For a statement explaining your rights under ERISA, see theOther Informationsection of the TEBP SPD.
Appendix
ForFLORIDA UNIONemployees, the following chart describes the plan coverage levels.
Health & Savings Plan Health & Reimbursement Plan PPO EPO
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Only(No out-of network benefits)
Annual Deductible
(applies to out-of-pocket maximum)
$1,250 Employee Only
$2,500 Employee + Spouse, Child(ren) or Family Non-Tenet: $800 Per Person
$2,400 Family Maximum Annual
Out-of-Pocket Maximum
$5,200 Employee Only
$10,400 Employee + Spouse,
Child(ren) or Family Unlimited $5,200 Per Person
$10,400 Family Maximum Unlimited $4,000 Per Person
$12,000 Family Maximum Unlimited $4,000 Per Person
$12,000 Family Maximum Physician Care
oOffice visit
oIP/OP/ER Tenet-employed or Advantage Health Network physician: You pay 10% after deductible
Contracted: You pay 20%
after deductible physician: You pay 10%
after deductible
Contracted: You pay 20%
after deductible
Contracted: You pay 20%
after deductible
You pay 60% after deductible
Tenet-employed or Advantage Health Network physician: You pay $15 / $30 co-pay per physician / specialist visit
Contracted: You pay $30 / $45 co-pay per physician / specialist visit oLab/basic
x-ray1 Tenet free-standing facility: FREE *
Non-Tenet free-standing facility: You pay
$30 co-pay per visit
Non-Tenet-employed physician / specialist office: You pay $30 / $45 co-pay if performed on day other than office visit oPreventive
services You pay $0 You pay full
cost You pay $0 You pay
full cost You pay $0 You pay
full cost You pay $0 Inpatient
Hospital Services2
Tenet facility: FREE after deductible *
Non-Tenet, gap exception:
You pay 10% after deductible
Non-Tenet, no gap exception: You pay 50%
after deductible
You pay 60% after deductible
Tenet facility: FREE *
Non-Tenet, gap exception:
You pay 20% after deductible
Non-Tenet, no gap exception: You pay 70%
after deductible
You pay 75% after deductible
Tenet facility: FREE *
Non-Tenet, gap exception:
You pay 10% after deductible
Non-Tenet, no gap exception: You pay 50%
after deductible
You pay 60% after deductible
Tenet facility: FREE *
Non-Tenet, gap exception: You pay $500 co-pay per admission
Non-Tenet, no gap exception: You pay 50% after deductible
Outpatient Hospital Services1, 2
Tenet facility: FREE after deductible *
Non-Tenet, gap exception:
You pay 10% after deductible
Non-Tenet, no gap exception: You pay 50%
after deductible
You pay 60% after deductible
Tenet facility: FREE *
Non-Tenet, gap exception:
You pay 20% after deductible
Non-Tenet, no gap exception: You pay 70%
after deductible
You pay 75% after deductible
Tenet facility: FREE *
Non-Tenet, gap exception:
You pay 10% after deductible
Non-Tenet, no gap exception: You pay 50%
after deductible
You pay 60% after deductible
Tenet facility: FREE *
Non-Tenet, gap exception: You pay $250 co-pay per admission
Non-Tenet, no gap exception: You pay 50% after deductible physician: You pay 10% after deductible
Contracted: You pay 20%
after deductible You pay
60% after deductible
Tenet-employed or Advantage Health Network physician: You pay 10%
after deductible
Contracted: You pay 20%
after deductible You pay 75% after deductible
Tenet-employed or Advantage Health Network physician: You pay 10% after deductible
Contracted: You pay 20%
after deductible You pay 60% after deductible
Tenet-employed or Advantage Health Network physician: You pay $15 / $30 co-pay per physician / specialist visit
Contracted: You pay $30 / $45 co-pay per physician / specialist visit
oHospital
delivery2 Tenet facility: FREE after deductible *
Non-Tenet, gap exception:
You pay 10% after deductible
Non-Tenet, no gap exception: You pay 50%
after deductible
Tenet facility: FREE *
Non-Tenet, gap exception:
You pay 20% after deductible
Non-Tenet, no gap exception: You pay 70%
after deductible
Tenet facility: FREE *
Non-Tenet, gap exception:
You pay 10% after deductible
