BlueCross G08S $30 PCP Copay + $0 virtual care from Teladoc Health ®
BlueCross BlueShield of Tennessee
Plan overview
Medical deductible
Individual: $2000
Family: $4000
Per Person: $2000
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $8200
Family: $16400
Per Person: $8200
Office visit
Primary Doctor
CoPay: $30.00
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: $60.00
CoInsurance: Not Applicable
Covered: Covered
Prescription drug information
Preferred brand drugs
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: $30 co-pay applies per 30-day supply and $75 co-pay applies per 90-day supply home delivery.
Non preferred brand drugs
CoPay: $60.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: $60 co-pay applies per 30 day supply and $150 co-pay applies for 90 day supply home delivery.
Generic drugs
CoPay: $15.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: $15 co-pay applies per 30-day supply and $37.50 co-pay applies per 90-day supply home delivery for Generic Drugs.
Specialty drugs
CoPay: $250.00
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: 25.00% 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: 25.00% 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: 25.00% Coinsurance after deductible
Covered: Covered
Urgent care facility
CoPay: $45.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Maternity
Labor and delivery hospital stay
CoPay: Not Applicable
CoInsurance: 25.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal office visit
CoPay: $30.00
CoInsurance: Not Applicable
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).