BlueCross G07S $10 PCP Copay at Blue of TN + $0 Virtual Care for Medical & Mental Health - 14002TN0400212 Health Insurance Plan
BlueCross BlueShield of Tennessee health insurance plan with the Plan ID 14002TN0400212. The plan is called BlueCross G07S $10 PCP Copay at Blue of TN + $0 Virtual Care for Medical & Mental Health.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 100.00% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 0.00% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 0.00% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 14002TN0400212 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Tennessee | ||||||||||||||||||
| Health Insurance Issuer | BlueCross BlueShield of Tennessee | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 14002TN0400212-02 | ||||||||||||||||||
| Provider Network(s) | BEHAVHEALTH VISIONBLUE DENTALBLUE PHARMACY BLUE-NETWORK-S | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 14002TN0400212-00 Standard On Exchange Plan - 14002TN0400212-01 |
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| Last Plan Update Date | Tue, 31 Oct 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of BlueCross G07S $10 PCP Copay at Blue of TN + $0 Virtual Care for Medical & Mental Health Health Insurance Plan, 14002TN0400212-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Chemotherapy
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year Therapy limited to 20 visits per type per year. The limit on the number of visits for therapy applies to all visits for that therapy, whether received in a Practitioner's office, outpatient facility or home health setting. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Diabetes Education
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Dialysis
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Durable Medical Equipment
Durable medical equipment over $500 requires prior authorization. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Emergency Room Services
|
YES | Tier 1: No Charge Tier 2: No Charge |
No Charge |
| Emergency Transportation/Ambulance
|
YES | Tier 1: 0.00% Tier 2: 0.00% |
0.00% |
| Eye Glasses for Children
Limit: 1.0 Visit(s) per Year |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Gender Affirming Care
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Generic Drugs
$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. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Year Therapy limited to 20 visits per type per year. The limit on the number of visits for therapy applies to all visits for that therapy, whether received in a Practitioner's office, outpatient facility or home health setting. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Home Health Care Services
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Hospice Services
Prior Authorization required for Inpatient Hospice. Penalties include reduced benefits or denial of claim. |
YES | Tier 1: 0.00% Tier 2: 0.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Prior Authorization required for certain Advanced Radiological Imaging services. Penalties include reduced benefits or denial of claim. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Prior Authorization required (except maternity). Penalties included reduced benefits or denial of claim. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Inpatient Physician and Surgical Services
Prior Authorization required (except maternity). Penalties included reduced benefits or denial of claim. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Mental/Behavioral Health Inpatient Services
Prior Authorization required. Penalties include reduced benefits or denial of claim. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Mental/Behavioral Health Outpatient Services
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. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Non-Preferred Brand Drugs
$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. 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. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Nutritional Counseling
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Prior Authorization required for Medically Necessary orthodontia. Penalties include reduced benefits or denial of claim. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Prior Authorization required for Outpatient Facility. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Year Therapy limited to 20 visits per type per year. The limit on the number of visits for therapy applies to all visits for that therapy, whether received in a Practitioner's office, outpatient facility or home health setting. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Prior Authorization required for Outpatient Surgery. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Preferred Brand Drugs
$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. 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. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Prenatal and Postnatal Care
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
$10 copay only applicable at Blue of TN Centers. Telehealth services are available through Teladoc with your plan. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Radiation
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Reconstructive Surgery