Non-Tenet, no gap exception: You pay 50%
after deductible
Tenet facility: FREE *
Non-Tenet, gap exception: You pay $500 co-pay per admission
Non-Tenet, no gap exception: You pay 50% after deductible
Emergency Care oEmergency
room service
You pay $100 ER fee (waived if admitted)
Tenet facility: FREE after deductible *
Tenet facility: FREE *
Non-Tenet facility: You
You pay
Tenet facility: FREE *
Non-Tenet facility: You
You pay
$100 ER fee (waived if admitted) You pay
You pay $100 ER fee (waived if admitted)
Tenet facility: FREE *
Non-Tenet facility: You pay 10% after
ForFLORIDA UNIONemployees(continued)
Health & Savings Plan Health & Reimbursement Plan PPO EPO
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Only(No out-of network benefits) physician: You pay 10% after deductible
Contracted: You pay 20%
after deductible pay 10% after deductible
Contracted: You pay 20%
after deductible
You pay 10% after deductible
Contracted: You pay 20%
after deductible
You pay 60% after deductible
Tenet-employed or Advantage Health Network physician: You pay $30 co-pay per visit
Contracted: You pay $45 co-pay per visit
oOutpatient physical / occupational / speech therapy4
You pay $45 co-pay per visit oDurable medical
equipment
oHome health care5 You pay 20% after deductible You pay 20% after
deductible You pay 20% after deductible You pay $0
oSkilled nursing4 Tenet facility: FREE after deductible *
Non-Tenet, gap exception:
You pay 10% after deductible
Non-Tenet, no gap exception: You pay 50%
after deductible
Tenet facility: FREE *
Non-Tenet, gap exception:
You pay 20% after deductible
Non-Tenet, no gap exception: You pay 70%
after deductible
Tenet facility: FREE *
Non-Tenet, gap exception:
You pay 10% after deductible
Non-Tenet, no gap exception: You pay 50%
after deductible
Tenet facility: FREE *
Non-Tenet, gap exception:
You pay $500 co-pay per admission
Non-Tenet, no gap exception:
You pay 50% after deductible
Mental Health / Substance Abuse
To ensure coverage, you must contact the Tenet Personal Health Team at 800-442-2353 prior to seeking treatment for mental health and substance abuse issues.
Inpatient
You pay 10% after deductible * You pay 60% after
deductible You pay 10% * You pay
75% after
deductible You pay 10% * You pay
60% after deductible
You pay $500 co-pay per admission *
Outpatient You pay $250 co-pay per
admission *
Office visit You pay $45 co-pay per visit *
* You will receive the greatest benefit coverage when services are provided at a Tenet facility. If you are enrolled in theHealth & Savings Planand receive care at a Tenet facility, the co-insurance is waived by the facility. If you are enrolled in theHealth & Reimbursement Plan,PPOorEPOand receive care at a Tenet facility, the deductible does not apply and co-insurance and/or co-pays are waived by the facility. These waiver benefits are not part of the official Tenet Employee Benefit Plan and are not reflected on statements from the medical carrier. The adjustment will be noted on the invoice from the health care provider. For information about Tenet discount policies, refer to Policy AD2.06.
Gap exception. Participants must obtain approval from the carrier before receiving services at a non-Tenet facility in order to receive a gap exception. Call the Member Services number on your medical ID card. Gap exceptions may be approved if services are not available at a Tenet facility within 45 miles of your home; or if it is an emergency admission; or if services are available at a Tenet facility within 45 miles of your home but your specific medical needs cannot be met (medical management review is required).
3 Maximum 20 visits per calendar year.
4 Maximum 60 days per calendar year.
5 Maximum 120 visits per calendar year.
ForFLORIDA NON-UNIONemployees, the following chart describes the plan coverage levels.
Health & Savings Plan Health & Reimbursement Plan
In-Network Out-of-Network In-Network Out-of-Network
Annual Deductible
(applies to out-of-pocket max.)
