BlueCross B15E $0 virtual care from Teladoc Health®
BlueCross BlueShield of Tennessee
Plan overview
Medical deductible
Individual: $10600
Family: $21200
Per Person: $10600
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $10600
Family: $21200
Per Person: $10600
Office visit
Primary Doctor
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Benefit Explanation: $0 Virtual care for telehealth services are available through Teladoc with your plan. Regular benefits apply for telehealth services provided by other network providers.
Specialist
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Prescription drug information
Preferred brand drugs
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: When a Brand Drug is chosen and a Generic Drug equivalent is available, You will pay a Penalty for the difference between the cost of the Brand Drug and the Generic Drug.
Non preferred brand drugs
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: When a Brand Drug is chosen and a Generic Drug equivalent is available, You will pay a Penalty for the difference between the cost of the Brand Drug and the Generic Drug.
Generic drugs
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
Specialty drugs
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Up to a 30-day supply. Must use a pharmacy in the specialty pharmacy network.
Inpatient coverage
Hospital services
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Benefit Explanation: Prior Authorization required (except maternity). Penalties include reduced benefits or denial of claim.
Inpatient services
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Benefit Explanation: Prior Authorization required (except maternity). Penalties include reduced benefits or denial of claim.
Emergency and urgent care
Emergency room
CoPay: $750.00 Copay with deductible
CoInsurance: No Charge after deductible
Covered: Covered
Urgent care facility
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Benefit Explanation:
Maternity
Labor and delivery hospital stay
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Pre and Postnatal office visit
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Vision
Routine Eye Exams for Children
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 1
Limit Unit: Exam(s) per Benefit Period
Major dental care
Routine dental checkups for children
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 1
Limit Unit: Exam(s) per 6 Months
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).