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year Therapy limited to 20 visits per type per year. Physical, speech or occupational therapy provided in the home does not require Prior Authorization. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Prior Authorization required for certain therapies. Penalties include reduced benefits or denial of claim. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Days per Year Medically Necessary and Appropriate inpatient care requiring medical, rehabilitative or nursing care in a restorative setting. Prior Authorization required. Penalties included reduced benefits or denial of claim. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Specialist Visit
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Specialty Drugs
Up to a 30-day supply. Must use a pharmacy in the preferred specialty pharmacy network. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Substance Abuse Disorder Inpatient Services
Prior Authorization required. Penalties include reduced benefits or denial of claim. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Substance Abuse Disorder Outpatient Services
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. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Transplant
All transplants require Prior Authorization or benefits will be denied. Call our consumer advisors before any pre-transplant evaluation or other transplant service is performed to request Prior Authorization and to obtain information about Transplant Network Providers. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Urgent Care Centers or Facilities
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Medically Necessary and Appropriate diagnostic radiology services, including x-rays, ultrasounds and bone density tests. Advanced Radiological Imaging services including MRIs, CT scans, PET scans and nuclear cardiac imaging are covered services, but are subject to different benefits than displayed here. Please refer to the Imaging (CT/PET scans, MRIs) benefit category on healthcare.gov or in the SBC for the appropriate benefits associated with those covered services. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
BlueCross G07S $0 Virtual Care for Medical & Mental Health Health Insurance Plan Variant 14002TN0400212-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1.0 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Zero Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 5% |
| Formulary ID | TNF008 |
| Formulary URL | URL |
| HIOS Product ID | 14002TN040 |
| Import Date | 2023-10-31 01:02:05 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 100.00% |
| Issuer ID | 14002 |
| Issuer Marketplace Marketing Name | BlueCross BlueShield of Tennessee |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | Yes |
| National Network | No |
| Network ID | TNN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Network Providers Statewide, Emergency Services Only out of state |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 14002TN0400212-02 |
| Plan Level Exclusions | No |
| Plan Marketing Name | BlueCross G07S $10 PCP Copay at Blue of TN + $0 Virtual Care for Medical & Mental Health |
| Plan Type | EPO |
| Plan Variant Marketing Name | BlueCross G07S $0 Virtual Care for Medical & Mental Health |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 95% |
| Service Area ID | TNS006 |
| Source Name | HIOS |
| Plan ID | 14002TN0400212 |
| State Code | TN |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $0 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $0 |
| Unique Plan Design | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of BlueCross G07S $10 PCP Copay at Blue of TN + $0 Virtual Care for Medical & Mental Health Health Insurance Plan, 14002TN0400212
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about BlueCross G07S $10 PCP Copay at Blue of TN + $0 Virtual Care for Medical & Mental Health, 14002TN0400212 Health Insurance Plan, 14002TN0400212
-
Does BlueCross G07S $10 PCP Copay at Blue of TN + $0 Virtual Care for Medical & Mental Health Health Insurance Plan, 14002TN0400212 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (14002TN0400212) Health Insurance Plan, Variant (14002TN0400212-02) offer Disease Management Programs?
Does (14002TN0400212) Health Insurance Plan, Variant (14002TN0400212-02) have Out Of Country Coverage?
Does (14002TN0400212) Health Insurance Plan, Variant (14002TN0400212-02) have Out of Service Area Coverage?
Does (14002TN0400212) Health Insurance Plan, Variant (14002TN0400212-02) offer Disease Management Programs?
Does BlueCross G07S $0 Virtual Care for Medical & Mental Health Health Insurance Plan, Variant (14002TN0400212-02) offer Disease Management Programs for Asthma?
Does BlueCross G07S $0 Virtual Care for Medical & Mental Health Health Insurance Plan, Variant (14002TN0400212-02) offer Disease Management Programs for Heart disease?
Does BlueCross G07S $0 Virtual Care for Medical & Mental Health Health Insurance Plan, Variant (14002TN0400212-02) offer Disease Management Programs for Depression?
Does BlueCross G07S $0 Virtual Care for Medical & Mental Health Health Insurance Plan, Variant (14002TN0400212-02) offer Disease Management Programs for Diabetes?
Does BlueCross G07S $0 Virtual Care for Medical & Mental Health Health Insurance Plan, Variant (14002TN0400212-02) offer Disease Management Programs for High blood pressure & high cholesterol?
Does BlueCross G07S $0 Virtual Care for Medical & Mental Health Health Insurance Plan, Variant (14002TN0400212-02) offer Disease Management Programs for Low back pain?
Does BlueCross G07S $0 Virtual Care for Medical & Mental Health Health Insurance Plan, Variant (14002TN0400212-02) offer Disease Management Programs for Pregnancy?
Does BlueCross G07S $0 Virtual Care for Medical & Mental Health Health Insurance Plan, Variant (14002TN0400212-02) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API