$1,250 Employee Only
$2,500 Employee + Spouse, Child(ren) or Family
$10,400 Employee + Spouse, Child(ren) or Family
Unlimited $5,200 Per Person
$10,400 Family Maximum Unlimited
Physician Care o Office visit o IP / OP / ER o Lab / basic
x-ray1
Tenet-employed or Advantage Health Network physician: You pay 10% after deductible
Contracted: You pay 20% after deductible
You pay 75%
after deductible
Tenet-employed or Advantage Health Network physician: You pay 10% after deductible
Contracted: You pay 20% after deductible
You pay 75%
after deductible
o Preventive
services You pay $0 You pay full cost You pay $0 You pay full cost
Inpatient Hospital Services2
Tenet facility: FREE after deductible *
Non-Tenet, gap exception: You pay 20%
after deductible
Non-Tenet, no gap exception: You pay 70%
after deductible
You pay 75%
after deductible
Tenet facility: FREE *
Non-Tenet, gap exception: You pay 20%
after deductible
Non-Tenet, no gap exception: You pay 70% after deductible
Tenet facility: FREE after deductible *
Non-Tenet, gap exception: You pay 20%
after deductible
Non-Tenet, no gap exception: You pay 70%
after deductible
You pay 75%
after deductible
Tenet facility: FREE *
Non-Tenet, gap exception: You pay 20%
after deductible
Non-Tenet, no gap exception: You pay 70% after deductible
You pay 75%
after deductible
Maternity Care
o Prenatal care Tenet-employed or Advantage Health Network physician: You pay 10% after deductible
Contracted: You pay 20% after deductible
You pay 75%
after deductible
Tenet-employed or Advantage Health Network physician: You pay 10% after deductible
Contracted: You pay 20% after
deductible You pay 75%
after deductible o Hospital
delivery2 Tenet facility: FREE after deductible *
Non-Tenet, gap exception: You pay 20%
after deductible
Non-Tenet, no gap exception: You pay 70%
after deductible
Tenet facility: FREE *
Non-Tenet, gap exception: You pay 20%
after deductible
Non-Tenet, no gap exception: You pay 70% after deductible
Emergency Care o Emergency
room service
You pay $100 ER fee (waived if admitted)
Tenet facility: FREE after deductible *
Non-Tenet facility: You pay 10% after deductible
You pay $100 ER fee (waived if admitted) You pay 10%
after deductible
You pay $100 ER fee (waived if admitted)
Tenet facility: FREE *
Non-Tenet facility: You pay 10% after deductible
You pay $100 ER fee (waived if admitted) You pay 10%
after deductible
o Ambulance You pay 20% after deductible You pay 20%
after deductible You pay 20% after deductible You pay 20%
after deductible
ForFLORIDA NON-UNIONemployees(continued)
Health & Savings Plan Health & Reimbursement Plan
In-Network
Out-of-Network In-Network Out-of-Network
Other Services
o Acupuncture /chiropractic care3
o Outpatient physical/
occupational/speech therapy4
Tenet-employed or Advantage Health Network physician: You pay 10% after deductible
Contracted: You pay 20% after deductible
You pay 75%
after deductible
Tenet-employed or Advantage Health Network physician: You pay 10% after deductible
Contracted: You pay 20% after deductible
You pay 75%
after deductible o Durable medical
equipment o Home health care5
You pay 20% after deductible You pay 20% after deductible
o Skilled nursing4
Tenet facility: FREE after deductible *
Non-Tenet, gap exception: You pay 20% after deductible
Non-Tenet, no gap exception: You pay 70%
after deductible
Tenet facility: FREE *
Non-Tenet, gap exception: You pay 20%
after deductible
Non-Tenet, no gap exception: You pay 70% after deductible
Mental Health / Substance Abuse
To ensure coverage, you must contact the Tenet Personal Health Team at 800-442-2353 prior to seeking treatment for mental health and substance abuse issues.
o Inpatient o Outpatient o Office visit
You pay 10% after deductible * You pay 75%
after deductible You pay 10% * You pay 75%
after deductible
* You will receive the greatest benefit coverage when services are provided at a Tenet facility.
If you are enrolled in theHealth & Savings Planand receive care at a Tenet facility, the co-insurance is waived by the facility.
If you are enrolled in theHealth & Reimbursement Planand receive care at a Tenet facility, the deductible does not apply and co-insurance is waived by the facility.
These waiver benefits are not part of the official Tenet Employee Benefit Plan and are not reflected on statements from the medical carrier. The adjustment will be noted on the invoice from the health care provider. For information about Tenet discount policies, refer to Policy AD2.06.
