NORDIFLEX 30 MG/3
NORDITROPIN NORDIFLEX 5 MG/1.5
NORDITROPIN NORDIFLX 15 MG/1.5
NOREL SR TABLET
NORETHINDRONE 0.35 MG TABLET
NORETHINDRONE 5 MG TABLET
NORGESTIMATE-ETH ESTRADIOL TAB
NORG-ETHIN ESTR 0.3-0.03 MG TB
NORG-ETHIN ESTRA 0.25-0.035 MG
NORINYL 1+35-28 TABLET
NORINYL 1+50-28 TABLET
NORITATE 1% CREAM
NORMAL SALINE FLUSH SYRINGE
NORMAL SALINE FLUSH SYRINGE
NOROXIN 400 MG TABLET
NORPACE 100 MG CAPSULE
NORPACE 150 MG CAPSULE
NORPACE CR 100 MG CAPSULE SA
NORPACE CR 150 MG CAPSULE SA
NORPRAMIN 10 MG TABLET
600
600
2500
6500
9000
400
400
400
300
400
600
1000
15000
150000
300000
2000
2000
200000
5000
350
325000
5000
7500
0
10000
30000
5000
15000
40000
350
5000
0
0
250
1000
1000
1000
900
900
400000
100000
150000
100000
150000
10000
100000
150000
MG
MG/HR
MG
MG
MG
MG/DOS
MG/DOS
MG/DOS
MG
MG
MG
%
MG
MG
MG
%
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
%
MG
MG
MG
MG
MG
MG
MG
MG
1099302
1099306
1099318
748974
751868
751871
751870
762007
312036
198045
317136
198046
198047
212575
212542
212549
152970
900577
152971
1250974
996661
1113053
1113050
996629
1293729
1014594
579177
1234886
213442
311027
847205
311033
311034
351926
847265
977840
977842
284473
798104
665022
827346
854140
854140
854142
854142
854144
854144
NOR-Q-D TABLET
NORTREL 0.5-35 TABLET
NORTREL 1/35 TABLET
NORTREL 1-35 TABLET
NORTREL 7-7-7-28 TABLET
NORTRIPTYLINE 10 MG/5 ML SOL
NORTRIPTYLINE HCL 10 MG CAP
NORVASC 10 MG TABLET
NORVASC 2.5 MG TABLET
NORVASC 5 MG TABLET
NORVIR 100 MG SOFTGEL CAP
NORVIR 100 MG TABLET
NORVIR 80 MG/ML SOLUTION
NOTUSS AC LIQUID
NOTUSS DC LIQUID
NOTUSS-NX LIQUID
NOTUSS-NXD LIQUID
NOTUSS-PE LIQUID
NOVACORT GEL
NOVAFERRUM SOLUTION
NOVAGESIC CAPLET
NOVAHISTINE DH LIQUID
NOVOLIN 70-30 100 UNIT/ML VIAL
NOVOLIN N 100 UNITS/ML VIAL
NOVOLIN R 100 UNIT/ML INNOLET
NOVOLIN R 100 UNITS/ML VIAL
NOVOLIN R 100 UNITS/ML VIAL
NOVOLOG 100 UNIT/ML VIAL
NOVOLOG FLEXPEN SYRINGE
NOVOLOG MIX 70-30 FLEXPEN SYRN
NOVOLOG MIX 70-30 VIAL
NOVOSEVEN 1,200 MCG VIAL
NOVOSEVEN RT 1,000 MCG VIAL
NOXAFIL 40 MG/ML SUSPENSION
NUCORT LOTION
NUCYNTA 100 MG TABLET
25000
50000
75000
350
500
1000
1000
777000
10000
10000
25000
50000
75000
10000
2500
5000
100000
100000
80000
2000
0
9375
9375
0
2000
100000
500000
4000
100000
100000
100000
100000
100000
100000
100000
0
0
1200
1000
40000
2000
100000
100000
50000
50000
75000
75000
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
ML
MG/5ML
0
%
ML
MG
MG/5ML
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
0
0
MCG
MG
MG
%
MG
MG
MG
MG
MG
MG
1149367
1149367
1149370
1149370
1149373
1149373
1149376
1149376
1149378
1149378
1040058
1242705
1242705
801057
606786
1190173
1367439
805659
805661
805663
1087614
606794
606794
584414
543546
884308
312055
312059
724568
1053753
1053697
261178
646456
801185
312071
312069
1090558
314152
312068
1090559
312070
1090560
1101019
1101019
1243587
207202
242446
NUCYNTA ER 100 MG TABLET

NUEDEXTA 20-10 MG CAPSULE
NULEV 0.125 MG CHEWABLE MELT
NULEV 0.125 MG CHEWABLE MELT
NULYTELY WITH FLAVOR PACKS SOL
NUOX GEL
NUTRESTORE POWDER PACKET
NUVARING VAGINAL RING
NUVIGIL 150 MG TABLET
NUZOLE 2% CREAM
NUZON GEL
NUZON GEL
NYAMYC 100,000 UNITS/GM POWDER
NYSTATIN 100,000 UNIT/GM CREAM
NYSTATIN 100,000 UNITS/GM OINT
NYSTATIN 150,000,000 UNITS PWD
NYSTATIN 500,000 UNIT ORAL TAB
NYSTATIN VAGINAL TABLET
NYSTATIN-TRIAMCINOLONE CREAM
NYSTATIN-TRIAMCINOLONE OINTM
NYSTOP 100,000 UNITS/GM POWDER
NYSTOP 100,000 UNITS/GM POWDER
OCELLA 3 MG-0.03 MG TABLET
OCTREOTIDE 1,000 MCG/ML VIAL
OCTREOTIDE ACET 100 MCG/ML AMP
OCTREOTIDE ACET 100 MCG/ML SYR
OCTREOTIDE ACET 200 MCG/ML VL
OCUDOX CONVENIENCE KIT
OCUDOX CONVENIENCE KIT
OCUFEN 0.03% EYE DROPS
OCUFLOX 0.3% EYE DROPS
OFLOXACIN 0.3% EAR DROPS
100000
100000
150000
150000
200000
200000
250000
250000
50000
50000
20000
125
125
0
6000
0
0
150000
250000
50000
2000
2000
2000
1E+08
1E+08
1E+08
150000
5E+08
1E+08
0
0
1E+08
1E+08
0
1000
100
100
200
50
50
500
500
50000
50000
30
300
300
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
0
%
0
0
MG
MG
MG
%
%
%
U/1G
U/1G
U/1G
MMU
U
U
MG
MG
U/1G
U/1G
MG
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG
MG
%
%
%
312075
198048
198049
198050
877490
205541
214073
750243
314154
314154
312077
312077
200034
200034
283639
283639
312078
312078
312079
312079
312076
312076
351107
351107
351108
351108
314155
314155
403970
403971
721787
403969
403972
898701
898706
861355
1291987
199119
198051
200329
790276
261091
544198
213199
731220
731220
312085
OFLOXACIN 0.3% EYE DROPS

OFLOXACIN 200 MG TABLET
OFORTA 10 MG TABLET
OGEN 0.625 TABLET
OGEN 2.5 TABLET
OGESTREL TABLET
OLANZAPINE 10 MG TABLET
OLANZAPINE 2.5 MG TABLET
OLANZAPINE ODT 10 MG TABLET
OLANZAPINE-FLUOXETINE 12-25 MG
OLEPTRO ER 150 MG TABLET
OLEPTRO ER 300 MG TABLET
OLUX-E 0.05% FOAM
OMECLAMOX-PAK COMBO PACK
OMEPRAZOLE 10 MG CAPSULE DR
OMEPRAZOLE DR 20 MG CAPSULE
OMEPRAZOLE DR 40 MG CAPSULE
OMNARIS 50 MCG NASAL SPRAY
OMNICEF 125 MG/5 ML SUSP
OMNICEF 250 MG/5 ML SUSPENSION
OMNICEF 300 MG CAPSULE
OMNIPRED 1% EYE DROPS
OMNIPRED 1% EYE DROPS
ONDANSETRON 4 MG/5 ML SOLUTION
300
200000
300000
400000
10000
750
3000
0
10000
10000
15000
15000
2500
2500
20000
20000
5000
5000
7500
7500
10000
10000
15000
15000
20000
20000
5000
5000
12000
12000
3000
6000
6000
150000
300000
50
20000
10000
20000
40000
50
125000
250000
300000
1000
1000
4000
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
MG
MG
MG
MG
MG/5ML
MG/5ML
MG
%
%
MG/5ML
312084
198052
312086
104894
312087
1191056
1191058
1191060
1232418
858091
858094
858097
858100
858103
977943
977943
977940
977940
977876
977876
977896
977896
977904
977904
977911
977911
977917
977917
977925
977925
977931
977931
830196
636109
207232
860807
544553
1085767
891876
891876
891882
891882
891889
891889
891894
891894
262226
ONDANSETRON HCL 24 MG TABLET

ONDANSETRON ODT 4 MG TABLET
ONDANSETRON ODT 8 MG TABLET
ONFI 10 MG TABLET
ONFI 20 MG TABLET
ONFI 5 MG TABLET
ONMEL 200 MG TABLET
ONSOLIS 1,200 MCG SOLUBLE FILM
ONSOLIS 200 MCG SOLUBLE FILM
OPANA 10 MG TABLET
OPANA 10 MG TABLET
OPANA 5 MG TABLET
OPANA 5 MG TABLET
OPANA ER 10 MG TABLET
OPANA ER 7.5 MG TABLET
OPANA ER 7.5 MG TABLET
OPIUM TINCTURE 10 MG/ML
OPTASE TOPICAL GEL
OPTIPRANOLOL 0.3% EYE DROPS
OPTIVAR 0.05% DROPS
ORACIT ORAL SOLUTION
ORALONE 0.1% PASTE
ORAMORPH SR 100 MG TABLET
ORAP 1 MG TABLET
24000
4000
8000
4000
8000
10000
20000
5000
200000
1200
200
400
600
800
10000
10000
5000
5000
10000
10000
15000
15000
20000
20000
30000
30000
40000
40000
5000
5000
7500
7500
0
120
300
500
0
100
100000
100000
15000
15000
30000
30000
60000
60000
1000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MCG
MCG
MCG
MCG
MCG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
ML
MG
%
%
ML
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
201653
284516
668658
647127
668660
1089037
998550
746686
746686
977526
1145932
352121
352119
352120
205570
994535
994528
994521
1102251
352065
749785
749158
749861
749859
749853
1149355
1149355
1146688
1146688
1149364
1149364
1367268
1367306
1367307
636141
1294255
1190120
1006110
1006684
901038
749737
753477
261249
352305
207240
351276
198056
ORAP 2 MG TABLET
ORAPRED 15 MG/5 ML SOLUTION
ORAPRED ODT 10 MG TABLET
ORASEP SPRAY
ORAVIG 50 MG BUCCAL TABLET
ORAXYL 20 MG CAPSULE
ORAXYL 20 MG CAPSULE
ORBIVAN CAPSULE
ORENCIA 125 MG/ML SYRINGE
ORFADIN 10 MG CAPSULE
ORGANIDIN NR 200 MG TABLET
ORPHENADRINE COMP FORTE TABLET
ORPHENADRINE COMP TABLET
ORPHENADRINE ER 100 MG TABLET
ORSYTHIA-28 TABLET
ORTHO EVRA PATCH
ORTHO TRI-CYCLEN 28 TABLET
ORTHO TRI-CYCLEN LO TAB- SAMPL
ORTHO-CYCLEN 28 TABLET
ORTHO-NOVUM 1-35-28 TABLET
ORTHO-NOVUM 7/7/7-28 TAB
OSCIMIN 0.125 MG TABLET
OSCIMIN 0.125 MG TABLET
OSCIMIN SL 0.125 MG TABLET
OSCIMIN SL 0.125 MG TABLET
OSCIMIN SR 0.375 MG TABLET
OSCIMIN SR 0.375 MG TABLET
OSCION 3% CLEANSER
OSCION 6% CLEANSER
OSCION 9% CLEANSER
OSMOPREP TABLET
OTOMAX-HC EAR DROPS
OTOZIN EAR DROPS
OVACE 10% WASH
OVACE PLUS 10% CREAM
OVACE PLUS 10% SHAMPOO
OVCON-35 28 TABLET
OVCON-50 28 TABLET
OVIDE 0.5% LOTION
OXANDRIN 10 MG TABLET
OXANDRIN 2.5 MG TABLET
OXANDROLONE 10 MG TABLET
OXANDROLONE 2.5 MG TABLET
2000
15000
10000
15000
30000
0
50000
20000
20000
50000
125000
5000
2000
5000
200000
50000
25000
100000
0
20000
0
0
250
1000
777000
125
125
125
125
375
375
3000
6000
9000
1500000
0
5400
10000
10000
10000
35
50
500
10000
2500
10000
2500
MG
MG/5ML
MG
MG
MG
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/24H
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
%
MG
0
%
%
%
%
MCG
MCG
%
MG
MG
MG
MG
312132
198057
312134
198059
312136
312137
283536
312138
1113313
1113313
1113316
1113316
207248
207249
404086
207074
1365660
1365847
1365850
863664
863599
863619
863628
863636
1049635
1049225
1049233
1049683
1049683
1049611
1049611
1049686
1049686
1049618
1049618
1049696
1049696
1049621
1049621
1049604
1049604
1049502
1049502
1049563
1049563
1049584
1049584
OXAPROZIN 600 MG TABLET

OXAZEPAM 10 MG CAPSULE
OXCARBAZEPINE 150 MG TABLET
OXCARBAZEPINE 300 MG/5 ML SUSP
OXECTA 5 MG TABLET
OXECTA 5 MG TABLET
OXECTA 7.5 MG TABLET
OXECTA 7.5 MG TABLET
OXISTAT 1% CREAM
OXISTAT 1% LOTION
OXSORALEN 1% LOTION
OXSORALEN-ULTRA 10 MG CAP
OXTELLAR XR 150 MG TABLET
OXYBUTYNIN 5 MG TABLET
OXYBUTYNIN 5 MG/5 ML SYRUP
OXYBUTYNIN CL ER 10 MG TABLET
OXYCODON-ACETAMINOPHEN 2.5-325
OXYCODONE HCL 10 MG TABLET
OXYCODONE HCL 5 MG CAPSULE
OXYCODONE HCL 5 MG CAPSULE
OXYCODONE HCL 5 MG/5 ML SOL
OXYCODONE HCL 5 MG/5 ML SOL
OXYCODONE HCL CR 10 MG TABLET
OXYCODONE HCL CR 10 MG TABLET
OXYCODONE HCL ER 20 MG TABLET
600000
10000
15000
30000
150000
300000
300000
600000
5000
5000
7500
7500
1000
1000
1000
10000
150000
300000
600000
5000
1000
10000
15000
5000
2500
7500
7500
10000
10000
15000
15000
20000
20000
30000
30000
5000
5000
5000
5000
5000
5000
10000
10000
20000
20000
40000
40000
MG
MG
MG
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG
%
%
%
MG
MG
MG
MG
MG
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG/5ML
MG
MG
MG
MG
MG
MG
1049599
1049599
1049214
1049216
1049270
1049272
1049221
1049223
1049658
637540
848768
1049589
1049504
1049504
1049545
1049545
1049565
1049565
1049576
1049576
1049586
1049586
1049595
1049595
1049601
1049601
977942
977942
977939
977939
977874
977894
977902
977909
977915
977923
977929
404448
835958
834346
834350
845992
999915
999913
895057
1012906
1012903

OXYCODONE-ACETAMINOPHEN 10-325
OXYCODONE-ASA 4.5-0.38-325 TAB
OXYCODONE-ASPIRIN 4.83-325 MG
OXYCODONE-IBUPROFEN 5-400 TAB
OXYCONTIN 10 MG TABLET SA
OXYCONTIN 15 MG TABLET
OXYMORPHONE HCL 10 MG TABLET
OXYMORPHONE HCL ER 10 MG TAB
OXYMORPHONE HCL ER 5 MG TABLET
OXYMORPHONE HCL ER 7.5 MG TAB
OXYTROL 3.9 MG/24HR PATCH
PACERONE 100 MG TABLET
PACNEX 7% WASH
PACNEX HP 7% CLEANSING PADS
PACNEX LP 4.25% CLEANSING PADS
PACNEX MX 4.25% CLEANSER
PALGIC 4 MG TABLET
PALGIC 4 MG/5 ML LIQUID
80000
80000
10000
10000
10000
10000
5000
5000
0
0
4835
5000
10000
10000
15000
15000
20000
20000
30000
30000
40000
40000
60000
60000
80000
80000
10000
10000
5000
5000
10000
15000
20000
30000
40000
5000
7500
3900
100000
200000
400000
7000
7000
4250
4250
4000
4000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
%
%
MG
MG/5ML
209329
209339
209350
209391
207086
763084
968915
968921
968929
968937
861710
1370748
1234994
1234978
1234986
213502
251872
314200
312216
214097
1191036
809002
809006
809010
200240
105446
105050
104838
314184
562790
562790
562791
562791
562815
562815
312241
312241
312242
312242
314199
314199
312243
312243
312244
312244
212381
1111345
PAMELOR 10 MG CAPSULE
PAMINE 2.5 MG TABLET
PAMINE FORTE 5 MG TABLET
PANCREAZE DR 10,500 UNIT CAP
PANCRELIPASE DR 5,000 UNIT CAP
PANDEL 0.1% CREAM
PANLOR DC CAPSULE
PANLOR SS TABLET
PANLOR SS TABLET
PANRETIN 0.1% GEL
PANTOPRAZOLE SOD DR 20 MG TAB
PANTOPRAZOLE SOD DR 40 MG TAB
PAPAVERINE 150 MG CAPSULE SA
PARAFON FORTE DSC 500 MG CAPLT
PARCAINE 0.5% EYE DROPS
PARCOPA 10 MG-100 MG ODT
PAREGORIC LIQUID
PARLODEL 2.5 MG TABLET
PARLODEL 5 MG CAPSULE
PARNATE 10 MG TABLET
PAROMOMYCIN 250 MG CAPSULE
PAROXETINE CR 12.5 MG TABLET
PAROXETINE CR 25 MG TABLET
PAROXETINE CR 25 MG TABLET
PAROXETINE HCL 10 MG TABLET
PAROXETINE HCL 10 MG/5 ML SUSP
PAROXETINE HCL 10 MG/5 ML SUSP
PASER GRANULES 4 GM PACKET
PATADAY 0.2% EYE DROPS
10000
25000
50000
75000
2500
5000
10500000
16800000
21000000
4200000
27000000
1000
0
0
0
100
20000
40000
150000
500000
500
10000
25000
250000
0
2500
5000
10000
250000
12500
12500
25000
25000
37500
37500
10000
10000
10000
10000
20000
20000
30000
30000
40000
40000
4000000
200
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
MG
MG
%
MG
MG
MG
MG
%
MG
MG
MG
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
1111337
1111341
211699
211699
213291
213291
207349
207349
207350
207350
211700
211700
828446
828446
828448
828448
828451
828451
848119
848121
404526
1041846
1014318
260409
261179
1236684
966914
966920
801054
206750
731328
352297
1191665
805009
805010
805007
805008
760029
790245
790247
760039
834046
834061
834040
834102
261345
206791
PATANASE 665 MCG NASAL SPRAY

PATANOL 0.1% EYE DROPS
PAXIL 10 MG TABLET
PAXIL 10 MG TABLET
PAXIL 10 MG/5 ML SUSPENSION
PAXIL 10 MG/5 ML SUSPENSION
PAXIL 20 MG TABLET
PAXIL 20 MG TABLET
PAXIL 30 MG TABLET
PAXIL 30 MG TABLET
PAXIL 40 MG TABLET
PAXIL 40 MG TABLET
PAXIL CR 12.5 MG TABLET
PAXIL CR 25 MG TABLET
PAXIL CR 25 MG TABLET
PCE 333 MG DISPERTAB
PCE 500 MG DISPERTAB
PCM LA TABLET
PEDIADERM AF KIT
PEDIADERM TA 0.1% KIT
PEDIAPRED 6.7 MG/5 ML SOLN
PEDI-DRI TOPICAL POWDER
PEDIPIROX-4 NAIL KIT
PEG 3350 ELECTROLYTE SOLN
PEG-3350 AND ELECTROLYTES SOLN
PEG-3350 WITH FLAVOR PACKS SOL
PEGANONE 250 MG TABLET
PEGASYS 180 MCG/0.5 ML SYRINGE
PEGASYS 180 MCG/ML VIAL
PEGASYS PROCLICK 135 MCG/0.5
PEGINTRON 120 MCG KIT
PEGINTRON REDIPEN 120 MCG
PENICILLIN VK 125 MG/5 ML SUS
PENICILLIN VK 250 MG TABLET
PENICILLIN VK 250 MG/5 ML LIQ
PENICILLIN VK 500 MG TABLET
PENLAC 8% SOLUTION
PENTASA 250 MG CAPSULE
600
100
10000
10000
10000
10000
20000
20000
30000
30000
40000
40000
12500
12500
25000
25000
37500
37500
333000
500000
0
1E+08
100
6700
1E+08
8000
0
0
0
250000
180
180
675
240
300
100
160
240
300
100
160
125000
250000
250000
500000
8000
250000
%
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
0
G
%
MG/5ML
U/1G
%
0
0
0
MG
MCG/ML
MCG/ML
MCG/ML
MCG
MCG
MCG
MCG
MCG
MCG
MCG
MCG
MG/5ML
MG
MG/5ML
MG
%
MG
580286
312288
312289
312289
312301
847469
104095
206873
1112779
1012266
1012266
1049625
1049650
1049637
1049640
1049642
1049647
848772
1246321
834135
854984
854988
854925
750104
834137
351988
351988
106387
856706
856797
856720
856825
856840
198075
198076
198077
198078
206714
207569
208316
1294128
1294483
541660
541660
541662
541662
541664
PENTASA 500 MG CAPSULE

PENTAZOCIN-ACETAMINOPHN 25-650
PENTAZOCINE-NALOXONE TABLET
PENTAZOCINE-NALOXONE TABLET
PENTOXIFYLLINE ER 400 MG TAB
PENTOXIL ER 400 MG TABLET
PEPCID 40 MG TABLET
PEPCID 40 MG/5 ML ORAL SUSP
P-EPHED-CPM SR 120-8 MG CAP
PERANEX HC 2-2% CREAM KIT
PERANEX HC 2-2% CREAM KIT
PERCOCET 10-325 MG TABLET
PERCOCET 2.5-325 MG TABLET
PERCODAN TABLET
PERFOROMIST 20 MCG/2 ML SOLN
PERIDEX 0.12% LIQUID
PERINDOPRIL ERBUMINE 2 MG TAB
PERIO MED DENTAL RINSE
PERIOGARD 0.12% ORAL RINSE
PERIOSTAT 20 MG TABLET
PERIOSTAT 20 MG TABLET
PERMETHRIN 5% CREAM
PERPHEN-AMITRIP 2 MG-10 MG TAB
PERPHENAZINE 16 MG TABLET
PERSANTINE 25 MG TABLET
PERTZYE DR 16,000 UNITS CAPS
PERTZYE DR 8,000 UNITS CAPSULE
PEXEVA 10 MG TABLET
PEXEVA 10 MG TABLET
PEXEVA 20 MG TABLET
PEXEVA 20 MG TABLET
PEXEVA 30 MG TABLET
500000
0
50000
50000
400000
400000
40000
40000
8000
2000
2000
10000
10000
2500
5000
7500
7500
4835
20
120
2000
4000
8000
630
120
20000
20000
5000
2000
25000
10000
4000
50000
16000
2000
4000
8000
25000
50000
75000
16000000
8000000
10000
10000
20000
20000
30000
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG
%
%
MG
MG
MG
MG
MG
MG
MG
MCG
%
MG
MG
MG
%
%
MG
MG
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
0
0
MG
MG
MG
MG
MG
541664
541666
541666
992443
992456
672065
284519
1047805
1094107
1094104
312347
1243777
1243785
198083
198083
312357
312357
198086
198086
702519
702519
312362
312362
199167
198089
198089
199168
199168
199164
199164
1234571
1234579
1113437
855863
855875
1313112
1313885
855671
855861
855873
1235874
207768
1101881
645216
1099808
656742
1047791
PEXEVA 30 MG TABLET
PEXEVA 40 MG TABLET
PEXEVA 40 MG TABLET
PHENADOZ 12.5 MG SUPPOSITORY
PHENADOZ 25 MG SUPPOSITORY
PHENA-PLUS TABLET
PHENA-S LIQUID
PHENAZOFORTE PLUS TABLET
PHENAZOPYRIDINE 100 MG TAB
PHENAZOPYRIDINE 200 MG TAB
PHENELZINE SULFATE 15 MG TAB
PHENFLU CD TABLET
PHENFLU CDX TABLET
PHENOBARBITAL 100 MG TABLET
PHENOBARBITAL 16.2 MG TABLET
PHENOBARBITAL 20 MG/5 ML ELIX
PHENOBARBITAL 20 MG/5 ML ELIX
PHENYLEPHRINE 10% EYE DROPS
PHENYLEPHRINE 2.5% EYE DROP
PHENYLHISTINE DH LIQUID
PHENYTEK 200 MG CAPSULE
PHENYTEK 300 MG CAPSULE
PHENYTOIN 125 MG/5 ML SUSP
PHENYTOIN 50 MG TABLET CHEW
PHENYTOIN SOD EXT 100 MG CAP
PHILITH 0.4-0.035 MG TABLET
PHISOHEX 3% CLEANSER
PHOS-FLUR 1.1% GEL
PHOSLO 667 MG GELCAP
PHOSLYRA 667 MG/5 ML SOLUTION
PHOSPHA 250 NEUTRAL TABLET
PHOSPHASAL TABLET
30000
40000
40000
12500
25000
0
0
0
100000
200000
15000
10000
10000
100000
100000
15000
15000
15000
15000
20000
20000
30000
30000
30000
60000
60000
60000
60000
100000
100000
10000
2500
0
200000
300000
125000
50000
100000
200000
300000
35
3000
1100
667000
667000
250000
81600
MG
MG
MG
MG
MG
MG
ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
0
MG
MG
MG/5ML
MG
MG
MG
MG
MCG
%
%
MG
MG
MG
MG
205739
993948
209827
827353
801925
1000917
1000647
1000862
1000897
1000939
1000913
1001004
1000642
198104
198105
239009
647237
647239
317573
312440
312441
861783
861822
198107
198108
763089
858079
979094
749198
213169
261116
284370
1005789
1005820
1005844
728126
1245745
582926
1236173
547064
1043650
604669
213621
213621
208593
208602
979338
PHOSPHOLINE IODIDE 0.125%

PHRENILIN FORTE CAPSULE
PHRENILIN TABLET
PHYSIOLYTE IRRIGATION SOLN
PHYSIOSOL IRRIGATION SOLN
PILOCARPINE 0.5% EYE DROPS
PILOCARPINE 1% EYE DROPS
PILOCARPINE HCL 5 MG TABLET
PILOCARPINE HCL 7.5 MG TABLET
PILOPINE HS 4% EYE GEL
PINDOLOL 10 MG TABLET
PINDOLOL 5 MG TABLET
PINNACAINE 20% OTIC DROPS
PIOGLITAZ-GLIMEPIR 30-2 MG TAB
PIOGLITAZ-GLIMEPIR 30-4 MG TAB
PIOGLITAZONE HCL 15 MG TABLET
PIOGLITAZONE-METFORMIN 15-500
PIOGLITAZONE-METFORMIN 15-850
PIROXICAM 10 MG CAPSULE
PIROXICAM 20 MG CAPSULE
PLAN B 0.75 MG TABLET
PLAN B ONE-STEP 1.5 MG TABLET
PLAQUENIL 200 MG TABLET
PLAVIX 300 MG TABLET
PLAVIX 75 MG TABLET
PLETAL 100 MG TABLET
PLETAL 50 MG TABLET
PLEXION CLEANSER
PLEXION CLEANSING CLOTHS
PLEXION SCT CREAM
PLIAGLIS 7%-7% CREAM
PODOCON-25 LIQUID
PODOFILOX 0.5% TOPICAL SOLN
POLY HIST DHC LIQUID
POLY HIST DM LIQUID
POLY HIST NC LIQUID
POLY HIST PD LIQUID
POLYCIN-B EYE OINTMENT
POLYCIN-B EYE OINTMENT
POLY-DEX EYE DROPS
POLY-DEX EYE OINTMENT
POLY-IRON 150 FORTE CAPSULE
125
650000
325000
0
0
500
1000
2000
4000
6000
5000
7500
4000
10000
5000
20000
2000
4000
15000
30000
45000
500000
850000
10000
20000
750
1500
200000
300000
75000
100000
50000
0
10000
0
7000
25000
500
7500
15000
15000
7500
0
0
100
0
1000
%
MG
MG
0
0
%
%
%
%
%
MG
MG
%
MG
MG
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
0
%
0
%
%
%
MG/ML
MG/5ML
ML
MG
MG
MG
%
0
MG
244967
244967
207638
311888
208451
208451
994835
1113048
1236060
1190294
1236115
1113051
1369724
1369728
1369732
1369736
829502
211813
751890
202088
1086377
312496
1193110
309318
199381
199376
312515
891453
314182
204882
312504
628953
198116
315183
312529
1112997
1113001
1113005
1113009
1037049
1037181
1116503
1116503
859033
859040
859044
858625
POLYMYXIN B-TMP EYE DROPS

POLYMYXIN B-TMP EYE DROPS
POLY-PRED EYE DROPS
POLY-PRED EYE DROPS
POLYTRIM EYE DROPS
POLYTRIM EYE DROPS
POLY-TUSSIN AC LIQUID
POLY-TUSSIN D LIQUID
POLY-TUSSIN DHC LIQUID
POLY-TUSSIN DM SYRUP
POLY-TUSSIN EX LIQUID
POLY-TUSSIN LIQUID
POMALYST 1 MG CAPSULE
PONSTEL 250 MG KAPSEALS
PONTOCAINE 2% SOLUTION
PORTIA-28 TABLET
POTABA 500 MG CAPSULE
POTABA 500 MG TABLET
POTASSIUM 25 MEQ TABLET EFF
POTASSIUM 25 MEQ TABLET EFF
POTASSIUM CIT-CITRIC ACID SLN
POTASSIUM CITRATE ER 10 MEQ TB
POTASSIUM CITRATE ER 5 MEQ TAB
POTASSIUM CL 10% (20 MEQ/15 ML
POTASSIUM CL 20 MEQ PACKET
POTASSIUM CL 20% (40 MEQ/15 ML
POTASSIUM CL 25 MEQ TAB EFF
POTASSIUM CL ER 10 MEQ CAPSULE
POTASSIUM CL ER 10 MEQ TABLET
POTASSIUM CL ER 8 MEQ CAPSULE
POTIGA 200 MG TABLET
POTIGA 50 MG TABLET
PRADAXA 150 MG CAPSULE
PRADAXA 75 MG CAPSULE
PRAMCORT 1% CREAM
PRAMCORT 1% CREAM
PRAMIPEXOLE 0.125 MG TABLET
0
0
500
500
0
0
7500
9375
4000
0
5000
0
1000
2000
3000
4000
250000
2000
0
500000
500000
25000
25000
0
750000
540000
10000
20000
20000
25000
750000
750000
1500000
600000
600000
200000
300000
400000
50000
150000
75000
1000
1000
125
250
500
750
0
0
%
%
0
0
MG/5ML
MG/5ML
MG/5ML
ML
MG
0
MG
MG
MG
MG
MG
%
MG
MG
MG
MEQ
MEQ
ML
MG
MG
%
MEQ
%
MEQ
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
MG
MG
MG
MG
859052
859048
1234519
1234519
1234396
1234396
1234322
1234322
1234509
1234509
1234514
1234514
1234338
1234338
1232621
1294336
861789
861792
213218
213219
213220
1000555
1005829
1005845
904460
904469
904477
904483
904458
904467
904475
904481
312593
312593
312594
312594
198141
198141
1011833
1011833
209248
213170
209247
209005
209005
209002
209002
PRAMIPEXOLE 1 MG TABLET
PRAMOSONE 1% CREAM
PRAMOSONE 1% CREAM
PRAMOSONE 1% LOTION
PRAMOSONE 1% LOTION
PRAMOSONE 1% OINTMENT
PRAMOSONE 1% OINTMENT
PRAMOSONE 2.5% CREAM
PRAMOSONE 2.5% CREAM
PRAMOSONE 2.5% LOTION
PRAMOSONE 2.5% LOTION
PRAMOSONE 2.5% OINTMENT
PRAMOSONE 2.5% OINTMENT
PRAMOTIC EAR DROPS
PRAMOX 1% GEL
PRANDIMET 1 MG-500 MG TABLET
PRANDIMET 2 MG-500 MG TABLET
PRANDIN 0.5 MG TABLET
PRANDIN 1 MG TABLET
PRANDIN 2 MG TABLET
PRASCION CLEANSER
PRASCION FC CLEANSING CLOTHS
PRASCION RA CREAM
PRAVACHOL 10 MG TABLET
PRAVASTATIN SODIUM 10 MG TAB
PRAZOSIN 1 MG CAPSULE
PRE-ATTACHED LTA KIT
PRE-ATTACHED LTA KIT
PRECOSE 100 MG TABLET
PRED FORTE 1% EYE DROPS
PRED FORTE 1% EYE DROPS
PRED MILD 0.12% EYE DROPS
PRED MILD 0.12% EYE DROPS
1000
1500
1000
1000
1000
1000
1000
1000
2500
2500
2500
2500
2500
2500
0
1000
1000
2000
500
1000
2000
10000
10000
10000
10000
20000
40000
80000
10000
20000
40000
80000
1000
1000
2000
2000
5000
5000
4000
4000
100000
25000
50000
1000
1000
120
120
MG
MG
%
%
%
%
%
%
%
%
%
%
%
%
0
%
MG
MG
MG
MG
MG
%
%
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
MG
MG
MG
%
%
%
%
205826
260285
198363
706546
211755
211755
283077
312614
343019
343019
314165
314165
249066
198144
198145
763183
763185
795858
198146
312615
312617
763179
763181
315187
205301
198148
762394
1101741
755702
208513
404550
150840
208949
202301
688242
826091
1000487
1000491
1000497
1000499
1000500
1313925
1305810
206205
866152
206206
848951
PRED-G 1% EYE DROPS

PRED-G S.O.P. EYE OINTMENT
PREDNICARBATE 0.1% CREAM
PREDNICARBATE 0.1% OINTMENT
PREDNISOL 1% EYE DROPS
PREDNISOL 1% EYE DROPS
PREDNISOLONE 15 MG/5 ML SOLN
PREDNISOLONE 6.7 MG/5 ML SOLN
PREDNISOLONE AC 1% EYE DROP
PREDNISOLONE AC 1% EYE DROP
PREDNISOLONE SOD 1% EYE DROP
PREDNISOLONE SOD 1% EYE DROP
PREDNISOLONE SOD PH 25 MG/5 ML
PREDNISONE 1 MG TABLET
PREDNISONE 2.5 MG TABLET
PREDNISONE 5 MG/5 ML SOLUTION
PREDNISONE 5 MG/ML SOLUTION
PREFEST TABLET
PREHIST D TABLET SA
PRELONE 15 MG/5 ML SYRUP
PREMARIN 0.3 MG TABLET
PREMARIN VAGINAL CREAM-APPL
PREMESIS RX TABLET
PREMPHASE 0.625-5 MG TABLET
PREMPRO 0.3 MG-1.5 MG TABLET
PREMPRO 0.45-1.5 MG TABLET
PREMPRO 0.625-2.5 MG TABLET
PREMPRO 0.625-5 MG TABLET
PRENATAL 19 TABLET
PREPOPIK POWDER PACKET
PREVACID 15 MG SOLUTAB
PREVACID 30 MG SOLUTAB
PREVACID DR 30 MG CAPSULE
PREVALITE POWDER
1000
0
100
100
1000
1000
15000
5000
1000
1000
1000
1000
25000
1000
10000
10000
10000
10000
2500
20000
5000
5000
5000
5000
5000
50000
0
0
15000
300
450
625
900
1250
625
1000
0
300
1500
2500
5000
0
0
15000
30000
30000
0
%
%
%
%
%
%
MG/5ML
MG/5ML
%
%
%
%
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG/5ML
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG
MG/GM
MG
MG
MG
MG
MG
MG
MG
0
MG
MG
MG
0
630194
999717
211275
753478
757969
850457
824876
794610
831870
1359271
261101
211691
797061
797065
207212
213295
1037261
904170
96304
198150
1014613
1014619
1014636
261353
206765
206766
206764
790267
790290
745752
993464
993468
993472
198152
198153
207765
207772
207773
207774
884526
404323
198365
198159
284254
312635
995447
996736
PREVIDENT 5000 PLUS CREAM

PREVIDENT 5000 SENSITIVE PASTE
PREVIDENT DENTAL RINSE
PREVIFEM TABLET
PREVPAC PATIENT PACK
PREZISTA 150 MG TABLET
PRIFTIN 150 MG TABLET
PRILOSEC DR 10 MG CAPSULE
PRILOSEC DR 10 MG SUSPENSION
PRILOSEC DR 2.5 MG SUSPENSION
PRIMALEV 2.5-300 MG TABLET
PRIMAQUINE 26.3 MG TABLET
PRIMIDONE 250 MG TABLET
PRIMIDONE 50 MG TABLET
PRIMLEV 10-300 MG TABLET
PRIMLEV 5-300 MG TABLET
PRIMLEV 7.5-300 MG TABLET
PRIMSOL 50 MG/5 ML ORAL SOLN
PRINIVIL 10 MG TABLET
PRISTIQ ER 100 MG TABLET
PRISTIQ ER 50 MG TABLET
PROAIR HFA 90 MCG INHALER
PROAMATINE 10 MG TABLET
PROAMATINE 2.5 MG TABLET
PROAMATINE 5 MG TABLET
PROBENECID 500 MG TABLET
PROBENECID-COLCHICINE TABS
PROCARDIA 10 MG CAPSULE
PROCARDIA XL 30 MG TABLET
PROCENTRA 5 MG/5 ML SOLUTION
PROCHIEVE 4% GEL
PROCHLORPERAZINE 10 MG TAB
PROCHLORPERAZINE 25 MG SUPP
PROCHLORPERAZINE 25 MG SUPP
PROCHLORPERAZINE 5 MG TABLET
PRO-CLEAR AC SYRUP
PRO-CLEAR CAPS
1100
1100
200
250
0
150000
400000
600000
75000
800000
150000
10000
10000
25000
20000
40000
2500
26300
250000
50000
10000
5000
7500
50000
10000
20000
5000
100000
30000
0
10000
2500
5000
500000
0
10000
30000
60000
90000
5000
4000
10000
25000
25000
5000
0
200000
%
%
%
MG
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
5ML
%
MG
MG
MG
MG
MG
MG
1115730
1115730
205913
205918
212219
205922
205924
213475
310879
310879
260311
260311
1291092
1291092
706544
706544
828364
828364
543492
543492
1291380
1291380
351396
351396
827322
827322
1090910
984086
796999
260243
312641
207634
261134
261134
108513
108513
108514
108514
351589
1245003
825425
825429
884619
992441
992438
992454
992447
PROCORT 1.85%-1.15% CREAM

PROCORT 1.85%-1.15% CREAM
PROCRIT 10,000 UNITS/ML VIAL
PROCTOCARE-HC 2.5% CREAM
PROCTOCARE-HC 2.5% CREAM
PROCTOCORT 1% CREAM
PROCTOCORT 1% CREAM
PROCTOCORT 30 MG SUPPOSITORY
PROCTOCORT 30 MG SUPPOSITORY
PROCTOCREAM-HC 2.5% CREAM
PROCTOCREAM-HC 2.5% CREAM
PROCTOFOAM-HC FOAM
PROCTOFOAM-HC FOAM
PROCTO-PAK 1% CREAM
PROCTO-PAK 1% CREAM
PROCTOSOL-HC 2.5% CREAM
PROCTOSOL-HC 2.5% CREAM
PROCTOZONE-HC 2.5% CREAM
PROCTOZONE-HC 2.5% CREAM
PRODRIN CAPLET
PRODRIN CAPLET
PROFERRIN-FORTE TABLET
PROFILNINE SD 1,000 UNITS VIAL
PROFILNINE SD 1,000-1,500 UNIT
PROGESTERONE 100 MG CAPSULE
PROGESTERONE 200 MG CAPSULE
PROGLYCEM 50 MG/ML ORAL SUSP
PROGRAF 0.5 MG CAPSULE
PROGRAF 0.5 MG CAPSULE
PROGRAF 1 MG CAPSULE
PROMACET 50-650 MG TABLET
PROMACTA 12.5 MG TABLET
PROMACTA 25 MG TABLET
PROMETHAZINE 12.5 MG SUPPOS
PROMETHAZINE 12.5 MG TABLET
PROMETHAZINE 25 MG SUPPOSITORY
PROMETHAZINE 25 MG TABLET
1850
1850
1000000
2000000
20000000
3000000
4000000
40000000
2500
2500
1000
1000
30000
30000
2500
2500
1000
1000
1000
1000
2500
2500
2500
2500
0
0
12000
1000000
1200000
100000
200000
50000
500
500
1000
1000
5000
5000
650000
12500
25000
50000
75000
12500
12500
25000
25000
%
%
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
%
%
%
%
MG
MG
%
%
%
%
%
%
%
%
%
%
MG
MG
MG
U
U
MG
MG
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
992475
992432
996757
991486
991528
1248057
992445
992459
992481
262080
261319
861424
861427
861430
861156
861164
861171
198165
1191013
1247445
1247445
828581
827751
828576
849279
849290
856448
856457
856724
856519
856733
856556
856578
856460
856481
856535
856569
856422
856429
198175
672912
997160
201961
1245492
207140
105467
546422
PROMETHAZINE 50 MG TABLET
PROMETHAZINE 6.25 MG/5 ML SYRP
PROMETHAZINE VC-CODEINE SYRUP
PROMETHAZINE-CODEINE SYRUP
PROMETHAZINE-DM SYRUP
PROMETHAZINE-PHENYLEPHRINE SYR
PROMETHEGAN 12.5 MG SUPPOS
PROMETHEGAN 25 MG SUPP
PROMETHEGAN 50 MG SUPPOSITORY
PROMETRIUM 100 MG CAPSULE
PROMETRIUM 200 MG CAPSULE
PROPAFENONE HCL 150 MG TABLET
PROPAFENONE HCL 225 MG TAB
PROPAFENONE HCL 300 MG TAB
PROPAFENONE HCL SR 225 MG CAP
PROPANTHELINE 15 MG TABLET
PROPARACAINE 0.5% EYE DROPS
PROPARACAINE-FLUOR EYE DROP
PROPARACAINE-FLUOR EYE DROP
PROPOXYPH-ACETAMINOPHEN 65-650
PROPOXYPH-ACETAMINOPHN 100-325
PROPOXYPH-ACETAMINOPHN 100-650
PROPOXYPHENE HCL 65 MG CAP
PROPOXYPHENE HCL 65 MG CAP
PROPRANOLOL 10 MG TABLET
PROPRANOLOL 20 MG/5 ML SOLN
PROPRANOLOL 40 MG/5 ML SOLN
PROPRANOLOL ER 120 MG CAPSULE
PROPRANOLOL/HCTZ 40/25 TAB
PROPRANOLOL/HCTZ 80/25 TAB
PROPYLTHIOURACIL 50 MG TABLET
PROQUIN XR 500 MG TABLET
PRO-RED AC SYRUP
PROSCAR 5 MG TABLET
PROSED-DS TABLET
PROSTIGMIN 15 MG TABLET
PROSTIN VR PEDI 500 MCG/ML AMP
PROTID TABLET SA
50000
6250
0
0
0
0
12500
25000
50000
100000
200000
150000
225000
300000
225000
325000
425000
15000
500
0
0
0
100000
100000
65000
65000
10000
20000
20000
40000
40000
60000
80000
120000
160000
60000
80000
40000
80000
50000
500000
0
5000
81600
15000
500
0
MG
MG/5ML
0
ML
0
ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
0
0
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
ML
MG
MG
MG
MCG/ML
MG
763308
352125
284400
284521
284520
905168
905172
746763
1000124
1000139
1000145
1091718
205535
104849
261287
598032
1000093
348726
966589
966622
997420
198467
314119
311975
616830
616817
616819
966524
966529
205532
1314654
206788
1294621
198181
1094109
1094122
903857
979365
349421
1046787
1046787
997012
759469
848949
312743
312743
312743
PROTONIX 40 MG SUSPENSION
PROTONIX DR 20 MG TABLET
PROTONIX DR 40 MG TABLET
PROTOPIC 0.03% OINTMENT
PROTOPIC 0.1% OINTMENT
PROTRIPTYLINE HCL 10 MG TABLET
PROTRIPTYLINE HCL 5 MG TABLET
PROVENTIL HFA 90 MCG INHALER
PROVERA 10 MG TABLET
PROVERA 2.5 MG TABLET
PROVERA 5 MG TABLET
PROVISC 10 MG/ML DISP SYRNG
PROZAC 10 MG PULVULE
PROZAC WEEKLY 90 MG CAPSULE
PRUDOXIN 5% CREAM
PSE BROM DM SYRUP
PSORCON E 0.05% CREAM
PSORCON E 0.05% OINTMENT
PUB ALLERGY RELIEF 180 MG TAB
PUB ASPIRIN EC 325 MG TABLET
PUB STOP SMOKING AID 2 MG GUM
PUB STOP SMOKING AID 4 MG GUM
PULMICORT 0.25 MG/2 ML RESPUL
PULMICORT 0.5 MG/2 ML RESPULE
PULMICORT 1 MG/2 ML RESPULE
PULMICORT 180 MCG FLEXHALER
PULMICORT 90 MCG FLEXHALER
PULMOZYME 1 MG/ML AMPUL
PUREFE PLUS CAPSULE
PURINETHOL 50 MG TABLET
PYLERA CAPSULE
PYRAZINAMIDE 500 MG TABLET
PYRIDIUM 100 MG TABLET
PYRIDIUM 200 MG TABLET
PYRIDOSTIGMINE BR 60 MG TABLET
PYRIL D SUSPENSION
PYRIL-CHLOR-PHEN TABLET
QUADRAPAX ELIXIR
QUADRAPAX ELIXIR
QUALAQUIN 324 MG CAPSULE
QUASENSE 0.15-0.03 MG TABLET
QUESTRAN PACKET
QUETIAPINE FUMARATE 100 MG TAB
40000
20000
40000
30
100
10000
5000
0
10000
2500
5000
10000
10000
20000
40000
90000
5000
60000
50
50
180000
325000
2000
4000
250
500
1000
180
90
1000
106000
50000
125000
500000
100000
200000
60000
5000
10000
16200
16200
324000
30
0
100000
100000
100000
MG
MG
MG
%
%
MG
MG
0
MG
MG
MG
MG/ML
MG
MG
MG
MG
%
ML
%
%
MG
MG
MG
MG
MG/2ML
MG/2ML
MG/2ML
MG
MG
MG/ML
MG
MG
MG
MG
MG
MG
MG
ML
MG
MG
MG
MG
MG
0
MG
MG
MG
317174
317174
317174
312744
312744
312744
312745
312745
312745
616483
616483
616483
616487
616487
616487
1312589
312748
312749
314203
312750
310796
310797
310809
852920
852906
852877
852913
997010
284440
966538
966542
845488
261962
198188
198189
860737
860738
705610
198190
198192
198193
826614
809481
905160
351989
351901
404432

