BlueCross S25S $55 PCP Copay + $0 Virtual Care for Medical & Mental Health - 14002TN0400188 Health Insurance Plan
BlueCross BlueShield of Tennessee health insurance plan with the Plan ID 14002TN0400188. The plan is called BlueCross S25S $55 PCP Copay + $0 Virtual Care for Medical & Mental Health.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.25% (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 29.75% 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 | 14002TN0400188 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 14002TN0400188-00 | ||||||||||||||||||
| 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 - 14002TN0400188-00 Standard On Exchange Plan - 14002TN0400188-01 Open to Indians below 300% FPL - 14002TN0400188-02 Open to Indians above 300% FPL - 14002TN0400188-03 73% AV Silver Plan - 14002TN0400188-04 |
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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 S25S $55 PCP Copay + $0 Virtual Care for Medical & Mental Health Health Insurance Plan, 14002TN0400188-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 50.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 50.00% |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
YES | 20.00% |
100.00% |
| Chemotherapy
|
YES | 50.00% |
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 | 50.00% |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 50.00% |
100.00% |
| Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months |
YES | 0.00% |
100.00% |
| Diabetes Education
|
YES | 50.00% |
100.00% |
| Dialysis
|
YES | 50.00% |
100.00% |
| Durable Medical Equipment
Durable medical equipment over $500 requires prior authorization. |
YES | 50.00% |
100.00% |
| Emergency Room Services
|
YES | $750.00, 50.00% |
$750.00, 50.00% |
| Emergency Transportation/Ambulance
|
YES | 50.00% |
50.00% |
| Eye Glasses for Children
Limit: 1.0 Visit(s) per Year |
YES | 0.00% |
100.00% |
| Gender Affirming Care
|
YES | 50.00% |
100.00% |
| Generic Drugs
30-day supply retail; up to 90-day supply home delivery. Copay per 30-day supply. |
YES | 50.00% Coinsurance after deductible |
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 | 50.00% |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years |
YES | 50.00% |
100.00% |
| Home Health Care Services
|
YES | 50.00% |
100.00% |
| Hospice Services
Prior Authorization required for Inpatient Hospice. Penalties include reduced benefits or denial of claim. |
YES | 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 | 50.00% |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 50.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Prior Authorization required (except maternity). Penalties included reduced benefits or denial of claim. |
YES | $2000.00 Copay per Stay, 50.00% |
100.00% |
| Inpatient Physician and Surgical Services
Prior Authorization required (except maternity). Penalties included reduced benefits or denial of claim. |
YES | 50.00% |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 50.00% |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
YES | 50.00% |
100.00% |
| Mental/Behavioral Health Inpatient Services
Prior Authorization required. Penalties include reduced benefits or denial of claim. |
YES | 50.00% |
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 | $55.00 |
100.00% |
| Non-Preferred Brand Drugs
30-day supply retail; up to 90-day supply home delivery. Copay per 30-day supply. 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 | 50.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | 50.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Prior Authorization required for Medically Necessary orthodontia. Penalties include reduced benefits or denial of claim. |
YES | 50.00% |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $55.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Prior Authorization required for Outpatient Facility. |
YES | $1500.00, 50.00% |
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 | 50.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Prior Authorization required for Outpatient Surgery. |
YES | 50.00% |
100.00% |
| Preferred Brand Drugs
30-day supply retail; up to 90-day supply home delivery. Copay per 30-day supply. 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 | 50.00% Coinsurance after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | 50.00% |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
PCP copay. Telehealth services are available through Teladoc with your plan. |
YES | $55.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 50.00% |
100.00% |
| Radiation
|
YES | 50.00% |
100.00% |
| Reconstructive Surgery
|
YES | 50.00% |
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 | 50.00% |
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 | 50.00% |
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 | 0.00% |
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 | 50.00% |
100.00% |
| Specialist Visit
|
YES | $100.00 |
100.00% |
| Specialty Drugs
