BlueCross S29S $60 PCP Copay + $0 virtual care from Teladoc Health ® + Adult Dental - 14002TN0400337 Health Insurance Plan
BlueCross BlueShield of Tennessee health insurance plan with the Plan ID 14002TN0400337. The plan is called BlueCross S29S $60 PCP Copay + $0 virtual care from Teladoc Health ® + Adult Dental.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.05% (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 29.95% 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 | 14002TN0400337 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| 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 | 14002TN0400337-00 | ||||||||||||||||||
| Provider Network(s) | BEHAVHEALTH 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 - 14002TN0400337-00 Standard On Exchange Plan - 14002TN0400337-01 Open to Indians below 300% FPL - 14002TN0400337-02 Open to Indians above 300% FPL - 14002TN0400337-03 73% AV Silver Plan - 14002TN0400337-04 |
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| Last Plan Update Date | Wed, 02 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of BlueCross S29S $60 PCP Copay + $0 virtual care from Teladoc Health ® + Adult Dental Health Insurance Plan, 14002TN0400337-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
$1,000 benefit maximum per calendar year for eligible adult dental services. Eligible services for routine, basic, and major adult dental apply to the annual benefit maximum. Adult orthodontia is not covered. Adult dental services over the benefit maximum are not covered. |
YES | 50.00% |
100.00% |
| Basic Dental Care - Child
|
YES | 50.00% |
100.00% |
| Chemotherapy
|
YES | 50.00% Coinsurance after deductible |
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 therapy, whether received in a Practitioner's office, outpatient facility or home health setting. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Limit: 1.0 Exam(s) per 6 Months |
YES | No Charge |
100.00% |
| Diabetes Education
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
Durable medical equipment, Prosthetics, and Orthotics over $1000 requires prior authorization. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | $750.00 Copay with deductible, 50.00% Coinsurance after deductible |
$750.00 Copay with deductible, 50.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
30-day supply retail; up to 90-day supply home delivery. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Habilitation Services
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. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years Limited to 1 per ear every 3 calendar years. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Prior Authorization required for Inpatient Hospice. |
YES | No Charge |
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% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Prior Authorization required (except maternity). Penalties include reduced benefits or denial of claim. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
Prior Authorization required (except maternity). Penalties include reduced benefits or denial of claim. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
$1,000 benefit maximum per calendar year for eligible adult dental services. Eligible services for routine, basic, and major adult dental apply to the annual benefit maximum. Adult orthodontia is not covered. Adult dental services over the benefit maximum are not covered. |
YES | 50.00% |
100.00% |
| Major Dental Care - Child
|
YES | 50.00% |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | 50.00% Coinsurance after deductible |
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 other outpatient services. Prior Authorization required for certain outpatient procedures. Penalties include reduced benefits or denial of claim. |
YES | $60.00 |
100.00% |
| 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 | 50.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | 50.00% Coinsurance after deductible |
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% Coinsurance after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $60.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Prior Authorization required for Outpatient Facility. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Year 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. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Prior Authorization required for Outpatient Surgery. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| 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 | 50.00% Coinsurance after deductible |
100.00% |
| Prenatal and Postnatal Care
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 | $60.00 |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
$0 Virtual care for telehealth services are available through Teladoc with your plan. Regular benefits apply for telehealth services provided by other network providers. |
YES | $60.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Durable medical equipment, Prosthetics, and Orthotics over $1000 requires prior authorization. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
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). |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year Therapy limited to 20 visits per therapy type per year. The limit on 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 auth request for certain therapies. Penalties include reduced benefits or claim denial. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Therapy limited to 20 visits per year. The limit on 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 auth request for certain therapies. Penalties include reduced benefits or claim denial. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Routine Dental Services (Adult)
