HSA Medical Plan

The HSA Medical Plan offers 100% coverage for in-network preventive care. For other health care services and prescription drugs, you must meet an annual deductible before benefits begin.

When you enroll in the HSA Medical Plan, a Health Savings Account (HSA) is automatically opened in your name with HealthEquity. Tenneco will make a contribution to your account, and you can elect to make your own pre-tax contributions as well, up to IRS limits.

In-Network vs. Out-of-Network Care

In-network providers have negotiated service rates with Credence BCBS. An out-of-network provider may charge more than Credence BCBS is willing to pay. Because of this, the out-of-network deductible is higher than the in-network deductible. Before receiving treatment, check with Credence BCBS to ensure a doctor, lab, hospital, specialist or other provider is in-network, how much care will cost and understand your health plan.

HSA Medical Plan: Key Features

The chart below summarizes how medical services are covered under the HSA Medical Plan.

Plan Feature In-Network Out-of-Network

Annual Deductible (aggregate)1

Individual: $1,500
Family: $3,000

Individual: $3,000
Family: $6,000

Annual Out-of-Pocket Maximum (aggregate)1

Individual: $3,750
Family: $7,500

Individual: $7,500
Family: $15,000

Preventive Care2

You pay nothing for plan-eligible preventive care; no deductible applies

You pay 40%, after deductible


You pay 20%, after deductible

You pay 40%, after deductible

Hospital Emergency Room Care

You pay 20%, after deductible

If claim is submitted with a non-emergency diagnosis, an additional $200 penalty will apply

You pay 20%, after deductible

If claim is submitted with a non-emergency diagnosis, you pay 40% after deductible

  1. “Aggregate” means the deductible or out-of-pocket maximum must be met at the full family level for any coverage tier other than individual coverage.
  2. For specific preventive services, a list of covered immunizations, visit limitations and/or pre-certification requirements, refer to the Summary Plan Descriptions at TennecoPlanDocs.com or visit credenceblue.com.


Prescription Drugs

CVS Caremark