QUILLIVANT XR 25 MG/5 ML SUSP
QUINAPRIL 10 MG TABLET
QUINAPRIL-HCTZ 10-12.5 MG TAB
QUINAPRIL-HCTZ 20-12.5 MG TAB
QUINARETIC 20-25 MG TABLET
QUINIDINE GLUC ER 324 MG TAB
QUINIDINE SULF ER 300 MG TAB
QUINIDINE SULFATE 200 MG TAB
QUINIDINE SULFATE 300 MG TAB
QUININE SULFATE 324 MG CAPSULE
QUIXIN 0.5% EYE DROPS
QVAR 40 MCG INHALER
QVAR 80MCG INHALER-SAMPLE NDC
RAMIPRIL 1.25 MG CAPSULE
RAMIPRIL 10 MG CAPSULE
RAMIPRIL 2.5 MG CAPSULE
RAMIPRIL 5 MG CAPSULE
RANEXA ER 1,000 MG TABLET
RANEXA ER 500 MG TABLET
RANITIDINE 15 MG/ML SYRUP
RANITIDINE 150 MG CAPSULE
RANITIDINE 300 MG CAPSULE
RANITIDINE 300 MG TABLET
RAPAFLO 4 MG CAPSULE
RAPAFLO 8 MG CAPSULE
RAPAMUNE 0.5 MG TABLET
RAPAMUNE 1 MG TABLET
RAPAMUNE 1 MG/ML ORAL SOLN
RAPAMUNE 2 MG TABLET
200000
200000
200000
25000
25000
25000
300000
300000
300000
400000
400000
400000
50000
50000
50000
5000
10000
20000
40000
5000
10000
20000
25000
324000
300000
200000
300000
324000
500
40
80
1250
10000
2500
5000
1000000
500000
15000
150000
300000
300000
4000
8000
500
1000
1000
2000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
MCG
MG
MG
MG
MG
MG
MG
MG
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG/ML
MG
1368459
602734
602736
860903
602737
860697
860709
860717
308273
352007
544400
758032
758027
795749
753543
1368368
1368360
1368370
1368293
1368320
1368330
1367420
207266
207265
213197
206958
206959
543879
352263
1086926
1363036
763079
759473
1244062
979115
1244064
404443
404444
752869
211322
752870
211323
752871
261135
802780
352211
352214
RAVICTI 1.1 GRAM/ML LIQUID

RAZADYNE 12 MG TABLET
RAZADYNE 4 MG/ML ORAL SOLUTION
RAZADYNE ER 16 MG CAPSULE
RE CHLORPHENYLCAINE OTIC DROPS
REBETOL 200 MG CAPSULE
REBETOL 40 MG/ML SOLUTION
REBIF 22 MCG/0.5 ML SYRINGE
REBIF 44 MCG/0.5 ML SYRINGE
REBIF TITRATION PACK
RECLIPSEN 28 DAY TABLET
RECOMBINATE 1,241-1,800 UNIT V
RECOMBINATE 220-400 UNIT VIAL
RECOTHROM 20,000 UNITS VIAL
REGLAN 10 MG TABLET
REGLAN 5 MG TABLET
REGRANEX 0.01% GEL
RELAFEN 500 MG TABLET
RELAFEN 750 MG TABLET
RELAGARD VAGINAL GEL
RELAGESIC TABLET
RELCOF C LIQUID
RELCOF DN PSE TABLET
RELCOF PE TABLET SA
RELENZA 5 MG DISKHALER
RELISTOR 12 MG/0.6 ML SYRINGE
RELISTOR 12 MG/0.6 ML VIAL
RELISTOR 8 MG/0.4 ML SYRINGE
RELPAX 20 MG TABLET
RELPAX 40 MG TABLET
REMERON 15 MG SOLTAB
REMERON 15 MG TABLET
REMEVEN 50% CREAM
REMODULIN 1 MG/ML VIAL
1100
12000
4000
4000
8000
16000
24000
8000
0
200000
40000
22
44
8
150
1500000
1800000
1800000
310000
310000
600000
20000000
10000
5000
10
500000
750000
0
650000
100000
0
0
5000
12000
12000
8000
20000
40000
15000
15000
30000
30000
45000
45000
50000
1000
10000
G
MG
MG
MG/ML
MG
MG
MG
MG
0
MG
MG/ML
MCG
MCG
MCG
MG
IU
IU
IU
UNITS
UNITS
UNITS
MU
MG
MG
%
MG
MG
%
MG
MG/5ML
0
MG
MG
MG/ML
MG/ML
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
MG/ML
352212
352213
1302483
857218
857226
891522
861377
861373
749210
211194
859331
858772
858784
152952
213068
152953
152954
351991
261309
152955
824961
799832
800497
848584
800499
999777
795953
900621
832900
892858
856562
856612
284449
311451
198196
198197
1111174
1297980
966555
746213
402092
208464
539384
208465
208463
208334
208328
REMODULIN 2.5 MG/ML VIAL

RENACIDIN IRRIGATION SOLN
RENAGEL 400 MG TABLET
RENAGEL 800 MG TABLET
RENO CAPS SOFTGEL
RENVELA 0.8 GM POWDER PACKET
RENVELA 2.4 GM POWDER PACKET
RENVELA 800 MG TABLET
REPAN 50-325-40 MG TABLET
REPREXAIN 10-200 MG TABLET
REPREXAIN 2.5-200 MG TABLET
REPREXAIN 5-200 MG TABLET
REQUIP 0.25 MG TABLET
REQUIP 0.5 MG TABLET
REQUIP 1 MG TABLET
REQUIP 2 MG TABLET
REQUIP 3 MG TABLET
REQUIP 4 MG TABLET
REQUIP 5 MG TABLET
REQUIP XL 12 MG TABLET
RESCON TABLET
RESCON-JR SR TABLET
RESCON-JR. SR TABLET
RESCON-MX SR TABLET
RESCON-MX SR TABLET
RESCRIPTOR 100 MG TABLET
RESCRIPTOR 200 MG TABLET
RESCULA 0.15% EYE DROPS
RESECTISOL 5% SOLUTION
RESERPINE 0.1 MG TABLET
RESERPINE 0.25 MG TABLET
RESPA A.R. TABLET SA
RESPA C&C IR TABLET
RESPA-BR TABLET SA
RESPAHIST-II TABLET SA
RESTASIS 0.05% EYE EMULSION
RESTORIL 15 MG CAPSULE
RESTORIL 22.5 MG CAPSULE
RESTORIL 30 MG CAPSULE
RESTORIL 7.5 MG CAPSULE
RETIN-A 0.01% GEL
RETIN-A 0.025% CREAM
2500
5000
0
400000
800000
1000
8000
24000
800000
0
10000
0
5000
250
500
1000
2000
3000
4000
5000
12000
2000
4000
6000
8000
40000
20000
3000
40000
40000
100000
200000
150
5000
100
250
0
20000
11000
19000
50
15000
22500
30000
7500
10
25
MG/ML
MG/ML
0
0
0
MG
MG
MG
0
MG
MG
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
MG
MG
MG
MG
MG
MG
%
MG
MG
MG
MG
%
%
701305
208330
208331
805370
805372
755298
201907
152772
882530
581645
207028
207028
995958
616114
643714
1242233
643722
616116
402095
402094
402093
664743
1114338
795745
795892
795894
795895
795896
746823
1114821
725055
1298334
902312
896790
902313
539485
616129
616131
616133
847330
795743
312817
248109
213510
201867
201868
206702
RETIN-A 0.025% GEL

RETIN-A 0.05% CREAM
RETIN-A 0.1% CREAM
RETIN-A MICRO 0.04% GEL
RETIN-A MICRO 0.1% GEL
RETROVIR 10 MG/ML SYRUP
RETROVIR 100 MG CAPSULE
RETROVIR 300 MG TABLET
REVATIO 10 MG/12.5 ML VIAL
REVATIO 20 MG TABLET
REVIA 50 MG TABLET
REVIA 50 MG TABLET
REVINA OINTMENT
REVLIMID 10 MG CAPSULE
REVLIMID 2.5 MG CAPSULE
REYATAZ 100 MG CAPSULE
REZIRA SOLUTION
RHEUMATREX 2.5 MG TABLET
RHINOCORT AQUA NASAL SPRAY
RHINOFLEX 500 MG-50 MG TABLET
RHINOFLEX-650 TABLET
RIBAPAK 200-400 MG DOSEPACK
RIBASPHERE 200 MG CAPSULE
RIBASPHERE 200 MG TABLET
RIBATAB 400-400 MG DOSEPACK
RIBATAB 400-600 MG DOSEPACK
RIBAVIRIN 200 MG CAPSULE
RIBAVIRIN 200 MG TABLET
RIDAURA 3 MG CAPSULE
RIFADIN 150 MG CAPSULE
RIFADIN 300 MG CAPSULE
RIFAMATE CAPSULE
25
50
100
40
100
10000
100000
300000
10000
20000
50000
50000
0
10000
15000
2500
25000
5000
100000
150000
200000
300000
60000
2500
2500
2500
2500
2500
32
50000
650000
400000
400000
600000
600000
200000
200000
400000
600000
400000
600000
200000
200000
3000
150000
300000
0
%
%
%
%
%
MG/ML
MG
MG
MG/ML
MG
MG
MG
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MCG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
198201
198202
206698
152915
856605
847621
861027
262077
262077
262222
262222
104781
104781
211489
211489
104782
104782
104783
104783
104784
104784
806297
806297
806298
806298
806299
806299
630890
630890
630974
630974
645037
645037
312828
312828
403825
403825
312829
312829
401953
401953
312830
312830
199387
199387
401954
401954
RIFAMPIN 150 MG CAPSULE

RIFAMPIN 300 MG CAPSULE
RIFATER TABLET
RILUTEK 50 MG TABLET
RIMANTADINE HCL 100 MG TAB
RINGERS IRRIGATION SOLUTION
RIOMET 500 MG/5 ML SOLUTION
RISPERDAL 0.25 MG TABLET
RISPERDAL 1 MG TABLET
RISPERDAL 1 MG/ML SOLUTION
RISPERDAL 1 MG/ML SOLUTION
RISPERDAL M-TAB 0.5 MG ODT
RISPERDAL M-TAB 0.5 MG ODT
RISPERDAL M-TAB 1 MG ODT
RISPERIDONE 0.25 MG ODT
RISPERIDONE 0.25 MG TABLET
RISPERIDONE 1 MG ODT
RISPERIDONE 1 MG TABLET
RISPERIDONE 1 MG/ML SOLUTION
RISPERIDONE 1 MG/ML SOLUTION
150000
300000
0
50000
100000
0
500000
250
250
500
500
1000
1000
1000
1000
2000
2000
3000
3000
4000
4000
500
500
1000
1000
2000
2000
3000
3000
4000
4000
250
250
250
250
500
500
500
500
1000
1000
1000
1000
1000
1000
2000
2000
MG
MG
0
MG
MG
0
MG/5ML
MG
MG
MG
MG
MG
MG
MG/ML
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
312831
312831
616698
616698
312832
312832
616705
616705
314211
314211
1091379
1091395
1091500
1091143
1091167
1091182
1091197
1091226
314214
312835
314215
312836
312837
314209
312839
312840
996484
207016
1010654
205886
102166
209006
209006
209007
209007
261283
261283
545229
1251185
312845
312846
314208
312847
283858
562704
312849
824959
RITALIN 10 MG TABLET
RITALIN 20 MG TABLET
RITALIN 5 MG TABLET
RITALIN LA 10 MG CAPSULE
RITALIN SR 20 MG TABLET
RIVASTIGMINE 1.5 MG CAPSULE
RIVASTIGMINE 3 MG CAPSULE
RIVASTIGMINE 4.5 MG CAPSULE
RIVASTIGMINE 6 MG CAPSULE
RIZATRIPTAN 10 MG ODT
RIZATRIPTAN 10 MG TABLET
RIZATRIPTAN 5 MG ODT
RIZATRIPTAN 5 MG TABLET
ROBAFEN AC SYRUP
ROBAXIN 500 MG TABLET
ROBAXIN-750 TABLET
ROBINUL 1 MG TABLET
ROBINUL FORTE 2 MG TABLET
ROCALTROL 0.25 MCG CAPSULE
ROCALTROL 1 MCG/ML ORAL SOLN
ROCALTROL 1 MCG/ML ORAL SOLN
ROMYCIN EYE OINTMENT
RONDEX-DM SYRUP
ROPINIROLE HCL 0.25 MG TABLET
ROPINIROLE HCL 0.5 MG TABLET
ROPINIROLE HCL 1 MG TABLET
ROPINIROLE HCL ER 12 MG TABLET
2000
2000
3000
3000
3000
3000
4000
4000
4000
4000
10000
20000
5000
10000
20000
30000
40000
20000
1500
3000
4500
6000
10000
10000
5000
5000
10000
500000
750000
1000
2000
250
250
500
500
1
1
500
0
250
500
1000
2000
3000
4000
5000
12000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MCG
MCG
MCG
MCG
MCG
MCG
MG/GM
ML
MG
MG
MG
MG
MG
MG
MG
MG
799055
799056
848582
799054
1148398
1251688
1006057
1020062
1020059
1013034
1006118
1049582
1050490
1050496
1049613
1049613
1049620
1049620
1049623
1049623
1049606
1049606
1049617
1049617
603162
1293487
628816
351850
1251413
1245286
861426
861428
861159
861167
861173
833710
833710
833712
833712
833714
833714
860898
860895
1050494
885235
885568
1000915

ROSADAN 0.75% CREAM
ROSADAN 0.75% GEL
ROSANIL CLEANSER KIT
ROSULA 10%-4% FOAM
ROSULA AQUEOUS GEL
ROSULA CLEANSER
ROSULA NS MEDICATED PADS
ROXICET 5-325 ORAL SOLUTION
ROXICET 5-325 TABLET
ROXICET 5-500 CAPLET
ROXICODONE 15 MG TABLET
ROXICODONE 5 MG/5 ML SOLUTION
ROXICODONE 5 MG/5 ML SOLUTION
ROXICODONE INTENSOL 20 MG/ML
ROXICODONE INTENSOL 20 MG/ML
ROZEREM 8 MG TABLET
R-TANNA TABLET
RU-HIST FORTE TABLET SA
RU-TUSS DM LIQUID
RU-TUSS TABLET
RYNEZE LIQUID
RYTHMOL 150 MG TABLET
RYTHMOL 225 MG TABLET
RYTHMOL SR 225 MG CAPSULE
RYZOLT ER 100 MG TABLET
SABRIL 500 MG POWDER PACKET
SABRIL 500 MG TABLET
SAFYRAL TABLET
SALACYN 6% CREAM
SALACYN 6% LOTION
SALAGEN 5 MG TABLET
2000
4000
6000
8000
750
750
0
10000
10000
0
10000
0
5000
500000
15000
15000
30000
30000
5000
5000
5000
5000
20000
20000
8000
25000
10000
45000
0
4000
150000
225000
225000
325000
425000
100000
100000
200000
200000
300000
300000
500000
500000
3000
6000
6000
5000
MG
MG
MG
MG
%
%
0
%
%
0
%
ML
MG
MG
MG
MG
MG
MG
MG
MG
MG/ML
MG/ML
MG/ML
MG/ML
MG
MG
MG
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
MG
1001006
543362
543666
667906
312887
1095689
477031
790884
312893
422998
667904
790888
312899
583170
1190696
824983
880890
1247825
849831
849835
857562
857566
197552
197552
212957
212957
212810
212810
207194
207198
207199
207200
207201
1149617
859979
859983
647555
803295
647556
833139
833143
833149
833146
833151
830761
213125
995354
SALAGEN 7.5 MG TABLET

SALEX 6% CREAM KIT
SALEX 6% LOTION
SALEX 6% SHAMPOO
SALICYLIC ACID 26% LIQUID
SALICYLIC ACID 27.5% LIQUID
SALICYLIC ACID 6% CREAM
SALICYLIC ACID 6% FOAM
SALICYLIC ACID 6% GEL
SALICYLIC ACID 6% LOTION
SALICYLIC ACID 6% SHAMPOO
SALKERA 6% FOAM
SALSALATE 500 MG TABLET
SALSALATE 750 MG TABLET
SAL-TROPINE 0.4 MG TABLET
SALVAX 6% FOAM
SALVAX DUO COMBO PACK
SALVAX DUO PLUS COMBO PACK
SAMSCA 15 MG TABLET
SAMSCA 30 MG TABLET
SANCTURA 20 MG TABLET
SANCTURA XR 60 MG CAPSULE
SANDIMMUNE 100 MG CAPSULE
SANDIMMUNE 100 MG/ML SOLN
SANDIMMUNE 100 MG/ML SOLN
SANDOSTATIN 0.05 MG/ML AMPUL
SANDOSTATIN 0.2 MG/ML VIAL
SANDOSTATIN 1 MG/ML VIAL
SANTYL OINTMENT
SAPHRIS 10 MG TAB SUBLINGUAL
SAPHRIS 5 MG TABLET SUBLINGUAL
SARAFEM 10 MG TABLET
SAVELLA 100 MG TABLET
SAVELLA 12.5 MG TABLET
SAVELLA TITRATION PACK
SCALACORT 2% LOTION
SCOPACE 0.4 MG TABLET
SE BPO 7-5.5% WASH KIT
7500
6000
6000
6000
26000
27500
6000
6000
6000
6000
6000
6000
500000
750000
400
6000
0
6000
15000
30000
20000
60000
100000
100000
100000
100000
25000
25000
50
100
200
500
1000
250000
10000
5000
10000
15000
20000
100000
12500
25000
50000
0
2000
400
7000
MG
%
%
%
%
%
%
%
%
%
%
%
MG
MG
MG
%
0
%
MG
MG
MG
MG
MG
MG
MG/ML
MG/ML
MG
MG
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
U/G
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
%
751902
749762
1006685
1000717
1006114
201625
998691
998687
94048
859186
859193
706548
238600
799026
799059
706549
729201
729203
1112246
656137
706958
706960
823998
823998
824002
824002
876429
876429
723782
866047
866049
212797
153639
153639
153639
153640
153640
153640
153638
153638
153638
284509
284509
284509
616485
616485
616485
SEASONALE 0.15-0.03 MG TAB

SEASONIQUE 0.15-0.03-0.01 TAB
SEB-PREV 10% CREAM
SEB-PREV 10% GEL
SEB-PREV 10% WASH
SECONAL SODIUM 100 MG CAPSULE
SECTRAL 200 MG CAPSULE
SECTRAL 400 MG CAPSULE
SEDAPAP TABLET
SELEGILINE HCL 5 MG CAPSULE
SELEGILINE HCL 5 MG TABLET
SELENIUM SULFIDE 2.25% SHAMPOO
SELENIUM SULFIDE 2.5% LOTION
SELFEMRA 10 MG CAPSULE
SELFEMRA 20 MG CAPSULE
SELSEB 2.25% SHAMPOO
SELZENTRY 150 MG TABLET
SELZENTRY 300 MG TABLET
SEMPREX-D 60 MG/8 MG CAPSULE
SENSIPAR 30 MG TABLET
SEPTRA 80-400 TABLET
SEPTRA 80-400 TABLET
SEPTRA DS TABLET
SEPTRA DS TABLET
SEPTRA SUSPENSION
SEPTRA SUSPENSION
SERADEX LIQUID
SEREVENT DISKUS 50 MCG
SEREVENT DISKUS 50 MCG
SEROMYCIN 250 MG CAPSULE
SEROQUEL 100 MG TABLET
30
150
10000
10000
10000
100000
200000
400000
650000
5000
5000
2250
2500
10000
20000
2250
150000
300000
60000
30000
60000
90000
400000
400000
800000
800000
0
0
30000
50
50
250000
100000
100000
100000
200000
200000
200000
25000
25000
25000
300000
300000
300000
400000
400000
400000
MG
MG
%
%
%
MG
MG
MG
MG
MG
MG
%
%
MG
MG
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
ML
ML
ML
MCG
MCG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
616489
616489
616489
895671
895671
895671
721793
721793
721793
721795
721795
721795
721797
721797
721797
853202
853202
853202
861064
861064
312938
312938
312940
312940
312941
312941
392038
206798
1090532
1100501
577033
208186
312952
487261
702313
312954
312955
1117536
106351
208185
763228
999939
763232
999946
763236
848164
314231
SEROQUEL XR 150 MG TABLET
SERTRALINE 20 MG/ML ORAL CONC
SERTRALINE 20 MG/ML ORAL CONC
SERTRALINE HCL 100 MG TABLET
SF 1.1% GEL
SFROWASA 4 GM/60 ML ENEMA
SILDEC-PE ORAL DROPS
SILDEC-PE SYRUP
SILDENAFIL 20 MG TABLET
SILVADENE 1% CREAM
SILVER NITRATE 0.5% SOLN
SILVER NITRATE 10% OINTMENT
SILVER NITRATE 10% SOLUTION
SILVER NITRATE APPLICATOR
SILVER SULFADIAZINE 1% CREAM
SILVER SULFADIAZINE 1% CREAM
SIMCOR 1,000-20 MG TABLET
SIMCOR 1,000-40 MG TABLET
SIMCOR 500-20 MG TABLET
SIMPONI 50 MG/0.5 ML SYRINGE
SIMVASTATIN 10 MG TABLET
50000
50000
50000
150000
150000
150000
200000
200000
200000
300000
300000
300000
400000
400000
400000
50000
50000
50000
20000
20000
100000
100000
25000
25000
50000
50000
1100
4000000
3500
12500
20000
1000
500
10000
10000
25000
50000
0
1000
1000
1000000
1000000
500000
500000
750000
50000
10000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/ML
MG/ML
MG
MG
MG
MG
MG
MG
%
GM/60M
MG/ML
MG/5ML
MG
%
%
%
%
%
%
0
%
%
MG
MG
MG
MG
MG
MG/0.5
MG
312961
198211
312962
200345
724606
724598
724602
792381
834341
153892
404406
261367
153893
352277
905011
1298427
543014
313036
1115894
1005853
1005834
1005856
1000946
562844
312997
313002
727820
727821
727822
804981
859203
724592
724590
706943
198215
315102
313043
315213
347099
1098161
238470
313072
1006107
1006116
1005819
1001714
999613
SINEMET 10-100 MG TABLET
SINEMET CR 25-100 TABLET
SINEMET CR 50-200 TABLET
SINGULAIR 10 MG TABLET
SINGULAIR 4 MG GRANULES
SINGULAIR 4 MG TABLET CHEW
SINGULAIR 5 MG TABLET CHEW
SKELAXIN 800 MG TABLET
SKELID 200 MG TABLET
SKLICE 0.5% LOTION
SOD CITRATE-CITRIC ACID SOLN
SOD FLUORIDE 0.5MG(1.1MG)TB
SOD SULFACE-SULFUR 9-4.5% WASH
SOD SULFACETAMIDE-SULFUR FOAM
SOD SULFACETAMIDE-SULFUR GREEN
SOD SULFACETAMIDE-SULFUR LOTN
SOD SULFACET-SULFUR 10-4% PAD
SOD SULFACET-SULFUR 10-5% GEL
SODIUM CHLORIDE 0.9% INHAL VL
SODIUM CHLORIDE 0.9% SOLUTION
SODIUM CHLORIDE 0.9% SYRINGE
SODIUM CHLORIDE 10% VIAL
SODIUM FLUORIDE 0.25 (0.55) MG
SODIUM FLUORIDE 0.5 MG/ML DROP
SODIUM FLUORIDE 1 MG (2.2 MG)
SODIUM HYALURONATE 0.1% LOTION
SODIUM HYDROXIDE 10% SOLUTION
SODIUM POLYSTYRENE SULF PWD
SODIUM SULFACETAMIDE 10% WASH
SODIUM SULFACETAMIDE MED PADS
SODIUM SULFACETAMIDE-SULFUR
SODIUM SULFACET-SULFUR WASH
SODIUM SULF-SULFUR CLEANSER
20000
40000
5000
80000
10000
25000
250000
100000
200000
10000
4000
4000
5000
800000
200000
500
0
500
9000
10000
10000
0
10000
10000
900
900
900
900
900
900
900
10000
3000
7000
250
500
1000
1000
1000
100
10000
0
10000
10000
10000
9000
10000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
ML
MG
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
MG
MG/ML
MG
MG
MG
%
%
MG
%
%
%
%
%
855644
750261
644304
730918
213695
404457
404458
404459
351793
261286
261285
313091
894861
894865
213069
213070
1020039
904571
904583
904593
904605
904567
904579
904589
904601
404063
857368
847365
847362
1085816
580261
198222
313096
198223
198224
152854
833164
833173
753481
992424
799830
1045404
643173
643175
643177
1045408
753544
SOLARAZE 3% GEL
SOLIA 0.15-0.03 MG TABLET
SOLTAMOX 10 MG/5 ML SOLN
SOMA 250 MG TABLET
SOMA 350 MG TABLET
SOMAVERT 10 MG VIAL
SOMAVERT 15 MG VIAL
SOMAVERT 20 MG VIAL
SOMNOTE 500 MG SOFTGEL
SONATA 10 MG CAPSULE
SONATA 5 MG CAPSULE
SORBITOL 3.3% UROLOGIC SOLN
SORIATANE 17.5 MG CAPSULE
SORIATANE 22.5 MG CAPSULE
SORIATANE CK 10 MG KIT
SORIATANE CK 25 MG KIT
SORILUX 0.005% FOAM
SORINE 120 MG TABLET
SORINE 80 MG TABLET
SOTALOL 120 MG TABLET
SOTRET 20 MG CAPSULE
SPECTAZOLE 1% CREAM
SPECTRACEF 200 MG DOSE PACK TB
SPECTRACEF 400 MG DOSE PACK TB
SPINOSAD 0.9% TOPICAL SUSP
SPIRIVA 18 MCG CP-HANDIHALER
SPIRONOLACTONE 100 MG TABLET
SPIRONOLACTONE-HCTZ 25-25 TAB
SPORANOX 10 MG/ML SOLUTION
SPORANOX 100 MG CAPSULE
SPORANOX 100 MG CAPSULE
SPRINTEC 28 DAY TABLET
SPRIX 15.75 MG NASAL SPRAY
SPRYCEL 100 MG TABLET
SRONYX 0.10-0.02 MG TABLET
3000
150
10000
250000
350000
10000
15000
20000
500000
10000
5000
3300
17500
22500
10000
25000
5
120000
160000
240000
80000
120000
160000
240000
80000
20000
1000
200000
400000
900
18
100000
25000
50000
0
10000
100000
100000
250
15750
100000
140000
20000
50000
70000
80000
0
%
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
MG
MG
MG
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
MG
%
MCG
MG
MG
MG
MG
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
749795
211832
856966
404552
810087
404553
730992
404551
810094
583459
284530
284529
1242558
315217
313107
313108
313109
313110
1099658
1099658
1099672
1099672
1099693
1099693
150985
831460
1312408
352317
617945
352318
352319
352320
352321
617947
858108
1306298
261314
1307063
1010603
1010608
1307058
1010606
1010609
404414
213337
314234
208094
ST JOSEPH ASA EC 81 MG TABLET

ST. JOSEPH LOW-DOSE ASPIRIN
STAGESIC 5-500 CAPSULE
STALEVO 100 TABLET
STALEVO 125 TABLET
STALEVO 150 TABLET
STALEVO 200 TABLET
STALEVO 50 TABLET
STALEVO 75 TABLET
STANNOUS FLUOR 0.63% RINSE
STARLIX 120 MG TABLET
STARLIX 60 MG TABLET
STATUSS GREEN LIQUID
STAVUDINE 1 MG/ML SOLUTION
STAVUDINE 15 MG CAPSULE
STAVZOR DR 125 MG CAPSULE
STERILE WATER FOR IRRIGATION
STIMATE 1.5 MG/ML NASAL SPRAY
STIVARGA 40 MG TABLET
STRATTERA 10 MG CAPSULE
STRIANT 30 MG MUCOADHESIVE
STRIBILD TABLET
STROMECTOL 3 MG TABLET
SUBOXONE 12 MG-3 MG SL FILM
SUBOXONE 2 MG-0.5 MG SL FILM
SUBOXONE 2 MG-0.5 MG TABLET SL
SUBOXONE 8 MG-2 MG TABLET SL
SUBUTEX 8 MG TABLET SL
SUCRAID 8,500 UNITS/ML SOLN
SUCRALFATE 1 GM TABLET
SUCRALFATE 1 GM/10 ML SUSP
81000
81000
5000
100000
125000
150000
200000
50000
75000
630
120000
60000
12500
1000
15000
20000
30000
40000
125000
125000
250000
250000
500000
500000
0
1500
40000
10000
100000
18000
25000
40000
60000
80000
30000
150000
3000
12000
2000
2000
4000
8000
8000
8000
0
1000000
100000
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
MG
MG/ML
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
ML
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
U/ML
MG
MG/ML
313123
1363780
1090623
763521
763576
763591
790840
1006707
1006120
1000673
1006688
1010234
198228
198335
198335
198334
198334
313134
313134
201185
285024
198232
208406
208406
1147793
313142
1012021
198238
198239
314227
758521
313159
727339
313165
313160
315223
313161
856789
1000976
1010238
1011875
1005850
1043025
581574
1043031
705008
213927
SUCRALFATE 1 GM/10 ML SUSP

SUDAHIST TABLET
SUDATEX G TABLET
SULAR ER 17 MG TABLET
SULAR ER 25.5 MG TABLET
SULAR ER 34 MG TABLET
SULAR ER 8.5 MG TABLET
SULFAC 10% EYE DROPS
SULFACETAMIDE 10% EYE DROPS
SULFACETAMIDE 10% EYE OINT
SULFACETAMIDE SOD 10% TOP SUSP
SULFACETAMIDE-SULFUR 8-4% SUSP
SULFADIAZINE 500 MG TABLET
SULFAMETHOXAZOLE-TMP DS TABLET
SULFAMETHOXAZOLE-TMP DS TABLET
SULFAMETHOXAZOLE-TMP SS TABLET
SULFAMETHOXAZOLE-TMP SS TABLET
SULFAMETHOXAZOLE-TMP SUSP
SULFAMETHOXAZOLE-TMP SUSP
SULFAMYLON 8.5% CREAM
SULFAMYLON POWDER PACKET
SULFASALAZINE DR 500 MG TAB
SULFATRIM SUSPENSION
SULFATRIM SUSPENSION
SULFAZINE 500 MG TABLET
SULFAZINE EC 500 MG TAB
SULF-PRED 10-0.23% EYE DROPS
SULINDAC 150 MG TABLET
SULINDAC 200 MG TABLET
SUMATRIPTAN 20 MG NASAL SPRAY
SUMATRIPTAN 4 MG/0.5 ML INJECT
SUMATRIPTAN 5 MG NASAL SPRAY
SUMATRIPTAN 6 MG/0.5 ML INJECT
SUMATRIPTAN 6 MG/0.5 ML VIAL
SUMATRIPTAN SUCC 100 MG TABLET
SUMAVEL DOSEPRO 6 MG/0.5 ML
SUMAXIN CLEANSING PADS
SUMAXIN TS TOPICAL SUSPENSION
SUMAXIN WASH
SUPHERA CREAM
SUPRAX 100 MG TABLET CHEWABLE
SUPRAX 100 MG/5 ML SUSPENSION
SUPRAX 200 MG TABLET CHEWABLE
SUPRAX 200 MG/5 ML SUSPENSION
SUPRAX 400 MG TABLET
100000
120000
400000
17000
25500
34000
8500
10000
10000
10000
10000
8000
500000
800000
800000
400000
400000
0
0
0
0
500000
0
0
500000
500000
250
150000
200000
20000
4000
5000
12000
12000
100000
25000
50000
3000
10000
8000
9000
0
100000
100000
200000
200000
400000
MG/ML
MG
MG
MG
MG
MG
MG
%
%
%
%
%
MG
MG
MG
MG
MG
ML
ML
0
0
MG
ML
ML
MG
MG
%
MG
MG
MG
MG/.5M
MG
MG/ML
MG/ML
MG
MG
MG
MG/ML
%
%
%
0
MG
MG/5ML
MG
MG/5ML
MG
1001690
880959
208645
208646
106834
213390
213392
352143
616283
616287
616292
1242697
1099269
1099060
1099052
1099056
1046775
1046775
1046986
1046986
1046984
1046984
1246306
1246317
1246290
1246315
725076
725068
725080
725064
725072
861041
861043
861045
1191313
1191319
1234976
853486
644290
966250
966250
966185
966185
966191
966191
966201
966201
SUPREP BOWEL PREP KIT

SURE COMFORT ALCOHOL PREP PADS
SURMONTIL 100 MG CAPSULE
SUSTIVA 200 MG CAPSULE
SUSTIVA 50 MG CAPSULE
SUSTIVA 600 MG TABLET
SUTENT 12.5 MG CAPSULE
SUTENT 25 MG CAPSULE
SUTENT 50 MG CAPSULE
SU-TUSS DM ELIXIR
SYEDA 28 TABLET
SYLATRON 296 MCG KIT
SYMAX DUOTAB
SYMAX DUOTAB
SYMAX FASTABS 0.125 MG TABLET
SYMAX FASTABS 0.125 MG TABLET
SYMAX-SL 0.125 MG TABLET SL
SYMAX-SL 0.125 MG TABLET SL
SYMBICORT 160-4.5 MCG INHALER
SYMBYAX 12-25 MG CAPSULE
SYMLIN 0.6 MG/ML VIAL
SYMLINPEN 120 PEN INJECTOR
SYMLINPEN 60 PEN INJECTOR
SYNALAR 0.01% SOLUTION
SYNALAR 0.025% CREAM
SYNALGOS-DC CAPSULE
SYNAREL 2 MG/ML NASAL SPRAY
SYNERA PATCH
SYNTHROID 100 MCG TABLET
17500
0
100000
25000
50000
200000
50000
600000
12500
25000
50000
20000
0
296
444
888
375
375
125
125
125
125
160
160
80
80
12000
12000
3000
6000
6000
600
1000
1000
10
25
0
2000
70000
100
100
112
112
125
125
150
150
ML
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/ML
MG/ML
MG/ML
%
%
MG
MG/ML
MG
MCG
MCG
MCG
MCG
MG
MG
MG
MG
966205
966205
966251
966251
966158
966158
966218
966218
966247
966247
966171
966171
966282
966282
208720
105590
833472
833472
833463
833463
313190
313190
198377
198377
198378
198378
207824
211354
207017
207017
886668
886673
886664
581626
728111
728115
1115700
261315
198240
313195
863669
544218
999832
1314792
1314685
207012
207010

SYPRINE 250 MG CAPSULE
TABLOID 40 MG TABLET
TACLONEX OINTMENT
TACLONEX OINTMENT
TACLONEX SUSPENSION
TACLONEX SUSPENSION
TACROLIMUS 0.5 MG CAPSULE
TACROLIMUS 0.5 MG CAPSULE
TACROLIMUS 1 MG CAPSULE
TAGAMET 300 MG TABLET
TALACEN CAPLET
TALWIN NX TABLET
TALWIN NX TABLET
TAMBOCOR 100 MG TABLET
TAMIFLU 12 MG/ML SUSPENSION
TAMIFLU 30 MG GELCAP
TAMIFLU 6 MG/ML SUSPENSION
TAMOXIFEN 10 MG TABLET
TAMOXIFEN 20 MG TABLET
TAMSULOSIN HCL 0.4 MG CAPSULE
TANAHIST-PD PEDIATRIC DROPS
TANDEM F CAPSULE
TANDEM OB CAPSULE
TANDEM PLUS CAPSULE
TAPAZOLE 10 MG TABLET
TAPAZOLE 5 MG TABLET
175
175
200
200
25
25
300
300
50
50
75
75
88
88
250000
40000
50
50
50
50
500
500
1000
1000
5000
5000
300000
0
0
0
100000
150000
50000
12000
30000
45000
6000
75000
10000
20000
400
2000
106000
106000
0
10000
5000
MG
MG
MG
MG
MCG
MCG
MG
MG
MG
MG
MCG
MCG
MCG
MCG
MG
MG
%
%
%
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/ML
MG
MG
MG/ML
MG
MG
MG
MG
MG/ML
MG
MG
MG
MG
MG
1088251
1088253
1088255
991233
261349
897782
897785
897846
897855
1002300
746609
153655
284496
212437
284497
212438
831196
831248
831300
831325
831349
707373
308974
308974
308971
308971
308972
308972
866303
866303
866305
866305
866307
866307
1009249
1009253
1009319
1009324
1190450
1011738
1011741
1011712
1011715
1011752
1011755
198241
485489
TARCEVA 100 MG TABLET

TARGRETIN 1% GEL
TARGRETIN 75 MG SOFTGEL
TARKA ER 1-240 MG TABLET
TASIGNA 150 MG CAPSULE
TASIGNA 200 MG CAPSULE
TASMAR 100 MG TABLET
TAZORAC 0.05% CREAM
TAZORAC 0.05% GEL
TAZORAC 0.1% CREAM
TAZORAC 0.1% GEL
TAZTIA XT 120 MG CAPSULE
TEARS AGAIN HYDRATE SOFTGEL
TEGRETOL 100 MG TABLET CHEW
TEGRETOL 100 MG TABLET CHEW
TEGRETOL 100 MG/5 ML SUSP
TEGRETOL 100 MG/5 ML SUSP
TEGRETOL 200 MG TABLET
TEGRETOL 200 MG TABLET
TEGRETOL XR 100 MG TABLET
TEKAMLO 150 MG-10 MG TABLET
TEKRAL SR 100 MG-120 MG TABLET
TEKTURNA 150 MG TABLET
TEKTURNA 300 MG TABLET
TEKTURNA HCT 150-12.5 MG TAB
TEKTURNA HCT 150-25 MG TABLET
TEKTURNA HCT 300-12.5 MG TAB
TEKTURNA HCT 300-25 MG TABLET
TEMAZEPAM 15 MG CAPSULE
TEMAZEPAM 22.5 MG CAPSULE
100000
150000
25000
1000
75000
240000
180000
2000
4000
150000
200000
100000
50
50
100
100
120000
180000
240000
300000
360000
1000000
100000
100000
100000
100000
200000
200000
100000
100000
200000
200000
400000
400000
150000
150000
300000
300000
120000
150000
300000
150000
150000
300000
300000
15000
22500
MG
MG
MG
%
MG
MG
MG
MG
MG
MG
MG
MG
%
%
%
%
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
198242
198243
261290
705617
705619
261289
261291
261288
861503
861440
861472
861510
827723
827726
1087680
206412
206413
746023
746030
201322
150750
152414
209285
209284
209283
313215
313215
260376
260376
313217
313217
313219
313219
313222
857635
857677
857683
313226
313227
198245
745768
351906
208365
351910
835829
835840
835809
TEMAZEPAM 30 MG CAPSULE
TEMAZEPAM 7.5 MG CAPSULE
TEMODAR 100 MG CAPSULE
TEMOVATE 0.05% CREAM
TEMOVATE 0.05% GEL
TEMOVATE 0.05% OINTMENT
TEMOVATE 0.05% SOLUTION
TENAR DM SYRUP
TENAR PSE LIQUID
TENCON TABLET
TENEX 1 MG TABLET
TENEX 2 MG TABLET
TENORETIC 100 TABLET
TENORETIC 50 TABLET
TENORMIN 100 MG TABLET
TERAZOL 3 80 MG SUPPOSITORY
TERAZOL 3 CREAM
TERAZOL 7 CREAM
TERAZOSIN 1 MG CAPSULE
TERBINAFINE HCL 250 MG TABLET
TERBUTALINE SULF 1 MG/ML VIAL
TERBUTALINE SULFATE 2.5 MG TAB
TERBUTALINE SULFATE 5 MG TAB
TERCONAZOLE 0.4% CREAM
TERCONAZOLE 0.8% CREAM
TERCONAZOLE 80 MG SUPPOSITORY
TERSI 2.25% FOAM
TESSALON 200 MG CAPSULE
TESSALON PERLE 100 MG CAP
TESTIM 1% (50MG) GEL
TESTOSTERONE CYP 100 MG/ML
TESTOSTERONE CYP 200 MG/ML
TESTOSTERONE ENAN 200 MG/ML
30000
7500
100000
140000
180000
20000
250000
5000
50
50
50
50
200000
40000
650000
1000
2000
100000
50000
100000
25000
50000
80000
800
400
1000
1000
10000
10000
2000
2000
5000
5000
250000
1000
2500
5000
400
800
80000
2250
200000
100000
50000
100000
200000
200000
MG
MG
MG
MG
MG
MG
MG
MG
%
%
%
%
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/ML
MG
MG
%
%
MG
%
MG
MG
MG
MG/ML
MG/ML
MG/ML
207214
542489
313245
603902
198250
198252
603992
261300
261301
352335
352336
206336
214081
404449
700418
404450
213360
844590
844813
844591
844829
208266
313277
208278
313306
237178
346574
317769
313291
314241
348472
208187
207840
313354
198270
198274
198275
313362
313361
313364
313366
1011870
1011872
1243771
1243786
757667
313387
TESTRED 10 MG CAPSULE
TETCAINE 0.5% EYE DROPS
TETRACAINE 0.5% EYE DROPS
TETRACAINE 0.5% EYE DROPS
TETRACYCLINE 250 MG CAPSULE
TETRACYCLINE 500 MG CAPSULE
TETRAVISC FORTE 0.5% EYE DROPS
TEVETEN 400 MG TABLET
TEVETEN 600 MG TABLET
TEVETEN HCT 600-12.5 MG TAB
TEVETEN HCT 600-25 MG TAB
TEXACORT 2.5% SOLUTION
THALITONE 15 MG TABLET
THALOMID 100 MG CAPSULE
THEO-24 ER 100 MG CAPSULE
THEOCHRON ER 100 MG TABLET
THEOPHYLLINE 80 MG/15 ML SOLN
THEOPHYLLINE ER 100 MG TABLET
THEOPHYLLINE ER 300 MG TAB
THEOPHYLLINE ER 450 MG TAB
THERMAZENE 1% CREAM
THIOLA 100 MG TABLET
THIORIDAZINE 10 MG TABLET
THIOTHIXENE 1 MG CAPSULE
THRIVE NICOTINE 2 MG GUM
THRIVE NICOTINE 4 MG GUM
THROMBIN-JMI 20,000 UNITS PUMP
THROMBIN-JMI 5,000 UNITS EPIST
THROMBIN-JMI 5,000 UNITS VIAL
THYROID 32.5 MG TABLET
10000
500
500
500
250000
500000
500
400000
600000
12500
600000
2500
15000
100000
150000
200000
50000
100000
200000
300000
400000
100000
200000
300000
80000
100000
200000
300000
400000
450000
600000
1000
100000
10000
100000
25000
50000
1000
10000
2000
5000
2000
4000
20000000
5000000
5000000
32500
MG
%
%
%
MG
MG
%
MG
MG
MG
MG
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/15M
MG
MG
MG
MG
MG
MG
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MU
MU
MU
MG
313387
313391
313391
313393
313393
903442
903316
903287
903309
903302
1299911
1299917
831296
831323
831193
831244
831347
831360
313406
860773
284404
284405
285016
1359134
198283
313407
313409
313408
198284
198284
198285
198285
198286
198286
670640
670646
861420
861422
539809
539811
477234
199519
801445
485486
313412
485485
313413
THYROID 32.5 MG TABLET