Up to a 30-day supply. Must use a pharmacy in the preferred specialty pharmacy network. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Prior Authorization required. Penalties include reduced benefits or denial of claim. |
YES | 50.00% |
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 | $55.00 |
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 | 50.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 50.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | 50.00% |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | 0.00% |
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 | 50.00% |
100.00% |
BlueCross S25S $55 PCP Copay + $0 Virtual Care for Medical & Mental Health Health Insurance Plan Variant 14002TN0400188-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.702524948285038 |
| 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 | Standard Silver Off Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $9000 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $4500 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $4,500 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| 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 | 100% |
| Formulary ID | TNF001 |
| 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 | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 14002 |
| Issuer Marketplace Marketing Name | BlueCross BlueShield of Tennessee |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| 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) | 14002TN0400188-00 |
| Plan Level Exclusions | No |
| Plan Marketing Name | BlueCross S25S $55 PCP Copay + $0 Virtual Care for Medical & Mental Health |
| Plan Type | EPO |
| Plan Variant Marketing Name | BlueCross S25S $55 PCP Copay + $0 Virtual Care for Medical & Mental Health |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $6,300 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $70 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $100 |
| SBC Scenario, Having Diabetes, Copayment | $500 |
| SBC Scenario, Having Diabetes, Deductible | $4,300 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $1,000 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $900 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $5 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | TNS001 |
| Source Name | HIOS |
| Plan ID | 14002TN0400188 |
| State Code | TN |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18900 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9450 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,450 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of BlueCross S25S $55 PCP Copay + $0 Virtual Care for Medical & Mental Health Health Insurance Plan, 14002TN0400188
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about BlueCross S25S $55 PCP Copay + $0 Virtual Care for Medical & Mental Health, 14002TN0400188 Health Insurance Plan, 14002TN0400188
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Does BlueCross S25S $55 PCP Copay + $0 Virtual Care for Medical & Mental Health Health Insurance Plan, 14002TN0400188 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (14002TN0400188) Health Insurance Plan, Variant (14002TN0400188-00) offer Disease Management Programs?
Does (14002TN0400188) Health Insurance Plan, Variant (14002TN0400188-00) have Out Of Country Coverage?
Does (14002TN0400188) Health Insurance Plan, Variant (14002TN0400188-00) have Out of Service Area Coverage?
Does (14002TN0400188) Health Insurance Plan, Variant (14002TN0400188-00) offer Disease Management Programs?
Does BlueCross S25S $55 PCP Copay + $0 Virtual Care for Medical & Mental Health Health Insurance Plan, Variant (14002TN0400188-00) offer Disease Management Programs for Asthma?
Does BlueCross S25S $55 PCP Copay + $0 Virtual Care for Medical & Mental Health Health Insurance Plan, Variant (14002TN0400188-00) offer Disease Management Programs for Heart disease?
Does BlueCross S25S $55 PCP Copay + $0 Virtual Care for Medical & Mental Health Health Insurance Plan, Variant (14002TN0400188-00) offer Disease Management Programs for Depression?
Does BlueCross S25S $55 PCP Copay + $0 Virtual Care for Medical & Mental Health Health Insurance Plan, Variant (14002TN0400188-00) offer Disease Management Programs for Diabetes?
Does BlueCross S25S $55 PCP Copay + $0 Virtual Care for Medical & Mental Health Health Insurance Plan, Variant (14002TN0400188-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does BlueCross S25S $55 PCP Copay + $0 Virtual Care for Medical & Mental Health Health Insurance Plan, Variant (14002TN0400188-00) offer Disease Management Programs for Low back pain?
Does BlueCross S25S $55 PCP Copay + $0 Virtual Care for Medical & Mental Health Health Insurance Plan, Variant (14002TN0400188-00) offer Disease Management Programs for Pregnancy?
Does BlueCross S25S $55 PCP Copay + $0 Virtual Care for Medical & Mental Health Health Insurance Plan, Variant (14002TN0400188-00) 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