BlueCross BlueShield of Tennessee

BlueCross S29E $60 PCP Copay + $0 virtual care from Teladoc Health + Adult Dental

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Plan Overview

Combined Medical and Drug Deductible	Individual: $5,300.00 Family: $10600 Per Person: $5300
Combined Medical and Drug Out of Pocket Maximum	Individual: $6,300.00 Family: $12600 Per Person: $6300

Office Visit

Primary Doctor	CoPay: $60.00 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: $120.00 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.
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.
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.
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.

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: $750.00 Copay with deductible CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: $60.00 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
Routine Dental Checkups for Adults	CoPay: Not Applicable CoInsurance: No Charge Covered: Covered Benefit Explanation: $1,000 benefit maximum per calendar year for eligible adult dental services. Eligible services for routine, basic, and major adult dental apply to the annual benefit maximum. Adult orthodontia is not covered. Adult dental services over the benefit maximum are not covered.

©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