THYROID 60 MG TABLET
THYROLAR-1 STRENGTH TABLET
THYROLAR-1/2 STRENGTH TAB
THYROLAR-1/4 STRENGTH TAB
TIAGABINE HCL 2 MG TABLET
TIAGABINE HCL 4 MG TABLET
TIAZAC 240 MG CAPSULE SA
TIAZAC 300MG CAP SA-SAMPLE NDC
TIAZAC ER 120 MG CAPSULE
TICLOPIDINE 250 MG TABLET
TIGAN 300 MG CAPSULE
TIKOSYN 125 MCG CAPSULE
TILIA FE 28 TABLET
TIMOLOL 0.25% EYE DROPS
TIMOLOL 0.25% GFS GEL-SOLUTION
TIMOLOL 0.5% EYE DROPS
TIMOLOL 0.5% GEL-SOLUTION
TIMOLOL MALEATE 10 MG TABLET
TIMOPTIC 0.25% OCUDOSE DROP
TIMOPTIC 0.5% OCUDOSE DROP
TIMOPTIC-XE 0.25% EYE SOLN
TIMOPTIC-XE 0.5% EYE SOLN
TINDAMAX 250 MG TABLET
TINDAMAX 500 MG TABLET
TINIDAZOLE 250 MG TABLET
TINIDAZOLE 500 MG TABLET
TIS-U-SOL IRRIGATION SOLN
TIZANIDINE HCL 2 MG CAPSULE
TIZANIDINE HCL 2 MG TABLET
TIZANIDINE HCL 4 MG TABLET
32500
60000
60000
90000
90000
60000
30000
15000
120000
180000
2000
4000
240000
300000
120000
180000
360000
420000
250000
300000
125
250
500
0
250
251
500
501
10000
10000
20000
20000
5000
5000
250
500
251
501
250000
500000
250000
500000
0
2000
2000
4000
4000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
%
%
MG
MG
MG
MG
MG
MG
%
%
%
%
MG
MG
MG
MG
0
MG
MG
MG
MG
485484
880945
313634
1087406
994839
997548
1305137
213194
213194
208813
208821
1011080
313415
309683
207846
207850
835596
835566
835570
835598
835600
835579
835574
198292
198293
198294
198295
198296
198297
855178
855194
151228
151228
845478
845478
151229
151229
845479
845479
152855
152855
151227
151227
891631
94346
1050394
94345

TL GARD RX TABLET
TL-FOL 500 CAPLET
TL-HEM 150 CAPLET
TL-HIST CD LIQUID
TL-HIST CM LIQUID
TL-SELECT CAPSULE
TOBI 300 MG/5 ML SOLUTION
TOBI 300 MG/5 ML SOLUTION
TOBRADEX EYE DROPS
TOBRADEX EYE OINTMENT
TOBRADEX ST EYE DROPS
TOBRAMYCIN 0.3% EYE DROPS
TOBRAMYCIN-DEXAMETH OPHTH SUSP
TOBREX 0.3% EYE DROPS
TOBREX 0.3% EYE OINTMENT
TOFRANIL 10 MG TABLET
TOFRANIL-PM 100 MG CAPSULE
TOLAZAMIDE 250 MG TABLET
TOLAZAMIDE 500 MG TABLET
TOLBUTAMIDE 500 MG TABLET
TOLMETIN SODIUM 200 MG TAB
TOLMETIN SODIUM 400 MG CAP
TOLMETIN SODIUM 600 MG TAB
TOLTERODINE TARTRATE 1 MG TAB
TOLTERODINE TARTRATE 2 MG TAB
TOPAMAX 100 MG TABLET
TOPAMAX 15 MG SPRINKLE CAP
TOPICORT 0.05% CREAM
TOPICORT 0.05% GEL
TOPICORT 0.05% OINTMENT
TOPICORT 0.25% CREAM
6000
1200
105000
150000
7500
2000
29000
300000
300000
100
100
300
300
100
300
300
10000
25000
50000
100000
125000
150000
75000
250000
500000
500000
200000
400000
600000
1000
2000
100000
100000
15000
15000
200000
200000
25000
25000
25000
25000
50000
50000
50
50
0
250
MG
MG
MG
MG
MG/5ML
MG
MG
MG/5ML
MG/5ML
%
%
%
%
%
%
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
%
%
94348
901326
901326
901328
901328
901334
901334
901336
901336
199889
199889
205316
205316
199890
199890
205315
205315
199888
199888
151226
151226
866414
866421
866429
866438
198369
198370
198371
198372
656660
352066
1100706
833709
833709
833711
833711
835603
835603
1248115
1248115
833713
833713
836395
896777
896781
896783
199353
TOPICORT 0.25% OINTMENT

TOPIRAGEN 100 MG TABLET
TOPIRAMATE 100 MG TABLET
TOPIRAMATE 15 MG SPRINKLE CAP
TOPROL XL 100 MG TABLET
TORSEMIDE 10 MG TABLET
TRACLEER 125 MG TABLET
TRACLEER 62.5 MG TABLET
TRADJENTA 5 MG TABLET
TRAMADOL ER 100 MG TABLET
TRAMADOL HCL 50 MG TABLET
TRAMADOL HCL 50 MG TABLET
TRAMADOL HCL ER 150 MG CAPSULE
TRAMADOL HCL ER 150 MG CAPSULE
TRAMADOL HCL ER 300 MG TABLET
TRAMADOL HCL ER 300 MG TABLET
TRAMADOL-ACETAMINOPHN 37.5-325
TRANDATE 100 MG TABLET
TRANDOLAPRIL 1 MG TABLET
250
100000
100000
200000
200000
25000
25000
50000
50000
100000
100000
15000
15000
200000
200000
25000
25000
25000
25000
50000
50000
100000
200000
25000
50000
10000
100000
20000
5000
125000
62500
5000
100000
100000
200000
200000
50000
50000
150000
150000
300000
300000
37500
100000
200000
300000
1000
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
199351
199352
897781
897783
897844
897853
883826
351875
542857
542967
1149627
313447
285032
856373
856364
856369
856377
861098
835721
207476
313450
106302
313451
106303
198300
199159
645649
645669
645651
997643
656882
645671
284593
284593
284595
284595
284592
284592
284594
284594
884799
849452
1234990
1248142
1085644
1085741
1085633
TRANDOLAPR-VERAPAM ER 1-240 MG
TRANEXAMIC ACID 650 MG TABLET
TRANSDERM-SCOP 1.5 MG/72HR
TRANXENE T-TAB 15 MG
TRANXENE T-TAB 3.75 MG
TRANXENE T-TAB 7.5 MG
TRANYLCYPROMINE SULF 10 MG TAB
TRAVATAN Z 0.004% EYE DROP
TRAZODONE 100 MG TABLET
TREAGAN OTIC DROPS
TRECATOR 250 MG TABLET
TRENTAL ER 400 MG TABLET
TRETINOIN 0.01% GEL
TRETINOIN 0.025% CREAM
TRETINOIN 0.025% GEL
TRETINOIN 10 MG CAPSULE
TRETIN-X 0.01% COMBO PACK
TRETIN-X 0.025% CREAM COMB PCK
TRETIN-X 0.025% GEL COMBO PACK
TRETIN-X 0.0375% CREAM
TREXALL 10 MG TABLET
TREXALL 5 MG TABLET
TREXALL 5 MG TABLET
TREXALL 7.5 MG TABLET
TREXALL 7.5 MG TABLET
TREXBROM LIQUID
TREXIMET 85-500 MG TABLET
TREZIX CAPSULE
TRIADVANCE TABLET
TRIAMCINOLONE 0.025% CREAM
TRIAMCINOLONE 0.025% LOTION
TRIAMCINOLONE 0.025% OINT
2000
4000
240000
180000
2000
4000
650000
1500
15000
3750
7500
10000
4
100000
150000
300000
50000
0
250000
400000
10
25
25
50
100
10000
10
25
25
375
50
100
10000
10000
15000
15000
5000
5000
7500
7500
30000
85000
0
90000
25
25
25
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
MG
MG
MG
MG
%
MG
MG
%
%
%
%
%
MG
%
%
%
%
%
%
MG
MG
MG
MG
MG
MG
MG
MG
ML
MG
MG
MG
%
%
%
1090641
1014314
1085745
1085636
1085728
1085686
1085640
1085798
198316
310812
198314
310818
1110806
847368
797973
847133
797976
847367
797979
198317
198318
999971
999990
999995
1000000
1000005
210710
309317
1114003
1114110
999799
540281
544518
1085773
1086259
198322
198323
198324
198325
313477
313477
583096
583122
905269
905273
905283
1359135
TRIAMCINOLONE 0.05% OINT

TRIAMCINOLONE 0.1% LOTION
TRIAMCINOLONE 0.1% OINTMENT
TRIAMCINOLONE 0.1% PASTE
TRIAMCINOLONE 0.5% OINTMENT
TRIAMCINOLONE 55 MCG NASAL SPR
TRIAMTERENE-HCTZ 37.5-25 MG CP
TRIAMTERENE-HCTZ 37.5-25 MG TB
TRIAMTERENE-HCTZ 50-25 MG CAP
TRIAMTERENE-HCTZ 75-50 MG TAB
TRIANEX 0.05% OINTMENT
TRIAZ 3% CLEANSER
TRIAZ 3% PAD
TRIAZ 6% CLEANSER
TRIAZ 6% PAD
TRIAZ 9% CLEANSER
TRIAZ 9% PAD
TRIAZOLAM 0.125 MG TABLET
TRIAZOLAM 0.25 MG TABLET
TRIBENZOR 20-5-12.5 MG TABLET
TRIBENZOR 40-10-25 MG TABLET
TRIBENZOR 40-5-25 MG TABLET
TRI-CHLOR 80% SOLUTION
TRICITRATES ORAL SOLUTION
TRICODE AR LIQUID
TRICODE GF LIQUID
TRICON CAPSULE
TRICOR 145 MG TABLET
TRICOR 48 MG TABLET
TRIDERM 0.1% CREAM
TRIESENCE 40 MG/ML VIAL
TRIFLUOPERAZINE 1 MG TABLET
TRIFLURIDINE 1% EYE DROPS
TRIFLURIDINE 1% EYE DROPS
TRIGLIDE 160 MG TABLET
TRIGLIDE 50 MG TABLET
TRIHEXYPHENIDYL 2 MG TABLET
TRIHEXYPHENIDYL 2 MG/5 ML ELX
TRIHEXYPHENIDYL 5 MG TABLET
TRI-LEGEST FE-28 DAY TABLET
500
100
100
100
100
500
500
55
25000
25000
0
0
500
3000
3000
6000
6000
9000
9000
125
250
20000
40000
40000
40000
40000
0
0
2000
30000
500
145000
48000
100
40000
1000
10000
2000
5000
1000
1000
160000
50000
2000
2000
5000
0
%
%
%
%
%
%
%
MCG
MG
MG
MG
MG
%
%
%
%
%
%
%
MG
MG
MG
MG
MG
MG
MG
0
ML
MG/ML
MG/ML
MG
MG
MG
%
ML
MG
MG
MG
MG
%
%
MG
MG
MG
MG/5ML
MG
MG
261356
261360
351992
262090
1311535
828377
828381
904158
860771
198332
313498
313499
313496
751905
749151
853319
308493
1099684
753479
762333
1365980
1365984
1244008
748865
285028
285028
313521
314238
857560
857564
151100
639888
639888
639888
995441
1303107
1368072
616959
1087427
1087389
992733
1087463
995485
1251405
727412
727413
876518
TRILEPTAL 150 MG TABLET

TRILEPTAL 300 MG/5 ML SUSP
TRI-LINYAH TABLET
TRILIPIX DR 135 MG CAPSULE
TRILIPIX DR 45 MG CAPSULE
TRILYTE WITH FLAVOR PACKETS
TRIMETHOBENZAMIDE 300 MG CAP
TRIMETHOPRIM 100 MG TABLET
TRIMIPRAMINE 25 MG CAPSULE
TRIMIPRAMINE 50 MG CAPSULE
TRIMIPRAMINE MALEATE 100 MG CP
TRINESSA TABLET
TRI-NORINYL 28 TABLET
TRIOXIN OTIC SUSPENSION
TRIPLE ANTIBIOTIC EYE OINT
TRIPOHIST 1.25 MG/5 ML LIQUID
TRI-PREVIFEM TABLET
TRI-SPRINTEC TABLET
TRI-VIT-FLUOR 0.25 MG/ML DROP
TRI-VIT-FLUOR 0.5 MG/ML DROP
TRI-VIT-FLUOR-IRON 0.25 MG/ML
TRIVORA-28 TABLET
TRIZIVIR TABLET
TRIZIVIR TABLET
TROPICAMIDE 0.5% EYE DROPS
TROPICAMIDE 1% EYE DROPS
TROSPIUM CHLORIDE 20 MG TABLET
TROSPIUM CHLORIDE ER 60 MG CAP
TRUSOPT 2% EYE DROPS
TRUVADA 200 MG-300 MG TABLET
TRYMINE CG LIQUID
TUDORZA PRESSAIR 400 MCG INH
TUSNEL C SYRUP
TUSSI-12 TABLET
TUSSICAPS 10 MG-8 MG CAPSULE
TUSSICAPS 5 MG/4 MG CAPSULE
TUSSIGON TABLET
TUSSIONEX PENNKINETIC SUSP
TUSSO-C SYRUP
TUSSO-DMR CAPSULE
TWINJECT 0.15 MG AUTO-INJECTOR
TWINJECT 0.3 MG AUTO-INJECTOR
TWYNSTA 40-10 MG TABLET
150000
300000
300000
600000
0
135000
45000
0
300000
100000
25000
50000
100000
0
0
1000
3500
1250
0
0
250
500
250
0
15000
15000
500
1000
20000
60000
2000
200000
200000
200000
225000
400
10000
0
10000
5000
0
0
10000
600000
150
300
40000
MG
MG
MG/5ML
MG
MG
MG
MG
0
MG
MG
MG
MG
MG
MG
MG
%
MG/GM
MG/5ML
MG
MG
MG/ML
MG/ML
MG/ML
MG
MG
MG
%
%
MG
MG
%
MG
MG
MG
ML
MCG
MG
0
MG
MG
MG
MG
MG/5ML
0
MG
MG
MG
876528
876523
876533
672152
993837
993892
1049666
857799
668691
1232718
1232720
1232714
1366556
1360949
1360949
1356673
834239
834243
1301039
1300108
836397
835605
835605
845314
845314
845315
845315
845316
845316
807730
807732
807734
807736
977992
977980
978320
978320
978056
978056
1301694
1301694
1301696
1301696
1245759
1245765
1245771
748312

TYKERB 250 MG TABLET
TYLENOL WITH CODEINE #3 TABLET
TYLENOL WITH CODEINE #4 TABLET
TYLOX 5-500 MG CAPSULE
TYVASO INHALATION STARTER KIT
TYZEKA 600 MG TABLET
TYZINE 0.1% NOSE DROPS
TYZINE 0.1% NOSE SPRAY
TYZINE PEDIATRIC 0.05% DROP
UCERIS 9 MG ER TABLET
U-CORT 1% CREAM
U-CORT 1% CREAM
ULESFIA 5% LOTION
ULORIC 40 MG TABLET
ULORIC 80 MG TABLET
ULTRABROM CAPSULE SA
ULTRABROM PD CAPSULE SA
ULTRACET TABLET
ULTRAM 50 MG TABLET
ULTRAM 50 MG TABLET
ULTRAM ER 100 MG TABLET
ULTRASE EC CAPSULE
ULTRASE MT-12 EC CAPSULE
ULTRAVATE 0.05% CREAM
ULTRAVATE 0.05% OINTMENT
ULTRAVATE PAC CREAM KIT
ULTRAVATE PAC CREAM KIT
ULTRAVATE PAC OINTMENT KIT
ULTRAVATE PAC OINTMENT KIT
ULTRAVATE X CREAM COMBO PACK
ULTRAVATE X CREAM COMBO PACK
ULTRAVATE X OINTMENT COMBO PAC
ULTRAVATE X OINTMENT COMBO PAC
ULTRESA DR 13,800 UNIT CAPSULE
UMECTA 40% MOUSSE
40000
80000
80000
250000
30000
60000
0
1740
600000
100
100
50
9000
1000
1000
5000
40000
80000
0
60000
37500
50000
50000
100000
100000
200000
200000
300000
300000
25000000
12001000
18000000
20000000
50
50
50
50
50
50
50
50
50
50
13800000
20700000
23000000
40000
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
%
MG
%
%
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
U
0
U
U
%
%
%
%
%
%
%
%
%
%
MG
MG
MG
%
1006679
832917
844831
844832
1299861
1299959
1299873
966233
966233
966235
966235
966237
966237
966238
966238
966246
966246
966241
966241
966228
966228
966243
966243
966244
966244
966286
966286
966232
966232
1299963
1299965
1047786
853328
904023
853332
1291141
828275
849646
477126
1093289
198342
349352
351155
746391
866813
835837
866107
UMECTA 40% SUSPENSION

UMECTA PD 40% SUSPENSION
UNIPHYL 400 MG TABLET
UNIPHYL 600 MG TABLET
UNIRETIC 15-12.5 TABLET
UNIRETIC 15-25 MG TABLET
UNIRETIC 7.5-12.5 MG TABLET
UNITHROID 100 MCG TABLET
UNIVASC 15 MG TABLET
UNIVASC 7.5 MG TABLET
UR N-C TABLET
URAMAXIN 20% FOAM
URAMAXIN 45% LOTION
URAMAXIN 45% UREA CREAM
URAMAXIN GT 45% KIT
URAMAXIN GT 45% PRE-FILLED APP
UREA 35% FOAM
UREA 35% LOTION
UREA 39% CREAM
UREA 40% CREAM
UREA 40% GEL
UREA 40% LOTION
UREA 40% NAIL FILM SUSP
UREA 40% NAIL KIT
UREA 45% CREAM
UREA 45% LOTION
40000
40000
400000
600000
15000
15000
7500
100
100
112
112
125
125
150
150
175
175
200
200
25
25
300
300
50
50
75
75
88
88
15000
7500
81600
20000
45000
45000
45000
45000
35000
35000
39000
40000
40000
40000
40000
40000
45000
45000
%
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MCG
MCG
MG
MG
MCG
MCG
MCG
MCG
MG
MG
MG
MG
MG
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
827406
416916
477225
791061
247760
857325
857332
857338
857344
1048340
1087457
992164
1087367
1048044
898517
603281
603282
1251290
829031
861134
858752
858735
858751
858747
858733
1101637
1048309
1048316
1047795
1047797
884709
313564
313565
284587
863562
104701
104699
104700
1099681
1099681
1099687
1099687
1099687
200285
349353
636042
636045
UREA 45% NAIL GEL

UREA 50% CREAM
UREA 50% NAIL GEL
UREA 50% NAIL STICK
UREA 50% OINTMENT
URECHOLINE 10 MG TABLET
URELLE TABLET
URETRON D-S TABLET
UREX 1 GM TABLET
URIBEL CAPSULE
URIN D.S. TABLET
UROCIT-K ER 15 MEQ TABLET
UROCIT-K SR 10 MEQ TABLET
UROCIT-K SR 5 MEQ TABLET
UROGESIC-BLUE TABLET
UROQID-ACID NO.2 500-500 TB
UROXATRAL 10 MG TABLET
URSO 250 MG TABLET
URSO FORTE 500 MG TABLET
URSODIOL 250 MG TABLET
URSODIOL 300 MG CAPSULE
URSODIOL 500 MG TABLET
USTELL CAPSULE
UTA CAPSULE
UTICAP CAPSULE
UTIRA-C TABLET
UTRONA-C TABLET
VAGIFEM 10 MCG VAGINAL TAB
VALACYCLOVIR HCL 1 GRAM TABLET
VALACYCLOVIR HCL 500 MG TABLET
VALCYTE 450 MG TABLET
VALCYTE 50 MG/ML SOLUTION
VALIUM 10 MG TABLET
VALIUM 2 MG TABLET
VALIUM 5 MG TABLET
VALPROIC ACID 250 MG CAPSULE
VALPROIC ACID 250 MG CAPSULE
VALPROIC ACID 250 MG/5 ML SOLN
VALSARTAN-HCTZ 160-12.5 MG TAB
VALSARTAN-HCTZ 160-25 MG TAB
VALSARTAN-HCTZ 320-25 MG TAB
45000
50000
50000
50000
50000
10000
25000
5000
50000
81000
0
1000000
118000
0
1620000
750000
540000
0
0
10000
250000
500000
250000
300000
500000
120000
120000
120000
0
0
10
1000000
500000
450000
50000
10000
2000
5000
250000
250000
250000
250000
250000
160000
160000
320000
320000
%
%
%
%
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG/5ML
MG/5ML
MG
MG
MG
MG
200284
212448
108780
1011724
1011735
998400
201848
201849
313570
313571
608934
1098416
1098418
543484
211765
858830
999653
858819
858806
858812
858815
1313864
1244529
1358772
1363650
645724
904382
883358
1302755
1009216
762334
313580
313580
313582
313582
313584
313584
314277
314277
313586
313586
313581
313581
808744
808744
808748
808748

VALTREX 1 GM CAPLET
VALTREX 500 MG CAPLET
VALTURNA 150-160 MG TABLET
VALTURNA 300-320 MG TABLET
VANACOF CD LIQUID
VANCOCIN HCL 125 MG PULVULE
VANCOCIN HCL 250 MG PULVULE
VANCOMYCIN HCL 125 MG CAPSULE
VANCOMYCIN HCL 250 MG CAPSULE
VANDAZOLE VAGINAL 0.75% GEL
VANDETANIB 100 MG TABLET
VANDETANIB 300 MG TABLET
VANOS 0.1% CREAM
VANOXIDE HC LOTION KIT
VASERETIC 10-25 MG TABLET
VASOLEX OINTMENT
VASOTEC 10 MG TABLET
VASOTEC 2.5 MG TABLET
VASOTEC 20 MG TABLET
VASOTEC 5 MG TABLET
VAYAROL CAPSULES
VAZOBID SUSPENSION
VAZOL LIQUID
VAZOTAB CHEWABLE TABLET
VAZOTAN SUSPENSION
V-COF SUSPENSION
VECTICAL 3 MCG/G OINTMENT
VELETRI 0.5 MG VIAL
VELETRI 1.5 MG VIAL
VELIVET 28 DAY TABLET
VENLAFAXINE HCL 100 MG TABLET
VENLAFAXINE HCL 37.5 MG TABLET
VENLAFAXINE HCL 37.5 MG TABLET
VENLAFAXINE HCL ER 150 MG CAP
VENLAFAXINE HCL ER 150 MG TAB
80000
1000000
500000
150000
300000
10000
125000
250000
125000
250000
750
100000
300000
100
5000
10000
0
10000
2500
20000
5000
630
10000
2000
15000
6000
6000
0
500
500
777000
100000
100000
25000
25000
37500
37500
50000
50000
75000
75000
150000
150000
150000
150000
225000
225000
MG
MG
MG
MG
MG
MG/5ML
MG
MG
MG
MG
%
MG
MG
%
%
MG
0
MG
MG
MG
MG
EA
MG/5ML
MG/5ML
MG
MG/5ML
MG/5ML
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
313583
313583
808751
808751
313585
313585
808753
808753
582595
861966
801095
859088
895970
897666
897630
897722
897683
897612
901434
897618
897640
897624
897649
897584
897590
897596
669750
795918
897614
897620
897626
897632
897586
897592
897598
824889
404537
539815
539817
1233850
207446
352219
546624
352218
205604
205604
861061
VENLAFAXINE HCL ER 37.5 MG CAP

VENLAFAXINE HCL ER 37.5 MG CAP
VENLAFAXINE HCL ER 37.5 MG TAB
VENLAFAXINE HCL ER 37.5 MG TAB
VENTAVIS 10 MCG/1 ML SOLUTION
VENTAVIS 20 MCG/1 ML SOLUTION
VENTOLIN HFA 90 MCG INHALER
VENTOLIN HFA 90 MCG INHALER
VERAMYST 27.5 MCG NASAL SPRAY
VERAPAMIL 120 MG TABLET
VERAPAMIL 360 MG CAP PELLET
VERAPAMIL ER 120 MG CAPSULE
VERAPAMIL ER 120 MG TABLET
VERAPAMIL ER PM 100 MG CAPSULE
VERDESO 0.05% FOAM
VEREGEN 15% OINTMENT
VERELAN 120 MG CAP PELLET
VERELAN PM 100 MG CAP PELLET
VERIPRED 20 20 MG/5 ML SOLN
VERSICLEAR LOTION
VESICARE 10 MG TABLET
VESICARE 5 MG TABLET
VESTURA 3 MG-0.02 MG TABLET
VEXOL 1% EYE DROPS
VFEND 200 MG TABLET
VFEND 40 MG/ML SUSPENSION
VFEND 50 MG TABLET
VIBRAMYCIN 100 MG CAPSULE
VIBRAMYCIN 100 MG CAPSULE
VIBRAMYCIN 25 MG/5 ML SUSP
37500
37500
37500
37500
75000
75000
75000
75000
10
20
0
0
275
120000
360000
40000
80000
120000
120000
180000
180000
240000
240000
100000
200000
300000
50
15000
120000
180000
240000
360000
100000
200000
300000
20000
25000
10000
5000
0
1000
200000
40000
50000
100000
100000
25000
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
0
0
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
MG
MG
MG
MG
MG
MG
MG
MG/5ML
%
MG
MG
MG
%
MG
MG
MG
MG
MG
MG/5ML
861061
702296
702296
1310202
856907
1310212
856898
1310270
856912
858838
897126
1102136
542059
284498
284499
285027
284500
404473
404473
1086776
1086780
1086786
1086790
995156
809990
809994
809998
810002
1247388
1247381
284428
351541
1252016
212118
542370
861032
211327
213405
1095715
1095693
207406
1243326
1243330
1243229
352050
1243346
208581
VIBRAMYCIN 25 MG/5 ML SUSP

VIBRAMYCIN 50 MG/5 ML SYRUP
VIBRAMYCIN 50 MG/5 ML SYRUP
VICODIN 5-300 MG TABLET
VICODIN 5-500 TABLET
VICODIN ES 7.5-300 MG TABLET
VICODIN ES 7.5-750 MG TABLET
VICODIN HP 10-300 MG TABLET
VICODIN HP 10-660 MG TABLET
VICOPROFEN 200-7.5 MG TAB
VICTOZA 2-PAK 18 MG/3 ML PEN
VICTRELIS 200 MG CAPSULE
VIDEX 2 GM PEDIATRIC SOLN
VIDEX EC 125 MG CAPSULE
VIGAMOX 0.5% EYE DROPS
VIGAMOX 0.5% EYE DROPS
VIIBRYD 10 MG TABLET
VIIBRYD TITRATION PACK
VIMPAT 10 MG/ML SOLUTION
VIMPAT 100 MG TABLET
VIMPAT 50 MG TABLET
VIOKACE 10,440-39,150 UNITS TB
VIOKACE 20,880-78,300 UNITS TB
VIOKASE 16 TABLET
VIOKASE 8 TABLET
VIORELE 28 DAY TABLET
VIRACEPT 250 MG TABLET
VIRACEPT 625 MG TABLET
VIRACEPT POWDER
VIRAMUNE 200 MG TABLET
VIRAMUNE 50 MG/5 ML SUSP
VIRAMUNE XR 400 MG TABLET
VIRASAL ANTIVIRAL WART REMOVER
VIRAZOLE 6 GM VIAL
VIREAD 150 MG TABLET
VIREAD POWDER
VIROPTIC 1% EYE DROPS
25000
50000
50000
5000
5000
7500
7500
10000
660000
200000
600
200000
2000000
125000
200000
250000
400000
500
500
10000
20000
40000
10001
10000
100000
150000
200000
50000
10440000
20880000
16000000
8000000
0
250000
625000
0
200000
50000
400000
27500
6000000
150000
200000
250000
300000
40000
1000
MG/5ML
MG/5ML
MG/5ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
MG
MG
MG
MG
MG/ML
MG
MG
MG
MG
IU
IU
0
U
0
MG
MG
MG
MG
MG/5ML
MG
%
GM
MG
MG
MG
MG
MG
%
208581
107078
1098139
1190113
856751
829032
995255
995255
995280
995280
1014472
1119573
1298199
808534
905170
905174
310176
284378
310172
1149634
310183
854803
855635
855928
855659
349434
349435
211798
213528
901483
901484
867506
417254
831393
1245420
1245430
1245441
1245449
854832
854836
854840
854852
854848
854844
855288
855296
855302
VIROPTIC 1% EYE DROPS

VIRT-PN DHA SOFTGEL
VISCOAT SYRINGE
VISCOAT SYRINGE
VISICOL TABLET
VISQID A-A TABLET
VISTARIL 25 MG CAPSULE
VISTRA 650 TABLET
VITAFOL-ONE CAPSULE
VITAMEDMD REDICHEW RX TAB CHEW
VITA-RESPA TABLET
VIVACTIL 10 MG TABLET
VIVACTIL 5 MG TABLET
VIVELLE 0.05 MG PATCH
VIVELLE-DOT 0.025 MG PATCH
VOLTAREN 0.1% EYE DROPS
VOLTAREN 1% GEL
VOLTAREN EC 75 MG TABLET
VOLTAREN-XR 100 MG TABLET SA
VORICONAZOLE 200 MG TABLET
VORICONAZOLE 50 MG TABLET
VOSOL 2% OTIC SOLUTION
VOSOL HC EAR DROPS
VOSPIRE ER 4 MG TABLET
VOSPIRE ER 8 MG TABLET
VOTRIENT 200 MG TABLET
V-R LICE CREAM RINSE
VUSION OINTMENT
VYTORIN 10-10 MG TABLET
VYVANSE 20 MG CAPSULE
WARFARIN SODIUM 1 MG TABLET
1000
27000
0
0
1500000
0
25000
25000
50000
50000
650000
29000
1000
2000
10000
5000
50
25
37
75
100
100
1000
75000
100000
200000
50000
2000
2000
4000
8000
200000
1000
250
10000
20000
40000
80000
20000
30000
40000
50000
60000
70000
1000
10000
2000
%
MG
MG/ML
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
MG
MG
MG
MG
%
%
MG
MG
MG
%
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
855312
855318
855324
855332
855338
855344
866907
866912
993688
993688
993693
993693
993511
993511
993528
993528
993537
993537
993545
993545
993564
993564
1300911
1370756
1370752
1245133
1245133
351487
351487
1245135
1245135
1087008
1087008
1115818
1115818
1087010
1087010
1087014
1087014
1087012
1087012
1087016
1087016
1115816
1115816
692694
692694
WARFARIN SODIUM 2.5 MG TABLET

WARFARIN SODIUM 7.5 MG TABLET
WELCHOL 3.75G PACKET
WELCHOL 625 MG TABLET
WELLBUTRIN 100 MG TABLET
WELLBUTRIN SR 100 MG TABLET
WELLBUTRIN XL 150 MG TABLET
WERA 0.5/0.035 MG 28 TABLET
WESTCORT 0.2% CREAM
WESTCORT 0.2% OINTMENT
WESTHROID 113.75 MG TABLET
WESTHROID 130 MG TABLET
2500
3000
4000
5000
6000
7500
3750
625000
100000
100000
75000
75000
100000
100000
150000
150000
200000
200000
150000
150000
300000
300000
500
200
200
113750
113750
129600
129600
146250
146250
16250
16250
162500
162500
195000
195000
260000
260000
32400
32400
325000
325000
48750
48750
64800
64800
MG
MG
MG
MG
MG
MG
GM
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
%
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
1245137
1245137
1087019
1087019
1120056
884742
1095224
542527
1148502
1148506
141927
141928
214003
214004
687025
687024
687023
687022
1114202
1232084
1232088
1357547
213292
213293
581757
805466
805462
584232
539789
856666
856984
856991
856996
664961
1049655
352132
261136
833470
746466
1307309
605686
644535
748302
1011854
1011854
1246113
1246113

WILATE 1,000-1,000 UNIT KIT
WILATE 450-450 UNIT KIT
WYMZYA FE CHEWABLE TABLET
XALATAN 0.005% EYE DROPS
XALKORI 200 MG CAPSULE
XALKORI 250 MG CAPSULE
XANAX 0.25 MG TABLET
XANAX 0.5 MG TABLET
XANAX 1 MG TABLET
XANAX 2 MG TABLET
XANAX XR 0.5 MG TABLET
XANAX XR 1 MG TABLET
XARELTO 10 MG TABLET
XELJANZ 5 MG TABLET
XELODA 150 MG TABLET
XELODA 500 MG TABLET
XENADERM OINTMENT
XENAZINE 12.5 MG TABLET
XENAZINE 25 MG TABLET
XIBROM 0.09% EYE DROPS
XIFAXAN 200 MG TABLET
XIFAXAN 550 MG TABLET
XODOL 10-300 TABLET
XODOL 5-300 TABLET
XODOL 7.5-300 MG TABLET
XOLEGEL 2% GEL
XOLOX 10-500 MG TABLET
XOPENEX 0.31 MG/3 ML SOLUTION
XOPENEX HFA 45 MCG INHALER
XTANDI 40 MG CAPSULE
X-VIATE 40% CREAM
X-VIATE 40% GEL
X-VIATE 40% LOTION
XYLOCAINE 2% JELLY
XYLOCAINE 2% JELLY
XYLOCAINE 4% SOLUTION
XYLOCAINE 4% SOLUTION
81250
81250
97500
97500
1000000
450000
400
5
200000
250000
250
500
1000
2000
500
1000
2000
3000
10000
15000
20000
5000
150000
500000
0
12500
25000
90
200000
550000
10000
5000
7500
2000
10000
310
630
1250
45
40000
40000
0
40000
2000
2000
4000
4000
MG
MG
MG
MG
UNITS
UNITS
MG
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
0
MG
MG
%
MG
MG
MG
MG
MG
%
MG
MG/3ML
MG/3ML
MG/3ML
MCG
MG
%
0
%
%
%
%
%
1367982
1367984
1367971
1368038
1367988
1368110
1368114
1368014
1367995
352257
855170
855174
748857
748856
628827
207077
207079
1098151
1098155
1020049
1020050
313758
199655
313761
313762
856946
583165
153734
583211
153735
580267
755272
827189
608798
827185
1011081
201737
755357
207271
207272
541070
645727
854903
854907
211500
859192
1147228
XYNTHA 1,000 UNIT KIT

XYNTHA 2,000 UNIT KIT
XYNTHA 250 UNIT KIT
XYNTHA 3,000 UNIT SYRINGE KIT
XYNTHA 500 UNIT KIT
XYNTHA SOLOFUSE 1,000 UNIT KIT
XYNTHA SOLOFUSE 2,000 UNIT KIT
XYNTHA SOLOFUSE 250 UNIT KIT
XYNTHA SOLOFUSE 500 UNIT KIT
XYREM 500 MG/ML ORAL SOLUTION
XYZAL 2.5 MG/5 ML SOLUTION
XYZAL 5 MG TABLET
YASMIN 28 TABLET
YAZ 28 TABLET
Y-COF DM TABLET
YODOXIN 210 MG TABLET
YODOXIN 650 MG TABLET
ZACARE 4% KIT
ZACARE 8% KIT
ZACLIR 4% CLEANSING LOTION
ZACLIR 8% CLEANSING LOTION
ZAFIRLUKAST 10 MG TABLET
ZAFIRLUKAST 20 MG TABLET
ZALEPLON 10 MG CAPSULE
ZALEPLON 5 MG CAPSULE
ZAMICET SOLUTION
ZANAFLEX 2 MG CAPSULE
ZANAFLEX 2 MG TABLET
ZANAFLEX 4 MG TABLET
ZANTAC 15 MG/ML SYRUP
ZANTAC 150 MG TABLET
ZANTAC 25 EFFERDOSE TABLET
ZANTAC 300 MG TABLET
ZARAH TABLET
ZARONTIN 250 MG CAPSULE
ZARONTIN 250 MG/5 ML SOLUTION
ZAROXOLYN 2.5 MG TABLET
ZAROXOLYN 5 MG TABLET
ZAVESCA 100 MG CAPSULE
Z-COF 8 DM ORAL SUSPENSION
ZEBETA 10 MG TABLET
ZEBETA 5 MG TABLET
ZEBUTAL CAPSULE
ZELAPAR 1.25 MG ODT TABLET
ZELBORAF 240 MG TABLET
1000000
2000000
250000
3000000
500000
1000000
2000000
250000
500000
500000
2500
5000
0
0
30000
210000
650000
4000
8000
4000
8000
10000
20000
10000
5000
0
2000
2000
4000
4000
6000
15000
150000
25000
300000
0
250000
250000
2500
5000
100000
175000
10000
5000
500000
1250
240000
AHFU
IU
AHFU
IU
UNITS
AHFU
IU
AHFU
UNITS
MG/ML
5ML
MG
MG
MG
MG
MG
MG
%
%
%
%
MG
MG
MG
MG
ML
MG
MG
MG
MG
MG
MG/ML
MG
MG
MG
MG
MG
MG/5ML
MG
MG
MG
ML
MG
MG
MG
MG
MG
895521
895525
895526
606854
606859
606861
753536
1235597
1001718
861830
861834
861838
1117104
1114135
861842
1095225
153652
152941
152942
152943
152944
1234982
823986
823982
823971
104377
104375
104378
213482
206771
104376
352304
999398
999406
854910
854918
854921
213461
213460
198352
199663
756209
313773
1294268
1294312
1244616
1244616
ZEMA-PAK 10 DAY 1.5 MG TABLET

ZEMPLAR 1 MCG CAPSULE
ZENCHENT 0.4 MG-35 MCG TABLET
ZENCHENT FE TABLET CHEWABLE
ZENCIA WASH
ZENPEP DR 10,000 UNITS CAPSULE
ZEOSA CHEWABLE TABLET
ZERIT 1 MG/ML SOLUTION
ZERIT 15 MG CAPSULE
ZERIT 20 MG CAPSULE
ZERIT 30 MG CAPSULE
ZERIT 40 MG CAPSULE
ZERLOR TABLET
ZESTORETIC 10-12.5 MG TABLET
ZESTORETIC 20-12.5 MG TABLET
ZESTORETIC 20-25 MG TABLET
ZESTRIL 10 MG TABLET
ZESTRIL 2.5 MG TABLET
ZESTRIL 5 MG TABLET
ZETIA 10 MG TABLET
ZFLEX TABLET
ZGESIC TABLET
ZIAC 10-6.25 MG TABLET
ZIAC 2.5-6.25 MG TABLET
ZIAC 5-6.25 MG TABLET
ZIAGEN 20 MG/ML SOLUTION
ZIAGEN 300 MG TABLET
ZIDOVUDINE 100 MG CAPSULE
ZIDOVUDINE 300 MG TABLET
ZIDOVUDINE 50 MG/5 ML SYRUP
ZINC SULFATE 220 MG CAPSULE
ZINOTIC EAR DROPS
ZINOTIC ES EAR DROPS
ZIOPTAN 0.0015% EYE DROPS
ZIOPTAN 0.0015% EYE DROPS
1500
1500
1500
1
2
4
35
35
9000
55000000
82000000
1.09E+08
1.36E+08
16000000
27000000
35
1000
15000
20000
30000
40000
0
10000
12500
25000
10000
2500
20000
30000
40000
5000
10000
500000
600000
10000
2500
5000
100000
300000
100000
300000
10000
220000
100
100
0
0
MG
MG
MG
MCG
MCG
MCG
MCG
MCG
%
MG
MG
MG
MG
MG
MG
MCG
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG/5ML
MG
MG
MG
MG/ML
MG
%
%
%
%
314286
313776
313777
313778
864650
1245904
863181
861417
211307
105260
212446
750149
226827
211511
750157
583482
104490
104491
152923
208220
213319
597774
349565
995070
1089023
104895
212447
104896
876690
876693
668606
208149
208149
861066
861066
212233
212233
208161
208161
854880
854894
854873
854876
1044431
153353
402169
213167
ZIPRASIDONE HCL 20 MG CAPSULE

ZIRGAN 0.15% OPHTHALMIC GEL
ZITHRANOL 1% SHAMPOO
ZITHRANOL-RR 1.2% CREAM
ZITHROMAX 1 GM POWDER PACKET
ZITHROMAX 100 MG/5 ML SUSP
ZITHROMAX 200 MG/5 ML SUSP
ZITHROMAX 250 MG TABLET
ZITHROMAX 250 MG Z-PAK TABLET
ZITHROMAX TRI-PAK 500 MG TAB
ZMAX 2 G/60 ML ORAL SUSPENSION
ZOCOR 10 MG TABLET
ZOCOR 20 MG TABLET
ZOCOR 40 MG TABLET
ZOCOR 5 MG TABLET
ZOCOR 80 MG TABLET
ZODEN DM DROPS
ZODEN DROPS
ZODRYL AC 40 SUSPENSION
ZODRYL DEC 30 SUSPENSION
ZOFRAN 4 MG TABLET
ZOFRAN 4 MG/5 ML ORAL SOLN
ZOFRAN 8 MG TABLET
ZOFRAN ODT 4 MG TABLET
ZOFRAN ODT 8 MG TABLET
ZOLINZA 100 MG CAPSULE
ZOLOFT 100 MG TABLET
ZOLOFT 100 MG TABLET
ZOLOFT 20 MG/ML ORAL CONC
ZOLOFT 20 MG/ML ORAL CONC
ZOLOFT 25 MG TABLET
ZOLOFT 25 MG TABLET
ZOLOFT 50 MG TABLET
ZOLOFT 50 MG TABLET
ZOLPIDEM TART ER 12.5 MG TAB
ZOLPIDEM TART ER 6.25 MG TAB
ZOLPIDEM TARTRATE 10 MG TABLET
ZOLPIDEM TARTRATE 5 MG TABLET
ZOLVIT 10 MG-300 MG/15 ML SOL
ZOMIG 2.5 MG TABLET
ZOMIG 5 MG NASAL SPRAY
ZOMIG 5 MG TABLET
20000
40000
60000
80000
150
1000
1200
1000000
100000
200000
250000
250000
500000
600000
500000
2000000
10000
20000
40000
5000
80000
3000
20000
1000
15000
4000
4000
8000
4000
8000
100000
100000
100000
20000
20000
25000
25000
50000
50000
12500
6250
10000
5000
10000
2500
5000
5000
MG
MG
MG
MG
%
%
%
MG
MG/5ML
MG/5ML
MG
MG
MG
MG
MG
G
MG
MG
MG
MG
MG
MG/ML
ML
MG
MG
MG
MG/5ML
MG
MG
MG
MG
MG
MG
MG/ML
MG/ML
MG
MG
MG
MG
MG
MG
MG
MG
ML
MG
MG
MG
901802
901803
1000095
904390
284408
404725
314285
403966
403967
977431
977436
977440
1357915
1233603
1111646
1357896
996584
1357938
1113492
1357884
748859
748864
213694
201903
201905
825321
209977
213706
1094447
1094447
995132
762621
1115764
1112224
993954
1248442
967021
857130
857133
857136
790889
545259
213995
213998
992399
153048
153048
ZOMIG ZMT 2.5 MG TABLET

