BlueCross B16E $50 PCP Copay + $0 virtual care from Teladoc Health®
BlueCross BlueShield of Tennessee
Plan overview
Medical deductible
Individual: $7500
Family: $15000
Per Person: $7500
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $10000
Family: $20000
Per Person: $10000
Office visit
Primary Doctor
CoPay: $50.00
CoInsurance: Not Applicable
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: $100.00
CoInsurance: Not Applicable
Covered: Covered
Prescription drug information
Preferred brand drugs
CoPay: $50.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: $50 co-pay applies after deductible per 30-day supply and $125 co-pay applies after deductible per 90-day supply.
Non preferred brand drugs
CoPay: $100.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: $100 co-pay applies after deductible per 30 day supply and $250 co-pay applies after deductible for 90 day supply for Non-Preferred Brand Drugs.
Generic drugs
CoPay: $25.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: $25 co-pay applies per 30-day supply and $62.50 co-pay applies per 90-day supply for Generic Drugs.
Specialty drugs
CoPay: $500.00 Copay after deductible
CoInsurance: Not Applicable
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: 50.00% Coinsurance 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: 50.00% Coinsurance 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: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Urgent care facility
CoPay: $75.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Maternity
Labor and delivery hospital stay
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal office visit
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Vision
Routine Eye Exams for Children
CoPay: Not Applicable
CoInsurance: 0.00%
Covered: Covered
Limit Quantity: 1
Limit Unit: Exam(s) per Benefit Period
Major dental care
Routine dental checkups for children
CoPay: Not Applicable
CoInsurance: 0.00%
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).