Gap exception. Participants must obtain approval from the carrier before receiving services at a non-Tenet facility in order to receive a gap exception. Call the Member Services number on your medical ID card. Gap exceptions may be approved if services are not available at a Tenet facility within 45 miles of your home; or if it is an emergency admission; or if services are available at a Tenet facility within 45 miles of your home but your specific medical needs cannot be met (medical management review is required).
3 Maximum 20 visits per calendar year.
4 Maximum 60 days per calendar year.
5 Maximum 120 visits per calendar year.
ForUNION employees in Georgia, Pennsylvania and El Paso, Texas,the following chart describes the plan coverage.
Health & Savings Plan Health & Reimbursement Plan PPO EPO
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Only(No out-of network benefits)
Annual
$2,500 Employee + Spouse / Child(ren) / Family Non-Tenet: $800 Per Person
$2,400 Family Maximum Spouse / Child(ren) / Family
Unlimited $5,200 Per Person
$10,400 Family Maximum Unlimited $4,000 Per Person
$12,000 Family Maximum Unlimited $4,000 Per Person
$12,000 Family Maximum
Ask your local HR
Tenet-preferred physician:
You pay 10% after deductible
Contracted: You pay 20%
after deductible
Ask your local HR
Contracted: You pay 20%
after deductible
You pay 75% after deductible
Tenet-employed physician: Ask your local
Tenet-preferred physician:HR You pay 10% after deductible
Contracted: You pay 20%
after deductible
You pay 60% after deductible
Tenet-employed physician: Ask your local HR
Tenet-preferred physician: You pay $15 / $30 co-pay per physician / specialist visit
Contracted: You pay $30 / $45 co-pay per physician / specialist visit
oLab/basic
x-ray1 Tenet free-standing facility: FREE *
Non-Tenet free-standing facility: You pay $30 co-pay per visit
Non-Tenet-employed physician / specialist office: You pay $30 / $45 co-pay if performed on day other than office visit
oPreventive
services You pay $0 You payfull cost You pay $0 You pay
full cost You pay $0 You pay
full cost You pay $0 Inpatient
Hospital Services2
Tenet facility: FREE after deductible *
Non-Tenet, gap exception: You pay 10%
after deductible
Non-Tenet, no gap exception: You pay 50%
after deductible
You pay 60% after deductible
Tenet facility: FREE *
Non-Tenet, gap exception:
You pay 20% after deductible
Non-Tenet, no gap exception: You pay 70%
after deductible
You pay 75% after deductible
Tenet facility: FREE *
Non-Tenet, gap exception:
You pay 10% after deductible
Non-Tenet, no gap exception: You pay 50%
after deductible
You pay 60% after deductible
Tenet facility: FREE *
Non-Tenet, gap exception: You pay $500 co-pay per admission
Non-Tenet, no gap exception: You pay 50%
after deductible
Outpatient Hospital Services1, 2
Tenet facility: FREE after deductible *
Non-Tenet, gap exception: You pay 10%
after deductible
Non-Tenet, no gap exception: You pay 50%
after deductible
You pay 60% after deductible
Tenet facility: FREE *
Non-Tenet, gap exception:
You pay 20% after deductible
Non-Tenet, no gap exception: You pay 70%
after deductible
You pay 75% after deductible
Tenet facility: FREE *
Non-Tenet, gap exception:
You pay 10% after deductible
Non-Tenet, no gap exception: You pay 50%
after deductible
You pay 60% after deductible
Tenet facility: FREE *
Non-Tenet, gap exception: You pay $250 co-pay per admission
Non-Tenet, no gap exception: You pay 50%
after deductible
Ask your local HR
Tenet-preferred physician:
You pay 10% after deductible
Contracted: You pay 20%
after deductible You pay
60% after deductible
Tenet-employed and/or Tenet-preferred physician:
Ask your local HR
Contracted: You pay 20%
after deductible
You pay 75% after deductible
Tenet-employed physician:
Ask your local HR
Tenet-preferred physician:
You pay 10% after deductible
Contracted: You pay 20%
after deductible You pay
60% after deductible
Tenet-employed physician: Ask your local HR
Tenet-preferred: You pay $15 / $30 co-pay per physician / specialist (initial visit only)
Contracted: You pay $30 / $45 co-pay per physician / specialist (initial visit only) oHospital
delivery2 Tenet facility: FREE after deductible *
Non-Tenet, gap exception:
You pay 10% after deductible