ZOMIG ZMT 5 MG TABLET
ZONALON 5% CREAM
ZONATUSS 150 MG CAPSULE
ZONEGRAN 100 MG CAPSULE
ZONEGRAN 25 MG CAPSULE
ZONISAMIDE 100 MG CAPSULE
ZORTRESS 0.25 MG TABLET
ZOTEX 12 SUSPENSION
ZOTEX PEDIATRIC DROPS
ZOTEX SYRUP
ZOTEX-12D SR TABLET
ZOTEX-C SYRUP
ZOTEX-D SYRUP
ZOTEX-EX CAPLET
ZOTEX-PE SR 30-6 MG TABLET
ZOVIA 1-35E TABLET
ZOVIA 1-50E TABLET
ZOVIRAX 200 MG CAPSULE
ZOVIRAX 200 MG/5 ML SUSP
ZOVIRAX 400 MG TABLET
ZOVIRAX 5% CREAM
ZOVIRAX 5% OINTMENT
ZOVIRAX 800 MG TABLET
Z-PRAM CREAM KIT
Z-PRAM CREAM KIT
Z-TUSS AC LIQUID
Z-TUSS DM SYRUP
Z-TUSS E LIQUID
ZUTRIPRO SOLUTION
ZYBAN SR 150 MG TABLET
ZYCLARA 2.5% CREAM PUMP
ZYCLARA 3.75% CREAM
ZYDONE 10-400 MG TABLET
ZYDONE 5-400 MG TABLET
ZYDONE 7.5-400 MG TABLET
ZYFLO CR 600 MG TABLET
ZYLET EYE DROPS
ZYLOPRIM 100 MG TABLET
ZYLOPRIM 300 MG TABLET
ZYMAXID 0.5% EYE DROPS
ZYPREXA 10 MG TABLET
2500
5000
5000
150000
100000
25000
100000
25000
50000
250
500
750
25000
35000
20000
30000
0
20000
350000
30000
0
0
200000
200000
400000
5000
5000
800000
2350
2350
2000
300000
30000
60000
150000
2500
3750
10000
5000
7500
600000
300
100000
300000
500
10000
10000
MG
MG
%
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
ML
MG/5ML
MG
MG
MG
MG
MG
MG
MG
%
%
MG
%
%
MG
0
ML
ML
MG
%
%
MG
MG
MG
MG
%
MG
MG
%
MG
MG
261337
261337
212405
212405
284514
284514
153046
153046
153047
153047
754503
754503
754504
754504
754505
754505
754506
754506
1020022
1020026
1100079
581614
262091
94185
94186
104063
105295
105825
105826
106892
200243
200290
201831
201831
205734
205988
206211
206629
206812
207208
207209
207210
207302
207302
208191
208303
208583
ZYPREXA 2.5 MG TABLET
ZYPREXA 5 MG TABLET
ZYPREXA 5 MG TABLET
ZYPREXA ZYDIS 10 MG TABLET
ZYRTEC 10 MG CHEWABLE TABLET
ZYRTEC 10 MG TABLET
ZYTIGA 250 MG TABLET
ZYVOX 100 MG/5 ML SUSPENSION
ZYVOX 600 MG TABLET
SUMYCIN
SUMYCIN
TAGAMET
RIMACTANE
LODINE
LODINE
HUMULIN 70-30
SEVOFLURANE
PODODERM
VIBRAMYCIN
VIBRAMYCIN
AMOXIL
CLINDA-DERM
EMGEL
PAREMYD
LODINE
FLOXIN
FLOXIN
FLOXIN
TERRAMYCIN WITH POLYMYXIN
TERRAMYCIN WITH POLYMYXIN
AMERICAINE
AMERICAINE
BREVOXYL
15000 MG
15000 MG
2500 MG
2500 MG
20000 MG
20000 MG
5000 MG
5000 MG
7500 MG
7500 MG
10000 MG
10000 MG
15000 MG
15000 MG
20000 MG
20000 MG
5000 MG
5000 MG
10000 MG
10000 MG
250000 MG
100000 MG/5ML
600000 MG
250 MG
500 MG
400 MG
300 MG
200 MG
300 MG
70-30/ML
STR N/A
25 %
50 MG
50 MG
125 MG/5ML
1%
2%
1 %-0.25 %
400 MG
200 MG
300 MG
400 MG
5-10000/G
5-10000/G
20 %
20 %
4%
208919
209141
209142
211498
213751
245667
247922
261160
261177
261329
284511
311446
312538
312741
313090
351936
360043
483425
483427
541963
542347
542355
542358
543789
546480
581698
688701
688708
750180
750242
759495
762813
797277
801086
833507
855666
856962
861715
861844
866070
866070
876229
876553
880695
992582
994039
995043
SUPRANE
COMPOUND 347
ETHRANE
LODINE
CECLOR
HYDROGEN PEROXIDE
CASCARA SAGRADA
MYCELEX
MYCOSTATIN
CUROSURF
CELLUGEL
SORBITOL-MANNITOL
POTASSIUM HYDROXIDE
PYROGALLIC ACID
SORBITOL
CECLOR
PEDIAHIST DM
FENOFIBRATE
FENOFIBRATE
ULTANE
ISOFLURANE
TERRELL
FORANE
CETACAINE
SCLEROSOL
ISOPROPYL ALCOHOL
CORTISPORIN
CORTOMYCIN
NEOCIDIN
NORGESTREL-ETHINY ESTRA
SYMPAK II
OVRAL
CLINDETS
AMBIFED-G DM
SCALACORT DK
VOLTAREN
HYDROCODONE W/ACETAMINOPHEN
SURVANTA
TORADOL
CORTALO
CORTALO
STERILE TALC
MIOCHOL-E
DURASAL
VENELEX
INFASURF
ZODRYL DAC 80
STR N/A
STR N/A
STR N/A
500 MG
500 MG
35 %
100 %
1%
100000/G
120MG/1.5
2%
0.54G-2.7G
5%
25 %
3%
250 MG
4-15-1MG/1
130 MG
43 MG
STR N/A
99.9 %
99.9 %
99.9 %
2%-14%-2%
4G
70 %
3.5-10K-1
3.5-10K-1
1.75MG-10K
0.5 MG-50
6-45-8-25
0.5 MG-50
1%
400-20-20
2%-2%-2%
25 MG
5 MG-500MG
25 MG/ML
10 MG
2%
2%
5G
1%
26 %
87MG-788MG
35MG/ML
2-30-10/10
995064
995067
995073
995077
995081
995084
995088
995095
995110
995118
995122
995125
997625
1001593
1010298
1010298
1012249
1012249
1012264
1012264
1014123
1014197
1014305
1050325
1085618
1086634
1088953
1088965
1088970
1088977
1089027
1089030
1094410
1094438
1095618
1098125
1098140
1099631
1145348
1148107
1191260
1234966
1236068
1244558
1246594
1247576
1247576
ZODRYL AC 80
ZODRYL DAC 40
ZODRYL AC 35
ZODRYL DAC 35
ZODRYL DAC 60
ZODRYL AC 60
ZODRYL DAC 30
ZODRYL AC 30
ZODRYL DAC 25
ZODRYL AC 25
ZODRYL DAC 50
ZODRYL AC 50
SOJOURN
TACHOSIL
XYLOCAINE
XYLOCAINE
LIDA MANTLE HC
LIDA MANTLE HC
PERANEX HC
PERANEX HC
SSS 10-4
OTICIN
TACHOSIL
URYL
ALLFEN CDX
PLURATUSS
ZODRYL DEC 80
ZODRYL DEC 40
ZODRYL DEC 35
ZODRYL DEC 60
ZODRYL DEC 25
ZODRYL DEC 50
PROHIST CF
PROHIST LQ
PROHIST CD
DUOVISC
DUOVISC
ENDAL CD
FOLGARD RX
AZITHROMYCIN
SYNALAR
CENTUSSIN DHC
DESPEC-PDC
MITOSOL
DISCOVISC
FLUCAINE
FLUCAINE
2-10MG/10
1-15MG/4.5
1-4MG/4ML
1-15-4MG/4
2-30MG/7.5
2-7.5/7.5
1-15MG/3.5
1-3.5/3.5
1-15-3MG/3
1-3MG/3ML
2-30-5MG/5
2MG-5MG/5
STR N/A
9.5X4.8 CM
5%
5%
2 %-2 %
2 %-2 %
1 %-3 %
1 %-3 %
10 %-4 %
0.1%-1%
4.8X4.8 CM
81.6-.12MG
200-20MG/5
4-7.5-10/5
30-10MG/10
15-4.5/4.5
15-4-80/4
30-7.5/7.5
15-3-60/3
30-5-100/5
2.5-25MG/5
10-2.5MG/5
2.5-10-25
0.35-0.4
0.5-0.55
2-5-7.5/5
1-2.2-25MG
500 MG
0.025 %
4-7.5-3/5
7.5-3-2.5
0.2 MG
40-17MG/ML
0.5%-0.25%
0.5%-0.25%
1294248
1300019
1305890
1305892
1305895
1305898
1305904
1305906
1305908
1305910
1312969
1356799
1356802
1356806
1356809
1356817
1362065
1370770
1372496
OTICIN HC
AMBIFED DM
ARTISS-DUPLOJECT
ARTISS
TISSEEL VHSD
TISSEEL VHSD
TISSEEL VHSD
TISSEEL VHSD
ARTISS
ARTISS
NOVAFERRUM
BROVEX PB C
BROVEX CB
BROVEX PB CX
BROVEX CBX
BROVEX PB
HEPARIN LOCK FLUSH
HYDROCORTISONE BUTYRATE
EFFER-K
10-10-1/ML
400-20-30
4ML
2 ML
10ML
4ML
2 ML
2 ML
4ML
10ML
15 MG/ML
4-10-10MG
4MG-10MG
4-10-20MG
4MG-20MG
10 MG-4 MG
6 UNIT/3ML
0.1 %
25 MEQ
Please select the appropriate check box below to indicate which product is amended by this filing.
INDIVIDUAL HEALTH BENEFIT PLANS (Complete SECTION A only)
SMALL / LARGE GROUP HEALTH BENEFIT PLANS (Complete SECTION B only)
This form filing compliance summary is to be submitted with your [endorsement][contract] to comply with the immediate market reform
requirements of the Patient Protection and Affordable Care Act (PPACA). These PPACA requirements apply only to policies for health insurance
coverage referred to as major medical in the statute, which is comprehensive health coverage that includes PPO and HMO coverage. This form
includes the requirements for grandfathered (coverage in effect prior to March 23, 2010) and non-grandfathered plans, and relevant statutes. Refer to
the relevant statute to ensure compliance. Complete each item to confirm that diligent consideration has been given to each. (If submitting your filings
electronically, bookmark the provision(s) in the form(s) that satisfy the requirement and identify the page/paragraph on this form.)
*For all filings, include the Type of Insurance (TOI) in the first column.
Check box if this is a paper filing.
COMPANY INFORMATION
Company Name
BlueCross BlueShield of
Tennessee
NAIC Number
54518
SERFF Tracking
Number(s) *if applicable
BCTN-129000543
Form Number(s) of Policy

being endorsed
BlueCross Bronze B01B06
BlueCross Silver S01-S16, S18
BlueCross Gold G01-G08, G10-G11
BlueCross Platinum P01-P04
BlueCross MSP PPO B04, S09, S11,
S12, G08, G11
Rate Impact
Yes
No
-1-
Reset Form
SECTION A Individual Health Benefit Plans

TOI
Category
Eliminate Pre-existing Condition Exclusions for Enrollees

Under Age 19
Statute Section
Grandfathered
[Sections 2704 and 1255 of the

PHSA/Section 1201 of the PPACA]
N/A
[Section 2711 of the PHSA/Section

1001 of the PPACA]
N/A
NonGrandfathered
Yes
No
If no, please explain.
Explanation:
Page Number:
Eliminate Annual Dollar Limits on Essential Benefits
Except allows for restricted annual dollar limits for essential
benefits for plan years prior to January 1, 2014.
Yes
No
Explanation:
Page Number:
Eliminate Lifetime Dollar Limits on Essential Benefits

1001 of the PPACA]
Yes
No
Yes
No
Explanation:
Page Number:
Prohibit Rescissions Except for fraud or intentional
misrepresentation of material fact.

1001 of PPACA]
Yes
No
Yes
No
If no, please explain
Explanation:
Page Number:

TOI
Category
Preventive Services Requires coverage and prohibits the

imposition of cost-sharing for specified preventative services.
Statute Section
Grandfathered
N/A

1001 of the PPACA]
NonGrandfathered
Yes
No
Explanation:
Page Number:
Extends Dependent Coverage for Children Until age 26 If
a policy offers dependent coverage, it must include dependent
coverage until age 26.

1001 of the PPACA]
Yes
No
Yes
No
Explanation:
Page Number:
Appeals Process Requires establishment of an internal
claims appeal process and external review process.

1001 of the PPACA]
N/A
[Section 2719A of the PHSA/Section

10101 of the PPACA]
N/A
Yes
No
Explanation:
Page Number:
Emergency Services Requires plans that cover emergency
services to provide such coverage without the need for prior
authorization, regardless of the participating status of the
provider, and at the in-network cost-sharing level.
Yes
No
Explanation:
Page Number:

TOI
Category
Access to Pediatricians Mandates that if designation of a

PCP for a child is required, the person be permitted to designate
a physician who specialized in pediatrics as the childs PCP if
the provider is in-network.
Statute Section

10101 of the PPACA]
Grandfathered
NonGrandfathered
Yes
N/A
No
Explanation:
Page Number:
Access to OB/GYNs Prohibits authorization or referral
requirements for obstetrical or gynecological care provided by
in-network providers who specialize in obstetrics or
gynecology.

10101 of the PPACA]
Yes
N/A
No
Explanation:
Page Number:
Reset Form

SECTION B Group Health Benefit Plans (Small and Large)
TOI
Category
Eliminate Pre-existing Condition Exclusions for Enrollees

Under Age 19
Statute Section
[Sections 2704 of the PHSA/Section

1201 of the PPACA]
Grandfathered
Yes
No
NonGrandfathered
Yes
No
Explanation:
Page Number:
Eliminate Annual Dollar Limits on Essential Benefits
Except allows for restricted annual dollar limits for essential
benefits for plan years prior to January 1, 2014.

1001 of the PPACA]
Yes
No
Yes
No
Explanation:
Page Number:
Eliminate Lifetime Dollar Limits on Essential Benefits

1001 of the PPACA]
Yes
No
Yes
No
Explanation:
Page Number:
Prohibit Rescissions Except for fraud or intentional
misrepresentation of material fact.

1001 of PPACA]
Yes
No
Yes
No
Explanation:
Page Number:

TOI
Category
Preventive Services Requires coverage and prohibits the

imposition of cost-sharing for specified preventative services
Statute Section
Grandfathered

1001 of the PPACA]
N/A
NonGrandfathered
Yes
No
Explanation:
Page Number:
Extends Dependent Coverage for Children Until age 26 If
a policy offers dependent coverage, it must include dependent
coverage until age 26.

1001 of the PPACA]
Yes
No
Yes
No
Explanation:
Page Number:
Appeals Process Requires establishment of an internal
claims appeal process and external review process.

1001 of the PPACA]
N/A
Yes
No
Explanation:
Page Number:
For plan years beginning before January 1, 2014, grandfathered group plans are not required to extend coverage to a child until the age of 26 if such child is
eligible to enroll in another employee-sponsored plan

TOI
Category
Emergency Services Requires plans that cover emergency

services to provide such coverage without the need for prior
authorization, regardless of the participating status of the
provider, and at the in-network cost-sharing level.
Statute Section

10101 of the PPACA]
Grandfathered
NonGrandfathered
Yes
N/A
No
Explanation:
Page Number:
Access to Pediatricians Mandates that if designation of a
PCP for a child is required, the person be permitted to
designate a physician who specialized in pediatrics as the
childs PCP if the provider is in-network.

10101 of the PPACA]
Yes
N/A
No
Explanation:
Page Number:
Access to OB/GYNs Prohibits authorization or referral
requirements for obstetrical or gynecological care provided by
in-network providers who specialize in obstetrics or
gynecology.

10101 of the PPACA]
Yes
N/A
No
Explanation:
Page Number:

www.bcbst.com
May 22, 2013
Ms. Victoria Stotzer
Tennessee Department of Commerce and Insurance
Actuarial Section, 4th Floor
500 James Robertson Parkway
Nashville, Tennessee 37243-1130
RE: BCBST INDV ONOFFEX Rev 04-2013 and related schedules
Dear Ms. Stotzer:
I apologize for the confusion, but our internal business unit has determined that some changes
need to be made to the attached schedules.
The following changes were made to the schedules. I am amending the filing, but wanted to
explain what the changes were.
Pharmacy Benefit Changes
Days Supply was corrected for the Pharmacy Prescription Drug Program for retail and
mail order Prescriptions on plans with a Ded/Coins Rx benefit
o
o
Retail network changed from up to 100 days to up to 30 days

Mail Order Network changed from up to 102 days to up to 90 days and the ESI
Select90 Network was added
The Provider-Administered Specialty Drugs benefit under the Practitioner OV section was
updated for all plans with an OV Copay
o
In-network benefits were changed from matching the OV benefit to match the
Specialty Drugs benefit for Self-administered Specialty Drugs
Medical Benefit Changes

The OON Ambulance benefit was changed for all plans to match the In-Network
coinsurance percentage with a MAC cut, instead of being at the standard OON benefit
level (50% of the MAC after Deductible)
o This was an oversight on our part that was replicated on our Plans & Benefits
template for the QHP submission and should return a deficiency were trying to
be proactive by making this correction to the schedules at this time.
For all plans with an OV Copay, the Office Surgery benefit was changed to pay standard
medical benefits (Ded/Coins) instead of apply the OV copay and the following fields were
updated to pay at 100% In-Network: Allergy testing; Allergy injections and allergy extract;
All other medicine injections, excluding Specialty Drugs; Supplies (associated with
Practitioner OV); and All Other Diagnostic Services for illness, injury or maternity care
(any place of service).
For plans with a split OV Copay benefit (PCP/Specialist), verbiage was added to the
schedule under the Diagnosis and treatment of illness and injury to define the Primary
Care Practitioner types (Internal Medicine, General Practice, Family Medicine, Pediatrics,
Obstetrics & Gynecology, Physician Assistant, Nurse Practitioner) and Specialists are
listed as All other Practitioners.
Additionally, the Maternity care benefit was updated to include only the PCP level
copay and the Non-routine treatments benefit was updated to include only the
Specialist level copay instead of listing both copay levels.
For HSA-qualified plans (B01, B02, B03, B04, B05, S09, S16), the Hospice benefit was
changed from 100% to match the standard Deductible/Coinsurance.
o
In order for a plan to be HSA-qualified, it cannot have any first dollar coverage.
This was an oversight on our part that was replicated on our Plans & Benefits
template for the QHP submission and should return a deficiency since these
plans were marked as HSA-compatible were trying to be proactive by making
this correction to the schedules at this time.
Thank you for your understanding. Your prompt attention is appreciated. If you have any
questions or need additional information, please e-mail Christina_Hart@bcbst.com or call (423)
535-3344.
Sincerely,
Christina Hart
Associate Contract Development Analyst
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:
Superseded Schedule Items

Please note that all items on the following pages are items, which have been replaced by a newer version. The newest version is located with the appropriate schedule
on previous pages. These items are in date order with most recent first.
Creation Date
Schedule Item
Status
Schedule
Schedule Item Name
Replacement
Creation Date
Attached Document(s)
06/26/2013
Replaced
07/31/2013
Supporting
Document
07/17/2013

(Abbreviated for TDCI Filing).xlsx
(Superceded)
05/23/2013
Replaced
07/31/2013
Form
Gold Schedules Network P G01 G02 and

G03
07/31/2013
Gold Schedules Network P G01 G02

and G03 rev.pdf (Superceded)
05/23/2013
Replaced
07/31/2013
Form
Gold Schedules Network P G04 G05 G06

and G07
07/31/2013

G06 and G07 rev.pdf (Superceded)
05/23/2013
Replaced
07/31/2013
Form
Gold Schedules Network S G01 G02 and

G03
07/31/2013
Gold Schedules Network S G01 G02

05/23/2013
Replaced
07/31/2013
Form
Gold Schedules Network S G04 G05 G06

and G07
07/31/2013

G06 and G07 rev.pdf (Superceded)
05/23/2013
Replaced
07/31/2013
Form
Gold Schedules Network E G08 G10 and

G11
06/26/2013
Gold Schedules Network E G08 G10

05/23/2013
Replaced
07/31/2013
Form

G11
06/26/2013

05/23/2013
Replaced
07/31/2013
Form

G11
06/26/2013

04/30/2013
Replaced
07/31/2013
Form
Individual Policy
06/26/2013
Individual Policy Language Core 4 1

and Exchange_Final Version rev
043013.pdf (Superceded)
04/29/2013
Replaced
07/31/2013
Form
05/23/2013
Bronze Schedules Network E.pdf

(Superceded)
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Product Name:
Creation Date
Filing Company:
Schedule Item
Status
Schedule
Schedule Item Name
Replacement
Creation Date
04/29/2013
Replaced
07/31/2013
Form
05/23/2013
Bronze Schedules Network P.pdf

(Superceded)
04/29/2013
Replaced
07/31/2013
Form
05/23/2013

revised.pdf (Superceded)
04/29/2013
Replaced
07/31/2013
Form
05/23/2013
Gold Schedules Network E G01 and

G02.pdf (Superceded)
04/29/2013
Replaced
07/31/2013
Form
05/23/2013
Gold Schedules Network E G04 and

G06.pdf (Superceded)
04/29/2013
Replaced
07/31/2013
Form
Gold Schedules Network E G08 G10 and

G11
05/23/2013
Gold Schedules Network E G08 G10

and G11.pdf (Superceded)
04/29/2013
Replaced
07/31/2013
Form

G03
05/23/2013

04/29/2013
Replaced
07/31/2013
Form
Gold Schedules Network P G04 G05 G06

and G07
05/23/2013

G06 and G07.pdf (Superceded)
04/29/2013
Replaced
07/31/2013
Form

G11
05/23/2013

04/29/2013
Replaced
07/31/2013
Form

G03
05/23/2013

04/29/2013
Replaced
07/31/2013
Form
Gold Schedules Network S G04 G05 G06

and G07
05/23/2013

G06 and G07.pdf (Superceded)
04/29/2013
Replaced
07/31/2013
Form

G11
05/23/2013

04/29/2013
Replaced
07/31/2013
Form
05/23/2013
Platinum Schedules Network E.pdf

(Superceded)
04/29/2013
Replaced
07/31/2013
Form
05/23/2013
Platinum Schedules Network P.pdf

(Superceded)
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Product Name:
Creation Date
04/29/2013
Filing Company:
Schedule Item
Status
Schedule
Replaced
07/31/2013
Form
Schedule Item Name
Replacement
Creation Date
05/23/2013
Platinum Schedules Network S.pdf
(Superceded)
SERFF Tracking #:
BCTN-129004734
State Tracking #:
H-130554
Company Tracking #:
State:
Tennessee
TOI/Sub-TOI:
Filing Company:
Product Name:
Attachment BCBST Individual Benefits Template (Abbreviated for TDCI Filing).xlsx is not a PDF
document and cannot be reproduced here.

Product Name: G01
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs

sigmoidoscopy
Outpatient Surgery
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
65% of the Maximum

Deductible
65% of the Maximum

Deductible
65% of the Maximum

Deductible
65% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
65% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
65% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
65% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
65% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$5,250
$15,750
Family Members.
1.
Page 10

Product Name: G02
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
75% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
75% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Product Name: G03
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription after $500
Brand Deductible
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply

Two months supply
Three months supply
(31 to 60 days)
(61 to 90 days)
(Up to 30 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60 after
N/A
N/A

Select90 Network
$8/$35/$60 after
$16/$70/$120 after
$24/$105/$180 after
Page 7
Out-of-Network 4
Specialty Drugs 1,2

list.
$120 Copayment per Prescription after $500 Brand Deductible
Out-of-Network
Not Covered
Pediatric Dental
Covered Services
Periodontics
Network Dentist
100%
100% of the Maximum

Deductible
80%
80% of the Maximum

Deductible
50%
50% of the Maximum

Deductible
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,000
$2,000
Family Members
Individual
Family
$4,000
$12,000
Family Members.
Copayment.
1.
Page 10

Product Name: G04
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
80% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,000
$2,000
Family Members
Individual
Family
$4,000
$12,000
Family Members.
Copayment.
1.
Page 10

Product Name: G05
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Brand Deductible
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply

Two months supply
Three months supply
(31 to 60 days)
(61 to 90 days)
(Up to 30 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60 after
N/A
N/A

Select90 Network
$8/$35/$60 after
$16/$70/$120 after
$24/$105/$180 after
Page 7
Out-of-Network 4
Specialty Drugs 1,2

list.
Out-of-Network
Not Covered
Pediatric Dental
Covered Services
Periodontics
Network Dentist
100%
100% of the Maximum

Deductible
80%
80% of the Maximum

Deductible
50%
50% of the Maximum

Deductible
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,500
$3,000
Family Members
Individual
Family
$4,500
$13,500
Family Members.
Copayment.
1.
Page 10

Product Name: G06
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
80% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,500
$3,000
Family Members
Individual
Family
$4,500
$13,500
Family Members.
Copayment.
1.
Page 10

Product Name: G07
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
100% after
$10 Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$10 Copayment
Allergy testing
100%
100%

sigmoidoscopy
Outpatient Surgery

Drugs
$100 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$10 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% after
$250 Copayment
100% of the Maximum

$250 Copayment
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
80% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$3/$25/$50
N/A
N/A

Select90 Network
$3/$25/$50
$6/$50/$100
$9/$75/$150
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,000
$4,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
Copayment.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
65% after
Deductible
Maternity care
65% after
Deductible
100%
Allergy testing
65% after
Deductible
100%
65% after
Deductible
100%
65% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
65% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

65% after
Deductible

65% after
Deductible

benefit.
Supplies
65% after
Deductible
Page 3

Facility charges
65% after
Deductible
100%

service)
65% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
65% after
Deductible
100%
65% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
65% after
Deductible
100%
65% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
65% after
Deductible
100%
65% after
Deductible
100%

65% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
65% after
Deductible
65% after
Deductible
100%
65% of the
Maximum
Allowable Charge
after Deductible
100%
65% of the
Maximum
Allowable Charge
after Deductible
65% after
Deductible
100%
65% after
Deductible
100%
65% of the
Maximum
Allowable Charge
after Deductible
65% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
65% after
Deductible
65% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
65% after
Deductible
Page 6

65% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
65% after
Deductible

65% after
Deductible
100%
Ambulance
65% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
65% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
65% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
65% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
65% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$5,250
$15,750
Family Members.
1.
Page 11

Product Name: G01
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs

sigmoidoscopy
Outpatient Surgery
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
65% of the Maximum

Deductible
65% of the Maximum

Deductible
65% of the Maximum

Deductible
65% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
65% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
65% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
65% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
65% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$5,250
$15,750
Family Members.
1.
Page 10

Product Name: G01
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs

sigmoidoscopy
Outpatient Surgery
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
65% of the Maximum

Deductible
65% of the Maximum

Deductible
65% of the Maximum

Deductible
65% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
65% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
65% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
65% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
65% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$5,250
$15,750
Family Members.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
75% after
Deductible
Maternity care
75% after
Deductible
100%
Allergy testing
75% after
Deductible
100%
75% after
Deductible
100%
75% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

75% after
Deductible

75% after
Deductible

benefit.
Supplies
75% after
Deductible
Page 3

Facility charges
75% after
Deductible
100%

service)
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
75% after
Deductible
100%
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
75% after
Deductible
100%
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
75% after
Deductible
100%
75% after
Deductible
100%

75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
75% after
Deductible
75% after
Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
75% after
Deductible
100%
75% after
Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
75% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
75% after
Deductible
75% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
75% after
Deductible
Page 6

75% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
75% after
Deductible

75% after
Deductible
100%
Ambulance
75% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
75% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
75% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 11

Product Name: G02
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
75% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
75% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Product Name: G02
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
75% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
75% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Product Name: G03
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Brand Deductible
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply

Two months supply
Three months supply
(31 to 60 days)
(61 to 90 days)
(Up to 30 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60 after
N/A
N/A

Select90 Network
$8/$35/$60 after
$16/$70/$120 after
$24/$105/$180 after
Page 7
Out-of-Network 4
Specialty Drugs 1,2

list.
Out-of-Network
Not Covered
Pediatric Dental
Covered Services
Periodontics
Network Dentist
100%
100% of the Maximum

Deductible
80%
80% of the Maximum

Deductible
50%
50% of the Maximum

Deductible
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,000
$2,000
Family Members
Individual
Family
$4,000
$12,000
Family Members.
Copayment.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$0 Copayment
N/A
N/A

Select90 Network
$0 Copayment
$0 Copayment
$0 Copayment
Out-of-Network 4
Page 7
Specialty Drugs 1,2
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
Copayment.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1

Covered Services
Providers
Covered Services

pregnancy
100%

sigmoidoscopy
Outpatient Surgery
Covered Services
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Benefits for
Benefits for
Covered Services
Covered Services
Covered Services
received from
received from
received from
Indian Health
Network Providers
Out-of-Network
Providers
Providers

100% after
$35 Copayment
100% after $50

Copayment
100%
Maternity care
100% after
$35 Copayment
100%
Allergy testing
100%
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Specialty Drugs
Surgery.
$120 Copayment per

Prescription
100%
100%
100%

50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
$50 Copayment

applicable benefit.
Supplies
100%
Page 3

Facility charges
80% after
Deductible
100%

service)
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
80% after
Deductible
100%
80% after
Deductible
100%

80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
80% after
Deductible
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% after
Deductible
100%
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
80% after
Deductible
100%
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
80% after
Deductible
Page 6

80% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
80% after
Deductible

80% after
Deductible
100%
Ambulance
80% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
80% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply
(Up to 30 days)
Generic Drug /
Non-Preferred Brand
Drug3
Two months supply

(31 to 60 days)
Generic Drug /
Non-Preferred Brand
Drug3
Three months supply

(61 to 90 days)
Generic Drug /
Non-Preferred Brand
Drug3
Retail network
$8/$35/$60
N/A
N/A

Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 8
Out-of-Network 4
100%
Specialty Drugs 1,2

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,000
$2,000
Family Members
Individual
Family
$4,000
$12,000
Family Members.
Copayment.
1.
Page 11

Product Name: G04
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
80% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,000
$2,000
Family Members
Individual
Family
$4,000
$12,000
Family Members.
Copayment.
1.
Page 10

Product Name: G04
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
80% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,000
$2,000
Family Members
Individual
Family
$4,000
$12,000
Family Members.
Copayment.
1.
Page 10

Product Name: G05
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Brand Deductible
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply

Two months supply
Three months supply
(31 to 60 days)
(61 to 90 days)
(Up to 30 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60 after
N/A
N/A

Select90 Network
$8/$35/$60 after
$16/$70/$120 after
$24/$105/$180 after
Page 7
Out-of-Network 4
Specialty Drugs 1,2

list.
Out-of-Network
Not Covered
Pediatric Dental
Covered Services
Periodontics
Network Dentist
100%
100% of the Maximum

Deductible
80%
80% of the Maximum

Deductible
50%
50% of the Maximum

Deductible
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,500
$3,000
Family Members
Individual
Family
$4,500
$13,500
Family Members.
Copayment.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$0 Copayment
N/A
N/A

Select90 Network
$0 Copayment
$0 Copayment
$0 Copayment
Out-of-Network 4
Page 7
Specialty Drugs 1,2
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
Copayment.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1

Covered Services
Providers
Covered Services

pregnancy
100%

sigmoidoscopy
Outpatient Surgery
Covered Services
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Benefits for
Benefits for
Covered Services
Covered Services
Covered Services
received from
received from
received from
Indian Health
Network Providers
Out-of-Network
Providers
Providers

100% after
$35 Copayment
100% after $50

Copayment
100%
Maternity care
100% after
$35 Copayment
100%
Allergy testing
100%
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Specialty Drugs
Surgery.
$120 Copayment per

Prescription
100%
100%
100%

50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
$50 Copayment

applicable benefit.
Supplies
100%
Page 3

Facility charges
80% after
Deductible
100%

service)
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
80% after
Deductible
100%
80% after
Deductible
100%

80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
80% after
Deductible
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% after
Deductible
100%
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
80% after
Deductible
100%
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
80% after
Deductible
Page 6

80% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
80% after
Deductible

80% after
Deductible
100%
Ambulance
80% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
80% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply
(Up to 30 days)
Generic Drug /
Non-Preferred Brand
Drug3
Two months supply

(31 to 60 days)
Generic Drug /
Non-Preferred Brand
Drug3
Three months supply

(61 to 90 days)
Generic Drug /
Non-Preferred Brand
Drug3
Retail network
$8/$35/$60
N/A
N/A

Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 8
Out-of-Network 4
100%
Specialty Drugs 1,2

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,500
$3,000
Family Members
Individual
Family
$4,500
$13,500
Family Members.
Copayment.
1.
Page 11

Product Name: G06
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
80% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,500
$3,000
Family Members
Individual
Family
$4,500
$13,500
Family Members.
Copayment.
1.
Page 10

Product Name: G06
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
80% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,500
$3,000
Family Members
Individual
Family
$4,500
$13,500
Family Members.
Copayment.
1.
Page 10

Product Name: G07
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
100% after
$10 Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$10 Copayment
Allergy testing
100%
100%

sigmoidoscopy
Outpatient Surgery

Drugs
$100 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
100% after
$10 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% after
$250 Copayment
100% of the Maximum

$250 Copayment
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
80% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
80% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$3/$25/$50
N/A
N/A

Select90 Network
$3/$25/$50
$6/$50/$100
$9/$75/$150
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,000
$4,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
Copayment.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
100% after
Deductible
Maternity care
100% after
Deductible
100%
Allergy testing
100% after
Deductible
100%
100% after
Deductible
100%
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
Deductible

100% after
Deductible

benefit.
Supplies
100% after
Deductible
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
100% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,100
$4,200
Family Members
Individual
Family
$2,100
$6,300
Family Members.
1.
Page 11

Product Name: G08
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,100
$4,200
Family Members
Individual
Family
$2,100
$6,300
Family Members.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
100%
Maternity care
100% after
$35 Copayment
100%
Allergy testing
100%
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
$100 Copayment
per Prescription
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
$50 Copayment

benefit.
Supplies
100%
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
100% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

list.
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
1.
Page 11

Product Name: G10
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$100 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Deductible
50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
100% after Network


90 days
days
Out-of-Network 2
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$0 Copayment
N/A
N/A

Select90 Network
$0 Copayment
$0 Copayment
$0 Copayment
Out-of-Network 4
Page 7
Specialty Drugs 1,2
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
Copayment.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1

Covered Services
Providers
Covered Services

pregnancy
100%

sigmoidoscopy
Outpatient Surgery
Covered Services
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Benefits for
Benefits for
Covered Services
Covered Services
Covered Services
received from
received from
received from
Indian Health
Network Providers
Out-of-Network
Providers
Providers

100% after
$35 Copayment
100% after $50

Copayment
100%
Maternity care
100% after
$35 Copayment
100%
Allergy testing
100%
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Specialty Drugs
Surgery.
$120 Copayment per

Prescription
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
$50 Copayment

applicable benefit.
Supplies
100%
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
100% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply
(Up to 30 days)
Generic Drug /
Non-Preferred Brand
Drug3
Two months supply

(31 to 60 days)
Generic Drug /
Non-Preferred Brand
Drug3
Three months supply

(61 to 90 days)
Generic Drug /
Non-Preferred Brand
Drug3
Retail network
$8/$35/$60
N/A
N/A

Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 8
Out-of-Network 4
100%
Specialty Drugs 1,2

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
Copayment.
1.
Page 11

Product Name: G11
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Deductible
50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
100% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Covered Services
Periodontics
Network Dentist
100%
100% of the Maximum

Deductible
80%
80% of the Maximum

Deductible
50%
50% of the Maximum

Deductible
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
Copayment.
1.
Page 10

Network: P
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
100% after
Deductible
Maternity care
100% after
Deductible
100%
Allergy testing
100% after
Deductible
100%
100% after
Deductible
100%
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
Deductible

100% after
Deductible

benefit.
Supplies
100% after
Deductible
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
100% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,100
$4,200
Family Members
Individual
Family
$2,100
$6,300
Family Members.
1.
Page 11

Product Name: G08
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,100
$4,200
Family Members
Individual
Family
$2,100
$6,300
Family Members.
1.
Page 10

Product Name: G08
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,100
$4,200
Family Members
Individual
Family
$2,100
$6,300
Family Members.
1.
Page 10

Product Name: G10
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$100 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Deductible
50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
100% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
days

90 days
Out-of-Network 2
Page 7
Specialty Drugs 1
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
1.
Page 10

Network: P
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$0 Copayment
N/A
N/A

Select90 Network
$0 Copayment
$0 Copayment
$0 Copayment
Out-of-Network 4
Page 7
Specialty Drugs 1,2
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
Copayment.
1.
Page 10

Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1

Covered Services
Providers
Covered Services

pregnancy
100%

sigmoidoscopy
Outpatient Surgery
Covered Services
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Benefits for
Benefits for
Covered Services
Covered Services
Covered Services
received from
received from
received from
Indian Health
Network Providers
Out-of-Network
Providers
Providers

100% after
$35 Copayment
100% after $50

Copayment
100%
Maternity care
100% after
$35 Copayment
100%
Allergy testing
100%
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Specialty Drugs
Surgery.
$120 Copayment per

Prescription
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
$50 Copayment

applicable benefit.
Supplies
100%
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
100% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply
(Up to 30 days)
Generic Drug /
Non-Preferred Brand
Drug3
Two months supply

(31 to 60 days)
Generic Drug /
Non-Preferred Brand
Drug3
Three months supply

(61 to 90 days)
Generic Drug /
Non-Preferred Brand
Drug3
Retail network
$8/$35/$60
N/A
N/A

Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 8
Out-of-Network 4
100%
Specialty Drugs 1,2

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
Copayment.
1.
Page 11

Product Name: G11
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Deductible
50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
100% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Covered Services
Periodontics
Network Dentist
100%
100% of the Maximum

Deductible
80%
80% of the Maximum

Deductible
50%
50% of the Maximum

Deductible
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
Copayment.
1.
Page 10

Product Name: G11
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Deductible
50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
100% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Covered Services
Periodontics
Network Dentist
100%
100% of the Maximum

Deductible
80%
80% of the Maximum

Deductible
50%
50% of the Maximum

Deductible
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
Copayment.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
100% after
Deductible
Maternity care
100% after
Deductible
100%
Allergy testing
100% after
Deductible
100%
100% after
Deductible
100%
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
Deductible

100% after
Deductible

benefit.
Supplies
100% after
Deductible
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
100% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,100
$4,200
Family Members
Individual
Family
$2,100
$6,300
Family Members.
1.
Page 11

Product Name: G08
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,100
$4,200
Family Members
Individual
Family
$2,100
$6,300
Family Members.
1.
Page 10

Product Name: G08
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,100
$4,200
Family Members
Individual
Family
$2,100
$6,300
Family Members.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
100%
Maternity care
100% after
$35 Copayment
100%
Allergy testing
100%
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
$100 Copayment
per Prescription
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
$50 Copayment

benefit.
Supplies
100%
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
100% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

100%
Page 8
Out-of-Network 2
Specialty Drugs 1

list.
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
1.
Page 11

Product Name: G10
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$100 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Deductible
50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
100% after Network


90 days
days
Out-of-Network 2
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
1.
Page 10

Product Name: G10
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$100 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Deductible
50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
100% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
days

90 days
Out-of-Network 2
Page 7
Specialty Drugs 1
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$0 Copayment
N/A
N/A

Select90 Network
$0 Copayment
$0 Copayment
$0 Copayment
Out-of-Network 4
Page 7
Specialty Drugs 1,2
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
Copayment.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1

Covered Services
Providers
Covered Services

pregnancy
100%

sigmoidoscopy
Outpatient Surgery
Covered Services
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Benefits for
Benefits for
Covered Services
Covered Services
Covered Services
received from
received from
received from
Indian Health
Network Providers
Out-of-Network
Providers
Providers

100% after
$35 Copayment
100% after $50

Copayment
100%
Maternity care
100% after
$35 Copayment
100%
Allergy testing
100%
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Specialty Drugs
Surgery.
$120 Copayment per

Prescription
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
$50 Copayment

applicable benefit.
Supplies
100%
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
100% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply
(Up to 30 days)
Generic Drug /
Non-Preferred Brand
Drug3
Two months supply

(31 to 60 days)
Generic Drug /
Non-Preferred Brand
Drug3
Three months supply

(61 to 90 days)
Generic Drug /
Non-Preferred Brand
Drug3
Retail network
$8/$35/$60
N/A
N/A

Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 8
Out-of-Network 4
100%
Specialty Drugs 1,2

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
Copayment.
1.
Page 11

Product Name: G11
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Deductible
50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
100% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Covered Services
Periodontics
Network Dentist
100%
100% of the Maximum

Deductible
80%
80% of the Maximum

Deductible
50%
50% of the Maximum

Deductible
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
Copayment.
1.
Page 10

Product Name: G11
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

Practitioner)
100% after
$35 Copayment
100% after $50

Copayment
50% of the Maximum

Deductible
Maternity care
100% after
$35 Copayment
Allergy testing
100%
100%

Drugs
50% of the Maximum
Deductible
$120 Copayment per

Prescription
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Deductible
50% of the Maximum

Deductible
100% after
$50 Copayment
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
100% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
100% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Covered Services
Periodontics
Network Dentist
100%
100% of the Maximum

Deductible
80%
80% of the Maximum

Deductible
50%
50% of the Maximum

Deductible
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
Copayment.
1.
Page 10
BLUECROSS BLUESHIELD OF TENNESSEE, INC.

PERSONAL HEALTH COVERAGE
[POLICY No. [xxxxxxxxxxxxx]]

[Effective Date [xx/xx/xxxx]]
[Premium [$xxxxx] per month]
NOTICE
Please read this Policy carefully and keep it in a safe place for future reference. It explains
Your Coverage from BlueCross BlueShield of Tennessee, Inc. If You have any questions about
this Policy or any matter related to Your membership in this Policy, please write or call Us at:
Customer Service Department
BlueCross BlueShield of Tennessee, Inc.
[1 Cameron Hill Circle]
[CHATTANOOGA, TENNESSEE 37402-0002]
[(800) 565-9140]
This Policy provides coverage for reconstructive breast surgery in certain

situations. Please read Your Policy carefully.
You may return this Policy within ten (10) days after its delivery and receive a
Premium refund if, after examination, you are not satisfied with it. Any benefits paid
will be deducted from the Premium refund.
This Policy pays secondary to other individual or group insurance coverage.
You are responsible for obtaining Prior Authorization when using a BlueCard PPO
Participating Provider or an Out of Network Provider.
[G. Henry Smith]

[Senior Vice-President, Operations and Chief Marketing Officer]
BCBST-INDV -ONOFFEX Rev 04-2013
TABLE OF CONTENTS
GET THE MOST FROM YOUR BENEFITS ...................................................................................... [!]

