BlueCross BlueShield of Tennessee

Gold G06S $35 PCP Copay + Free Telehealth + Rx Copays

Plan Overview

Medical Deductible
  • Individual: $2,750
  • Family: $5,500
  • Per Person: $2,750
Prescription Drug Deductible
  • Individual: $0
  • Family: $0
  • Per Person: $0
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $6,350
  • Family: $12,700
  • Per Person: $6,350

Office Visit

Primary Doctor
  • CoPay: $35.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Telehealth services are available through PhysicianNow with your plan.
Specialist
  • CoPay: $50.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: $35.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: 30-day supply retail; up to 90-day supply home delivery or Plus90 network. 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: $60.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: 30-day supply retail; up to 90-day supply home delivery or Plus90 network. 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: $8.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: 30-day supply retail; up to 90-day supply home delivery or Plus90 network.
Specialty Drugs
  • CoPay: $120.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Up to a 30-day supply. Must use a pharmacy in specialty pharmacy network.

Inpatient Coverage

Hospital Services
  • CoPay: Not Applicable
  • CoInsurance: 20.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Prior Authorization required (except maternity). Penalties included reduced benefits or denial of claim.
Inpatient Services
  • CoPay: Not Applicable
  • CoInsurance: 20.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Prior Authorization required (except maternity). Penalties included reduced benefits or denial of claim.

Emergency and Urgent Care

Emergency Room
  • CoPay: $500.00 Copay with deductible
  • CoInsurance: 20.00% Coinsurance after deductible
  • Covered: Covered
Urgent Care Facility
  • CoPay: $50.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Maternity

Labor and Delivery Hospital Stay
  • CoPay: Not Applicable
  • CoInsurance: 20.00% Coinsurance after deductible
  • Covered: Covered
Pre and Postnatal Office Visit
  • CoPay: $35.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Vision

Routine Eye Exams For Children
  • CoPay: $0.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Visit(s) per Year

Major Dental Care

Routine Dental Checkups for Children
  • CoPay: Not Applicable
  • CoInsurance: 0.00%
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Visit(s) per 6 Months
Basic Dental Care - Child
  • CoPay: Not Applicable
  • CoInsurance: 20.00%
  • Covered: Covered
Major Dental Care - Child
  • CoPay: Not Applicable
  • CoInsurance: 50.00%
  • Covered: 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
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© 2024 HealthMarkets Insurance Agency. All rights reserved.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN14002TN0400207ACA1

© 2024 HealthMarkets Insurance Agency. All rights reserved.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN14002TN0400207ACA1

© 2024 HealthMarkets Insurance Agency. All rights reserved.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN14002TN0400207ACA1