Non-Tenet, no gap exception: You pay 50%
after deductible
Tenet facility: FREE *
Non-Tenet, gap exception:
You pay 20% after deductible
Non-Tenet, no gap exception: You pay 70%
after deductible
Tenet facility: FREE *
Non-Tenet, gap exception:
You pay 10% after deductible
Non-Tenet, no gap exception: You pay 50%
after deductible
Tenet facility: FREE *
Non-Tenet, gap exception: You pay $500 co-pay per admission
Non-Tenet, no gap exception: You pay 50%
after deductible
Tenet facility: FREE after deductible *
Non-Tenet facility: You pay 10% after deductible
You pay
Tenet facility: FREE *
Non-Tenet facility: You pay 10% after deductible
You pay
Tenet facility: FREE *
Non-Tenet facility: You pay 10% after deductible
You pay
You pay $100 ER fee (waived if admitted)
Tenet facility: FREE *
Non-Tenet facility: You pay 10% after deductible
ForUNION employees in Georgia, Pennsylvania and El Paso, Texas(continued)
Health & Savings Plan Health & Reimbursement Plan PPO EPO
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Only(No out-of network benefits)
Other Services oAcupuncture /
chiropractic care3
Tenet-employed physician:
Ask your local HR
Tenet-preferred physician:
You pay 10% after deductible
Contracted: You pay 20%
after deductible physician: Ask your local HR
Contracted: You pay 20%
after deductible
Contracted: You pay 20% after deductible
You pay 60% after deductible
Tenet-employed physician: Ask your local HR
Tenet-preferred physician: You pay $30 co-pay per visit
Contracted: You pay $45 co-pay per visit oOutpatient physical /
occupational / speech therapy4
You pay $45 co-pay per visit oDurable medical
equipment
oHome health care5 You pay 20% after deductible You pay 20% after
deductible You pay 20% after
deductible You pay $0
oSkilled nursing4 Tenet facility: FREE after deductible *
Non-Tenet, gap exception:
You pay 10% after deductible
Non-Tenet, no gap exception: You pay 50%
after deductible
Tenet facility: FREE *
Non-Tenet, gap exception: You pay 20%
after deductible
Non-Tenet, no gap exception: You pay 70%
after deductible
Tenet facility: FREE *
Non-Tenet, gap exception: You pay 10% after deductible
Non-Tenet, no gap exception: You pay 50% after deductible
Tenet facility: FREE *
Non-Tenet, gap exception: You pay
$500 co-pay per admission
Non-Tenet, no gap exception:
You pay 50% after deductible
Mental Health / Substance Abuse
To ensure coverage, you must contact the Tenet Personal Health Team at 800-442-2353 prior to seeking treatment for mental health and substance abuse issues.
Inpatient
You pay 10% after deductible * You pay 60% after
deductible You pay 10% * You pay
75% after
deductible You pay 10% * You pay 60% after deductible
You pay $500 co-pay per admission *
Outpatient You pay $250 co-pay per admission *
Office visit You pay $45 co-pay per visit *
* You will receive the greatest benefit coverage when services are provided at a Tenet facility. If you are enrolled in theHealth & Savings Planand receive care at a Tenet facility, the co-insurance is waived by the facility. If you are enrolled in theHealth & Reimbursement Plan,PPOorEPOand receive care at a Tenet facility, the deductible does not apply and co-insurance and/or co-pays are waived by the facility. These waiver benefits are not part of the official Tenet Employee Benefit Plan and are not reflected on statements from the medical carrier. The adjustment will be noted on the invoice from the health care provider. For information about Tenet discount policies, refer to Policy AD2.06.
Gap exception. Participants must obtain approval from the carrier before receiving services at a non-Tenet facility in order to receive a gap exception. Call the Member Services number on your medical ID card. Gap exceptions may be approved if services are not available at a Tenet facility within 45 miles of your home; or if it is an emergency admission; or if services are available at a
Gap exception. Participants must obtain approval from the carrier before receiving services at a non-Tenet facility in order to receive a gap exception. Call the Member Services number on your medical ID card. Gap exceptions may be approved if services are not available at a Tenet facility within 45 miles of your home; or if it is an emergency admission; or if services are available at a