ENROLLING IN THE PLAN ......................................................................................................... [!]
WHEN COVERAGE BEGINS ....................................................................................................... [!]
WHEN COVERAGE ENDS .......................................................................................................... [!]
GENERAL PROVISIONS ............................................................................................................. [!]
PRIOR AUTHORIZATION, CARE MANAGEMENT, MEDICAL POLICY AND PATIENT SAFETY.............. [!]
INTER-PLAN PROGRAMS .......................................................................................................... [!]
CLAIMS AND PAYMENT ........................................................................................................... [!]
GRIEVANCE PROCEDURE .......................................................................................................... [!]
NOTICE OF PRIVACY PRACTICES ............................................................................................... [!]
GENERAL LEGAL PROVISIONS ................................................................................................... [!]
INDEPENDENT LICENSEE OF THE BLUECROSS BLUESHIELD ASSOCIATION .................................... [!]
RELATIONSHIP WITH NETWORK PROVIDERS ............................................................................. [!]
STATEMENT OF RIGHTS UNDER THE NEWBORNS AND MOTHERS HEALTH PROTECTION
ACT ........................................................................................................................................ [!]
WOMEN'S HEALTH AND CANCER RIGHTS ACT OF 1998 .............................................................. [!]
GOVERNING LAWS .................................................................................................................. [!]
SUBROGATION OR RIGHT OF RECOVERY ................................................................................... [!]
DEFINITIONS ........................................................................................................................... [!]
Attachment D: ........................................................................................................................ [!]
ELIGIBILITY .............................................................................................................................. [!]
Get the Most from Your Benefits

1. Please Read Your Policy carefully. This Policy describes the terms and conditions of Your
Coverage and includes all attachments, which are incorporated herein by reference.
BlueCross, "We," "Us" and "Our" mean BlueCross BlueShield of Tennessee, Inc. You and
Your mean a Subscriber. Subscriber means the individual to whom We have issued this
Policy. Member means a Subscriber or a Covered Dependent. Coverage means the
insurance benefits Members are entitled to under this Policy.
Please read this Policy carefully. It describes Your rights and duties as a
Subscriber/Member. It is important to read the entire Policy. Certain services are not
Covered by Us. Other Covered services are limited.
Any Grievance related to Coverage under this Policy will be resolved in accordance with
the Grievance Procedure section of this Policy.
Questions: Please contact one of Our consumer advisors at the number on the back of Your
Member ID card, if You have any questions when reading this Policy. Our consumer advisors
are also available to discuss any other matter related to Your Coverage under this Policy.
2. How A PPO Plan Works - You have a PPO plan. BlueCross BlueShield of Tennessee contracts
with a network of doctors, hospitals and other health care facilities and professionals.
These Providers, called Network Providers, agree to special pricing arrangements.
Your PPO plan has two levels of benefits. By using Network Providers, You receive the
highest level of benefits. However, You can choose to use Providers that are not Network
Providers. These Providers are called Out-of-Network Providers. When You use Out-ofNetwork Providers, Your benefits will be lower. You will also be responsible for amounts
that an Out-of-Network Provider bills above Our Maximum Allowable Charge and any
amounts not Covered by Your Plan.
Attachment A: Covered Services and Exclusions details medical Covered Services and
exclusions and Attachment B: Other Exclusions lists services excluded under the Plan.
Attachment C: Schedule of Benefits, shows how Your benefits vary for services received
from Network and Out-of-Network Providers. Attachment C: Schedule of Benefits will also
show You that the same service might be paid differently depending on where You receive
the service.
By using Network Providers, You maximize Your benefits and avoid being billed the
difference between what the Plan pays and what the Out-of-Network Provider charges.
This amount can be substantial.
3. Your BlueCross BlueShield of Tennessee Identification Card. Once Your Coverage becomes
effective, You will receive a BlueCross BlueShield of Tennessee, Inc. Member identification
(ID) card. Doctors and hospitals nationwide recognize it. The Member ID card is the key to
receiving the benefits of the health plan. Carry it at all times. Please be sure to show the
Member ID card each time You receive medical services, especially whenever a Provider
recommends hospitalization.
Our customer service number is on the back of Your Member ID card. This is an important
phone number. Call this number if You have any questions. Also, call this number if You are
receiving services from Providers outside of Tennessee or from Out-of-Network Providers to
make sure all Prior Authorization procedures have been followed. See the section entitled
Prior Authorization for more information.
If Your Member ID card is lost or stolen, or another card is needed for a Covered Dependent
not living with You, use Member self-service on bcbst.com or call the number listed at the
beginning of this Policy. You may want to record Your Member ID number for safekeeping.
4. Always use Network Providers, including pharmacies, durable medical equipment suppliers,
skilled nursing facilities and home infusion therapy Providers. See Attachment A: Covered
Services and Exclusions for an explanation of a Network Provider. Call the Plans consumer
advisors to verify that a Provider is a Network Provider or visit bcbst.com and click Find a
Doctor.
If Your doctor refers You to another doctor, hospital or other health care Provider, or You
see a covering physician in Your doctors practice, please make sure that the Provider is a
Network Provider. When using Out-of-Network Providers, You will be responsible for the
difference between what the Plan pays and what the Out-of-Network Provider charges.
This amount can be substantial.
5. Ask Our consumer advisors if the Provider is in the specific network shown on Your Member
ID card. Since BlueCross has several networks, a Provider may be in one BlueCross network,
but not in all of Our networks. Check out Our website, bcbst.com, for more information on
Providers in each network.
6. To find out if BlueCross considers a service to be Medically Necessary, please refer to Our
Medical Policy Manual at bcbst.com. Search for Medical Policy Manual. Decisions about
whether a service is Experimental/Investigational or Medically Necessary are for the
purposes of determining what is Covered under this Policy. You and Your doctor decide
what services You will receive.
7. Prior Authorization is required for certain services. Reference the Prior Authorization, Care
Management, Medical Policy and Patient Safety section of Your Policy for a partial list.
Make sure Your Provider obtains Prior Authorization before any planned hospital stays
(except maternity admissions), skilled nursing and rehabilitative facility admissions, certain
outpatient procedures, Advanced Radiological Imaging services, and before ordering certain
Specialty Drugs, and Durable Medical Equipment. Call Our consumer advisors to find out if
Your admission or other service has received Prior Authorization.
8. To save money when getting a Prescription filled, ask if a generic equivalent is available.
9. In a true Emergency it is appropriate to go to an Emergency room (see Emergency definition
in the Definitions Section of this Policy.) However, most conditions are not Emergencies and
are best handled with a call to Your doctors office.
[You also can call the 24/7 Nurseline, where a registered nurse will help You decide the right
care at the right time in the right place. Call toll-free [1-800-818-8581] to speak one-on-one
with a Registered Nurse[ or for hearing impaired dial [TTY 1-888-308-7231]].
10. Ask that Your Provider report any Emergency admissions to BlueCross within 24 hours or the
next business day.
11. Get a second opinion before undergoing elective Surgery.
12. When You are contemplating Surgery or facing a medical decision, get support and advice by
calling [1-800-818-8581][ or for hearing impaired dial [TTY 1-888-309-7231]]. Many
conditions have more than one valid treatment option. Our nurses can help You discuss
these treatment options with Your doctor so that You can make an informed decision.
Some common conditions with multiple treatment options include:
Back pain;
Heart bypass Surgery and angioplasty;
Womens health including uterine problems, hysterectomy, maternity, menopause,

hormone replacement, and ovarian cancer; arthritis of the major joints;
Mens health, including benign prostatic hyperplasia, cancer, and PSA testing;
Breast cancer and ductal carcinoma in situ, including surgical and other therapy, and
reconstruction.
13. [Our contracts with Providers include alternative payment methodologies including, but not
limited to:
Diagnosis Related Group (DRG) payments
Discounted fee-for-service payments[, and ]
Patient-centered medical home programs[, and ][.]
[Bundled payments for episodes of care.]
Your cost share will be based on the applicable contracted payment methodology for the
services received. [In the case of bundled payments for episodes of care, Your cost share
may be based on the lead Provider for that episode of care. For example, if you have knee
replacement Surgery and the surgeon and hospital participate in a bundled payment
program, Your cost share for all services included in the bundled episode of care will be
based on the inpatient hospital services section of the Schedule of Benefits.]
14. Notify [Our consumer advisors at the number listed on the back of Your Member ID
card][the Exchange at [XXX-XXX-XXXX]] if changes in the following occur for You or any of
Your Covered Dependents:
Name
Address
Telephone number
Status of any other health insurance You might have
Birth of additional dependents
Marriage or divorce
Death
Adoption
[Citizenship status]
RIGHT TO RECEIVE AND RELEASE INFORMATION You authorize Our receipt, use and release of
personal information for Yourself and all Covered Dependents. This authorization includes any
and all medical records, obtained, used or released in connection with administration of the
Policy, subject to applicable laws. Such authorization is deemed given by Your signature on the
Application. Additional authorization and/or consent may be required whenever You obtain
Covered Services under this Policy. This authorization remains in effect throughout the period
You are Covered under this Policy. This authorization survives the termination of the Coverage
to the extent that such information or records relate to services rendered while You were
insured under the Policy.
You may also be required to authorize the release of personally identifiable health information
in connection with the administration of the Policy.
Enrolling in the Plan

A. Open Enrollment Period
You may apply to enroll in Coverage for You and Your dependents during this time period and
elect new Coverage during this period in subsequent years.
B. Limited Open Enrollment Periods and Special Enrollment Periods
You may enroll in or change enrollment in Coverage outside of the initial and annual Open
Enrollment periods, based on an occurrence of one of the following triggering events:
1. You or Your dependent loses Minimum Essential Coverage;
2. You gain a dependent or become a dependent through marriage, birth, adoption or
placement for adoption;
3. You experience enrollment or non-enrollment in Coverage that is unintentional,
inadvertent, or erroneous and is the result of an error, misrepresentation, or inaction of
an officer, employee, or agent of [BlueCross][the Exchange] as determined by [Us][the
Exchange]. In such cases, [BlueCross][the Exchange] may take such action as may be
necessary to correct or eliminate the effects of such error, misrepresentation, or
inaction;
4. You or Your dependent adequately demonstrates to [Us][the Exchange] that BlueCross
substantially violated a material provision of this Policy.
5. You are determined newly eligible or newly ineligible for Advanced Payments of the
Premium Tax Credit (APTC) or You have a change in eligibility for Cost-Sharing
Reductions (CSR), regardless of whether or not You are already enrolled in a Qualified
Health Plan (QHP).
6. You or Your dependent gains access to new Coverage as a result of a permanent
move[.][;]
7. [You or Your dependent, who were not previously a citizen, national, or lawfully present
individual, gains such status;
8. You or Your dependent is an Indian, as defined by section 4 of the Indian Health Care
Improvement Act, may enroll in a QHP or change from one QHP to another one time per
month;
9. You or Your dependent demonstrates to the Exchange, in accordance with guidelines
issued by the Department of Health and Human Services (HHS), that You or Your
dependent meet other exceptional circumstances as the Exchange may provide.]
You or Your dependent has sixty (60) days from the date of a triggering event, unless
specifically stated otherwise, to enroll in or change enrollment in Coverage.
C. Adding Dependents
After You are Covered, You may apply to add a dependent who became eligible after You
enrolled, as follows:
1. The following are Custody Events that permit adding children to the Coverage: Your or
Your spouses newborn child is Covered from the moment of birth. A legally adopted
child, or a child for whom You or Your spouse has been appointed legal guardian by a
court of competent jurisdiction and, the children are placed in Your physical custody
may be Covered under the Plan. You must enroll the child within sixty (60) days from
the occurrence of the Custody Event.
If You fail to enroll the child, Your Policy will not cover the child after thirty-one (31)
days from when You acquire the child. If the legally adopted (or placed) child has
Coverage of his/her medical expenses from a public or private agency or entity, You may
not add the child to Your Policy until that Coverage ends.
2. Any other new family dependent (e.g., if You marry) may be added as a Covered
Dependent, if You complete and submit a signed Application to [Us][the Exchange]
within sixty (60) days of the triggering event. [We][The Exchange] will determine if that
person is eligible for Coverage.
D. Notification of Change in Status
You must submit an Application [Change Form to Us][for eligibility to the Exchange] if any
changes occur in Your status, or the status of a Covered Dependent, within sixty (60) days
from the date of the event causing that change. Such events include, but are not limited to:
(1) marriage; (2) divorce; (3) death; (4) dependency status; (5) enrollment in Medicare; or
(6) coverage by another Payor. These are called qualifying events. You must also submit an
Application [Change Form to Us][for eligibility to the Exchange] if You or a Covered
Dependent have a change of address. This is not a qualifying event[, unless You move
outside of Tennessee].
When Coverage Begins

If You are eligible, have applied, and have paid the Premium, We will notify You of Your Effective
Date.
A. Open Enrollment Period
1. Initial Open Enrollment Period
For a Coverage selection received by [Us][the Exchange] from You:
a. On or before December 15, 2013, You will receive a Coverage Effective Date of
January 1, 2014;
b. Between the first and fifteenth day of the month for any month between January
and March 2014, You will receive a Coverage Effective Date of the first day of the
following month; and
c. Between the sixteenth and last day of the month for any month between December
2013 and March 2014, You will receive a Coverage Effective Date of the first day of
the second following month.
2. Annual Open Enrollment Period
For a Coverage selection made during the annual Open Enrollment period, Your
Coverage will be effective as of the first day of the following benefit year.
B. Limited Open Enrollment Periods and Special Enrollment Periods
Except as specified in Section C. Adding Dependents, for a Coverage selection received by
[Us][the Exchange] from You:
1) Between the first and fifteenth day of any month, You will receive a Coverage Effective
Date of the first day of the following month; and
2) Between the sixteenth and the last day of any month, You will receive a Coverage
Effective Date of the first day of the second following month.
C. Adding Dependents
For newborns, adoption, or placement of a child, Coverage will be effective as of the date of
the Qualifying Event (i.e., birth, adoption or guardianship) if the dependent is enrolled
within sixty (60) days of the Qualifying Event, and We receive any Premium required for
Coverage.
In the event of marriage, if the Application [and required Premium are][is] received within
sixty (60) days of the marriage and the Application is approved, Coverage will be effective on
the first day of the month following the date of the marriage.
D. Premiums
You must pay the Premiums due for Your Policy in full on or before the due date. Premiums
must be received by Us. This Policy will not become effective until the initial Premium has
been paid in full. [You have a fifteen (15) day grace period in which to pay your initial
Premium. If the initial Premium is not paid in full by the 15th day following Your assigned
Effective Date, Your Policy will not be effectuated and no benefits will be received under
Your Plan.]
1. Returned Check Fee
You will be charged a fee for any check or draft not honored by Your financial
institution.
When Coverage Ends

A. Termination of Policy
Your Policy is guaranteed renewable, until the first of the following occurs:
1. We do not receive the required Premium for Your Coverage when it is due; or
2. You request to terminate the Policy and give [Us][the Exchange] advance written notice.
Termination will take place the first day of the month following Our receipt of such
notice; or
3. [You act in such a disruptive manner as to prevent or adversely affect Our ability to
administer the Policy; or]
4. [You fail to cooperate with Us as required by this Policy; or]
5. You move outside of Tennessee; or
6. You have made a material misrepresentation or committed fraud against Us. This
provision includes, but is not limited to, furnishing incorrect or misleading information
or permitting the improper use of Your Member ID card. If You make a material
misrepresentation or commit fraud against Us, We may rescind Your Policy. This means
We will return all Premiums less any claims paid. If the claims paid exceed the
Premiums paid, We have the right to collect that amount from You. We will notify You
thirty (30) days in advance of any rescission; or
7. We decide to terminate the type of Coverage You have, for all persons who have a
similar Policy, after offering You replacement Coverage; or
8. If We cease to offer Coverage in the individual market[.][; or]
9. [The Exchange determines You are no longer eligible for Coverage in a QHP through the
Exchange. The Exchange will notify You that You are no longer eligible for Coverage and
the last day of Coverage will be the last day of the month following the month in which
the Exchange notice was sent.]
B. Termination of Covered Dependent Coverage
Your Covered Dependents Coverage will automatically terminate on the earliest of the
following dates:
1. The date that Your Coverage terminates; or
2. The last day of the month for which You paid Your Covered Dependents Premium; or
3. The date a Covered Dependent is no longer eligible, (e.g., [the day the Covered
Dependent turns 26][upon renewal, if the Covered Dependent has turned 26]); or
4. The date a Covered Dependent enters active duty with the armed forces of any country.
C. Exceptions to Covered Dependent Termination of Coverage
Coverage for a mentally retarded or physically handicapped Covered Dependent will not
stop due to age, if he or she is incapable of self-support and mainly dependent upon You at
that time. Coverage will continue as long as:
1. You continue to pay the required Premium for the Covered Dependents Coverage; and
2. Your own Coverage under the Policy remains in effect; and
10
3. You provide Us with required proof of the Covered Dependents incapacity and
dependency. Initial proof of the Covered Dependents incapacity and dependency must
be furnished to Us within sixty (60) days of the Covered Dependents attainment of the
Limiting Age. We may require this proof again, but not more than once a year.
D. Grace Period
[You have a thirty-one (31) day grace period in which to pay your Premium. A grace period
is a specific time after Your Premium is due, during which You can pay Your Premium,
without a lapse in Coverage.]
[You have a three-month grace period in which to pay all outstanding Premiums. During this
grace period, Your Coverage will continue and claims for Covered Services incurred during
the first month of the grace period will be processed. We may suspend payments to
Providers rendering services to You and Your Covered Dependents during the second and
third months of the grace period.]
[If You do not pay the Premium due, in full, by the end of the three-month grace period,
Your Coverage will terminate the last day of the first month of the three-month grace
period.
[If You are an APTC recipient][If You are APTC eligible], You will be liable for Providers
charges for services rendered during the second and third months of the grace period.
[If You are not receiving an APTC][If You are not APTC eligible], You will be liable for
Providers charges for services rendered during the entire grace period.]
If You pay the Premium in full during the grace period, Your Coverage will continue and
claims for Covered Services incurred during the grace period will be honored.
[If You do not pay the Premium due, in full, during the grace period, Your Coverage will
terminate retroactive to the Premium due date. We may suspend payments to Providers
rendering services to You and Your Covered Dependents during the grace period. You will
be liable for Providers charges for services rendered during the grace period.]
E. Payment For Services Rendered After Termination of Coverage
If You or Your Covered Dependents receive and We pay for Covered Services after the
termination of Your Coverage, We may recover the amount we paid for such Covered
Services from You, plus any costs of recovering such Charges, including Our attorneys fees.
F. Right to Request a Hearing
You may request that We conduct a Grievance Hearing to appeal the termination of Your
membership for cause, as explained in the Grievance Procedure section of this Policy. The
fact that You have requested a hearing does not postpone or prevent Us from terminating
Your Coverage. If Your Coverage is reinstated following that hearing, You may submit any
claims for Covered Services rendered after Your Coverage was terminated to Us for
consideration, in accordance with the Claims and Payment section of this Policy.
11
GENERAL PROVISIONS
A. Entire Policy: Changes
The Policy consists of: (1) this Policy; [(2) Your Application; ]([2/3]) the Attachments; and
([3/4]) any other attached papers, including the Schedule of Benefits. The terms of this
Policy can be changed only if: (1) We agree in writing; and (2) one of Our authorized officers
agrees to the change.
No agent or employee may change this Policy, or waive any of its provisions.
We may change the terms of the Policy when Your Policy renews. We will notify You in
writing at least thirty (30) days before the effective date of any change. Your continued
payment of Premiums indicates acceptance of a change. Any notice of change will be
mailed to You at the address shown in Our records.
B. Subscriber Interplan Transfers
If You move out of Tennessee to an area served by another BlueCross or BlueShield Plan
(the Other Plan,) and You have Your Premium bills sent to Your new address, Your
Coverage will be transferred to the Other Plan serving Your new address. The Other Plan
must offer You at least its conversion policy through the Subscriber Interplan Transfer
program.
The conversion policy will provide Coverage without a medical exam or a health statement.
If You accept the conversion policy:
You will receive credit for the length of Your enrollment with Us under this Policy
toward the conversion policys waiting periods, if any exist; and
Any physical or mental conditions Covered by Us will be provided by the conversion
policy without a new waiting period, if the conversion policy offers this Coverage to
others carrying the same policy.
However, the Premium rates and benefits available from the Other Plan may vary
significantly from those offered by Us.
The Other Plan may also offer You Coverage outside the Subscriber Transfer program.
Because these additional coverages are outside the program, that Plan:
May not apply time enrolled in this Policy to waiting periods, if any exist.
C. Applicable Law
The laws of Tennessee govern this Policy.
D. Notices
All notices required by this Policy must be in writing. Notices to Us should be addressed to:
Chattanooga, TN [37402]
We will send notices to You at the most recent address in Our files.
12
You are responsible for notifying Us of Your and Your Covered Dependents address
changes.
E. Legal Action
You cannot bring legal action under this policy until sixty (60) days after proof of loss has
been furnished. You cannot bring legal action after three (3) years after the time proof of
loss is required.
F. Right to Request Information
We have the right to request any additional necessary information or records with respect
to any Member Covered or claiming benefits under the Policy.
G. Coordination of Benefits
This is an Individual Policy, not subject to the Coordination of Benefits Regulation. If You or
Your Covered Dependents have other coverage, whether group or individual, this Policy will
always pay secondary. Other coverage means other comprehensive medical coverage and
does not include limited benefit coverage. Benefits will be calculated as the difference
between the amount paid by the other coverage and the greater of Our Maximum
Allowable Charge or the amount such other coverage considers allowable expense.
If such other coverage also states that it will always pay secondary, benefits under this
Policy will be calculated as 50% of Our Maximum Allowable Charge.
In any event, Our liability shall be limited to the amount We would have paid in the absence
of other insurance.
H. Benefits When Covered Under Medicare
When a Member becomes Covered under Medicare, the benefits under this Policy will be
reduced so that the sum of benefits under Medicare and this Policy will not be greater than:
The Medicare Approved Amount for Providers who accept Medicare assignment; or
The total amount charged for Providers who do not accept Medicare assignment.
I.
Administrative Errors
If We make an error in administering the benefits under this Policy, We may provide
additional benefits or recover any overpayments from any person, insurance company, or
plan. Any recovery must begin within eighteen (18) months (or the time frame allowed by
law) from the date the claim was paid. This time limit does not apply if the Member did not
provide complete information or if material misstatements or fraud have occurred.
No such error may be used to demand more benefits than those otherwise due under this
Policy.
J.
Overinsurance Termination Provision

We have the right to request information, in advance of premium payment, about whether
or not You are eligible for benefits under another group or individual contract, including:
Another hospital, surgical, medical or major medical expense insurance policy;
Any BlueCross and BlueShield Plan; or
13
Any medical practice or other prepayment plan.

We also have the right to terminate this Policy if You fail to give correct information about
other coverage.
K. Time Limit on Certain Defenses
After two (2) years from the Effective Date of this policy, no misstatements, except
fraudulent misstatements, made by the Applicant in the Application for such policy shall be
used to void the policy or to deny a claim for loss incurred after the expiration of such twoyear period.
14
Prior Authorization, Care Management, Medical Policy

and Patient Safety
BlueCross provides services to help manage Your care including, performing Prior
Authorization of certain services to ensure they are Medically Necessary, Concurrent Review
of hospitalization, discharge planning, lifestyle and health counseling, catastrophic medical
and transplant case management and the development and publishing of medical policy.
BlueCross does not make medical treatment decisions under any circumstances. You may
always elect to receive services that do not comply with BlueCross Care Management
requirements or medical policy, but doing so may affect the Coverage of such services.
1. Prior Authorization
Some Covered Services must be Authorized by BlueCross in advance in order to be paid at
the Maximum Allowable Charge without Penalty. Obtaining Prior Authorization is not a
guarantee of Coverage. All provisions of this Policy must be satisfied before Coverage for
services will be provided.
Services that require Prior Authorization include, but are not limited to:
Inpatient Hospital stays (except maternity admissions)
Skilled nursing facility and rehabilitation facility admissions
Certain Outpatient Surgeries and/or procedures
Certain Specialty Drugs
Certain Prescription Drugs (if Covered by a Prescription Drug card)
Advanced Radiological Imaging services
Durable Medical Equipment (DME)
Prosthetics
Orthotics
Certain musculoskeletal procedures (including, but not limited to spinal surgeries, spinal
injections, and hip, knee, and shoulder surgeries)
Other services not listed at the time of publication may be added to the list of services
that require Prior Authorization. Notice of changes to the Prior Authorization list will be
made via Our Web site and the Member newsletter. You may also call Our consumer
advisors at the number on the back of Your Member ID card to find out which services
Refer to Attachment C: Schedule of Benefits for details on benefit penalties for failure to
Network Providers in Tennessee will request Prior Authorization for You.
You are responsible for requesting Prior Authorization when using [Providers outside
Tennessee and ]Out-of-Network Providers, or benefits will be reduced or denied.
For the most current list of services that require Prior Authorization, call Our consumer
advisors or visit Our website at bcbst.com.
BlueCross may authorize some services for a limited time. BlueCross must review any
request for additional days or services.
15
Network Providers in Tennessee are required to comply with all of BlueCrosss medical
management programs. You are held harmless (not responsible for Penalties) if a Network
Provider in Tennessee fails to comply with the Care Management program and Prior
Authorization requirements, unless You agreed that the Provider should not comply with
such requirements.
The Member is not held harmless if:
A. [A Network Provider outside Tennessee (known as a BlueCard PPO Participating
Provider) fails to comply with Care Management program and Prior Authorization
requirements, or]
B. Member obtains services from an Out-of-Network Provider.
If You use an Out-of-Network Provider, [or a Provider outside Tennessee, such as a Blue
Card PPO Participating Provider, ]You are responsible for ensuring that the Provider
obtains the appropriate Authorization prior to treatment. Failure to obtain the necessary
Authorization may result in additional Member Payments and reduced Plan payment.
Contact Our consumer advisors for a list of Covered Services that require Prior
Authorization.
2. Care Management
A number of Care Management programs are available to Members, including those with
low-risk health conditions, potentially complicated medical needs, chronic illness and/or
catastrophic illnesses or injuries.
Lifestyle and Health Education - Lifestyle and health education is for healthy Members and
those with low-risk health conditions that can be self-managed with educational materials
and tools. The program includes: (1) wellness, lifestyle, and condition-specific educational
materials; (2) an on-line resource for researching health topics; and (3) a toll-free number
[(800-656-8123)] for obtaining information on more than 1,200 health-related topics.
Lifestyle Coaching inspires, engages, and guides individuals to make lasting changes in their
lives to improve their health and well-being. Through this voluntary program, You have
access to a personal health assessment and personal wellness report, and a wellness portal
filled with interactive health trackers and resources, as well as self-directed programs
designed to support and motivate You to take charge of Your health. You also have
unlimited access to Your dedicated lifestyle health coach. Communicate with Your coach via
secure email or phone. Your lifestyle health coach can work with you on weight loss or
weight management, improving nutrition, optimizing fitness, stress management, blood
pressure management, cholesterol management, and tobacco cessation. To speak with a
lifestyle health coach, call toll free [1-800-818-8581], select option [3].
Low Risk Case Management - Low risk case management, including disease management, is
performed for Members with conditions that require a daily regimen of care. Registered
nurses work with health care Providers, the Member and primary care givers to coordinate
care. Specific programs include: (1) Pharmacy Care Management for certain populations; (2)
Emergency services management program; (3) transition of care program; (4) conditionspecific care coordination program; and (5) disease management.
Healthy Focus Disease Management - The Healthy Focus Disease Management Program is a
voluntary program available to Members with Coronary Artery Disease, Chronic Obstructive
Pulmonary Disease, Congestive Heart Failure, Diabetes, and Asthma. Through this program,
You may receive outreach from our nurses. With this program, You may receive extra
16
resources and personalized attention to help manage chronic health conditions and help
You take better care of Yourself. To speak with a nurse today about your chronic condition,
call toll free [1-800-818-8581], select option [1], or for hearing impaired dial [TTY 1-888-3087231].
Healthy Focus Nurseline - 24/7 Nurseline - This program offers You unlimited access to a
registered nurse 24/7/365. Our nurses can assist you with symptom assessment, short term
care decisions, or any health related question or concern. You may also call for decision
support and advice when contemplating Surgery, considering treatment options, and
making major health decisions. Call toll free [1-800-818-8581], select option [2], or for
hearing impaired dial [TTY 1-888-308-7231].
Catastrophic Medical and Transplant Case Management - Members with terminal illness,
severe injury, major trauma, cognitive or physical disability, or Members who are transplant
candidates may be served by Our catastrophic medical and transplant case management
program. Registered nurses work with health care Providers, the Member, and primary
caregivers to coordinate the most appropriate, cost-efficient care settings. Case managers
maintain regular contact with Members throughout treatment, coordinate clinical and
health plan Coverage issues, and help families utilize available community resources.
After evaluation of the Members condition, it may be determined that alternative
treatment is Medically Necessary and Appropriate.
In that event, alternative benefits for services not otherwise specified as Covered Services in
Attachment A: Covered Services and Exclusions may be offered to the Member. Such benefits
shall not exceed the total amount of benefits under this Policy, and will only be offered in
accordance with a written case management or alternative treatment plan agreed to by the
Members attending physician and BlueCross.
Emerging Health Care Programs - Care Management is continually evaluating emerging
health care programs. These are processes that demonstrate potential improvement in
access, quality, efficiency, and Member satisfaction.
When We approve an emerging health care program, services provided through that
program are Covered, even though they may normally be excluded under this Policy.
Care Management services, emerging health care programs and alternative treatment plans may
be offered to eligible Members on a case-by-case basis to address their unique needs. Under no
circumstances does a Member acquire a vested interest in continued receipt of a particular level
of benefits. Offer or confirmation of Care Management services, emerging health care programs
or alternative treatment plans to address a Members unique needs in one instance shall not
obligate the Plan to provide the same or similar benefits for any other Member.
3. Medical Policy
Medical Policy looks at the value of new and current medical science. Its goal is to make
sure that Covered Services are safe and effective, and have proven medical value.
Medical policies are based on an evidence-based research process that seeks to determine
the scientific merit of a particular medical technology. Determinations with respect to
technologies are made using technology evaluation criteria. Technologies include devices,
procedures, medications and other emerging medical services.
17
Medical policies state whether or not a technology is Medically Necessary, Investigational or

cosmetic. As technologies change and improve, and as Members needs change, We may
reevaluate and change medical policies without formal notice. You may check Our medical
policies at bcbst.com. Enter medical policy in the Search field.
Medical policies sometimes define certain terms. If the definition of a term defined in Our
medical policy differs from a definition in this Policy, the medical policy definition controls.
4. Patient Safety
If You have a concern with the safety or quality of care You received from a Network Provider,
please call Us at the number on the back of Your Member ID card. Your concern will be noted
and investigated by Our Clinical Risk Management department.
18
Inter-Plan Programs
Out-of-Area Services
BlueCross BlueShield of Tennessee (BlueCross) has a variety of relationships with other Blue Cross
and/or Blue Shield Licensees ("Inter-Plan Programs"). Whenever You obtain healthcare services
outside of BlueCrosss service area ("Service Area"), the claims for these services may be processed
through one of these Inter-Plan Programs, which includes the BlueCard Program.
Typically, when accessing care outside the Service Area, You will obtain care from healthcare
Providers that have a contractual agreement (i.e., are "participating Providers") with the local Blue
Cross and/or Blue Shield Licensee in that other geographic area ("Host Blue"). In some instances,
You may obtain care from non-participating Providers. BlueCrosss payment practices in both
instances are described below.
A. BlueCard PPO Program
When You are outside the Service Area and need healthcare services or information about
Network doctors or hospitals, call 1-800-810-BLUE (2583).
Under the BlueCard PPO Program, (BlueCard) when You access Covered Services within the
area served by a Host Blue, BlueCross will remain responsible for fulfilling BlueCrosss
contractual obligations under this Agreement. However, the Host Blue is responsible for
contracting with and generally handling all interactions with its participating Providers.
Whenever You access Covered Services outside BlueCrosss service area and the claim is
processed through BlueCard, the amount You pay for Covered Services is calculated based on
the lower of:
The Billed Charges for Your Covered Services; or
The negotiated price that the Host Blue makes available to BlueCross.
Often, this negotiated price will be a simple discount that reflects an actual price that the
Host Blue pays to Your healthcare Provider. Sometimes, it is an estimated price that takes into
account special arrangements with Your healthcare Provider or Provider group that may include
types of settlements, incentive payments, and/or other credits or charges. Occasionally, it may
be an average price, based on a discount that results in expected average savings for similar
types of healthcare Providers after taking into account the same types of transactions as with
an estimated price.
Estimated pricing and average pricing, going forward, also take into account adjustments to
correct for over- or underestimation of modifications of past pricing for the types of transaction
modification noted above. However, such adjustments will not affect the price BlueCross uses
for Your claim because they will not be applied retroactively to claims already paid.
Laws in a small number of states may require the Host Blue to add a surcharge to Your
calculation. If any state laws mandate other liability calculation methods, including a surcharge,
We would then calculate Your liability for any Covered Services according to applicable law.
REMEMBER: You are responsible for receiving Prior Authorization from Us. If Prior
Authorization is not received, Your benefits may be reduced or denied. Call the number on the
back of Your Member ID card for Prior Authorization. In case of an Emergency, You should seek
immediate care from the closest health care Provider.
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B. Non-Participating Healthcare Providers Outside BlueCrosss Service Area

1. Member Liability Calculation
When Covered Services are provided outside of BlueCrosss service area by nonparticipating Providers, the amount You pay for such services will generally be based on
either the Host Blues non-participating Provider local payment or the pricing arrangements
required by applicable law. In these situations, You may be liable for the difference
between the amount that the non-participating Provider bills and the payment BlueCross
will make for the Covered Services as set forth in this paragraph.
2. Exceptions
In certain situations, BlueCross may use other payment bases, such as Covered Billed Charges,
the payment We would make if the healthcare services had been obtained within Our Service
Area, or a special negotiated payment, as permitted under Inter-Plan Programs Policies, to
determine the amount BlueCross will pay for services rendered by non-participating
Providers. In these situations, You may be liable for the difference between the amount that
the non-participating Provider bills and the payment BlueCross will make for the Covered
Services as set forth in this paragraph.
C. BlueCard WorldwideProgram
If You are outside the United States, Puerto Rico and the U.S. Virgin Islands, You may be able to
take advantage of the BlueCard Worldwide Program when accessing Covered health services. The
BlueCard Worldwide Program is unlike the BlueCard Program in certain ways, in that while the
BlueCard Worldwide Program provides a network of contracting inpatient hospitals, it offers only
referrals to doctors and other outpatient Providers. When You receive care from doctors and
other outpatient Providers, You will typically have to pay the doctor or other outpatient Provider
and submit a claim to obtain reimbursement for these services.
20
Claims and Payment

When You or Your Covered Dependents receive Covered Services from a Network Provider, the
Provider will submit a claim to Us. If You receive Covered Services from an Out-of-Network
Provider, either You or the Provider must submit a claim form to the Plan. If You receive
Covered Services from an Out-of-Network Pharmacy, You must submit a claim form to the Plan.
We will review the claim, and let You, or the Provider, know if We need more information,
before We pay or deny the claim. We follow our internal administration procedures when We
process claims.
1. Claims
Federal regulations use several terms to describe a claim: pre-service claim; post-service
claim; and a claim for Urgent Care.
A. A pre-service claim is any claim that requires approval of a Covered Service in advance
of obtaining medical care as a condition of receipt of a Covered Service, in whole or in
part.
B. A post-service claim is a claim for a Covered Service that is not a pre-service claim the
medical care has already been provided to the Member. Only post-service claims can be
billed to the Plan, or You.
C. Urgent Care is medical care or treatment that, if delayed or denied, could seriously
jeopardize: (1) the life or health of the claimant; or (2) the claimants ability to regain
maximum function. Urgent Care is also medical care or treatment that, if delayed or
denied, in the opinion of a physician with knowledge of the claimants medical
condition, would subject the claimant to severe pain that cannot be adequately
managed without the medical care or treatment. A claim for denied Urgent Care is
always a pre-service claim.
2. Claims Billing
A. You should not be billed or charged for Covered Services rendered by Network
Providers, except for required Member payments. The Network Provider will submit
the claim directly to Us.
B. You may be charged or billed by an Out-of-Network Provider for Covered Services
rendered by that Provider. If You or Your Covered Dependents use an Out-of-Network
Provider, You are responsible for the difference between what the Plan pays and what
the Out-of-Network Provider charges. You are also responsible for complying with any
of Our medical management policies or procedures (including, obtaining Prior
Authorization of such Services, when necessary).
If You are charged, or receive a bill, to be reimbursed, You must submit the claim to Us
within one (1) year and ninety (90) days from the date a Covered Service was received.
If You do not submit a claim, within the one (1) year and ninety (90) day time period, it
will not be paid.
C. Claims for services received from Non-Contracted Providers are handled in the same
manner as described above for Out-of-Network Providers.
D. You may request a claim form by contacting Our consumer advisors. We will send You a
claim form within fifteen (15) days. You must submit proof of payment acceptable to Us
21
with the claim form. We may also request additional information or documentation if it
is reasonably necessary to make a Coverage decision concerning a claim.
Mail all medical and dental claim forms to:
Claims Service Center

[1 Cameron Hill Circle Suite [0002]]
Chattanooga, Tennessee [37402[-0002]]
Mail pediatric vision claims to BlueCrosss Vision Claims Administrator:
[EyeMed Vision Care]
[ATTN: OON CLAIMS]
[P.O. Box 8504]
[Mason, OH 45040]
E. A Network Provider or an Out-of-Network Provider may refuse to render, or reduce or
terminate a service that has been rendered, or require You to pay for what You believe
should be a Covered Service.
F. Providers may bill or charge for Covered Services differently. Network Providers are
reimbursed based on Our agreement with them. Different Network Providers have
different reimbursement rates for different services. Your Out-of-Pocket expenses can
be different from Provider to Provider.
3. Payment
A. If You or Your Covered Dependent received Covered Services from a Network Provider,
We will pay the Network Provider directly. These payments are made according to Our
agreement with that Network Provider. You authorize assignment of benefits to that
Network Provider. Covered Services will be paid at the Network Benefit level.
B. Out-of-Network Providers may or may not file claims for You or Your Covered
Dependents. A completed claim form for Covered Services must be submitted in a
timely manner. We will reimburse You, unless You have assigned benefits to the
Provider. You will be responsible for the difference in the Billed Charges and the
Maximum Allowable Charge for that Covered Service. Our payment fully discharges Our
obligation related to that claim.
C. Non-Contracted Providers may or may not file Your or Your Covered Dependents claims
for You. Either way, the Network Benefit level shown in Attachment C: Schedule of
Benefits will apply to claims for Covered Services received from Non-Contracted
Providers. However, You will be responsible for the difference between what the Plan
pays and what the Non-Contracted Provider charges.
D. If this Policy is terminated, all claims for Covered Services rendered prior to the
termination date, must be submitted to Us within one (1) year and ninety (90) days from
the date the Covered Services were received.
E. We will pay benefits within thirty (30) days after We receive a claim form that is
complete. Claims are processed in accordance with BlueCrosss internal administrative
processes, and based on the information in Our possession at the time We receive the
22
claim form. We are not responsible for over or under payment of claims if Our
information is not complete or is inaccurate. We will make reasonable efforts to obtain
and verify relevant facts when claim forms are submitted. Payment for Covered
Services is more fully described in Attachment C: Schedule of Benefits.
F. At least monthly, You will receive an Explanation of Benefits (EOB) that describes how a
claim was treated. For example, paid, denied, how much was paid to the Provider, and
also let You know if You owe an additional amount to that Provider. The Plan will make
the EOB available to You at bcbst.com, or by calling Our consumer advisors at the
number on the back of Your Member ID card.
G. You are responsible for paying any applicable Copayments, Coinsurance, or Deductible
amounts to the Provider. If We pay such amounts to a Provider on Your behalf, We may
collect those amounts directly from You.
4. Assignment
If You assign payment for a claim to a Provider, We must honor that assignment. If You have
paid the Provider, and also assigned payment for the claim to the Provider, You must
request repayment from that Provider.
23
Grievance Procedure
1. Introduction
Our Grievance procedure (the Procedure) is intended to provide a fair, quick and
inexpensive method of resolving any and all Disputes with Us. Such Disputes include: any
matters that cause You to be dissatisfied with any aspect of Your relationship with Us; any
Adverse Benefit Determination concerning a claim; or any other claim, controversy, or
potential cause of action You may have against Us.
Adverse Benefit Determination means:
A. A determination by a health carrier or its designee utilization review organization that,
based upon the information provided, a request for a benefit under the health carrier's
health benefit plan does not meet the health carrier's requirements for medical
necessity, appropriateness, healthcare setting, level of care or effectiveness and the
requested benefit is therefore denied, reduced or terminated or payment is not
provided or made, in whole or in part, for the benefit;
B. The denial, reduction, termination or failure to provide or make payment, in whole or in
part, for a benefit based on a determination by a health carrier of a Covered person's
eligibility to participate in the health carrier's health benefit plan; or
C. Any prospective review or retrospective review determination that denies, reduces, or
terminates or fails to provide or make payment for, in whole or in part, a benefit.
Please contact Our consumer advisors, at the number on the back of Your Member ID card:
(1) to file a claim; (2) if You have any questions about this Policy or other documents related
to Your Coverage (e.g. an explanation of benefits or monthly claims statement); or (3) to
initiate a Grievance concerning a Dispute.
A. The Procedure can only resolve Disputes that are subject to Our control.
B. You cannot use this Procedure to resolve a claim that a Provider was negligent.
Network Providers are independent contractors. They are solely responsible for making
treatment decisions in consultation with their patients. You may contact Us; however,
to complain about any matter related to the quality or availability of services, or any
other aspect of Your relationship with Providers.
C. Under this Procedure:
1. If a Provider does not render, or reduces or terminates a service that has been
rendered, or requires You to pay for what You believe should be a Covered Service,
You may submit a Claim to Us to obtain a determination concerning whether the
Policy will cover that service. As an example, if a Pharmacy does not provide You
with a prescribed medication or requires You to pay for that Prescription, You may
submit a claim to Us to obtain a determination about whether it is Covered by the
Policy. Providers may be required to hold You harmless for the cost of services in
some circumstances.
2. Providers may also appeal an Adverse Benefit Determination through Our Provider
dispute resolution procedure.
3. Our determination will not be an Adverse Benefit Determination if: (1) a Provider is
required to hold You harmless for the cost of services rendered; or (2) until We have
24
rendered a final Adverse Benefit Determination in a matter being appealed through

the Provider dispute resolution procedure.
D. You may request a form from Us to authorize another person to act on Your behalf
concerning a Dispute.
E. You and We may agree to skip one or more of the steps of this Procedure if it will not
help to resolve Our Dispute.
F. Any Dispute will be resolved in accordance with applicable Tennessee or Federal laws
and regulations, and this Policy.
2. Description of the Review Procedures
A. Inquiry
An Inquiry is an informal process that may answer questions or resolve a potential
Dispute. You should contact a consumer advisor if You have any questions about how to
file a claim or to attempt to resolve any Dispute. Making an Inquiry does not stop the
time period for filing a claim or beginning a Dispute. You do not have to make an
Inquiry before filing a Grievance.
B. Grievance
You must submit a written request asking Us to reconsider an Adverse Benefit
Determination, or take a requested action to resolve another type of Dispute (Your
"Grievance"). You must begin the Dispute process within one-hundred and eighty (180)
days from the date We issue notice of an Adverse Benefit Determination or from the
date of the event that is otherwise causing You to be dissatisfied with Us. If You do not
initiate a Grievance within one-hundred and eighty (180) days of when We issue an
Adverse Benefit Determination, You may give up the right to take any action related to
that Dispute. The Grievance process that was in effect on the date(s) of service for
which you received an Adverse Benefit Determination will apply.
Contact Our consumer advisors at the number on the back of Your Member ID card for
assistance in preparing and submitting Your Grievance. They can provide You with the
appropriate form to use in submitting a Grievance. This is the first level Grievance
procedure and is mandatory.
1. Grievance Hearing
After We have received and reviewed Your Grievance, Our first level Grievance
committee will meet to consider Your Grievance and any additional information that
You or others submit concerning that Grievance. In Grievances concerning urgent
care or pre-service claims, We will appoint one or more qualified reviewer(s) to
consider such Grievances. Individuals involved in making prior determinations
concerning Your Dispute are not eligible to be voting members of the first level
Grievance committee or reviewers. The Committee or reviewers have full
discretionary authority to make eligibility, benefit and/or claim determinations,
pursuant to the Policy.
2. Written Decision
The committee or reviewers will consider the information presented, and You will
receive a written decision concerning Your Grievance as follows:
25
i.
ii.
iii.
For a pre-service claim, within thirty (30) days of receipt of Your request for
review;
For a post-service claim, within sixty (60) days of receipt of Your request for
review; and
For a pre-service, urgent care claim, within seventy-two (72) hours of receipt of
Your request for review.
The decision of the Committee will be sent to You in writing and will contain:
i.
ii.
iii.
A statement of the committees understanding of Your Grievance;

The basis of the committees decision; and
Reference to the documentation or information upon which the committee
based its decision. We will send You a copy of such documentation or
information, without charge, upon written request.
3. Second Level Grievance Procedure

You may file a written request for reconsideration within ninety (90) days after We issue the
first level Grievance committees decision. This is called a second level Grievance.
Information on how to submit a second level Grievance will be provided to You in the
decision letter following the first level Grievance review.
Your decision concerning whether to file a second level Grievance has no effect on Your
rights to any other benefits under the Policy. Any person involved in making a decision
concerning Your Dispute (e.g. first level committee members) will not be a voting member
of the second level Grievance committee.
A. Grievance Hearing
You may request an in-person or telephonic hearing before the second level Grievance
committee. You may also request that the second level Grievance committee
reconsider the decision of the first level committee, even if You do not want to
participate in a hearing concerning Your Grievance. If You wish to participate, Our
representatives will contact You to explain the hearing process and schedule the time,
date and place for that hearing.
In either case, the second level committee will meet and consider all relevant
information presented about Your Grievance, including:
1. Any new, relevant information that You submit for consideration; and
2. Information presented during the hearing. Second level Grievance committee
members may ask You questions during the hearing. You may make a closing
statement to the committee at the end of the hearing.
3. If You wish to bring a personal representative with You to the hearing, You must
notify Us at least five (5) days in advance and provide the name, address and
telephone number of Your personal representative.
B. Written Decision
After the hearing, the second level committee will meet in closed session to make a
decision concerning Your Grievance. That decision will be sent to You in writing. The
written decision will contain:
26
1. A statement of the second level committees understanding of Your Grievance;

2. The basis of the second level committees decision; and
3. Reference to the documentation or information upon which the second level
committee based its decision. Upon written request, We will send You a copy of any
such documentation or information, without charge.
4. Independent Review of Medical Necessity Determinations or Coverage Rescissions
If Your Grievance involves a Medical Necessity or a Coverage rescission determination,
then either: (1) after completion of the mandatory first level Grievance; or (2) after
completion of the mandatory first level Grievance immediately followed by completion of
the second level Grievance, You may request that the Dispute be submitted to a neutral
third party, selected by Us, to independently review and resolve such Dispute(s). If You
request an independent review following the mandatory first level Grievance, You waive
Your right to a second level Grievance and Your right to present testimony during the
Grievance Procedure. Your request for independent review must be submitted in writing
within one-hundred and eighty (180) days after the date You receive notice of the
committees decision. Receipt shall be deemed to have occurred no more than two (2) days
after the date of issuance of the committees decision. Any person involved in making a
decision concerning Your Dispute will not be a voting member of the independent review
panel or committee.
Your decision concerning whether to request independent review has no effect on Your
rights to any other benefits under the Policy.
We will pay the fee charged by the independent review organization and its reviewers if
You request that We submit a Dispute to independent review. You will be responsible for
any other costs that You incur to participate in the independent review process, including
attorneys fees.
We will submit the necessary information to the independent review entity within five (5)
business days after receiving Your request for review. We will provide copies of Your file,
excluding any proprietary information to You, upon written request. The reviewer may
also request additional medical information from You. You must submit any requested
information, or explain why that information is not being submitted, within five (5)
business days after receiving that request from the reviewer.
The reviewer must submit a written determination to You and Us within forty-five (45) days
after receipt of the independent review request. In the case of a life threatening condition,
the decision must be issued within seventy-two (72) hours after receiving the review
request. Except in cases involving a life-threatening condition, the reviewer may request
an extension of up to five (5) business days to issue a determination to consider additional
information submitted by You or Us.
The reviewers decision must state the reasons for the determination based upon: (1) the
terms of the Policy; (2) Your medical condition; and (3) information submitted to the
reviewer. The reviewers decision may not expand the terms of Coverage of the Policy.
27
No action at law or in equity shall be brought to recover on this Policy until sixty (60) days
after a claim has been filed as required by this Policy. No such action shall be brought
beyond three (3) years after the time the claim is required to be filed.
28
NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY
LEGAL OBLIGATIONS
BlueCross BlueShield of Tennessee, Inc. is required to maintain the privacy of all medical
information as required by applicable laws and regulations (hereafter referred to as Our legal
obligations); provide this notice of privacy practices to You; inform You of Our legal obligations;
and advise You of additional rights concerning Your medical information. We must follow the
privacy practices contained in this notice from its effective date of April 14, 2003, until this
notice is changed or replaced.
We reserve the right to change privacy practices and the terms of this notice at any time, as
permitted by Our legal obligations. Any changes made in these privacy practices will be
effective for all medical information that is maintained including medical information created or
received before the changes are made. All Subscribers will be notified of any changes by
receiving a new notice of Our privacy practices.
You may request a copy of this notice of privacy practices at any time by contacting BlueCross
BlueShield of Tennessee, Privacy Office.
ORGANIZATIONS COVERED BY THIS NOTICE
This notice applies to the privacy practices of BlueCross BlueShield of Tennessee, Inc. and its
subsidiaries or affiliated covered entities. Medical information about Our Subscribers and
Members may be shared with each other as needed for treatment, payment or health care
operations.
USES AND DISCLOSURES OF MEDICAL INFORMATION
Your medical information may be used and disclosed for treatment, payment, and health care
operations, for example:
TREATMENT: Your medical information may be disclosed to a doctor or hospital that asks for it
to provide treatment to You.
PAYMENT: Your medical information may be used or disclosed to pay claims for services, which
are Covered under Your health insurance policy.
HEALTH CARE OPERATIONS: Your medical information may be used and disclosed to determine
Premiums, conduct quality assessment and improvement activities, to engage in care
coordination or case management, accreditation, conducting and arranging legal services, and
for other similar administrative purposes.
AUTHORIZATIONS: You may provide written authorization to use Your medical information or
to disclose it to anyone for any purpose. You may revoke Your authorization in writing at any
time. That revocation will not affect any use or disclosure permitted by Your authorization while
it was in effect. We cannot use or disclose Your medical information for any reason except
those described in this notice, without Your written authorization.
29
AS REQUIRED BY LAW: Your medical information may be used or disclosed as required by state
or federal laws.
COURT OR ADMINISTRATIVE ORDER: Medical information may be disclosed in response to a
court or administrative order, subpoena, discovery request, or other lawful process, under
certain circumstances.
MARKETING: Your medical information may be used to provide information about healthrelated benefits, services or treatment alternatives that may be of interest to You. Your medical
information may be disclosed to a business associate assisting Us in providing that information
to You. You may opt-out of receiving further information (see the instructions for opting out at
the end of this notice), unless the information is provided to You in a newsletter or in person or
concerns products or services of nominal value.
MILITARY AUTHORITIES: Medical information of Armed Forces personnel may be disclosed to
Military authorities under certain circumstances. Medical information may be disclosed to
authorized federal officials as required for lawful intelligence, counterintelligence, and other
national security activities.
PERSONAL REPRESENTATIVE: Your medical information may be disclosed to a family member,
friend or other person as necessary to help with Your health care or with payment for Your
health care. You must agree We may do so, as described in the Individual Rights section of this
notice below.
POLICY ADMINISTRATION: Your medical information or individually identifiable information
may be received for Premium rating, policy administration or other activities relating to the
creation, renewal or replacement of a health insurance or benefits contract. If We do not issue
that contract, Your medical information will not be used or further disclosed for any other
purpose, except as required by law.
RESEARCH: Our legal obligations permit Your medical information to be used or disclosed for
research purposes. If You die, Your medical information may be disclosed to a coroner, medical
examiner, funeral director or organ procurement organization.
VICTIM OF ABUSE: If You are reasonably believed to be a victim of abuse, neglect, domestic
violence or other crimes, medical information may be released to the extent necessary to avert
a serious threat to Your health or safety or to the health or safety of others. Medical
information may be disclosed, when necessary, to assist law enforcement officials to capture an
individual who has admitted to participation in a crime or has escaped from lawful custody.
30
INDIVIDUAL RIGHTS
You have the right to look at or get copies of Your medical information, with limited exceptions.
You must make a written request, using a form available from the Privacy Office, to obtain
access to Your medical information. If You request copies of Your medical information, We will
charge [$.25] per page,[ $10] per hour for staff time required to copy that information, and
postage if You want the copies mailed to You. If You request an alternative format, the charge
will be based upon Our cost of providing Your medical information in that format. If You prefer,
We will prepare a summary or explanation of Your medical information for a fee. For a more
detailed explanation of the fee structure, please contact the Privacy Office. We will require
advance payment before copying Your medical information.
You have the right to receive an accounting of any disclosures of Your medical information made
by Us or a business associate for any reason, other than treatment, payment, health care
operations purposes after April 14, 2003. This accounting will include the date the disclosure
was made, the name of the person or entity the disclosure was made to, a description of the
medical information disclosing the reason for the disclosure, and certain other information. If
You request an accounting more than once in a 12-month period, there may be a reasonable
cost-based charge for responding to those additional requests. Please contact the Privacy Office
for a more detailed explanation of the fees charged for such accountings.
You have the right to request restrictions on Our use or disclosure of Your medical information
We are not required to agree to such requests. We will only restrict the use or disclosure of
Your medical information as set forth in a written agreement that is signed by a
representative of the Privacy Office on behalf of BlueCross BlueShield of Tennessee.
If You reasonably believe that sending confidential medical information to You in the normal
manner will endanger You, You have the right to make a written request, We communicate that
information to You by a different method or to a different address. If there is an immediate
threat, You may make that request by calling a consumer advisor or The Privacy Officer at [1888-455-3824] and follow up with a written request when feasible. We must accommodate
Your request if it is reasonable, specifies how and where to communicate with You, and
continues to permit Us to collect Premium and pay claims under Your health Policy.
You have the right to make a written request that We amend Your medical information. Your
request must explain why the information should be amended. We may deny Your request if
the medical information You seek to amend was not created by Us or for other reasons
permitted by Our legal obligations. If Your request is denied, We will provide a written
explanation of the denial. If You disagree, You may submit a written statement that will be
included with Your medical information. If We accept Your request, We will make reasonable
efforts to inform the people that You designate about that amendment and will amend any
future disclosures of that information.
If you receive this notice on Our web site or by electronic mail (e-mail), You may request a
written copy of this notice, by contacting the Privacy Office.
31
QUESTIONS AND COMPLAINTS

