(844) 967-1917
BlueCross BlueShield of Tennessee

Silver S01S Free Telehealth

Plan Overview

Combined Medical and Drug Deductible
  • Individual: $725
  • Family: $1,450
  • Per Person: $725
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $7,000
  • Family: $14,000
  • Per Person: $7,000

Office Visit

Primary Doctor
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Telehealth services are available through PhysicianNow with your plan.
Specialist
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: $50 co-pay applies per 30 day supply and $125 co-pay applies per 90 day supply for Preferred Brand Drugs on Preventive Drug List. Deductible/Coinsurance for other Preferred Brand Drugs, 30-day supply retail; up to 90-day supply home delivery or Plus90 Retail 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: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: $100 co-pay applies per 30 day supply and $250 co-pay applies for 90 day supply for Non-Preferred Brand Drugs on Preventive Drug List. Deductible/Coinsurance for other Non-Preferred Brand Drugs, 30-day supply retail; up to 90-day supply home delivery or Plus90 Retail 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: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: $20 co-pay applies per 30 day supply and $50 co-pay applies per 90 day supply for Generic Drugs on Preventive Drug List. Deductible/Coinsurance for other Generic Drugs, 30-day supply retail; up to 90-day supply home delivery or Plus90 Retail Network.
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 included 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 included reduced benefits or denial of claim.

Emergency and Urgent Care

Emergency Room
  • CoPay: $500.00 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: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • 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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