$1,000 benefit maximum per calendar year for eligible adult dental services. Eligible services for routine, basic, and major adult dental apply to the annual benefit maximum. Adult orthodontia is not covered. Adult dental services over the benefit maximum are not covered. |
YES | No Charge |
100.00% |
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Benefit Period |
YES | 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 | 50.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $120.00 |
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
|
YES | 50.00% Coinsurance after deductible |
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 other outpatient services. Prior Authorization required for certain outpatient procedures. Penalties include reduced benefits or denial of claim. |
YES | $60.00 |
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% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | 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 | 50.00% Coinsurance after deductible |
100.00% |
BlueCross S29S $60 PCP Copay + $0 virtual care from Teladoc Health ® + Adult Dental Health Insurance Plan Variant 14002TN0400337-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.700484523158198 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Silver Off Exchange Plan |
| 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, Pregnancy |
| EHB Percent of Total Premium | 0.965 |
| First Tier Utilization | 100% |
| Formulary ID | TNF001 |
| Formulary URL | URL |
| HIOS Product ID | 14002TN040 |
| Import Date | 2024-10-02 01:01:28 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| 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 | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| 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 | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 14002TN0400337-00 |
| Plan Marketing Name | BlueCross S29S $60 PCP Copay + $0 virtual care from Teladoc Health ® + Adult Dental |
| Plan Type | EPO |
| Plan Variant Marketing Name | BlueCross S29S $60 PCP Copay + $0 virtual care from Teladoc Health ® + Adult Dental |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $880 |
| SBC Scenario, Having a Baby, Copayment | $120 |
| SBC Scenario, Having a Baby, Deductible | $5,300 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $600 |
| SBC Scenario, Having Diabetes, Deductible | $5,000 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $900 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,900 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | TNS001 |
| Source Name | HIOS |
| Plan ID | 14002TN0400337 |
| 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 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $10600 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5300 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $5,300 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $12600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6300 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,300 |
| 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 S29S $60 PCP Copay + $0 virtual care from Teladoc Health ® + Adult Dental Health Insurance Plan, 14002TN0400337
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about BlueCross S29S $60 PCP Copay + $0 virtual care from Teladoc Health ® + Adult Dental, 14002TN0400337 Health Insurance Plan, 14002TN0400337
-
Does BlueCross S29S $60 PCP Copay + $0 virtual care from Teladoc Health ® + Adult Dental Health Insurance Plan, 14002TN0400337 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (14002TN0400337) Health Insurance Plan, Variant (14002TN0400337-00) offer Disease Management Programs?
Does (14002TN0400337) Health Insurance Plan, Variant (14002TN0400337-00) have Out Of Country Coverage?
Does (14002TN0400337) Health Insurance Plan, Variant (14002TN0400337-00) have Out of Service Area Coverage?
Does (14002TN0400337) Health Insurance Plan, Variant (14002TN0400337-00) offer Disease Management Programs?
Does BlueCross S29S $60 PCP Copay + $0 virtual care from Teladoc Health ® + Adult Dental Health Insurance Plan, Variant (14002TN0400337-00) offer Disease Management Programs for Asthma?
Does BlueCross S29S $60 PCP Copay + $0 virtual care from Teladoc Health ® + Adult Dental Health Insurance Plan, Variant (14002TN0400337-00) offer Disease Management Programs for Heart disease?
Does BlueCross S29S $60 PCP Copay + $0 virtual care from Teladoc Health ® + Adult Dental Health Insurance Plan, Variant (14002TN0400337-00) offer Disease Management Programs for Depression?
Does BlueCross S29S $60 PCP Copay + $0 virtual care from Teladoc Health ® + Adult Dental Health Insurance Plan, Variant (14002TN0400337-00) offer Disease Management Programs for Diabetes?
Does BlueCross S29S $60 PCP Copay + $0 virtual care from Teladoc Health ® + Adult Dental Health Insurance Plan, Variant (14002TN0400337-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does BlueCross S29S $60 PCP Copay + $0 virtual care from Teladoc Health ® + Adult Dental Health Insurance Plan, Variant (14002TN0400337-00) offer Disease Management Programs for Low back pain?
Does BlueCross S29S $60 PCP Copay + $0 virtual care from Teladoc Health ® + Adult Dental Health Insurance Plan, Variant (14002TN0400337-00) offer Disease Management Programs for Pregnancy?
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