If You want more information concerning the companies' privacy practices or have questions or
concerns, please contact the Privacy Office.
If:
You are concerned that We have violated Your privacy rights; or
You disagree with a decision made about access to Your medical information or in
response to a request You made to amend or restrict the use or disclosure of Your
medical information; or
You wish to request We communicate with You by alternative means or at alternative
locations;
please contact the Privacy Office.
You may also submit a written complaint to the U.S. Department of Health and Human Services.
We will furnish the address where You can file a complaint with the U.S. Department of Health
and Human Services upon request.
We support Your right to protect the privacy of Your medical information. There will be no
retaliation in any way if You choose to file a complaint with Us or with the U.S. Department of
Health and Human Services.
The Privacy Office

[(888) 455-3824]
[(423) 535-1976 FAX]
[Privacy_office@bcbst.com]
32
General Legal Provisions

The Plan is an Independent Licensee of the BlueCross
BlueShield Association
You acknowledge this Policy is a contract solely between You and BlueCross BlueShield of
Tennessee, Inc. BlueCross is an independent corporation operating under a license from the
BlueCross BlueShield Association, an association of independent BlueCross and BlueShield Plans,
(the Association). The Association permits BlueCross to use the Associations Service Marks in
Our service area. BlueCross is not contracting as the agent of the Association. You further
acknowledge and agree that:
(1) You have not entered into this Policy based upon representations by any person
other than BlueCross; and
(2) No person, entity, or organization other than BlueCross shall be held accountable or
liable to You for any of the obligations to You created under this Policy.
This paragraph shall not create any additional obligations on the part of BlueCross other than
those created under this Policy.
Relationship with Network Providers

Network Providers are Independent Contractors and are not Our employees, agents or
representatives. Network Providers contract with Us and We have agreed to pay them for rendering
Covered Services to You. Network Providers are solely responsible for making all medical treatment
decisions in consultations with their Member-patients. We do not make medical treatment decisions
under any circumstances.
[We have the discretionary authority to make benefit or eligibility determinations and interpret
the terms of Coverage under this Policy (Coverage Decisions.) We make those Coverage
Decisions based on the terms of this Policy, Our benefit policies, other relevant sources of
information, Our participation agreements with Network Providers and applicable State or
Federal laws.]
We have participation agreements with the Network Providers. These permit Network
Providers to dispute Our Coverage decisions if they disagree with those decisions. If Your
Network Provider does not dispute a Coverage Decision, You may request reconsideration of the
Coverage decision as explained in the Grievance Procedure section of this Policy. The
participation agreement requires Network Providers to fully and fairly explain Coverage
decisions to You, upon request, if You decide to request that We reconsider a Coverage
decision.
The Plan or a Network Provider may end their relationship with each other at any time. A
Network Provider may also limit the number of Members that he, she or it will accept as
patients during the term of this Policy. We do not promise that any specific Network Provider
will be available to render services while You or Your Covered Dependents are Covered by this
Policy.
33
Continuity of Care
When a Network Provider no longer has an agreement with Us and becomes an Out of Network
Provider, benefits will be available for Covered Services received from such Provider after such
Provider terminates its agreement with Us or We terminate such agreement without cause.
Benefits will be available as if such Provider were still a Network Provider:
For up to one-hundred and twenty (120) days following notice that the agreement
between the Provider and Us has been terminated, provided the Member was under
active treatment for a particular illness or injury on the date such agreement was
terminated and Covered Services are for the same illness or injury; or
Until completion of postpartum care, if the Member was in the second trimester of
pregnancy on the date such agreement was terminated; or
Until discharge, if the Member was under treatment at an inpatient facility on the date
such agreement was terminated.
The now Out-of-Network Provider must agree to continue to provide Covered Services on the
same terms and conditions as applied under its former agreement with Us.
[Our Payment Methods For Network Providers

The Plans agreements with Network Providers include different payment arrangements. In an
effort to control costs and improve quality of care, we use various alternative Provider payment
methodologies including, but not limited to, Diagnosis Related Group (DRG) payments,
discounted fee-for-service payments, patient-centered medical home programs, bundled
payments for episodes of care, pay-for-performance initiatives, and other quality improvement
and/or cost containment programs.]
Statement of Rights Under the Newborns and Mothers

Health Protection Act
Under federal law, health insurance issuers offering health insurance coverage generally may not
restrict benefits for any hospital length of stay in connection with childbirth for the mother or
newborn child to less than forty-eight (48) hours following a vaginal delivery, or less than ninety-six
(96) hours following a delivery by cesarean section. However, the issuer may pay for a shorter stay
if the attending Provider (e.g., Your physician, nurse midwife, or physician assistant), after
consultation with the mother, discharges the mother or newborn earlier. Also, under federal law,
issuers may not set the level of benefits or out-of pocket costs so that any later portion of the 48hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any
earlier portion of the stay. In addition, an issuer may not, under federal law, require that a physician
or other health care Provider obtain Authorization for prescribing a length of stay of up to fortyeight (48) hours (or ninety-six (96) hours). However, to use certain Providers or facilities, or to
reduce Your Out of-Pocket costs, You may be required to obtain precertification. For information on
precertification, contact Us.
Womens Health and Cancer Rights Act of 1998

Patients who undergo a mastectomy, and who elect breast reconstruction in connection with
the mastectomy, are entitled to Coverage for:
34
Reconstruction of the breast on which the mastectomy was performed;

Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
Prostheses and treatment of physical complications at all stages of the mastectomy,
including lymphedemas in a manner determined in consultation with the attending
physician and the patient.
The Coverage may be subject to Coinsurance and Deductibles consistent with those established
for other benefits. Please refer to the body of this Policy or call Our consumer advisors for more
details.
Governing Laws
Tennessee laws govern Your benefits.
Subrogation and Right of Recovery

You agree that We shall be subrogated to and/or have the right to recover amounts paid to
provide Covered Services to You and Your Covered Dependents for illnesses or injuries caused
by third parties, including the right to recover the reasonable value of prepaid services rendered
by Network Providers.
We shall have first lien against any payment, judgment or settlement of any kind that You or
Your Covered Dependents receive from or on behalf of such third parties for medical expenses,
for the costs of Covered Services and any costs of recovering such amounts from those third
parties. We may notify those parties of its lien without notice to or consent from You or Your
Covered Dependents.
Without limitation, We may enforce Our rights of subrogation and recovery against any tort
feasors, other responsible third parties or against available insurance coverages, including
underinsured or uninsured motorist coverages. Such actions may be based in tort, contract or
other cause of action to the fullest extent permitted by law.
To enable Us to protect Our rights under this section, You are required to notify Us promptly if
an illness or injury is caused by a third party. You are also required to cooperate with Us and to
execute any documents that We deem necessary to protect Our rights under this section. If You
or Your Covered Dependents settle any claim or action against any third party without Our
consent, You shall be deemed to have been made whole by the settlement, and We shall be
entitled to immediately collect the present value of Our rights as a first priority claim from the
settlement fund. Any such proceeds of settlement or judgment shall be held in trust by You for
Our benefit. We shall also be entitled to recover reasonable attorneys fees incurred in
collecting proceeds held by You in such circumstances.
35
DEFINITIONS
Defined terms are capitalized. When such defined words are used in this Policy, they will have
the meaning set forth in this section. Words that are defined in the Plans medical policies and
procedures have the same meaning if used in this Policy.
1. Acute - An illness or injury that is both severe and of short duration.
2. Advanced Payments of the Premium Tax Credit (APTC) - Payment of the tax credits
specified in section 36B of the Internal Revenue Code (as added by section 1401 of the
Affordable Care Act) which are provided on an advance basis to an eligible individual enrolled in
a Qualified Health Plan (QHP) through an Exchange.
3. Affordable Care Act (ACA) The Patient Protection and Affordable Care Act of 2010 (Pub. L.
111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111152).
4. Advanced Radiological Imaging Services such as MRIs, MRAs, CAT scans, CT scans, PET
scans, nuclear medicine and other similar technologies.
5. Application A form that must be completed in full before You or Your dependents will be
considered for Coverage under the Policy.
6. Application Change Form A form that must be completed to make a change in Your
Coverage under the Policy. Changes can include adding or terminating dependents or a change
in Your level of coverage. This form is also used to make administrative changes, such as a
change in name or address.
7. Average Wholesale Price A published suggested wholesale price of the drug by the
manufacturer.
8. Behavioral Health Services - Any services or supplies that are Medically Necessary and
Appropriate to treat: a mental or nervous condition; alcoholism; chemical dependence; drug
abuse or drug addiction.
9. Billed Charges The amount that a Provider or Dentist charges for services rendered. Billed
Charges may be different from the amount that We determine to be the Maximum Allowable
Charge for services.
10. BlueCard PPO Participating Provider A physician, Hospital, licensed skilled nursing facility,
home health care Provider or other Provider who contracts with other BlueCross and/or
BlueShield Plans, Blue Card PPO Plans and/or whom We have Authorized to provide Covered
Services to Members.
11. BlueCross, We, Us, Our, the Plan, or the Policy BlueCross BlueShield of Tennessee, Inc.
12. Brand Deductible - The amount that must be paid by You before benefits are provided for
Preferred Brand Drugs, Non-Preferred Brand Drugs or Self-administered Specialty Drugs under
this Policy. The Brand Deductible will not apply toward satisfying any other Deductible.
13. Calendar Year - The period of time beginning at 12:01 A.M. on January 1st and ending 12:00
A.M. on the following December 31st.
36
14. Care Management A program that promotes cost effective coordination of care for
Members with complicated medical needs, chronic illnesses, and/or catastrophic illnesses or
injuries.
15. CHIP The State Childrens Health Insurance Program established under title XXI of the
Social Security Act (42 U.S.C. 1396 et. seq.)
16. Clinical Trials - Studies performed with human subjects to test new drugs or combinations of
drugs, new approaches to Surgery or radiotherapy or procedures to improve the diagnosis of
disease and the quality of life of the patient.
17. Coated Lenses A substance added to a finished lens on one or both surfaces.
18. Coinsurance Sharing of the cost of Covered Services by the Plan and You, after Your
Deductible has been satisfied. The Plans Coinsurance amounts for network and out-of-network
Covered Services are specified in Attachment C: Schedule of Benefits. Your Coinsurance is
calculated as 100% minus the Plans Coinsurance. In addition to Your Coinsurance, You are
responsible for the difference between the Billed Charge and the Maximum Allowable Charge
for Covered Services if the Billed Charge of a Non-Contracted Provider or an Out-of-Network
Provider is more than the Maximum Allowable Charge for such services.
Coinsurance applies to the Maximum Allowable Charge for Covered Services. For example, if
the Out-of-Network Providers Billed Charge is $5,000 and the Maximum Allowable Charge for
Network Providers is $3,000, the Coinsurance percentage is based upon $3,000, not $5,000. In
this example, You are responsible for the $2,000 charge difference plus Your Coinsurance on the
$3,000 Maximum Allowable Charge.
19. Complications of Pregnancy Conditions requiring Hospital Confinement (when the
pregnancy is not terminated) whose diagnoses are distinct from pregnancy but are adversely
affected by pregnancy or caused by pregnancy, such as Acute nephritis, nephrosis, cardiac
decompensation, missed abortion, and similar medical and surgical conditions of comparable
severity, non-elective cesarean section, ectopic pregnancy that is terminated, and spontaneous
termination of pregnancy, that occurs during a period of gestation in which a viable birth is not
possible.
Complications of Pregnancy does not include false labor; occasional spotting; physician
prescribed rest during the period of pregnancy; morning sickness; hyperemesis gravidarum and
similar conditions associated with the management of a difficult pregnancy not constituting a
nosologically distinct complication of pregnancy.
20. Compound Drug - An outpatient Prescription Drug, which is not commercially prepared by a
licensed pharmaceutical manufacturer in a dosage form approved by the food and drug
administration (FDA) and that contains at least one ingredient classified as a Legend Drug.
21. Concurrent Review The process of evaluating care during the period when Covered
Services are being rendered.
22. Copayment The dollar amount specified in Attachment C: Schedule of Benefits that You
are required to pay directly to a Provider or Network Pharmacy for certain Covered Services.
You must pay such Copayments at the time You receive those Services.
23. Cosmetic Service Any surgical or non-surgical treatment, drugs, or devices intended to
alter or reshape the body for the purpose of improving appearance or self-esteem. Our medical
37
policy establishes the criteria for what is cosmetic, and what is Medically Necessary and
Appropriate.
24. Cost-Sharing Reductions (CSR) Reductions in cost sharing, any expenditure required by or
on behalf of an enrollee with respect to essential health benefits, for an eligible individual
enrolled in a silver level plan in the Exchange or for an individual who is an Indian enrolled in a
QHP in the Exchange.
25. Covered Dependent - A Subscribers family member who: (1) meets the eligibility
requirements of this Policy; (2) has been enrolled for Coverage; and (3) for whom We have
received the applicable Premium for Coverage.
26. Covered Family Members - A Subscriber and his or her Covered Dependents.
27. Covered Services, Coverage or Covered - Those Medically Necessary and Appropriate
services and supplies that are set forth in Attachment A: Covered Services and Exclusions of this
Policy. Covered Services are subject to all the terms, conditions, exclusions and limitations of
this Policy.
28. Custodial Care - Any services or supplies provided to assist an individual in the activities of
daily living, as determined by Us. This includes, but not limited to eating, bathing, dressing or
other self-care activities.
29. Deductible - The dollar amount, specified in Attachment C: Schedule of Benefits, that You
must incur and pay for Covered Services during a Calendar Year before We provide benefits for
services. There are separate Deductible amounts for Network Providers and for Out-of-Network
Providers. The Deductible(s) will apply to the Out of Pocket Maximum(s.)
Copayments, penalties and any balance of charges (the difference between Billed Charges and
the Maximum Allowable Charge for Covered Services) will not be considered when determining
if this Deductible is satisfied.
30. Dentist - A doctor of dentistry duly licensed and qualified under applicable laws to practice
dentistry at the time and place Covered Services are performed.
31. Drug Formulary - A list designating that Prescription Drugs and drug products are approved
for reimbursement under this Policy. This list is subject to periodic review and modification by
Us.
32. Effective Date - The date Your Coverage under this policy begins.
33. Eligible Providers - All services must be rendered by a Practitioner or Provider type listed in
the Plans Provider Directory of Network Providers, or as otherwise required by Tennessee law.
The services provided by a Practitioner must be within his/her/its specialty, degree, licensure or
accreditation. All services must be rendered by the Practitioner or Provider, or the delegate
actually billing for the Practitioner or Provider, and be within the scope of his/her/its licensure.
34. Emergency A sudden and unexpected medical condition that manifests itself by
symptoms of sufficient severity, including severe pain, that a prudent layperson, who possesses
an average knowledge of health and medicine could reasonably expect to result in:
a. serious impairment of bodily functions; or
b. serious dysfunction of any bodily organ or part; or
c. placing the prudent laypersons health in serious jeopardy.
38
Examples of Emergency conditions include: (1) severe chest pain; (2) uncontrollable bleeding; or
(3) unconsciousness.
35. Emergency Care Services - Those services and supplies delivered in a hospital emergency
department that are Medically Necessary and Appropriate in the treatment of an Emergency.
36. Exchange A governmental agency or non-profit entity that meets the applicable standards
under the Affordable Care Act and makes Qualified Health Plans (QHPs) available to qualified
individuals.
37. Experimental and/or Investigational Drugs Drugs or medicines that are labeled: Caution
limited by federal law to Investigational use.
38. Generic Drug - A Prescription Drug that has the same active ingredients, strength or
concentration, dosage form and route of administration as a Brand Name Drug. The FDA
approves each Generic Drug as safe and effective as a specific Brand Name Drug.
39. Habilitative Therapy - Therapies or other treatments that enable a person (e.g., a child) with
a disability to attain functional abilities, or lessen the deterioration of function over time.
40. Hospital Confinement When the Member is treated as a registered bed patient at a
Hospital or other Provider facility and incurs a room and board charge.
41. Hospital Services - Covered Services that are Medically Appropriate to be provided by an
Acute care hospital.
42. Incapacitated Child an unmarried child who is, and continues to be, both (1) incapable of
self-sustaining employment by reason of intellectual disabilities (excluding mental illness) or
physical handicap, or is mentally handicapped and has qualified for Social Security Insurance
disability benefits; and (2) chiefly dependent upon the Subscriber or Subscribers spouse for
economic support and maintenance.
If the child reaches this Plans Limiting Age while Covered under this Plan, proof of such
incapacity and dependency must be furnished within thirty-one (31) days of when the child
reaches the Limiting Age.
Incapacitated dependents of Subscribers of new groups, or of Subscribers who are newly eligible
under this Plan, are eligible for Coverage if they were Covered under the Subscribers or the
Subscribers spouses previous health benefit plan, and have less than a sixty-three (63) day
break in Coverage from the prior plan. We may ask You to furnish proof of the incapacity and
dependency upon enrollment.
We may ask for proof that the child continues to meet the conditions of incapacity and
dependency, but not more frequently than annually.
43. [Indian Health Provider A Provider associated with the Indian Health Service, an Indian
Tribe, Tribal Organization, or Urban Indian Organization that renders Covered Services to a
Member that is an Indian (as defined in section 4(d) of the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450b(d))).]
44. Investigational - The definition of Investigational is based on the BlueCross and BlueShield
of Tennessees technology evaluation criteria. Any technology that fails to meet ALL of the
following four criteria is considered to be Investigational.
a. The technology must have final approval from the appropriate governmental regulatory
bodies, as demonstrated by:
39
i. This criterion applies to drugs, biological products, devices and any other product or
procedure that must have final approval to market from the U.S. Food and Drug
Administration or any other federal governmental body with authority to regulate
the use of the technology.
ii. Any approval that is granted as an interim step in the U.S. Food and Drug
Administrations or any other federal governmental bodys regulatory process is not
sufficient.
b. The scientific evidence must permit conclusions concerning the effect of the technology
on health outcomes, as demonstrated by:
i.
The evidence should consist of well-designed and well-conducted investigations

published in peer-reviewed journals. The quality of the body of studies and the
consistency of the results are considered in evaluating the evidence.
ii.
The evidence should demonstrate that the technology could measure or alter the
physiological changes related to a disease, injury, illness, or condition. In addition,
there should be evidence or a convincing argument based on established medical
facts that such measurement or alteration affects health outcomes.
c. The technology must improve the net health outcome, as demonstrated by:
i.
The technology's beneficial effects on health outcomes should outweigh any

harmful effects on health outcomes.
d. The improvement must be attainable outside the Investigational settings, as

demonstrated by:
i.
In reviewing the criteria above, the medical policy panel will consider physician
specialty society recommendations, the view of prudent medical Practitioners
practicing in relevant clinical areas and any other relevant factors.
The Medical Director, in accordance with applicable ERISA standards, shall have
discretionary authority to make a determination concerning whether a service or supply is
an Investigational. If the Medical Director does not Authorize the provision of a service or
supply, it will not be a Covered Service. In making such determinations, the Medical Director
shall rely upon any or all of the following, at his or her discretion:
a. Your medical records, or
b. the protocol(s) under which proposed service or supply is to be delivered, or
c. any consent document that You have executed or will be asked to execute, in order to
receive the proposed service or supply, or
d. the published authoritative medical or scientific literature regarding the proposed
service or supply in connection with the treatment of injuries or illnesses such as those
experienced by You, or
e. regulations or other official publications issued by the FDA and HHS, or
f.
the opinions of any entities that contract with the Plan to assess and coordinate the
treatment of Members requiring non-experimental or Investigational Services, or
g. the findings of the BlueCross BlueShield Association Technology Evaluation Center or

other similar qualified evaluation entities
40
45. Legend Drugs A drug that, by law, can be obtained only by Prescription and bears the
label, Caution: Federal law prohibits dispensing without a Prescription.
46. Limiting Age (or Dependent Child Limiting Age) The age at which a child will no longer be
considered an eligible Dependent
47. Mail Order Network BlueCross BlueShield of Tennessees network of mail service
Pharmacy facilities.
48. Maintenance Care Medical services (including skilled services and therapies), Prescription
Drugs, supplies and equipment for chronic, static or progressive medical conditions where the
services (including skilled services and therapies), drugs, supplies and equipment: (1) fail to
contribute toward cure; (2) fail to improve unassisted clinical function; (3) fail to significantly
improve health; and (4) are indefinite or long-term in nature. This exclusion also applies to drugs
used to treat chemical dependency.
49. Maximum Allowable Charge The amount that We, at Our sole discretion, have
determined to be the maximum amount payable for a Covered Service. That determination will
be based upon Our contract with a Network Provider or the amount payable based on Our fee
schedule for the Covered Services rendered by Out-of-Network Providers.
50. Medicaid The program for medical assistance established under title XIX of the Social
Security Act (42 U.S.C. 1396 et. seq.)
51. Medical Director - The physician designated by Us, or that physicians designee, who is
responsible for the administration of Our Medical Policy and Medical Management programs,
including its authorization program.
52. Medically Appropriate Services which have been determined by BlueCross, in its sole
discretion, to be of value in the care of a specific Member. To be Medically Appropriate a
service must:
a. be Medically Necessary;
b. be consistent with generally accepted standards of medical practice for the Members
medical condition;
c. be provided in the most appropriate site and at the most appropriate level of service for
the Members medical condition;
d. not be provided solely to improve a Members condition beyond normal variation in
individual development, appearance and aging;
e. not be for the sole convenience of the Provider, Member or Members family.
53. Medically Necessary or Medical Necessity Services procedures, treatments, supplies,
devices, equipment, facilities or drugs (all services) that a medical Practitioner, exercising
prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating,
diagnosing or treating an illness, injury or disease or its symptoms, and that are:
a. in accordance with generally accepted standards of medical practice; and
b. clinically appropriate in terms of type, frequency, extent, site and duration and
considered effective for the patient's illness, injury or disease; and
c. not primarily for the convenience of the patient, physician or other health care Provider;
and
d. not more costly than an alternative service or sequence of services at least as likely to
produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of
that patient's illness, injury or disease.
41
For these purposes, "generally accepted standards of medical practice" means standards
that are based on credible scientific evidence published in peer-reviewed medical literature
generally recognized by the relevant medical community, physician specialty society
recommendations, and the views of medical Practitioners practicing in relevant clinical areas
and any other relevant factors.
54. Medicare Title XVIII of the Social Security Act, as amended, and Coverage under this
program.
55. Member, You, Your - Any person enrolled as a Subscriber or Covered Dependent under this
Policy.
56. Member Payment The dollar amounts for Covered Services that You are responsible for as
set forth in Attachment C: Schedule of Benefits, including Copayments, Deductibles,
Coinsurance and Penalties.
57. Minimum Essential Coverage Coverage under any of the following, as defined in section
5000A(f) of the Internal Revenue Code: (1) Government sponsored programs; (2) an eligible
employer-sponsored plan; (3) a health plan offered in the individual market within a State; (4) a
grandfathered health plan; (5) other health benefits coverage, such as a State health benefits
risk pool.
58. Necessary Dental Care - Any treatment or service prescribed by a Dentist that the Plan
determines to be necessary and appropriate.
59. Network Benefit The payment level that applies to Covered Services received from a
Network Provider. See Attachment C: Schedule of Benefits.
60. Network Dentist A Dentist who has signed a Preferred Dental Agreement with the Plan.
61. Network Pharmacy - a Pharmacy that has entered into a Network Pharmacy Agreement
with the Plan or its agent to legally dispense Prescription Drugs to You[, either in person or
through mail order].
62. Network Provider - A Provider who has contracted with Us to provide Covered Services to
Members at specified rates. Such Providers may be referred to as Blue Card PPO participating
Providers, participating Hospitals, Transplant Network, etc.
63. Non-Contracted Provider A Provider that renders Covered Services to a Member, but is in
a specialty category or type with which We do not contract. A Non-Contracted Provider is
different from an Out-of-Network Provider. A Non-Contracted Provider is not eligible to hold a
contract with Us. Provider types that are considered Non-Contracted can change, as We
contract with different Provider types. A Provider's status as a Non-Contracted Provider,
Network Provider, or Out-of-Network Provider can and does change. We reserve the right to
change a Provider's status.
64. Non Preferred Brand Drug or Elective Drug - a Prescription Drug identified by its registered
trademark or product name given by its manufacturer, labeler or distributor that is not
considered a Preferred Drug by the Plan. Usually there are lower cost alternatives to some NonPreferred Brand Drugs.
65. Open Enrollment The period, as defined by the Department of Health and Human
Services, in which individuals can select a choice of Coverage.
42
66. Ophthalmologist A person or a doctor of medicine (M.D.) or osteopathy (D.O.) who

specializes in the comprehensive care of the eyes and visual system to prevent, diagnose, and
treat any eye disease, disorder, or injury.
67. Optician One who is licensed to fit, adjust, and dispense eyeglasses and other optical
devices on the written Prescription of a licensed Ophthalmologist or Optometrist.
68. Optometrist A doctor of optometry (O.D.) who is trained to detect and correct vision
problems primarily by prescribing eyeglasses or contact lenses.
69. Oral Appliance a device placed in the mouth and used to treat mild to moderate
obstructive sleep apnea by repositioning or stabilizing the lower jaw, tongue, soft palate or
uvula. An Oral Appliance may also be used to treat TMJ or TMD by stabilizing the jaw joint. An
Oral Appliance is not the same as an occlusal splint, which is used to treat malocclusion or
misalignment of teeth.
70. Out-of-Network Pharmacy - a Pharmacy that has not entered into a service agreement with
BlueCross or its agent to provide benefits under this Policy at specified rates to You.
71. Out-of-Network Provider Any Provider who is an eligible Provider type but who does not
hold a contract with Us to provide Covered Services.
72. Out-of-Pocket Maximum - The total dollar amount, as stated in Attachment C: Schedule of
Benefits, that You must incur and pay for Covered Services during the Calendar Year, including
Deductible and Coinsurance. There are two (2) Out-of-Pocket Maximums one for services
rendered by Network Providers and one for services rendered by Out-of-Network Providers.
Penalties and any balance of charges (the difference between Billed Charges and the Maximum
Allowable Charge for Covered Services) will not be considered when determining if an Out of
Pocket Maximum has been satisfied.
When the In-Network Out-of-Pocket Maximum is satisfied, benefits are payable at 100% for
other Covered Services from Network Providers incurred by the Member during the remainder
of that Annual Benefit Period, excluding applicable Copayments and Penalties, and any balance
of charges (the difference between Billed Charges and the Maximum Allowable Charge).
When the Out-of-Network Out-of-Pocket Maximum is satisfied, benefits are payable at 100% for
expenses for other Covered Services incurred by the Member during the remainder of that
Annual Benefit Period, excluding applicable Copayments and Penalties, and any balance of
charges (the difference between Billed Charges and the Maximum Allowable Charge).
73. Oversized Lens Any lens with an eyesize of 61mm or greater.
74. Payor(s) - An insurer, health maintenance organization, no-fault liability insurer, self-insurer
or other entity that provides or pays for Your health care benefits.
75. Penalty/Penalties Additional Member Payments required as a result of failure to obtain
Prior Authorization for Certain Covered Services listed in Attachment C: Schedule of Benefits as
requiring such Prior Authorization. The Penalty will be a reduction in payment for Covered
Services.
76. Periodic Health Screening An assessment of patients health status at intervals set forth
in Our Medical Policy for the purpose of maintaining health and detecting disease in its early
state. This assessment should include:
43
a. complete history or interval update of the patients history and a review of systems; and
b. a physical examination of all major organ systems, and preventive screening tests per
Our medical policy.
77. Pharmacy - A state or federally licensed establishment that is physically separate and apart
from the office of a physician or authorized Practitioner, and where Legend Drugs are dispensed
by Prescription by a pharmacist licensed to dispense such drugs and products under the laws of
the state in which he or she practices.
78. Pharmacy and Therapeutics Committee (or P&T Committee) - A panel of Our participating
pharmacists, Network Providers, Medical Directors and Pharmacy directors that reviews
medications for safety, efficacy and cost effectiveness. The P&T Committee evaluates
medications for addition and deletion from the: 1) Drug Formulary; 2) Preferred Brand Drug list;
3) Prior Authorization Drug list; and 4) Quantity Limitation list. The P&T Committee may also set
dispensing limits on medications.
79. Practitioner A person licensed by the State to provide medical services.
80. Preferred Brand Drug - Brand Name Drugs that We have reviewed for clinical
appropriateness, safety, therapeutic efficacy, and cost effectiveness. The Preferred Brand Drug
list is reviewed at least annually by the P&T Committee.
81. [Preferred Formulary A list of specific generic and brand name Prescription Drugs Covered
by the Plan subject to Quantity Limitations, Prior Authorization and Step Therapy. The Preferred
Formulary is subject to periodic review and modification at least annually by the Plans
Pharmacy and Therapeutics Committee. The Preferred Formulary is available for review at
bcbst.com, or by calling the toll-free number on the back of Your Member ID card.]
82. Preferred Specialty Pharmacy Network - a Pharmacy that has entered into a Network
Pharmacy agreement with the Plan or its agent to legally dispense self-administered Specialty
Drugs to You.
83. Premium - The total payment for Coverage under the Policy.
84. Prescription - a written or verbal order issued by a physician or duly licensed Practitioner
practicing within the scope of his or her licensure and authorized by law to a pharmacist or
dispensing physician for a drug, or drug product to be dispensed.
85. Prescription Contraceptive Drugs - Prescription Drug products that are indicated for the
prevention of pregnancy.
86. Prescription Drug - a medication containing at least one Legend Drug that may not be
dispensed under applicable state or federal law without a Prescription, and/or insulin.
87. [Preventive Drugs Drugs that are prescribed (1) for a Member who has developed risk
factors for a disease that has not yet become a health issue; (2) to prevent the reoccurrence of a
disease from which the Member has recovered; or (3) as part of preventive care procedures.
The Plan maintains a list of Preventive Drugs, which is reviewed periodically by Our Pharmacy
and Therapeutics Committee. In keeping with accepted standards of medical practice, not all
therapeutic classes of drugs are included on the Preventive Drug list.]
88. Prior Authorization, Authorized A review conducted by Us, prior to the delivery of certain
services, to determine if such services will be considered Covered Services.
44
89. Prior Authorization Drugs- Prescription Drugs that are only eligible for reimbursement after
prior authorization from Us as determined by the P&T Committee.
90. Provider A person or entity that is engaged in the delivery of health services who or that is
licensed, certified or practicing in accordance with applicable State or Federal laws.
91. Qualified Health Plan (QHP) A health plan that has in effect a certification that it meets
the standards under the Affordable Care Act and is issued or recognized by the Exchange
through which such plan is offered.
92. Qualified Medical Child Support Order A medical child support order issued by a court of
competent jurisdiction that creates or recognizes the existence of a childs right to receive
benefits for which a Subscriber is eligible under this Policy. Such order shall identify the
Subscriber and each such child by name and last known mailing address; give a description of
the type and duration of coverage to be provided to each child; and identify each health plan to
which such order applies.
93. Quantity Limitation Quantity limitations applied to certain Prescription Drug products as
determined by the Pharmacy and Therapeutics Committee.
94. Select90 Network BlueCrosss network of retail pharmacies that are permitted to dispense
Prescription Drugs to BlueCross Members on the same terms as pharmacies in the Mail Order
Network.
95. Specialty Drugs Injectable, infusion and select oral medications that require complex care,
including special handling, patient education and continuous monitoring. Specialty Drugs are
listed on the Specialty Drugs list. Specialty Drugs are categorized as Provider-administered or
self-administered.
96. Standard Lens Standard glass or plastic (CR39) in clear or Rose Tint #1 or #2. Any lens that
will fit any frame with an eyesize less than 61 mm.
97. Standard Frame Any frame that has a retail value of [$100.00-$200.00] or less.
98. Step Therapy A form of Prior Authorization that begins drug therapy for a medical
condition with the most cost-effective and safest drug therapy and progresses to alternate drugs
only if necessary. Prescription Drugs subject to Step Therapy guidelines are: (1) used only for
patients with certain conditions; and (2) Covered only for patients who have failed to respond
to, or have demonstrated an intolerance to, alternate Prescription Drugs, as supported by
appropriate medical documentation; and (3) when used in conjunction with selected
Prescription Drugs for the treatment of Your condition.
99. Subscriber, You, Your An individual who meets all applicable eligibility requirements, has
applied for Coverage, for whom We have received the applicable Premium for Coverage and to
whom we have issued the Policy.
100. Surgery or Surgical Procedure - Medically Necessary and Appropriate surgeries or
procedures. Surgeries involve an excision or incision of the bodys skin or mucosal tissues,
treatment of broken or dislocated bones, and/or insertion of instruments for exploratory or
diagnostic purposes into a natural body opening.
101.Telemedicine the use of two-way real time electronic communications (e.g., email,
telephone call, fax) and used for medical diagnostic, and therapeutic purposes between a
Practitioner and a Member from one site to another.
45
102. Transplant Maximum Allowable Charge (TMAC) - The amount that We, in Our sole
discretion, have determined to be the maximum amount payable for Covered Services for Organ
Transplants. Each type of Organ Transplant has a separate TMAC.
103. Transplant Network - A network of hospitals and facilities, each of which has agreed to
perform specific organ transplants. For example, some hospitals might contract to perform
heart transplants, but not liver transplants.
104. Transplant Network Institution A facility or hospital that has contracted with Us (or with
an entity on Our behalf) to provide Transplant Services for some or all organ and bone marrow
transplant procedures Covered under this Policy. For example, some hospitals might contract to
perform heart transplants, but not liver transplants. A Contracted Transplant Institution is a
Network Provider when performing contracted transplant procedures in accordance with the
requirements of this Policy.
105. Transplant Service - Medically Necessary and Appropriate Services listed as Covered under
the Transplant Service section in Attachment A: Covered Services and Exclusions of this Policy.
106. Vision Examination A comprehensive ophthalmologic service as defined in the Current
Procedural Technology (CPT) and the Documentation Guidelines listed under Eyes
examination items. Comprehensive ophthalmologic service describes a general evaluation of
the complete visual system. The comprehensive services constitute a single service entity but
need not be performed at one session. The service includes history, general medical
observation, external and ophthalmologic examinations, gross visual fields and basic
sensorimotor examination. It often includes, as indicated, biomicroscopy, examination with
cyclopedia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment
programs.
107.Well Woman Exam A routine visit every Calendar Year to a Provider. The visit may
include Medically Necessary and Medically Appropriate mammogram and cervical cancer
screenings.
46
POLICY
Attachment A: Covered Services and Exclusions
Plan benefits are based on the Maximum Allowable Charge for Medically Necessary and Appropriate
services and supplies and for Necessary Dental Care described in this Attachment A and provided in
accordance with the benefit schedules set forth in this Policys Attachment C: Schedule of Benefits.
To be eligible for benefits, all services or supplies must be provided in accordance with the Plans
medical policies and procedures. (See the Prior Authorization, Care Management, Medical Policy and
Patient Safety section for more information.)
This Attachment sets forth Covered Services and exclusions (services not Covered), and is arranged
according to type of services.
Please also read Attachment B: Other Exclusions.
Your benefits are greater when You use Network Providers. The Plan contracts with Network Providers.
Network Providers have agreed to accept the Maximum Allowable Charge as the basis for payment to
the Provider for Covered Services. (See the Definitions section for an explanation of Maximum
Allowable Charge and Covered Services.) Network Providers have also agreed not to bill You for
amounts above the Maximum Allowable Charge.
Out-of-Network Providers do not have a contract with the Plan. This means they may be able to
charge You more than the Maximum Allowable Charge (the amount set by the Plan in its contracts with
Network Providers). When You use an Out-of-Network Provider for Covered Services, You will be
responsible for any difference between what the Plan pays and what the Out-of-Network Provider
charges. This means that You may owe the Out-of-Network Provider a large amount of money.
Obtaining services not listed as a Covered Service in this Attachment or not in accordance with Our
medical policy and Care Management procedures may result in the denial of benefits or a reduction in
reimbursement for otherwise eligible Covered Services.
Obtaining Prior Authorization is not a guarantee of Coverage. All provisions of the Policy must be
satisfied before benefits for Covered Services will be provided. The Plans medical policies can help Your
Provider determine if a proposed service will be Covered.
When more than one treatment alternative exists, each is Medically Appropriate and Medically
Necessary, and each would meet Your needs, We reserve the right to provide payment for the least
expensive Covered Service alternative.
A clinical trial is a prospective biomedical or behavioral research study of human subjects that is
designed to answer specific questions about biomedical or behavioral interventions (vaccines, drugs,
treatments, devices, or new ways of using known drugs, treatments, or devices). Clinical Trials are used
to determine whether new biomedical or behavioral interventions are safe, efficacious, and effective.
Routine patient care associated with an approved clinical trial will be Covered under the Policys
benefits in accordance with the Plans medical policies and procedures.
47
A. Ambulance Services
Medically Necessary and Appropriate land or air transportation, services, supplies and
medications by a licensed ambulance service when time or technical expertise of the
transportation is essential to reduce the probability of harm to You.
1. Covered Services
a. Medically Necessary and Appropriate land or air transportation from the scene of an
accident or Emergency to the nearest appropriate hospital.
2. Exclusions
a. Transportation for Your convenience.
b. Transportation that is not essential to reduce the probability of harm to You.
c. Services when You are not transported to a hospital.

B. Behavioral Health
Medically Necessary and Appropriate treatment of mental health and substance abuse
disorders (behavioral health conditions) characterized by abnormal functioning of the mind
or emotions and in which psychological, emotional or behavioral disturbances are the
dominant features.
1. Prior Authorization is required for:
a. All inpatient levels of care, which include Acute care, residential care, and partial
hospital care; and intensive outpatient programs.
b. Electro-convulsive therapy (ECT), whether performed on an inpatient or outpatient

basis.
c. Outpatient visits do not require Prior Authorization.

