BlueCross S26S $40 PCP Copay + $0 virtual care from Teladoc Health ® - 14002TN0400257 Health Insurance Plan

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 therapy, whether received in a Practitioner's office, outpatient facility or home health setting.

Limit: 1.0 Exam(s) per 6 Months

Durable medical equipment, Prosthetics, and Orthotics over $1000 requires prior authorization.

Limit: 1.0 Item(s) per Benefit Period

$25 co-pay applies per 30-day supply and $62.50 co-pay applies per 90-day supply home delivery for Generic Drugs.

Limit: 20.0 Visit(s) per Year

Therapy limited to 20 visits per therapy type per year. Limits do not apply to services for treatment of autism spectrum disorders. Physical, speech or occupational therapy provided in the home does not require Prior Authorization.

Limit: 1.0 Item(s) per 3 Years

Limited to 1 per ear every 3 calendar years.

Limit: 60.0 Visit(s) per Year

Prior Authorization required for Inpatient Hospice.

Prior Authorization required for certain Advanced Radiological Imaging services. Penalties include reduced benefits or denial of claim.

Prior Authorization required (except maternity). Penalties include reduced benefits or denial of claim.

Prior Authorization required (except maternity). Penalties include reduced benefits or denial of claim.

Prior Authorization required. Penalties include reduced benefits or denial of claim.

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.

$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.

Prior Authorization required for Medically Necessary orthodontia. Penalties include reduced benefits or denial of claim.

Prior Authorization required for Outpatient Facility.

Limit: 20.0 Visit(s) per Year

PCP copay for Physical, Speech, Occupational Therapy. Deductible/coinsurance for other outpatient services. Therapy limited to 20 visits per therapy type per year. Cardiac and Pulmonary Rehab limited to 36 visits. The limit on the number of visits for therapy applies to all visits for that therapy type, whether received in a Practitioner's office, outpatient facility or home health setting. Limits do not apply to services for treatment of autism spectrum disorders. Prior authorization request for certain therapies. Penalties include reduced benefits or claim denial.

Prior Authorization required for Outpatient Surgery.

$50 co-pay applies after deductible per 30-day supply and $125 co-pay applies after deductible per 90-day supply home delivery.

$0 Virtual care for telehealth services are available through Teladoc with your plan. Regular benefits apply for telehealth services provided by other network providers.

Durable medical equipment, Prosthetics, and Orthotics over $1000 requires prior authorization.

Covered Services: Surgery to correct significant defects from congenital causes, (except where specifically excluded), accidents or disfigurement from a disease state. Reconstructive breast Surgery as a result of a mastectomy or partial mastectomy (other than lumpectomy).

Limit: 20.0 Visit(s) per Year

PCP copay for Physical and Occupational Therapy. Therapy limited to 20 visits per therapy type per year. The limit on the number of visits for therapy applies to all visits for that therapy type, whether received in a Practitioner's office, outpatient facility or home health setting. Limits do not apply to services for treatment of autism spectrum disorders. Prior authorization request for certain therapies. Penalties include reduced benefits or claim denial.

Limit: 20.0 Visit(s) per Year

PCP copay for Speech Therapy. Therapy limited to 20 visits per year. The limit on the number of visits for therapy applies to all visits for that therapy type, whether received in a Practitioner's office, outpatient facility or home health setting. Limits do not apply to services for treatment of autism spectrum disorders. Prior authorization request for certain therapies. Penalties include reduced benefits or claim denial.

Limit: 1.0 Exam(s) per Benefit Period

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.

Up to a 30-day supply. Must use a pharmacy in the preferred specialty pharmacy network.

Prior Authorization required. Penalties include reduced benefits or denial of claim.

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.

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.

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.