BlueCross BlueShield of Tennessee

BlueCross S25E $55 PCP Copay + $0 virtual care from Teladoc Health

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Plan Overview

Medical Deductible	Individual: $0.00 Family: $0 Per Person: $0
Prescription Drug Deductible	Individual: $4,500.00 Family: $9000 Per Person: $4500
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,900.00 Family: $17800 Per Person: $8900

Office Visit

Primary Doctor	CoPay: $55.00 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: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30-day supply retail; up to 90-day supply home delivery. 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. Drug deductible applies.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30-day supply retail; up to 90-day supply home delivery. 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. Drug deductible applies.
Generic Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30-day supply retail; up to 90-day supply home delivery. Drug deductible applies.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Up to a 30-day supply. Must use a pharmacy in the preferred specialty pharmacy network. Drug deductible applies.

Inpatient Coverage

Hospital Services	CoPay: $2000.00 Copay per Stay CoInsurance: 50.00% 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% 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 CoInsurance: 50.00% Covered: Covered
Urgent Care Facility	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered
Pre and Postnatal Office Visit	CoPay: $55.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Benefits are determined by place of service. Benefits displayed are for services received in an office setting; separate benefits may apply for outpatient services. Prior Authorization required for certain outpatient procedures. Penalties include reduced benefits or denial of claim.

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

©1998-2015 BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association. BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace. 1 Cameron Hill Circle, Chattanooga TN 37402-0001