Call the number on the back of Your Member ID card if You have questions about Prior
Authorization requirements for Behavioral Health Services.
IMPORTANT NOTE: All inpatient treatment (including Acute, residential, and partial
hospitalization and intensive outpatient treatment) requires Prior Authorization. If You
receive inpatient treatment, including treatment for substance abuse, that did not receive
Prior Authorization, and You sign a Provider's waiver stating that You will be responsible for
the cost of the treatment, You will not receive Plan benefits for the treatment. You will be
financially responsible, according to the terms of the waiver.
2. Covered Services
a. Inpatient and outpatient service for care and treatment of mental health disorders
and substance abuse disorders.
b. Care Management benefits may be available.
c. Outpatient treatment visits for medication management. These visits do not count
toward the number of mental health outpatient visits per year. Medication
management means pharmacological management, including Prescription, use, and
review of medication with no more than minimal medical psychotherapy.
48
3. Exclusions
a. Pastoral counseling.
b. Marriage and family counseling without a behavioral health diagnosis.
c. Vocational and educational training and/or services.
d. Custodial or domiciliary care.
e. Conditions without recognizable ICD-[9-10] diagnostic classification, such as adult
child of alcoholics (ACOA), and co-dependency and self-help programs.
f.
Sleep disorders.
g. Services related to mental retardation.

h.
Court ordered behavioral health care, or care received to avoid prosecution or

incarceration. Court ordered examinations and treatment, unless Medically
Necessary.
i.
Pain management.
j.
Hypnosis or regressive hypnotic techniques.
C. Dental Services Medically Necessary for all Members

Medically Necessary and Appropriate services performed by a doctor of dental Surgery
(DDS), a doctor of medical dentistry (DMD) or any Practitioner licensed to perform dental
related oral Surgery except as indicated below. For Pediatric Dental Benefits see section
Dental Services Pediatric Dental.
1. Covered Services
a. Dental services and oral surgical care to treat intraoral cancer, or to treat accidental
injury to the jaw, sound natural teeth, mouth, or face, due to external trauma. The
Surgery and services to treat accidental injury must be started within three (3)
months and completed within twelve (12) months of the accident.
b. For dental services not listed in subsection a. above, general anesthesia, nursing and
related hospital expenses in connection with an inpatient or outpatient dental
procedure are Covered, only when one of the five (5) conditions listed below is met.
Prior Authorization for inpatient services is required.
i. Complex oral Surgical Procedures that have a high probability of complications
due to the nature of the Surgery;
ii. Concomitant systemic disease for which the patient is under current medical
management and that significantly increases the probability of complications;
iii. Mental illness or behavioral condition that precludes dental Surgery in the
office;
iv. Use of general anesthesia and the Members medical condition requires that
such procedure be performed in a Hospital; or
49
v. Dental treatment or Surgery performed on a Member eight (8) years of age or

younger, where such procedure cannot be safely provided in a dental office
setting.
c. Oral Appliances to treat obstructive sleep apnea, if Medically Necessary.
2. Exclusions
a. Routine dental care and related services including, but not limited to: (1) crowns; (2)
caps; (3) plates; (4) bridges; (5) dental x-rays; (6) fillings; (7) tooth extraction, except
as listed above; (8) periodontal Surgery; (9) root canals; (10) preventive care
(cleanings, x-rays); (11) replacement of teeth (including implants, false teeth,
bridges); (12) bone grafts (alveolar Surgery); (13) treatment of injuries caused by
biting and chewing; (14) treatment of teeth roots; and (15) treatment of gums
surrounding the teeth.
b. Treatment for correction of underbite, overbite, and misalignment of the teeth
including but not limited to, braces for dental indications, orthognathic Surgery, and
occlusal splints and occlusal appliances to treat malocclusion/misalignment of teeth.
c. Extraction of impacted teeth, including wisdom teeth.
D. Dental Services - Orthodontia - Pediatric Only
Orthodontia when performed in conjunction with Medically Necessary and Appropriate
orthognathic Surgery for members under age nineteen (19). Prior Authorization for
Medically Necessary orthodontia must be obtained from the Plan, or benefits will be
reduced or denied.
1. Covered
a. Medically Necessary and Appropriate non-cosmetic orthodontia when performed in
conjunction with orthognathic Surgery for members under age nineteen (19).
2. Exclusions
a. Orthodontia for members over age nineteen (19).
b. Cosmetic orthodontia.
E. Dental Services Pediatric Dental
This Pediatric Dental section provides a wide range of benefits to Cover most services
associated with dental care for dependents under age nineteen (19).
If a Member transfers from the care of one Dentist to another during the course of
treatment, or if more than one Dentist renders services for one dental procedure, benefits
will not exceed those that would have been provided had one Dentist rendered the service.
When more than one treatment alternative exists, meets generally accepted standards of
professional dental care, and offers a favorable prognosis for Your condition, We reserve the
right to provide payment for the least expensive Covered Service alternative.
I.
Diagnostic Services
A. Exams
50
1. Covered
a. Standard exams including comprehensive, periodic, detailed/extensive
limited and periodontal oral evaluations (exams).
2. Limitations
a. No more than one standard exam in any six (6) month period.
3. Exclusions
a. Re-evaluations and consultations.
B. X-rays
1. Covered
a. Full mouth series, intraoral and bitewing radiographs (x-rays).
2. Limitations
a. No more than one full mouth set of x-rays in any sixty (60) month period. A
full mouth set of x-rays is defined as either an intraoral complete series or
panoramic x-ray. Benefits provided for either include benefits for all
necessary intraoral and bitewing films taken on the same day.
b. No more than four (4) bitewing films in any six (6) month period. Bitewing
films must be taken on the same date of service.
3. Exclusions
a. Extraoral, skull and bone survey, sialography, and tomographic survey x-ray
films, cephalometric films and diagnostic photographs.
II. Preventive Services
A. Prophylaxis (Cleanings)
1. Covered
a. Child prophylaxis (cleaning) for primary and permanent teeth.
2. Limitations
a. No more than one (1) of any prophylaxis or periodontal maintenance
procedure in any six (6) month period.
b. Periodontal maintenance procedures are subject to additional limitations
listed below under Basic Periodontics, and may be subject to a different
Coverage level under Attachment C: Schedule of Benefits.
B. Fluoride Treatment
1. Covered
a. Topical fluoride treatments, performed with or without a prophylaxis.
51
2. Limitations
a. No more than one (1) fluoride treatment in any six (6) month period.
b. Fluoride must be applied separately from prophylaxis paste.
C. Other Preventive Services
1. Covered
a. Sealants, preventive resin restorations, space maintainers.
b. Palliative (emergency) treatment for the relief of pain.
2. Limitations
a. No more than one (1) sealant, or preventive resin restoration, or resin
infiltration per first or second molar tooth per thirty-six (36) months. Resin
infiltrations are subject to a different Coverage level under Attachment C:
Schedule of Benefits.
b. No more than one (1) re-cementation in any twelve (12) month period.
3. Exclusions
a. Nutritional and tobacco counseling, oral hygiene instructions provided by a
Dentist.
III. Basic Restorative Services
A. Fillings and Stainless Steel Crowns
1. Covered
a. Amalgam restorations (silver fillings), resin composite restorations (tooth
colored fillings), resin infiltrations, stainless steel crowns.
2. Limitations
a. No more than one amalgam or resin restoration per tooth surface in any
twelve (12) month period.
b. Replacement of existing amalgam and resin composite restorations Covered
only after twelve (12) months from the date of initial restoration.
c. Replacement of stainless steel crowns Covered only after sixty (60) months
from the date of initial restoration.
d. No more than one (1) sealant, preventive resin restoration, or resin
infiltration per first or second molar tooth per thirty-six (36) months.
(Sealant/Preventive resins are subject to additional limitations listed under
Preventive Services, and may be subject to a different Coverage level under
Attachment C: Schedule of Benefits.
3. Exclusions
a. Gold foil restorations.
B. Other Basic Restorative Services
52
1. Covered
a. Repair of full and partial dentures and bridges.
b. Crown and Inlay re-cementation.
c. Denture services including adjustments, relining, rebasing and tissue
conditioning.
d. General anesthesia & IV sedation only when administered by a properly
licensed Dentist in a dental office in conjunction with Covered Surgery
procedures or when necessary due to concurrent medical conditions.
2. Limitations
a. No more than one repair per denture per twenty-four (24) months.
b. Denture adjustments are Covered separately from the denture only after six
(6) months from the date of initial placement.
c. No more than one (1) denture reline or rebase in any thirty-six (36) month
period.
IV. Major Restorative & Prosthodontic Services
A. Single Tooth Restorations
1. Covered
a. Crowns (resin, porcelain, cast, and full cast), inlays and onlays (metallic,
resin and porcelain), and veneers.
2. Limitations
a. Only for the treatment of severe carious lesions or severe fracture on
permanent teeth, and only when teeth cannot be adequately restored with
an amalgam or resin composite restoration (filling).
b. For permanent teeth only.
c. Replacement of single tooth restorations or fixed partial dentures. Covered
only after sixty (60) months from the date of initial placement.
3. Exclusions
a. Temporary and provisional crowns.
B. Multiple Tooth Restorations Bridges
1. Covered
a. Fixed partial dentures (bridges), including pontics, retainers, and abutment
crowns, inlays, and onlays (resin, porcelain, and full cast).
2. Limitations
a. Only for treatment where a missing tooth or teeth cannot be adequately
restored with a removable partial denture.
c. Replacement of fixed partial dentures or single tooth restorations. Covered
only after sixty (60) months from the date of initial placement.
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3. Exclusions
a. Interim pontic and retainer crowns.
C. Removable Prosthodontics (Dentures)
1. Covered
a. Complete, immediate and partial dentures.
2. Limitations
a. If, in the construction of a denture, the Member and the Dentist decide on a
personalized restoration or to employ special rather than standard
techniques or materials, benefits provided shall be limited to those which
would otherwise be provided for the standard procedures or materials (as
determined by the Plan).
c. Replacement of removable dentures Covered only after sixty (60) months
from the date of initial placement.
3. Exclusions
a. Interim (temporary) dentures.
D. Other Major Restorative & Prosthodontic Services
1. Covered
a. Crown and bridge services including core buildups, post and core, and
repair.
b. Implants and Implant supported prosthetics, including local anesthetic.
2. Limitations
a. The benefits provided for crown and bridge restorations include benefits for
the services of crown preparation, temporary or prefabricated crowns,
impressions and cementation.
b. Benefits will not be provided for a core build-up separate from those
provided for crown construction, except in those circumstances where
benefits are provided for a crown because of severe carious lesions or
fracture is so extensive that retention of the crown would not be possible.
c. Post and core services are Covered only when performed in conjunction
with a Covered crown or bridge.
d. Crown, inlay, onlay, and veneer repair are Covered separately only after
twelve (12) months from the date of initial placement.
e. Implant limited to one (1) per tooth per sixty (60) months.
f. Bone graft for implant is Covered if implant is Covered.
g. Implant debridement is limited to one (1) per tooth per sixty (60) months
and is Covered, if implant is Covered.
h. Replacement of implant supported prosthesis is Covered only after sixty
(60) months from the date of any prosthesis placement.
54
3. Exclusions
a. Other major restorative services including protective restoration and
coping.
b. Other prosthodontic services including overdenture, precision attachments,
connector bars, stress breakers and coping metal.
c. Temporary and interim implant abutment.
V. Endodontics (treatment of the dental pulp or root canal)
A. Basic Endodontics
1. Covered
a. Pulpotomy, pulpal therapy.
2. Limitations
a. For primary teeth only.
b. Not Covered when performed in conjunction with major endodontic
treatment.
c. The benefits for basic endodontic treatment include benefits for x-rays, pulp
vitality tests, and protective restoration provided in conjunction with basic
endodontic treatment. However, pulp vitality tests and protective
restorations are not Covered when billed separately from other endodontic
services.
3. Exclusions
a. Pulpal debridement.
B. Major Endodontics
1. Covered Services
a. Root canal treatment and re-treatment, apexification, pulpal regeneration,
apicoectomy services, root amputation, retrograde filling, hemisection, pulp
cap.
2. Limitations
a. The benefits for major endodontic treatment include benefits for x-rays,
pulp vitality tests, pulpotomy, pulpectomy and protective restoration and
temporary filling material provided in conjunction with major endodontic
treatment. However, pulp vitality tests and protective restorations are not
Covered when billed separately from other endodontic services.
3. Exclusions
a. Implantation, canal preparation, and incomplete endodontic therapy.
VI. Periodontics
55
A. Basic Periodontics
1. Covered
a. Non-surgical periodontics, including periodontal scaling and root planing,
full mouth debridement and periodontal maintenance procedure.
2. Limitations
a. No more than one (1) periodontal scaling and root planing per quadrant in
any twenty-four (24) month period.
b. No more than one (1) full mouth debridement per lifetime.
c. No more than four (4) of any prophylaxis (cleanings) or periodontal
maintenance procedure in any twelve (12) month period. Cleanings are
subject to additional limitations listed under Preventive Services, and may
be subject to a different Coverage level under Attachment C: Schedule of
Benefits.
d. Benefits for periodontal maintenance are provided only after active
periodontal treatment (surgical or non-surgical), and no sooner than ninety
(90) days after completion of such treatment.
e. Benefits for periodontal scaling and root planing, full mouth debridement,
periodontal maintenance and prophylaxis are not provided when more than
one of these procedures is performed on the same day.
3. Exclusions
a. Provisional splinting, scaling in the presence of gingival inflammation,
antimicrobial medication and dressing changes.
B. Major Periodontics
1. Covered
a. Surgical periodontics including gingivectomy, gingivoplasty, gingival flap
procedure, crown lengthening, osseous Surgery and bone and tissue
grafting.
b. Benefits provided for major periodontics include benefits for services
related to ninety (90) days of postoperative care.
2. Limitations
a. No more than one (1) major periodontal surgical procedure in any thirty-six
(36) month period.
3. Exclusions
a. Tissue regeneration and apically positioned flap procedure.
VII. Oral Surgery
A. Basic Oral Surgery
1. Covered
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a. Non-surgical or simple extractions.

2. Limitations
a. Benefits provided for basic oral Surgery include benefits for suturing and
postoperative care.
3. Exclusions
a. Benefits for general anesthesia or intravenous sedation when performed in
conjunction with basic oral Surgery.
B. Major Oral Surgery
1. Covered
a. Surgical extractions (including removal of impacted teeth), coronectomy,
and other oral surgical procedures typically not Covered under a medical
plan.
b. Benefits provided for major oral Surgery include benefits for local
anesthesia, suturing and postoperative care.
2. Limitations
a. Benefits for general anesthesia or intravenous (IV) sedation are provided
only in connection with major oral Surgery procedures, and only when
provided by a Dentist licensed to administer such agents.
3. Exclusion
a. Oral Surgery typically Covered under a medical plan, including but not
limited to, excision of lesions and bone tissue, treatment of fractures,
suturing, wound and other repair procedures.
b. Harvesting of bone for use in autogenous grafting.
VIII.
General Pediatric Dental Exclusions
Pediatric Dental Coverage does not provide benefits for the following services, supplies
or charges:
A. Services rendered by a Dentist beyond the scope of his or her license.
B. Dental services which are free, or for which You are not required or legally obligated
to pay or for which no charge would be made if You had no dental Coverage.
C. Dental services Covered by any medical insurance Coverage, or by any other nondental contract or certificate issued by BlueCross or any other insurance company,
carrier, or plan. For example, removal of impacted teeth, tumors of lip and gum,
accidental injuries to the teeth, etc.
D. Dental care or treatment not specifically listed in Attachment C: Schedule of
Benefits.
E. Any treatment or service that the Plan determines is not Necessary Dental Care that
does not offer a favorable prognosis, that does not meet generally accepted
standards of professional dental care, or that is experimental in nature.
57
F. Charges for any hospital or other surgical or treatment facility and any additional
fees charged by a Dentist for treatment in any such facility.
G. Dental services with respect to congenital malformations or primarily for cosmetic
or aesthetic purposes including cosmetic orthodontia.
H. Replacement of tooth structure lost from wear or attrition.
I. Dental services resulting from loss or theft of a denture, crown, bridge or removable
orthodontic appliance.
J. Charges for a prosthetic device that replaces one or more lost, extracted or
congenitally missing teeth before Your Coverage becomes effective under the Plan
unless it also replaces one (1) or more natural teeth extracted or lost after Your
Coverage became effective.
K. Diagnosis for, or fabrication of, adjustment or maintenance and cleaning of
maxillofacial prosthesis, appliances or restorations necessary to correct bite
problems or restore the occlusion.
L. Diagnostic dental services such as diagnostic tests and oral pathology services.
M. Adjunctive dental services including all local and general anesthesia, sedation, and
analgesia (except as provided under a Covered Surgery).
N. Charges for the treatment of desensitizing medicaments, drugs, occlusal guards and
adjustments, mouthguards, microabrasion, behavior management, and bleaching.
O. Charges for the treatment of professional visits outside the dental office or after
regularly scheduled hours or for observation.
P. Charges for the inhalation of nitrous oxide/analgesia, anxiolysis.
F. Dental Temporomandibular Joint Dysfunction (TMJ) for all Members
Medically Necessary and Appropriate services to diagnose and treat temporomandibular
joint syndrome or dysfunction (TMJ or TMD).
1. Covered Services
a. Diagnosis and management of TMJ or TMD. Non-surgical treatment of TMJ or TMD
is limited as indicated in Attachment C: Schedule of Benefits.
b. Surgical treatment of TMJ or TMD, if performed by a qualified oral surgeon or
maxillofacial surgeon.
c. Non-surgical TMJ includes: (1) history and exam; (2) office visit; (3) x-rays; (4)
diagnostic study casts; (5) medications; and (6) Oral Appliances to stabilize jaw joint.
2. Exclusions
a. Treatment for routine dental care and related services including, but not limited to:
(1) crowns; (2) caps; (3) plates; (4) bridges; (5) dental x-rays; (6) fillings; (7)
periodontal Surgery; (8) tooth extraction; (9) root canals; (10) preventive care
(cleanings, x-rays); (11) replacement of teeth (including implants, false teeth,
bridges); (12) bone grafts (alveolar Surgery); (13) treatment of injuries caused by
biting and chewing; (14) treatment of teeth roots; and (15) treatment of gums
surrounding the teeth.
b. Treatment for correction of underbite, overbite, and misalignment of the teeth
including braces for dental indications.
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G. Diabetes Treatment
Medically Necessary and Appropriate diagnosis and treatment of diabetes. In order to be
Covered, such services must be prescribed and certified by a Practitioner as Medically
Necessary. The treatment of diabetes consists of medical equipment, supplies, and
outpatient self-management training and education, including nutritional counseling. See
Pharmacy Prescription Drug Program for additional Diabetic benefits.
1. Covered Services
a. Insulin pumps, infusion devices, and appurtenances, not subject to the benefit limit
for durable medical equipment indicated in Attachment C: Schedule of Benefits.
Insulin pump replacement is Covered only for pumps older than forty-eight (48)
months and if the pump cannot be repaired;
b. Podiatric appliances for prevention of complications associated with diabetes.
2. Exclusions
a. Treatments or supplies that are not prescribed and certified by a Practitioner as
being Medically Necessary.
b. Supplies not required by state statute.
H. Diagnostic Services
Medically Necessary and Appropriate diagnostic radiology services and laboratory tests.
Prior Authorization for Advanced Radiological Imaging must be obtained from the Plan, or
benefits will be reduced or denied.
1. Covered Services
a. Imaging services ordered by a Practitioner, including x-ray, ultrasound, bone density
test, and Advanced Radiological Imaging Services. Advanced Radiological Imaging
Services include MRIs, CT scans, PET scans, and nuclear cardiac imaging.
b. Diagnostic laboratory services ordered by a Practitioner.
2. Exclusions
a. Diagnostic Services that are not Medically Necessary and Appropriate.
b. Diagnostic Services not ordered by a Practitioner.
I.
Durable Medical Equipment (DME)

Medically Necessary and Appropriate medical equipment or items that: (1) in the absence of
illness or injury, are of no medical or other value to You; (2) can withstand repeated use in
an ambulatory or home setting;(3) require the Prescription of a Practitioner for purchase;
(4) are approved by the FDA for the illness or injury for which it is prescribed; and (5) are not
solely for Your convenience.
1. Covered Services
a. Rental of durable medical equipment - Maximum allowable rental charge not to
exceed the total Maximum Allowable Charge for purchase. If You rent the same
59
type of equipment from multiple DME Providers, and the total rental charges from
the multiple Providers exceed the purchase price of a single piece of equipment,
You will be responsible for amounts in excess of the Maximum Allowable Charge for
purchase.
b. The repair, adjustment or replacement of components and accessories necessary for
the effective functioning of Covered equipment.
c. Supplies and accessories necessary for the effective functioning of Covered durable
medical equipment.
d. The replacement of items needed as the result of normal wear and tear, defects or
obsolescence and aging. Insulin pump replacement is Covered only for pumps older
than forty-eight (48) months and only if the pump cannot be repaired.
2. Exclusions
a. Charges exceeding the total cost of the Maximum Allowable Charge to purchase the
equipment.
b. Unnecessary repair, adjustment or replacement or duplicates of any such
equipment.
c. Supplies and accessories that are not necessary for the effective functioning of the
Covered equipment.
d. Items to replace those that were lost, damaged, stolen or prescribed as a result of
new technology.
e. Items that require or are dependent on alteration of home, workplace or
transportation vehicle.
f. Motorized scooters, exercise equipment, hot tubs, pool, and saunas.
g. Deluxe or enhanced equipment. The most basic equipment that will provide
the needed medical care will determine the benefit.
h. Computerized or gyroscopic mobility systems, roll about chairs, geriatric chairs, hip
chairs, and seat lifts of any kind.
i. Patient lifts, auto tilt chairs, air fluidized beds, or air flotation beds, unless approved
by Case Management for a Member who is in Case Management.
j. Portable ramp for a wheelchair.
J.
Emergency Care Services

Medically Necessary and Appropriate health care services and supplies furnished in a
Hospital emergency department that are required to determine, evaluate and/or treat an
Emergency until such condition is stabilized, as directed or ordered by the Practitioner or
Hospital protocol.
1. Covered Services
a. Medically Necessary and Appropriate Emergency services, supplies and medications
necessary for the diagnosis and stabilization of Your Emergency condition.
b. Practitioner services.
Note that an observation stay that occurs in conjunction with an ER visit will be subject
to member cost share under the Outpatient Facility Services section, below, in addition
to member cost share for the ER visit.
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2. Exclusions
a. Treatment of a chronic, non-Emergency condition, where the symptoms have
existed over a period of time, and a prudent layperson who possesses an average
knowledge of health and medicine would not believe it to be an Emergency.
b. Services received for inpatient care or transfer to another facility once Your medical
condition has stabilized, unless Prior Authorization is obtained from the Plan within
twenty-four (24) hours or the next working day.
K. Family Planning and Reproductive Services
Medically Necessary and Appropriate family planning services and those services to
diagnose and treat diseases that may adversely affect fertility.
1. Covered Services
a. Benefits for: (1) family planning; (2) history; (3) physical examination; (4) diagnostic
testing; and (5) genetic testing.
b. Sterilization procedures.
c. Services or supplies for the evaluation of infertility.
d. Medically Necessary and Appropriate termination of a pregnancy.
e. Injectable and implantable hormonal contraceptives and vaginal barrier methods
including initial fitting, insertion and removal.
2. Exclusions
a. Services or supplies that are designed to create a pregnancy, enhance fertility or
improve conception quality, including but not limited to: (1) artificial insemination;
(2) in vitro fertilization; (3) fallopian tube reconstruction; (4) uterine reconstruction;
(5) assisted reproductive technology (ART) including but not limited to GIFT and
ZIFT; (6) fertility injections; (7) fertility drugs; (8) services for follow-up care related
to infertility treatments.
b. Services or supplies for the reversals of sterilizations.
c. Induced abortion unless: (1) the health care Practitioner certifies in writing that the
pregnancy would endanger the life of the mother, or; (2) the pregnancy is a result of
rape or incest.
L. Home Health Care Services
Medically Necessary and Appropriate services and supplies provided in Your home by a
Practitioner who is primarily engaged in providing home health care services. Home visits
by a skilled nurse require Prior Authorization. Physical, speech or occupational therapy
provided in the home does not require Prior Authorization, but does apply to the Therapy
Services visit limits shown in Attachment C: Schedule of Benefits.
1. Covered Services
a. Part-time, intermittent health services, supplies, and medications, by or under the
supervision of a registered nurse.
b. Home infusion therapy.
61
c. Rehabilitative therapies such as physical therapy, occupational therapy, etc. (subject

to the limitations of the Therapeutic/Rehabilitative/Habilitative benefit.)
d. Medical social services.
e. Dietary guidance.
f. Coverage is limited as indicated in Attachment C: Schedule of Benefits.
2. Exclusions
a. Items such as non-treatment services or: (1) routine transportation; (2) homemaker
or housekeeping services; (3) behavioral counseling; (4) supportive environmental
equipment; (5) Maintenance Care or Custodial Care; (6) social casework; (7) meal
delivery; (8) personal hygiene; and (9) convenience items.
M. Hospice
Medically Necessary and Appropriate services and supplies for supportive care where life
expectancy is six (6) months or less.
1. Covered Services
a. Benefits will be provided for: (1) part-time intermittent nursing care; (2) medical
social services; (3) bereavement counseling; (4) medications for the control or
palliation of the illness; (5) home health aide services; and (6) physical or respiratory
therapy for symptom control.
2. Exclusions
a. Inpatient hospice services, unless approved by Case Management.
b. Services such as: (1) homemaker or housekeeping services; (2) meals; (3)
convenience or comfort items not related to the illness; (4) supportive
environmental equipment; (5) private duty nursing; (6) routine transportation; and
(7) funeral or financial counseling.
N. Inpatient Hospital Services
Medically Necessary and Appropriate services and supplies in a Hospital that: (1) is a
licensed Acute care institution; (2) provides Inpatient services; (3) has surgical and medical
facilities primarily for the diagnosis and treatment of a disease and injury; and (4) has a staff
of Physicians licensed to practice medicine and provides twenty-four (24) hour nursing care
by graduate registered nurses. Psychiatric hospitals are not required to have a surgical
facility.
Prior Authorization for Covered Services must be obtained from the Plan, or benefits will be
reduced or denied.
1. Covered Services
a. Room and board in a semi-private room (or private room if room and board charges
are the same as for a semi-private room); general nursing care; medications,
injections, diagnostic services and special care units.
b. Attending Practitioners services for professional care.
62
c. Maternity and delivery services (including routine nursery care and Complications of
Pregnancy). If the hospital or physician provides services to the baby and submits a
claim in the babys name, benefits may be Covered for the baby and mother as
separate Members, requiring payment of applicable Member Copayments and/or
Deductibles.
2. Exclusions
a. Inpatient stays primarily for therapy (such as physical or occupational therapy).
b. Private duty nursing.
c. Services that could be provided in a less intensive setting.
d. Private room when not Authorized by the Plan and room and board charges are in
excess of semi-private room.
e. Blood or plasma provided at no charge to the patient.
O. Organ Transplants
Organ Transplants - (As soon as Your Practitioner tells You that You might need a transplant,
You or Your Practitioner must contact the Plans Transplant Case Management department).
Medically Necessary and Appropriate services and supplies provided to You, when You are
the recipient of the following organ transplant procedures: (1) heart; (2) heart/lung; (3)
bone marrow; (4) lung; (5) liver; (6) pancreas; (7) pancreas/kidney; (8) kidney; (9) small
bowel; and (10) small bowel/liver. Benefits may be available for other organ transplant
procedures that, in Our sole discretion, are not Experimental or Investigational and that are
Medically Necessary and Medically Appropriate.
You have access to three levels of benefits: (1) Transplant Network, (2) In-Network, and (3)
Out-of-Network. If You go to a Transplant Network Provider, You will have the highest level
of benefits. (See section 3. f. for Kidney transplant benefit information).
Transplant services or supplies that have not received Prior Authorization will not be
Covered. Prior Authorization is the pre-treatment authorization that must be obtained
from Us before any pre-transplant evaluation or any Covered Procedure is performed. (See
Prior Authorization Procedures below.)
1. Prior Authorization Procedures
To obtain Prior Authorization, You or Your Practitioner must contact the Plans Transplant
Case Management department before pre-transplant evaluation or Transplant Services are
received. Authorization should be obtained as soon as possible after You have been
identified as a possible candidate for Transplant Services.
Transplant Case Management is a mandatory program for those Members seeking
Transplant Services. Call the number on the back of Your Member ID card for Our consumer
advisors, and ask to be transferred to Transplant Case Management. We must be notified of
the need for a transplant in order for the pre-transplant evaluation and the transplant to be
Covered Services.
63
2. Covered Services
The following Medically Necessary and Appropriate Transplant Services and supplies that
have received Prior Authorization and are provided in connection with a Covered Procedure:
a. Medically Necessary and Appropriate services and supplies, otherwise Covered
under this Policy;
b. Medically Necessary and Appropriate services and supplies for each listed organ
transplant are Covered only when Transplant Case Management approves a
transplant. Not all Network Providers are in Our Transplant Network. Please
check with a Transplant case manager to see which Hospitals are in Our Transplant
Network , Or check on Our website: bcbst.com;
c. Travel expenses for Your evaluation prior to a Covered Procedure, and to and from
the site of a Covered Procedure by: (1) private car; (2) ground or air ambulance; or
(3) public transportation. This includes travel expenses for You and a companion. A
companion must be Your spouse, family member, Your guardian or other person
approved by Transplant Case Management. In order to be reimbursed, travel must
be approved by Transplant Case Management. In many cases, travel will not be
approved for kidney transplants.
i. Travel by private car is limited to reimbursement at the IRS mileage rate in
effect at the time of travel to and from a facility in the Transplant Network.
ii. Meals and lodging expenses are Covered, limited to $150 daily.
iii. The aggregate limit for travel expenses is $10,000 per Covered Procedure.
iv. Travel Expenses are Covered only if You go to a Transplant Network Institution;
d. Donor Organ Procurement. If the donor is not a Member, Covered Services for the
donor are limited to those services and supplies directly related to the Transplant
Service itself: (1) testing for the donors compatibility; (2) removal of the organ from
donors body; (3) preservation of the organ; (4) transportation of the organ to the
site of transplant; and (5) donor follow-up care. Services are Covered only to the
extent not Covered by other health Coverage. The search process and securing the
organ are also Covered under this benefit. Complications of donor organ
procurement are not Covered. The cost of Donor Organ Procurement is included in
the total cost of Your Organ Transplant.
3. Conditions/Limitations
The following limitations and/or conditions apply to services, supplies or Charges:
a. You or Your Practitioner must notify Transplant Case Management prior to Your
receiving any Transplant Service, including pre-transplant evaluation, and obtain
Prior Authorization. If Transplant Case Management is not notified, the transplant
and related procedures will not be Covered at all;
64
b. Transplant Case Management will coordinate all Transplant Services, including pretransplant evaluation. You must cooperate with Us in coordination of these
services;
c. Failure to notify Us of proposed Transplant Services, or to coordinate all transplant
related services with Us, will result in the reduction or exclusion of payment for
those services;
d. You must go through Transplant Case Management and receive Prior Authorization
for Your transplant to be Covered;
e. Once You have notified Transplant Case Management and received Prior
Authorization, You may decide to have the transplant performed outside the
Transplant Network. However, Your benefits will be greatly limited, as described
below. Only the Transplant Maximum Allowable Charge for the Service provided
will be Covered;
i. Transplant Network transplants. You have the transplant performed at a
Transplant Network Provider. You receive the highest level of reimbursement
for Covered Services. The Plan will reimburse the Transplant Network Provider
at the benefit level listed in Attachment C: Schedule of Benefits, at the
Transplant Maximum Allowable Charge. The Transplant Network Provider
cannot bill You for any amount over the Transplant Maximum Allowable Charge
for the transplant, which limits Your liability;
ii. Network transplants. You have the transplant performed outside the Transplant
Network, but still at a facility that is a Network Provider or a BlueCard PPO
Participating Provider. The Plan will reimburse the Network or BlueCard PPO
Participating Provider at the benefit level listed in Attachment C: Schedule of
Benefits, limited to the Transplant Maximum Allowable Charge. There is no
maximum to Your liability. The Provider also has the right to bill You for any
amount not Covered by the Plan this amount may be substantial;
iii. Out-of-Network transplants. You have the transplant performed by an Out-ofNetwork Provider (i.e., outside the Transplant Network, and not at a facility that
is a Network Provider or a BlueCard PPO Participating Provider). The Plan will
reimburse the Out-of-Network Provider only at the benefit level listed in
Attachment C: Schedule of Benefits, limited to the Transplant Maximum
Allowable Charge. There is no maximum to Your liability. The Out-of-Network
Provider also has the right to bill You for any amount not Covered by the Plan this amount may be substantial;
You can find out what the Transplant Maximum Allowable Charge is for Your transplant
by contacting Transplant Case Management. Remember, the Transplant Maximum
Allowable Charge can and does change from time to time.
f.
Kidney transplants. There are two (2) levels of benefits for kidney transplants: InNetwork and Out-of-Network:
i. Network kidney transplants. You have a kidney transplant performed at a
facility that is a Network Provider or a BlueCard PPO Participating Provider. You
receive the highest level of reimbursement for Covered Services. The Network
65
or BlueCard PPO Participating Provider cannot bill You for any amount over the
Maximum Allowable Charge for the transplant, which limits Your liability;
ii. Out-of-Network kidney transplants. You have a kidney transplant performed by
an Out-of-Network Provider (i.e. not at a facility that is a Network Provider or a
BlueCard PPO Participating Provider). The Plan will reimburse the Out-ofNetwork Provider only at the benefit level listed in Attachment C: Schedule of
Benefits, at the Maximum Allowable Charge. There is no maximum to Your
liability. The Out-of-Network Provider also has the right to bill You for any
amount not Covered by the Plan; this amount may be substantial;
g. If You go through Transplant Case Management for Your transplant, follow its
procedures, cooperate fully with them, and have Your transplant performed at a
Transplant Network Institution, the transplant expenses specified in Attachment C:
Schedule of Benefits, are Covered.
4. Exclusions
The following services, supplies and Charges are not Covered under this section:
a. Transplant and related services that did not receive Prior Authorization;
b. Any service specifically excluded under Attachment B, Other Exclusions, except as
otherwise provided in this section;
c. Services or supplies not specified as Covered Services under this section;
d. Any attempted Covered Procedure that was not performed, except where such
failure is beyond Your control;
e. Non-Covered Services;
f. Services that would be Covered by any private or public research fund, regardless of
whether You applied for or received amounts from such fund;
g. Any non-human, artificial or mechanical organ;
h. Payment to an organ donor or the donors family as compensation for an organ, or
payment required to obtain written consent to donate an organ;
i. Donor services including screening and assessment procedures that have not
received Prior Authorization from Us;
j. Removal of an organ from a Member for purposes of transplantation into another
person, except as Covered by the Donor Organ Procurement provision as described
above;
k. Harvest, procurement, and storage of stem cells, whether obtained from peripheral
blood, cord blood, or bone marrow when reinfusion is not scheduled or anticipated
to be scheduled within an appropriate time frame for the patients Covered stem
cell transplant diagnosis.
l. Other non-organ transplants (e.g., cornea) are not Covered under this Section, but
may be Covered as an Inpatient Hospital Service or Outpatient Facility Service, if
Medically Necessary.
Note: If You receive Prior Authorization through Transplant Case Management, but do
not obtain services through the Transplant Network, You will have to pay the Provider
any additional charges not Covered by the Plan.
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P. Outpatient Facility Services

Medically Necessary and Appropriate diagnostics, therapies and Surgery occurring in an
outpatient facility that includes: (1) outpatient Surgery centers; (2) the outpatient center of
a hospital; (3) outpatient diagnostic centers; and (4) certain surgical suites in a Practitioners
office. Prior Authorization as required for certain outpatient services must be obtained
from the Plan, or benefits will be reduced or denied.
1. Covered Services
a. Practitioner services.
b. Outpatient diagnostics (such as x-rays and laboratory services).
c. Outpatient treatments (such as medications and injections).
d. Outpatient Surgery and supplies.
e. Observation stays less than twenty-four (24) hours.
f. Telemedicine
2. Exclusions
a. Rehabilitative therapies in excess of the terms of the Therapeutic/
Rehabilitative/Habilitative benefit.
b. Services that could be provided in a less intensive setting.
Q. Pharmacy Prescription Drug Program for retail and mail order Prescriptions
Medically Necessary and Appropriate pharmaceuticals for the treatment of disease or
injury.
[If You have a Prescription filled at an Out-of-Network Pharmacy, You must pay all expenses
and file a claim for reimbursement with Us. Reimbursement is based on the Maximum
Allowable Charge, less any applicable Non-Preferred Brand Name Drug Deductible,
Coinsurance, and/or Drug Copayment amount.]
Some products may be subject to additional Quantity, Step Therapy Limitations, and Prior
Authorizations specified by the Plans P & T Committee.
[If You choose a Non-Preferred Brand Drug when a Generic Drug equivalent is available, You
will be financially responsible for the amount by which the cost of the Non-Preferred Brand
Drug exceeds the Generic Drug cost plus the required Generic Drug Copayment.]
[If You or the prescribing physician choose a Non-Preferred Brand Drug when a Generic Drug
equivalent is available, You will be financially responsible for the amount by which the cost
of the Non-Preferred Brand Drug exceeds the Generic Drug cost plus the required Generic
Drug Copayment.]
1. Covered Services
a. This Policy covers the following at 100%, in accordance with the Womens
Preventive Services provision of the Affordable Care Act:
67
i.
ii.
iii.
iv.
v.
Generic contraceptives;
vaginal ring;
hormonal patch;
and emergency contraception available with a Prescription.
Brand name Prescription Contraceptive Drugs are Covered as any other
Prescription, if a Generic Drug equivalent is available. See Attachment C:
b. Prescription Drugs and supplies for the treatment of diabetes:

i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
Blood glucose monitors, including monitors designed for the legally blind;
Test strips for blood glucose monitors;
Visual reading and urine test strips;
Insulin; Injection aids;
Syringes;
Lancets;
Oral hypoglycemic agents;
Glucagon emergency kits.
Injectible incretin mimetics when used in conjunction with selected Prescription
Drugs for the treatment of diabetes.
c. Prescription Drugs must be:

i.
ii.
iii.
iv.
prescribed on or after Your Coverage begins;

approved for use by the Food and Drug Administration (FDA);
dispensed by a licensed pharmacist [or] [network physician];
listed on the [[Preferred] Formulary];
d. Treatment of phenylketonuria (PKU), including special dietary formulas while under

the supervision of a Practitioner.
e. Medically Necessary Prescription Drugs used during the induction or
stabilization/dose-reduction phases of chemical dependency treatment.
f. Drugs with a Prescription that are listed with an A or B recommendation by the
United States Preventive Services Task Force (USPSTF).
g. Immunizations administered at a Network Pharmacy.
2. Limitations
a. Refills must be dispensed pursuant to a Prescription. If the number of refills is not
specified in the Prescription, benefits for refills will not be provided beyond one
year from the date of the original Prescription.
b. The Plan has time limits on how soon a Prescription can be refilled. If You request a
refill too soon, the Network Pharmacy will advise You when Your Prescription
benefit will Cover the refill.
c. Prescription and non-Prescription medical supplies, devices and appliances are not
Covered, except for syringes used in conjunction with injectable medications or
other supplies used in the treatment of diabetes and/or asthma.
68
d. Immunological agents, including but not limited to: (1) biological sera, (2) blood, (3)
blood plasma; or (4) other blood products are not Covered, except for blood
products required by hemophiliacs.
e. Injectable drugs, are Covered only when: (1) intended for self-administration; or (2)
defined by the Plan.
f. Compound Drugs are only Covered when filled or refilled at a Network Pharmacy.
The Network Pharmacy must submit the claim through the Plans Pharmacy benefit
manager. The claim must contain a valid national drug code (NDC) number for all
ingredients in the Compound Drug. The Compound Drug claim will apply the NonPreferred Brand Drug Copayment/Coinsurance.
g. [Prescription Drugs that are commercially packaged or commonly dispensed in
quantities less than a thirty (30) calendar day supply (e.g. Prescription items that are
dispensed based on a certain quantity for a therapeutic regimen) will be subject to
one Drug Copayment, provided the quantity does not exceed the FDA approved
dosage for four calendar weeks.]
If You abuse or over use Pharmacy services outside of Our administrative procedures, We
may restrict Your Pharmacy access. We will work with You to select a Network Pharmacy,
and You can request a change in Your Network Pharmacy.
3. Exclusions
In addition to the limitations and exclusions specified in Attachment A: Covered Services and
Exclusions and Attachment B: Other Exclusions, benefits are not available under this section
for the following:
a. drugs that are prescribed, dispensed or intended for use while You are confined in a
hospital, skilled nursing facility or similar facility, except as otherwise Covered in the
Policy;
b. any drugs, medications, Prescription devices, dietary supplements or vitamins,
available over-the-counter that do not require a Prescription by Federal or State
law; and/or Prescription Drugs dispensed in a doctors office, except as otherwise
Covered in the Policy;
c. any Prescription Drug purchased outside the United States, except those authorized
by Us;
d. any Prescription dispensed by or through a non-retail internet Pharmacy;
e. contraceptives that require administration or insertion by a Provider (e.g., non-drug
devices, implantable products ), except as otherwise Covered in the Policy;
f. medications intended to terminate a pregnancy;
g. non-medical supplies or substances, including support garments, regardless of their
intended use;
h. artificial appliances;
i. allergen extracts;
j. Prescription Drugs You are entitled to receive without charge in accordance with
any workers compensation laws or any municipal, state, or federal program;
k. replacement Prescriptions resulting from lost, spilled, stolen, or misplaced
medications (except as required by applicable law);
69
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.
w.
x.
drugs dispensed by a Provider other than a Pharmacy or dispensing physician;

administration or injection of any drugs;
Prescription Drugs used for the treatment of infertility;
Prescription Drugs not on the [[Preferred] Formulary];
anorectics (any drug or medicine for the purpose of weight loss and appetite
suppression);
all newly FDA approved drugs prior to review by the Plans P & T Committee.
Prescription Drugs that represent an advance over available therapy according to
the P & T Committee will be reviewed within at least six (6) months after FDA
approval. Prescription Drugs that appear to have therapeutic qualities similar to
those of an already marketed drug, will be reviewed within at least twelve (12)
months after FDA approval;
any Prescription Drugs or medications used for the treatment of sexual dysfunction,
including but not limited to erectile dysfunction, delayed ejaculation, anorgasmia
and decreased libido;
Prescription Drugs used for cosmetic purposes including, but not limited to: (1)
drugs used to reduce wrinkles; (2) drugs to promote hair-growth; (3) drugs used to
control perspiration; (4) drugs to remove hair; and (5) face cream products;
Prescription Drugs used during the maintenance phase of chemical dependency
treatment, unless Authorized by Us;
FDA approved drugs used for purposes other than those approved by the FDA
unless the drug is recognized for the treatment of the particular indication in one of
the standard reference compendia;
Specialty Drugs filled or refilled at a Pharmacy not participating in the Preferred
Specialty Pharmacy Network;
drugs used to enhance athletic performance;
Experimental and/or Investigational Drugs;
GENERIC DRUGS
Prescription drugs are classified as brand or generic. A given drug can change from brand to
generic or from generic to brand. Sometimes a given drug is no longer available as a Generic Drug.
These changes can occur without notice. If You have any questions, please contact Our consumer
advisors by calling the number of the back of Your Member ID card.
We will retain any refunds, rebates, reimbursements or other payments representing a return of
monies paid for Covered Services under this Section.
The drug formulary referenced in this Section is subject to change. Current lists can be found at
bcbst.com, or by calling the number on the back of Your Member ID card.
R. Pharmacy Prescription Drug Program for Self-Administered Specialty Drugs
Medically Necessary and Appropriate Specialty Drugs for the treatment of disease,
administered by a Practitioner or home health care agency and listed as a self-administered
drug on the Plans Specialty Drug list. Certain Specialty Drugs require Prior Authorization
from the Plan, or benefits will be reduced or denied. Call Our consumer advisors at the
70
number on the back of Your Member ID card or check Our website, bcbst.com, to find out
which Specialty Drugs require Prior Authorization.
1. Covered Services
a. Self-administered Specialty Drugs. Only those drugs listed as self-administered
Specialty Drugs are Covered under this benefit.
2. Exclusions
a. Provider-administered Specialty Drugs as identified on the Plans Specialty Drug list.
Refer to section V. Provider-Administered Specialty Drugs for benefit Coverage
information.
b. FDA-approved drugs used for purposes other than those approved by the FDA,
the standard reference compendia.
Specialty Drugs You have a distinct network for Specialty Drugs: the Preferred Specialty
Pharmacy Network. To receive benefits for self-administered Specialty Drugs, You must
use a Preferred Specialty Pharmacy Network Provider.
S. Practitioner Office Services
Medically Necessary and Appropriate services in a Practitioners office.
1. Covered Services
a. Diagnosis and treatment of illness or injury. (Note that allergy skin testing is Covered
only in the Practitioner office setting. Medically Necessary RAST
(radioallergosorbent test), FAST (fluorescent allergosorbent test), or MAST (multiple
radioallergosorbent test) is Covered in the Practitioner office setting and in a
licensed laboratory).
b. Injections and medications administered in a Practitioners office, except Specialty
Drugs. (See Provider Administered Specialty Drugs section for information on
Coverage).
c. Second surgical opinions given by a Practitioner who is not in the same medical
group as the Practitioner who initially recommended Surgery.
d. Preventive/Well Care Services.
i. Preventive health exam for adults and children and related services as outlined
below and performed by the physician during the preventive health exam or
referred by the physician as appropriate, including:
Screenings and counseling services with an A or B recommendation by the
United States Preventive Services Task Force (USPSTF)
Bright Futures recommendations for infants, children and adolescents
supported by the Health Resources and Services Administration (HRSA)
Preventive care and screening for women as provided in the guidelines
supported by HRSA, and
Immunizations recommended by the Advisory Committee on Immunization
Practices (ACIP) that have been adopted by the Centers for Disease Control
and Prevention (CDC).
71
Generally, specific preventive services are Covered for plan years beginning one
year after the guidelines or recommendation went into effect. The frequency of
visits and services are based on information from the agency responsible for the
guideline or recommendation, or the application of medical management.
These services include but are not limited to:
Annual Well Woman Exam, including cervical cancer screening, screening
mammography at age forty (40) and older, and other USPSTF screenings
with an A or B rating.
Colorectal cancer screening for members age 50-75.
Prostate cancer screening for men age fifty (50) and older.
Screening and counseling in the primary care setting for alcohol misuse and
tobacco use.
Dietary counseling for adults with hyperlipidemia, hypertension, Type 2
diabetes, obesity, coronary artery disease and congestive heart failure.
FDA-approved contraceptive methods, sterilization procedures and
counseling for women with reproductive capacity. Note that Prescription
contraceptive products are Covered under the Pharmacy Prescription Drug
Program section.
HPV testing once every 3 years for women age 30 and older.
Lactation counseling by a trained Provider during pregnancy or in the postpartum period, and manual breast pump.
e. Coverage may be limited as indicated in Attachment C: Schedule of Benefits.
2. Exclusions
a. Office visits, physical exams and related immunizations and tests, when required
solely for: (1) sports; (2) camp; (3) employment; (4) travel; (5) insurance; (6)
marriage or legal proceedings.
b. Routine foot care for the treatment of: (1) flat feet; (2) corns; (3) bunions; (4)
calluses; (5) toenails; (6) fallen arches; and (7) weak feet or chronic foot strain.
c. Rehabilitative therapies in excess of the limitations of the Therapeutic/
Rehabilitative/Habilitative benefit.
d. Dental procedures, except as otherwise indicated in this Policy.
T. Prosthetics/Orthotics
Medically Necessary and Appropriate devices used to correct or replace all or part of a body
organ or limb that may be malfunctioning or missing due to: (1) birth defect; (2) accident; (3)
illness; or (4) Surgery.
1. Covered Services
a. The initial purchase of surgically implanted prosthetic or orthotic devices.
b. The repair, adjustment or replacement of components and accessories necessary for
the effective functioning of Covered equipment.
72
c. Splints and braces that are custom made or molded, and are incidental to a
Practitioners services or on a Practitioners order.
d. The replacement of Covered items required as a result of normal wear and tear,
defects or obsolescence and aging.
e. The initial purchase of artificial limbs or eyes,
f. The first set of eyeglasses or contact lenses required to adjust for vision changes due
to cataract Surgery and obtained within six (6) months following the Surgery.
g. Hearing aids for Members under age eighteen (18), limited as indicated in
Attachment C: Schedule of Benefits.
2. Exclusions
a. Hearing aids for Members age eighteen (18) or older.
b. Prosthetics primarily for cosmetic purposes, including but not limited to wigs, or
other hair prosthesis or transplants.
c. Items to replace those that were lost, damaged, stolen or prescribed as a result of
new technology.
d. The replacement of contacts after the initial pair has been provided following
cataract Surgery.
e. Foot orthotics, shoe inserts and custom made shoes except as required by law for
diabetic patients or as a part of a leg brace.
U. Provider-Administered Specialty Drugs
Medically Necessary and Appropriate Specialty Drugs for the treatment of disease,
administered by a Practitioner or home health care agency and listed as a Provideradministered drug on the Plans Specialty Drug list. Certain Specialty Drugs require Prior
Authorization from the Plan, or benefits will be reduced or denied. Call Our consumer
advisors at the number on the back of Your Member ID card or check Our website,
bcbst.com, to find out which Specialty Drugs require Prior Authorization.
1. Covered Services
a. Provider-administered Specialty Drugs, including administration by a qualified
Provider. Only those drugs listed as Provider-administered Specialty Drugs are
Covered under this benefit.
2. Exclusions
a. Self-administered Specialty Drugs as identified on the Plans formulary.
b. FDA-approved drugs used for purposes other than those approved by the FDA,
the standard reference compendia.
V. Reconstructive Surgery
Medically Necessary and Appropriate Surgical Procedures intended to restore normal form
or function.
1. Covered Services
73
a. Surgery to correct significant defects from congenital causes, (except where

specifically excluded), accidents or disfigurement from a disease state.
b. Reconstructive breast Surgery as a result of a mastectomy or partial mastectomy
(other than lumpectomy) including Surgery on the non-diseased breast needed to
establish symmetry between the two breasts.
2. Exclusions
a. Services, supplies or prosthetics primarily to improve appearance.
b. Surgeries to correct or repair the results of a prior Surgical Procedure, the primary
purpose of which was to improve appearance, and surgeries to improve appearance
following a prior Surgical Procedure, even if that prior procedure was a Covered
Service.
c. Surgeries and related services to change gender (transsexual Surgery).
W. Skilled Nursing/Rehabilitative Facility Services
Medically Necessary and Appropriate Inpatient care provided to Members requiring
medical, rehabilitative or nursing care in a restorative setting. Services shall be considered
separate and distinct from the levels of Acute care rendered in a hospital setting, or
custodial or functional care rendered in a nursing home. Prior Authorization for Covered
Services must be obtained from the Plan, or benefits will be reduced or denied.
1. Covered Services
a. Room and board in a semi-private room, general nursing care, medications,
diagnostics and special care units.
b. The attending Practitioners services for professional care.
c. Coverage is limited as indicated in the Attachment C: Schedule of Benefits.
2. Exclusions
a. Custodial, domiciliary or private duty nursing services.
b. Skilled Nursing services not received in a Medicare certified skilled nursing facility.
X. Supplies
Those Medically Necessary and Appropriate expendable and disposable supplies for the
treatment of disease or injury.
1. Covered Services
a. Supplies for the treatment of disease or injury used in a Practitioners office,
outpatient facility or inpatient facility.
b. Supplies for treatment of disease or injury that are prescribed by a Practitioner and
cannot be obtained without a Practitioners Prescription.
c. Coverage is limited as indicated in Attachment C: Schedule of Benefits.
2. Exclusions
a. Supplies that can be obtained without a Prescription (except for diabetic supplies).
Examples include but are not limited to: (1) adhesive bandages; (2) dressing material
74
for home use; (3) antiseptics; (4) medicated creams and ointments; (5) cotton
swabs; and (6) eyewash.
Y. Therapeutic/Rehabilitative/Habilitative Services
Medically Necessary and Appropriate therapeutic, rehabilitative, and habilitative services
performed in a Practitioners office, outpatient facility or home health setting and intended
to enable a person with a disability to attain functional abilities, or to restore or improve
bodily function lost as the result of illness, injury, autism in children under age twelve (12),
or cleft palate.
1. Covered Services
a. Outpatient, home health or office therapeutic, rehabilitative and habilitative
services that are expected to result in significant and measurable improvement in
Your condition resulting from an Acute disease, injury, autism in children under age
twelve (12), or cleft palate. The services must be performed by, or under the direct
supervision of a licensed therapist, upon written authorization of the treating
Practitioner.
b. Therapeutic/Rehabilitative/Habilitative Services include: (1) physical therapy; (2)
speech therapy for restoration of speech; (3) occupational therapy; (4) manipulative
therapy; and (5) cardiac and pulmonary rehabilitative services.
i. Speech therapy is Covered only for disorders of articulation and swallowing,
resulting from Acute illness, injury, stroke, autism in children under age twelve
(12), or cleft palate when treatment is provided by a duly licensed audiologist or
speech pathologist for hearing, speech, voice or language disorders.
c. Coverage is limited, as indicated in Attachment E: Schedule of Benefits.
i. The limit on the number of visits for therapy applies to all visits for that therapy,
whether received in a Practitioners office, outpatient facility or home health
setting.
ii. Services received during an inpatient hospital, skilled nursing or rehabilitative
facility stay are Covered as shown in the inpatient hospital, skilled nursing and
rehabilitative facility section, and are not subject to the therapy visit limits.
2. Exclusions
a. Treatment beyond what can reasonably be expected to significantly improve health,
including therapeutic treatments for ongoing maintenance or palliative care.
b. Enhancement therapy that is designed to improve Your physical status beyond Your
pre-injury or pre-illness state.
c. Complementary and alternative therapeutic services, including, but not limited to:
(1) massage therapy; (2) acupuncture; (3) craniosacral therapy; (4) vision exercise
therapy; and (5) neuromuscular reeducation. Neuromuscular reeducation refers to
any form of athletic training, rehabilitation program or bodily movement that
requires muscles and nerves to learn or relearn a certain behavior or specific
75
sequence of movements. Neuromuscular reeducation is sometimes performed as

part of a physical therapy visit.
d. Modalities that do not require the attendance or supervision of a licensed therapist.
These include, but are not limited to: (1) activities that are primarily social or
recreational in nature; (2) simple exercise programs; (3) hot and cold packs applied
in the absence of associated therapy modalities; (4) repetitive exercises or tasks that
You can perform without a therapist, in a home setting; (5) routine dressing
changes; and (6) custodial services that can ordinarily be taught to You or a
caregiver.
e. Behavioral therapy, play therapy, communication therapy, and therapy for self
correcting language dysfunctions as part of speech therapy, physical therapy or
occupational therapy programs. Behavioral therapy and play therapy for behavioral
health diagnoses may be Covered under the Behavioral Health benefit.
f. Duplicate therapy. For example, when You receive both occupational and speech
therapy, the therapies should provide different treatments and not duplicate the
same treatment.
Z. Vision Medically Necessary for all Members
Medically Necessary and Appropriate diagnosis and treatment of diseases and injuries that
impair vision.
1. Covered Services
a. Services and supplies for the diagnosis and treatment of diseases and injuries to the
eye.
b. The first set of eyeglasses or contact lenses required to adjust for vision changes due
to cataract Surgery and obtained within six (6) months following the Surgery.
2. Exclusions
a. Routine vision services, including services, surgeries and supplies to detect or
correct refractive errors of the eyes.
b. Eyeglasses, contact lenses and examinations for the fitting of eyeglasses and contact
lenses.
c. Eye exercises and/or therapy.
d. Visual training.
AA. Vision Pediatric Vision
This Pediatric Vision section provides a wide range of benefits to Cover services associated
with vision care for dependents under age nineteen (19).
Plan benefits are based on the services and supplies described in this Attachment A:
Covered Services and Exclusions and provided in accordance with the benefit schedules set
forth in this Policys Attachment C: Schedule of Benefits.
Medically Necessary and Appropriate routine vision care services.
76
1. Covered Services
a. Routine vision services, including services and supplies to detect or correct
refractive errors of the eyes.
2. Limitations
a. Vision examinations are Covered once every Calendar Year.
b. Eyeglass frames are Covered once every Calendar Year.
c. Eyeglass lenses or contact lenses are Covered once every Calendar Year.
d. Prescription sunglasses will be handled as any other lens.
e. Benefits are not available more frequently than as specified in Attachment C:
f. Discounts do not apply for benefits provided by other group benefit plans or
promotional offers.
3. Exclusions:
a. Medical and/or surgical treatment of the eye, eyes, or supporting structure,
including surgeries to detect or correct refractive errors of the eyes.
b. Eye exercises and/or therapy.
c. Orthoptic or vision training, subnormal vision aids and any associated supplemental
testing; Aniseikonic lenses.
d. Medical and/or surgical treatment of the eye, eyes or supporting structures.
e. Charges for vision testing examinations, lenses and frames ordered while insured
but not delivered within sixty (60) days after Coverage is terminated.
f. Charges for non-prescription sunglasses, photosensitive, anti-reflective or other
optional charges when the charge exceeds the amount allowable for regular lenses.
g. Charges filed for procedures determined by the Plan to be special or unusual, (i.e.
orthoptics, vision training, subnormal vision aids, aniseikonic lenses, tonography,
corneal refractive therapy, etc.)
h. Charges for lenses that do not meet the Z80.1 or Z80.2 standards of the American
National Standards Institute.
i. Charges in excess of the Covered benefit as established by the Plan.
j. Oversized Lenses.
k. Corrected eyewear required by an employer as a condition of employment, and
safety eyewear unless specifically Covered under the plan.
l. Non-Prescription lenses and frames, and non-Prescription sunglasses.
m. Services or materials provided by any other group benefit providing vision care.
n. Two (2) pairs of glasses in lieu of bifocals.
o. Charges for replacement of broken, lost, or stolen lenses, contact lenses, or frames.
p. Charges for services or materials from an Ophthalmologist, Optometrist or Optician
acting outside the scope of his or her license.
q. Charges for any additional service required outside basic vision analyses for contact
lenses, except fitting fees.
77
POLICY
Attachment B: Other Exclusions
This Policy does not provide benefits for the following services, supplies or charges:
1. Services or supplies not listed as Covered Services under Attachment A: Covered
Services and Exclusions;
2. Services or supplies that are determined to be not Medically Necessary and
Appropriate;
3. Services or supplies that are Investigational in nature including, but not limited to: (1)
drugs; (2) biologicals; (3) medications; (4) devices; and (5) treatments;
4. Services or supplies provided by a Provider that is not accredited or licensed or are
outside the scope of his/her/its license.
5. Illness or injury resulting from war, that occurred before Your Coverage began under
this Policy and that is Covered by: (1) veterans benefit; or (2) other coverage for which
You are legally entitled;
6. Self treatment or training;
7. Staff consultations required by hospital or other facility rules;
8. Services that are free;
9. Services or supplies for the treatment of work related illness or injury, regardless of the
presence or absence of workers compensation coverage. This exclusion does not apply
to injuries or illnesses of an Employee who is (1) a sole-proprietor of the Group, unless
required by law to carry workers compensation insurance; (2) a partner of the Group,
unless required by law to carry workers compensation insurance; or (3) a corporate
officer of the Group, provided the officer filed an election not to accept Workers
Compensation with the appropriate government department;
10. Personal, physical fitness, recreational or convenience items and services, even if
ordered by a licensed Practitioner, including but not limited to: weight loss programs
and equipment; physical fitness/exercise programs and equipment; devices and
computers to assist in communication or speech (e.g., Dynabox); air conditioners,
humidifiers, air filters and heaters; saunas, swimming pools and whirlpools; water
purifiers; tanning beds; televisions; barber and beauty services;
11. Services or supplies received before Your Effective Date for Coverage with this Plan;
12. Services or supplies related to a Hospital Confinement, received before Your Effective
Date for Coverage with this Plan;
13. Services or supplies received after Your Coverage under this Plan ceases for any reason.
This is true even though the expenses relate to a condition that began while You were
Covered. The only exception to this is described under the Extended Benefits section.
14. Services or supplies received in a dental or medical department maintained by or on
behalf of the employer, mutual benefit association, labor union or similar group;
78
15. Services or charges to complete a claim form or to provide medical records or other
administrative functions. We will not charge You or Your legal representative for
statutorily required copying charges;
16. Charges for failure to keep a scheduled appointment;
17. Charges for telephone consultations, e-mail or web based consultations, except as may
be provided for by specially arranged Care Management programs or emerging health
care programs as described in the Prior Authorization, Care Management, Medical
Policy and Patient Safety section of this Policy;
18. Court ordered examinations and treatment, unless Medically Necessary;
19. Room, board and general nursing care rendered on the date of discharge, unless
admission and discharge occur on the same day;
20. Charges in excess of the Maximum Allowable Charge for Covered Services;
21. Any service stated in the Attachment A as a non-Covered Service or limitation;
22. Charges for services performed by You or Your spouse, or Your or Your spouses parent,
sister, brother or child;
23. Any charges for handling fees;
24. Safety items, or items to affect performance primarily in sports-related activities;
25. Services or supplies, including bariatric Surgery, for weight loss or to treat obesity, even
if You have other health conditions that might be helped by weight loss or reduction of
obesity. This exclusion applies whether You are of normal weight, overweight, obese or
morbidly obese;
26. Services or supplies related to treatment of complications (except Complications of
Pregnancy) that are a direct or closely related result of a Members refusal to accept
treatment, medicines, or a course of treatment that a Provider has recommended or has
been determined to be Medically Necessary, including leaving an inpatient medical
facility against the advice of the treating physician;
27. Services considered cosmetic, except when Medically Appropriate per medical policy.
This exclusion also applies to surgeries to improve appearance following a prior Surgical
Procedure, even if that prior procedure was a Covered Service. Services that could be
considered cosmetic include, but are not limited to: (1) keloid removal; (2)
dermabrasion; (3) chemical peels; (4) breast augmentation; (5) lipectomy; (6) laser
resurfacing; (7) sclerotherapy injections, laser or other treatment of spider veins and
varicose veins; (8) rhinoplasty; (9) panniculectomy/abdominoplasty; (10) Botulinum
toxin;
28. Services that are always considered cosmetic, including but not limited to: (1) removal
of tattoos; (2) facelifts; (3) body contouring or body modeling; (4) injections to smooth
wrinkles; (5) piercing ears or other body parts; (6) rhytidectomy or rhytidoplasty
(Surgery for the removal or elimination of wrinkles); (7) thigh plasty; (8) brachioplasty;
29. Blepharoplasty and browplasty;
79
30. Charges relating to surrogate pregnancy, including but not limited to maternity and
delivery charges, whether or not the surrogate mother is Covered under this plan;
31. Sperm preservation;
32. Services or supplies for orthognathic Surgery, a discipline to specifically treat
malocclusion except as appropriate per medical policy and when performed in
conjunction with orthodontia for members under age 19. Orthognathic Surgery is not
Surgery to treat cleft palate.
33. Services or supplies for Maintenance Care;
34. Private duty nursing;
35. Services or supplies to treat sexual dysfunction, regardless of cause, including but not
limited to erectile dysfunction, delayed ejaculation, anorgasmia and decreased libido;
36. Charges for injuries due to chewing or biting or received in the course of other dental
procedures;
37. Services or supplies related to complications of cosmetic procedures, complications of
bariatric Surgery; re-operation of bariatric Surgery or body remodeling after weight loss.
38. Cranial orthosis, including helmet or headband, for the treatment of non-synostotic
plagiocephaly;
39. Chelation therapy, except for (1) control of ventricular arrhythmias or heart block
associated with digitalis toxicity; (2) Emergency treatment of hypercalcemia; (3) extreme
conditions of metal toxicity, including thalassemia with hemosiderosis; (4) Wilsons
disease (hepatolenticular degeneration); and (5) lead poisoning;
40. Vagus nerve stimulation for the treatment of depression;
41. Balloon sinuplasty for treatment of chronic sinusitis;
42. Treatment for benign gynecomastia;
43. Treatment for hyperhidrosis;
44. Intradiscal annuloplasty to treat discogenic back pain. This procedure provides
controlled delivery of heat to the intervertebral disc through an electrode or coil.
80
POLICY
Attachment D: ELIGIBILITY
If You are eligible for Coverage, You can enroll under this Policy[ upon payment of the required
Premium for such Coverage]. [The Exchange will be responsible for making eligibility
determinations for enrollment in Coverage through the Exchange, in accordance with the
requirements specified under the Affordable Care Act (ACA).] If there is a question about
eligibility, [We][the Exchange] will make the final decision.
A. Subscriber
To be eligible to enroll as a Subscriber in this Plan [through the Exchange], You must:
1. Be a resident of Tennessee, not residing outside the United States of America for more
than 6 months out of the year;
2. Not be Covered under any other individual or group health policy or plan of benefits;
3. Be a citizen of the United States of America or maintain a student visa, work visa and/or
a valid green card;
4. [Not be incarcerated, other than incarceration pending the disposition of charges;]
5. Complete an Application, for You and any dependent You want to cover; and
6. Submit the completed and signed Application to [Us][the Exchange].
B. Covered Dependents
You can apply for Coverage for Your dependents, at the same time You apply[ for Coverage
through the Exchange]. Your dependents must be listed on Your Application, and be:
1. Your current spouse, as recognized under Tennessee law; or
2. Your or Your spouses (1) natural child; (2) legally adopted child (including children
placed with You for the purposes of adoption); (3) step-child(ren); or (4) children for
whom You or Your spouse are legal guardians, or for whom You have a Qualified
Medical Child Support Order. The child(ren) must also be under age 26.
81
[One Cameron Hill Circle]

bcbst.com
BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association
Registered marks of the BlueCross BlueShield Association, an Association of Independent BlueCross BlueShield Plans
This document has been classified as public information
82

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%
Mail Order Network up to 102

days
100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
50% after
Deductible
Maternity care
50% after
Deductible
100%
Allergy testing
50% after
Deductible
100%
50% after
Deductible
100%
50% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

50% after
Deductible

50% after
Deductible

benefit.
Supplies
50% after
Deductible
Page 3

Facility charges
50% after
Deductible
100%

service)
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
50% after
Deductible
100%
50% after
Deductible
100%

50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
50% after
Deductible
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
50% after
Deductible
50% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
50% after
Deductible
Page 6

50% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
50% after
Deductible

50% after
Deductible
100%
Ambulance
50% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,500
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 11

Product Name: B01
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,500
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

days
100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
50% after
Deductible
Maternity care
50% after
Deductible
100%
Allergy testing
50% after
Deductible
100%
50% after
Deductible
100%
50% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

50% after
Deductible

50% after
Deductible

benefit.
Supplies
50% after
Deductible
Page 3

Facility charges
50% after
Deductible
100%

service)
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
50% after
Deductible
100%
50% after
Deductible
100%

50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
50% after
Deductible
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
50% after
Deductible
50% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
50% after
Deductible
Page 6

50% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
50% after
Deductible

50% after
Deductible
100%
Ambulance
50% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 11

Product Name: B02
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

days
100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
80% after
Deductible
Maternity care
80% after
Deductible
100%
Allergy testing
80% after
Deductible
100%
80% after
Deductible
100%
80% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

80% after
Deductible

80% after
Deductible

benefit.
Supplies
80% after
Deductible
Page 3

Facility charges
80% after
Deductible
100%

service)
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
80% after
Deductible
100%
80% after
Deductible
100%

80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
80% after
Deductible
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% after
Deductible
100%
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
80% after
Deductible
80% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
80% after
Deductible
Page 6

80% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
80% after
Deductible

80% after
Deductible
100%
Ambulance
80% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 11

Product Name: B03
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

days
100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
100% after
Deductible
Maternity care
100% after
Deductible
100%
Allergy testing
100% after
Deductible
100%
100% after
Deductible
100%
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
Deductible

100% after
Deductible

benefit.
Supplies
100% after
Deductible
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$5,300
$10,600
Family Members
Individual
Family
$5,300
$15,900
Family Members.
1.
Page 11

Product Name: B04
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$5,300
$10,600
Family Members
Individual
Family
$5,300
$15,900
Family Members.
1.
Page 10

Product Name: B01
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,500
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Product Name: B02
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Product Name: B03
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Network: P
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

days
100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
100% after
Deductible
Maternity care
100% after
Deductible
100%
Allergy testing
100% after
Deductible
100%
100% after
Deductible
100%
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
Deductible

100% after
Deductible

benefit.
Supplies
100% after
Deductible
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$5,300
$10,600
Family Members
Individual
Family
$5,300
$15,900
Family Members.
1.
Page 11

Product Name: B04
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$5,300
$10,600
Family Members
Individual
Family
$5,300
$15,900
Family Members.
1.
Page 10

Product Name: B04
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$5,300
$10,600
Family Members
Individual
Family
$5,300
$15,900
Family Members.
1.
Page 10

Product Name: B05
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$6,250
$12,500
Family Members
Individual
Family
$6,250
$18,750
Family Members.
1.
Page 10

Product Name: B06
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply

Two months supply
Three months supply
(31 to 60 days)
(61 to 90 days)
(Up to 30 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$3/$75/$250
N/A
N/A

Select90 Network
$3/$75/$250
$6/$150/$500
$9/$225/$750
Page 7
Out-of-Network 4
Specialty Drugs 1,2
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$6,350
$12,700
Family Members
Individual
Family
$6,350
$19,050
Family Members.
Copayment.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

days
100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
50% after
Deductible
Maternity care
50% after
Deductible
100%
Allergy testing
50% after
Deductible
100%
50% after
Deductible
100%
50% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

50% after
Deductible

50% after
Deductible

benefit.
Supplies
50% after
Deductible
Page 3

Facility charges
50% after
Deductible
100%

service)
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
50% after
Deductible
100%
50% after
Deductible
100%

50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
50% after
Deductible
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
50% after
Deductible
50% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
50% after
Deductible
Page 6

50% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
50% after
Deductible

50% after
Deductible
100%
Ambulance
50% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,500
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 11

Product Name: B01
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,500
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Product Name: B01
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,500
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

days
100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
50% after
Deductible
Maternity care
50% after
Deductible
100%
Allergy testing
50% after
Deductible
100%
50% after
Deductible
100%
50% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

50% after
Deductible

50% after
Deductible

benefit.
Supplies
50% after
Deductible
Page 3

Facility charges
50% after
Deductible
100%

service)
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
50% after
Deductible
100%
50% after
Deductible
100%

50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
50% after
Deductible
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% after
Deductible
100%
50% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
50% after
Deductible
50% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
50% after
Deductible
Page 6

50% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
50% after
Deductible

50% after
Deductible
100%
Ambulance
50% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 11

Product Name: B02
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Product Name: B02
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
50% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
50% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
50% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

days
100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
80% after
Deductible
Maternity care
80% after
Deductible
100%
Allergy testing
80% after
Deductible
100%
80% after
Deductible
100%
80% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

80% after
Deductible

80% after
Deductible

benefit.
Supplies
80% after
Deductible
Page 3

Facility charges
80% after
Deductible
100%

service)
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
80% after
Deductible
100%
80% after
Deductible
100%

80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
80% after
Deductible
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% after
Deductible
100%
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
80% after
Deductible
80% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
80% after
Deductible
Page 6

80% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
80% after
Deductible

80% after
Deductible
100%
Ambulance
80% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 11

Product Name: B03
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Product Name: B03
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$4,000
$8,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

days
100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
100% after
Deductible
Maternity care
100% after
Deductible
100%
Allergy testing
100% after
Deductible
100%
100% after
Deductible
100%
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
Deductible

100% after
Deductible

benefit.
Supplies
100% after
Deductible
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$5,300
$10,600
Family Members
Individual
Family
$5,300
$15,900
Family Members.
1.
Page 11

Product Name: B04
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$5,300
$10,600
Family Members
Individual
Family
$5,300
$15,900
Family Members.
1.
Page 10

Product Name: B04
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$5,300
$10,600
Family Members
Individual
Family
$5,300
$15,900
Family Members.
1.
Page 10

Product Name: B05
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$6,250
$12,500
Family Members
Individual
Family
$6,250
$18,750
Family Members.
1.
Page 10

Product Name: B06
Network: S
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply

Two months supply
Three months supply
(31 to 60 days)
(61 to 90 days)
(Up to 30 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$3/$75/$250
N/A
N/A

Select90 Network
$3/$75/$250
$6/$150/$500
$9/$225/$750
Page 7
Out-of-Network 4
Specialty Drugs 1,2
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$6,350
$12,700
Family Members
Individual
Family
$6,350
$19,050
Family Members.
Copayment.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

days
100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
65% after
Deductible
Maternity care
65% after
Deductible
100%
Allergy testing
65% after
Deductible
100%
65% after
Deductible
100%
65% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
65% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

65% after
Deductible

65% after
Deductible

benefit.
Supplies
65% after
Deductible
Page 3

Facility charges
65% after
Deductible
100%

service)
65% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
65% after
Deductible
100%
65% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
65% after
Deductible
100%
65% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
65% after
Deductible
100%
65% after
Deductible
100%

65% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
65% after
Deductible
65% after
Deductible
100%
65% of the
Maximum
Allowable Charge
after Deductible
100%
65% of the
Maximum
Allowable Charge
after Deductible
65% after
Deductible
100%
65% after
Deductible
100%
65% of the
Maximum
Allowable Charge
after Deductible
65% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
65% after
Deductible
65% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
65% after
Deductible
Page 6

65% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
65% after
Deductible

65% after
Deductible
100%
Ambulance
65% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
65% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
65% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
65% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$5,250
$15,750
Family Members.
1.
Page 11

Product Name: G01
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs

sigmoidoscopy
Outpatient Surgery
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
65% of the Maximum

Deductible
65% of the Maximum

Deductible
65% of the Maximum

Deductible
65% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
65% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
65% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
65% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$5,250
$15,750
Family Members.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

days
100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
75% after
Deductible
Maternity care
75% after
Deductible
100%
Allergy testing
75% after
Deductible
100%
75% after
Deductible
100%
75% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

75% after
Deductible

75% after
Deductible

benefit.
Supplies
75% after
Deductible
Page 3

Facility charges
75% after
Deductible
100%

service)
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
75% after
Deductible
100%
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
75% after
Deductible
100%
75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
75% after
Deductible
100%
75% after
Deductible
100%

75% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
75% after
Deductible
75% after
Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
75% after
Deductible
100%
75% after
Deductible
100%
75% of the
Maximum
Allowable Charge
after Deductible
75% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
75% after
Deductible
75% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
75% after
Deductible
Page 6

75% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
75% after
Deductible

75% after
Deductible
100%
Ambulance
75% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
75% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 11

Product Name: G02
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
75% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$0 Copayment
N/A
N/A

Select90 Network
$0 Copayment
$0 Copayment
$0 Copayment
Out-of-Network 4
Page 7
Specialty Drugs 1,2
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
Copayment.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1

Covered Services
Providers
Covered Services

pregnancy
100%

sigmoidoscopy
Outpatient Surgery
Covered Services
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Benefits for
Benefits for
Covered Services
Covered Services
Covered Services
received from
received from
Indian Health
Providers
Out-of-Network
Providers
Providers
100% after
$35 PCP / $50 Specialist
Copayment
Maternity care
100% after
Copayment
100%
Allergy testing
100% after
Copayment
100%
100% after
Copayment
100%
100% after
Copayment
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Specialty Drugs
Surgery.
Office Surgery, including anesthesia,
performed in and billed by the Practitioners
office
100% after
Copayment

Authorization is required and not obtained,
and services are Medically Necessary,
benefits may be reduced to 40% for Out-ofNetwork Providers[ and for Network
liability to the Member greater than$2,500
above what the Member would have paid
100% after
had Prior Authorization been obtained, then
$35
PCP
/ $50 Specialist
the Member may contact customer service to
Copayment
have the claim reviewed and adjusted and
the reduction will be limited to $2,500.
(Services that are determined to not be
Medically Necessary are not Covered.)
Network Providers[ in Tennessee] are
responsible for obtaining Prior Authorization;
Member is not responsible for penalty when[
Tennessee] Network Providers do not obtain
Prior Authorization.
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Surgeries include incisions, excisions,

biopsies, injection treatments, fracture
treatments, applications of casts and splints,
sutures, and invasive diagnostic services (e.g.,
colonoscopy, sigmoidoscopy and endoscopy).
Does not apply to Specialty Drugs. See
section for applicable benefit.
Supplies
100% after
Copayment
100% after
Copayment
Page 3

Facility charges
80% after
Deductible
100%

service)
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
80% after
Deductible
100%
80% after
Deductible
100%

80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
80% after
Deductible
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% after
Deductible
100%
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
80% after
Deductible
80% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
80% after
Deductible
Page 6

80% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
80% after
Deductible

80% after
Deductible
100%
Ambulance
80% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply
(Up to 30 days)
Generic Drug /
Non-Preferred Brand
Drug3
Two months supply

(31 to 60 days)
Generic Drug /
Non-Preferred Brand
Drug3
Three months supply

(61 to 90 days)
Generic Drug /
Non-Preferred Brand
Drug3
Retail network
$8/$35/$60
N/A
N/A

Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 8
Out-of-Network 4
100%
Specialty Drugs 1,2

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,000
$2,000
Family Members
Individual
Family
$4,000
$12,000
Family Members.
Copayment.
1.
Page 11

Product Name: G04
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Maternity care
Allergy testing

Drugs

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
100% after
Copayment
50% of the Maximum

Deductible
100% after
Copayment
100% after
Copayment
100% after
Copayment
100% after
Copayment
100% after
Copayment
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
contact customer service to have the claim reviewed $35 PCP / $50 Specialist
Copayment
50% of the Maximum

Deductible

benefit.
Supplies
100% after
Copayment
50% of the Maximum

Deductible
100% after
Copayment
50% of the Maximum

Deductible

Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
80% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,000
$2,000
Family Members
Individual
Family
$4,000
$12,000
Family Members.
Copayment.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$0 Copayment
N/A
N/A

Select90 Network
$0 Copayment
$0 Copayment
$0 Copayment
Out-of-Network 4
Page 7
Specialty Drugs 1,2
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
Copayment.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1

Covered Services
Providers
Covered Services

pregnancy
100%

sigmoidoscopy
Outpatient Surgery
Covered Services
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Benefits for
Benefits for
Covered Services
Covered Services
Covered Services
received from
received from
Indian Health
Providers
Out-of-Network
Providers
Providers
100% after
Copayment
Maternity care
100% after
Copayment
100%
Allergy testing
100% after
Copayment
100%
100% after
Copayment
100%
100% after
Copayment
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Specialty Drugs
Surgery.
office
100% after
Copayment

100% after
$35
PCP
/ $50 Specialist
Copayment
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

Supplies
100% after
Copayment
100% after
Copayment
Page 3

Facility charges
80% after
Deductible
100%

service)
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
80% after
Deductible
100%
80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
80% after
Deductible
100%
80% after
Deductible
100%

80% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
80% after
Deductible
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% after
Deductible
100%
80% after
Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
80% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
80% after
Deductible
80% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
80% after
Deductible
Page 6

80% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
80% after
Deductible

80% after
Deductible
100%
Ambulance
80% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply
(Up to 30 days)
Generic Drug /
Non-Preferred Brand
Drug3
Two months supply

(31 to 60 days)
Generic Drug /
Non-Preferred Brand
Drug3
Three months supply

(61 to 90 days)
Generic Drug /
Non-Preferred Brand
Drug3
Retail network
$8/$35/$60
N/A
N/A

Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 8
Out-of-Network 4
100%
Specialty Drugs 1,2

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,500
$3,000
Family Members
Individual
Family
$4,500
$13,500
Family Members.
Copayment.
1.
Page 11

Product Name: G06
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Maternity care
Allergy testing

Drugs

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
100% after
Copayment
50% of the Maximum

Deductible
100% after
Copayment
100% after
Copayment
100% after
Copayment
100% after
Copayment
100% after
Copayment
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Copayment
50% of the Maximum

Deductible

benefit.
Supplies
100% after
Copayment
50% of the Maximum

Deductible
100% after
Copayment
50% of the Maximum

Deductible

Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
80% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,500
$3,000
Family Members
Individual
Family
$4,500
$13,500
Family Members.
Copayment.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

days
100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
100% after
Deductible
Maternity care
100% after
Deductible
100%
Allergy testing
100% after
Deductible
100%
100% after
Deductible
100%
100% after
Deductible
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
Deductible

100% after
Deductible

benefit.
Supplies
100% after
Deductible
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
100%
Page 8
Out-of-Network 2
Specialty Drugs 1

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,100
$4,200
Family Members
Individual
Family
$2,100
$6,300
Family Members.
1.
Page 11

Product Name: G08
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$2,100
$4,200
Family Members
Individual
Family
$2,100
$6,300
Family Members.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

100%

days
100%
Out-of-Network 2
Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
100%
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Covered Services
Maternity care
Allergy testing

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Network Benefits
Benefits for
Benefits for
for Covered
Covered Services
Covered Services
received from
from Network
Indian Health
Out-of-Network
Providers
Providers
Providers
100% after
$35 PCP / $50
Specialist
Copayment
100% after
$35 PCP / $50
Specialist
Copayment
100% after
$35 PCP / $50
Specialist
Copayment
100% after
$35 PCP / $50
Specialist
Copayment
100% after
$35 PCP / $50
Specialist
Copayment
100%
100%
100%
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Drugs
100% after
$35 PCP / $50
Specialist
Copayment
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

100% after
$35 PCP / $50
Specialist
Copayment

benefit.
Supplies
100% after
$35 PCP / $50
Specialist
Copayment
100% after
$35 PCP / $50
Specialist
Copayment
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
100%
Page 8
Out-of-Network 2
Specialty Drugs 1

list.
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
1.
Page 11

Product Name: G10
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Maternity care
Allergy testing

Drugs

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
100% after
Copayment
50% of the Maximum

Deductible
100% after
Copayment
100% after
Copayment
100% after
Copayment
100% after
Copayment
100% after
Copayment
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Copayment
50% of the Maximum

Deductible

benefit.
Supplies
100% after
Copayment
50% of the Maximum

Deductible
100% after
Copayment
50% of the Maximum

Deductible

Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
100% after Network

Mail Order Network up

to 102 days

days
Out-of-Network 2
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
Page 7
Specialty Drugs 1
list.
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
100% of the Maximum

Allowable Charge
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
100%
100% of the Maximum

Allowable Charge
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100% of the Maximum
Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100% of the Maximum

Allowable Charge
100%
Maternity care
100%
Allergy testing
100%
100%
100%

Drugs
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 2

100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

benefit.
Supplies
Page 3
Facility charges
service)
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Facility charges
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

Outpatient Surgery
Facility charges
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

Supplies
100%
100%

100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge
100% of the Maximum
Allowable Charge
Page 4

100%
100% of the Maximum

Allowable Charge

technologies.
100%
100% of the Maximum

Allowable Charge
100%
100%
100% of the Maximum

Allowable Charge
100% of the Maximum
Allowable Charge

maternity care
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
Page 5
Therapy Services:
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Ambulance
100%
100% of the Maximum

Allowable Charge
Hospice Care
100%
100% of the Maximum

Allowable Charge

this schedule.
calendar year
Prosthetics
Prosthetics
Page 6

except kidney
Transplant
Network
benefits:
100%
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC)
Network Providers:
100%

Out-of-Network
Providers:
100% of
Maximum
Allowable Charge
(MAC), Out-of
applies, amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$0 Copayment
N/A
N/A

Select90 Network
$0 Copayment
$0 Copayment
$0 Copayment
Out-of-Network 4
Page 7
Specialty Drugs 1,2
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist

100%
100% of the Maximum

Allowable Charge

Periodontics
100%
100% of the Maximum

Allowable Charge

100%
100% of the Maximum

Allowable Charge
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$0
Members
$0
Family Members.
$0
Members.
Individual
Family
Copayment.
1.
Page 10

Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1

Covered Services
Providers
Covered Services

pregnancy
100%

sigmoidoscopy
Outpatient Surgery
Covered Services
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Out-of-Network
Benefits for
Benefits for
Covered Services
Covered Services
Covered Services
received from
received from
Indian Health
Providers
Out-of-Network
Providers
Providers
100% after
Copayment
Maternity care
100% after
Copayment
100%
Allergy testing
100% after
Copayment
100%
100% after
Copayment
100%
100% after
Copayment
100%
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 2

Specialty Drugs
Surgery.
office
100% after
Copayment

100% after
$35
PCP
/ $50 Specialist
Copayment
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible

Supplies
100% after
Copayment
100% after
Copayment
Page 3

Facility charges
100% after
Deductible
100%

service)
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

Outpatient Surgery
Facility charges
100% after
Deductible
100%
100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
Page 4

Supplies
100% after
Deductible
100%
100% after
Deductible
100%

100% after
Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible
50% of the
Maximum
Allowable Charge
after Deductible

technologies.
100% after
Deductible
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% after
Deductible
100%
100% after
Deductible
100%
100% of the
Maximum
Allowable Charge
after Deductible
100% of the
Maximum
Allowable Charge
after Deductible
Page 5

maternity care
100% after
Deductible
100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
Therapy Services:
this schedule.
100% after
Deductible
Page 6

100% after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible
100%
50% of the
Maximum
Allowable
Charge after
Deductible

calendar year
Prosthetics
Prosthetics
100% after
Deductible

100% after
Deductible
100%
Ambulance
100% after
Deductible
100%
100%
100%
Hospice Care
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
50% of the
Maximum
Allowable
Charge after
Deductible
Page 7

except kidney

Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
100% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply
(Up to 30 days)
Generic Drug /
Non-Preferred Brand
Drug3
Two months supply

(31 to 60 days)
Generic Drug /
Non-Preferred Brand
Drug3
Three months supply

(61 to 90 days)
Generic Drug /
Non-Preferred Brand
Drug3
Retail network
$8/$35/$60
N/A
N/A

Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 8
Out-of-Network 4
100%
Specialty Drugs 1,2

Network
100%
Out-of-Network
Not Covered
Pediatric Dental
Covered Services

Periodontics
Network Dentist
100%
80%
50%
Indian Health
Provider Network
Dentist
Out-of-Network
Dentist
100%
100% of the
Maximum
Allowable Charge
after Deductible
100%
80% of the
Maximum
Allowable Charge
after Deductible
100%
50% of the
Maximum
Allowable Charge
after Deductible
Page 9
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 10
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
Copayment.
1.
Page 11

Product Name: G11
Network: E
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Maternity care
Allergy testing

Drugs

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
100% after
Copayment
50% of the Maximum

Deductible
100% after
Copayment
100% after
Copayment
100% after
Copayment
100% after
Copayment
100% after
Copayment
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Copayment
50% of the Maximum

Deductible

benefit.
Supplies
100% after
Copayment
50% of the Maximum

Deductible
100% after
Copayment
50% of the Maximum

Deductible

Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Supplies
50% of the Maximum

Deductible
50% of the Maximum

Deductible

50% of the Maximum

Deductible
Page 4

technologies.
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum

Deductible
100% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney
Transplant
Network
benefits:
100% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
100% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible;
Amounts over TMAC
do not apply to the
Out-of-Pocket
Maximum and are not
Covered.
Network Providers:
100% after Network

Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum applies
and amounts
over MAC do not
not Covered.
One month supply

Two months supply
Three months supply
(Up to 30 days)
(31 to 60 days)
(61 to 90 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60
N/A
N/A

Select90 Network
$8/$35/$60
$16/$70/$120
$24/$105/$180
Page 7
Out-of-Network 4
Specialty Drugs 1,2
list.
Out-of-Network
Not Covered
Pediatric Dental
Covered Services
Periodontics
Network Dentist
100%
100% of the Maximum

Deductible
80%
80% of the Maximum

Deductible
50%
50% of the Maximum

Deductible
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$3,500
$7,000
Family Members
Individual
Family
$3,500
$10,500
Family Members.
Copayment.
1.
Page 10

Product Name: G01
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs

sigmoidoscopy
Outpatient Surgery
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
65% of the Maximum

Deductible
65% of the Maximum

Deductible
65% of the Maximum

Deductible
65% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
65% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
65% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
65% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$5,250
$15,750
Family Members.
1.
Page 10

Product Name: G02
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery

Covered Services
Providers
100%
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Maternity care
Allergy testing

Drugs
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

benefit.
Supplies
Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum

Deductible
75% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
75% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
75% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
75% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.

days
Out-of-Network 2
Page 7
Specialty Drugs 1
Out-of-Network
Not Covered
Pediatric Dental
Network Dentist
100%
100% of the Maximum

Deductible

Periodontics
80%
80% of the Maximum

Deductible

50%
50% of the Maximum

Deductible
Covered Services
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$0
Family Members
$5,000
Family Members
Individual
Family
$6,350
$19,050
Family Members.
1.
Page 10

Product Name: G03
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Maternity care
Allergy testing

Drugs

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
100% after
Copayment
50% of the Maximum

Deductible
100% after
Copayment
100% after
Copayment
100% after
Copayment
100% after
Copayment
100% after
Copayment
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Copayment
50% of the Maximum

Deductible

benefit.
Supplies
100% after
Copayment
50% of the Maximum

Deductible
100% after
Copayment
50% of the Maximum

Deductible

Page 3
Facility charges

service)
Facility charges
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum

Deductible
50% of the Maximum
Deductible

Outpatient Surgery
Facility charges
50% of the Maximum

Deductible
50% of the Maximum

Deductible

Supplies

50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 4

technologies.
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum

Deductible
80% of the Maximum
Deductible

maternity care
50% of the Maximum

Deductible
50% of the Maximum

Deductible
Page 5
Therapy Services:
50% of the Maximum

Deductible
50% of the Maximum

Deductible
50% of the Maximum

Deductible

this schedule.
calendar year
Prosthetics
Prosthetics
Ambulance
Hospice Care
100%
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 6

except kidney

Transplant
Network
benefits:
80% after
Network
Deductible,
applies.
Network Providers
Network
(Network Providers
Network include
Tennessee and
BlueCard PPO
Providers outside
Tennessee):
80% of Transplant
Maximum Allowable
Charge (TMAC) after
Network Deductible,
applies. Amounts
over TMAC do not
are not Covered.
Network Providers:
80% after Network
Out-of-Network
Providers:
50% of Maximum
Allowable Charge
Maximum
applies, amounts
over MAC do not
not Covered.
Covered.
One month supply

Two months supply
Three months supply
(31 to 60 days)
(61 to 90 days)
(Up to 30 days)
Generic Drug /
Generic Drug /
Generic Drug /
Retail network
$8/$35/$60 after
N/A
N/A

Select90 Network
$8/$35/$60 after
$16/$70/$120 after
$24/$105/$180 after
Page 7
Out-of-Network 4
Specialty Drugs 1,2

list.
Out-of-Network
Not Covered
Pediatric Dental
Covered Services
Periodontics
Network Dentist
100%
100% of the Maximum

Deductible
80%
80% of the Maximum

Deductible
50%
50% of the Maximum

Deductible
Page 8
Pediatric Vision
Benefit
Network
Out-of-Network
$0 Copayment

Charge

completed.)
$0 Copayment
$0 Copayment
Frames:

equivalent

Charge
Charge
Charge

Single Vision
$0 Copayment
Bifocal
$0 Copayment
Trifocal
$0 Copayment
Lenticular
$0 Copayment
$0 Copayment

Charge
Charge
Charge
Charge
Charge
Lens Options:
UV Treatment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
$0 Copayment
Contact Lenses

Charge
Charge
Charge
Charge
Charge


contact lenses

Charge
Page 9
Deductible
Individual
Family


Charge
In-Network Services
Providers
Providers
$1,000
$2,000
Family Members
Individual
Family
$4,000
$12,000
Family Members.
Copayment.
1.
Page 10

Product Name: G04
Network: P
Covered Services

Covered Services
Providers
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
Preventive Care
Includes:
Well woman exam
Prevention (CDC).
Page 1
Covered Services

pregnancy
sigmoidoscopy
Outpatient Surgery
Maternity care
Allergy testing

Drugs

Covered Services
Providers
100%
50% of the Maximum
Deductible
100%
50% of the Maximum

Deductible
100%
50% of the Maximum

Deductible
100% after
Copayment
50% of the Maximum

Deductible
100% after
Copayment
100% after
Copayment
100% after
Copayment
100% after
Copayment
100% after
Copayment
50% of the Maximum

Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
50% of the Maximum
Deductible
Page 2

100% after
Copayment
50% of the Maximum

Deductible

benefit.
Supplies
100% after
Copayment
50% of the Maximum

Deductible
100% after
Copayment
50% of the Maximum

Deductible

Tennessee (BlueCard P

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SERFF Tracking #: BCTN-129004734

State Tracking #: H-130554

H16I Individual Health - Major Medical/H16I.005A Individual - Preferred Provider (PPO)

BlueCross BlueShield of Tennessee

BlueCross BlueShield of Tennessee

State Filing Description:

SERFF Tracking #: BCTN-129004734

State Tracking #: H-130554

H16I Individual Health - Major Medical/H16I.005A Individual - Preferred Provider (PPO)

BlueCross BlueShield of Tennessee

Status of Filing in Domicile: Pending

PPACA Notes: null

Company and Contact

State of Domicile: Tennessee

H16I Individual Health - Major Medical/H16I.005A Individual - Preferred Provider (PPO)

BlueCross BlueShield of Tennessee

Objection Letters and Response Letters

Schedule Item Name

Gold Schedules Network P G01 G02 and G03

Gold Schedules Network P G04 G05 G06 and G07

Gold Schedules Network S G01 G02 and G03

Gold Schedules Network S G04 G05 G06 and G07

BCBST Individual Benefits Template

Bronze Schedules Network E

Bronze Schedules Network P

Bronze Schedules Network S

Gold Schedules Network E G01 and G02

Gold Schedules Network E G04 and G06

Gold Schedules Network P G01 G02 and G03

Gold Schedules Network P G04 G05 G06 and G07

H16I Individual Health - Major Medical/H16I.005A Individual - Preferred Provider (PPO)

BlueCross BlueShield of Tennessee

Schedule Item Name

Gold Schedules Network S G01 G02 and G03

Gold Schedules Network S G04 G05 G06 and G07

Platinum Schedules Network E

Platinum Schedules Network P

Platinum Schedules Network S

Gold Schedules Network E G08 G10 and G11

Gold Schedules Network P G08 G10 and G11

Gold Schedules Network S G08 G10 and G11

Letter of Explanation of Changes

H16I Individual Health - Major Medical/H16I.005A Individual - Preferred Provider (PPO)

BlueCross BlueShield of Tennessee

Schedule Item Status

Cover Letter Accident & Health

Third Party Authorization

Rates - All NEW Forms Require RATES

PPACA Uniform Compliance Summary

Letter of Explanation of Changes

Supporting Document (revised)

BCBST Individual Benefits Template

BCBST Individual Benefits Template

Bronze Schedules Network E

Bronze Schedules Network P

Bronze Schedules Network S

Gold Schedules Network E G01 and G02

Gold Schedules Network E G04 and G06

H16I Individual Health - Major Medical/H16I.005A Individual - Preferred Provider (PPO)

BlueCross BlueShield of Tennessee

Schedule Item Status

Gold Schedules Network E G08 G10 and G11