BlueCross BlueShield of Tennessee health insurance plan with the Plan ID 14002TN0400212. The plan is called Gold G07S $10 PCP Copay + Free Telehealth.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 76.04% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 23.96% 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 76.95% (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 23.05% 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 | ||||||||||||||||||
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Health Insurance Plan Year | 2022 | ||||||||||||||||||
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 | 14002TN0400212-01 | ||||||||||||||||||
Provider Network(s) | ['TNN002'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 20 Aug 2024 06:14 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 | Sat, 14 Aug 2021 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 20 Aug 2024 06:14 GMT |
Plan Attribute | Value |
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AV Calculator Output Number | 0.769482409 |
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2022 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | Standard Gold On Exchange Plan |
Dental Only Plan | No |
Disease Management Programs Offered | Asthma, Heart Disease, Diabetes |
EHB Percent of Total Premium | 1 |
First Tier Utilization | 20% |
Formulary ID | TNF007 |
Formulary URL | URL |
HIOS Product ID | 14002TN040 |
Import Date | 8/14/2021 0:43 |
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 Actuarial Value | 76.04% |
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 | Yes |
Network ID | TNN002 |
Out of Country Coverage | Yes |
Out of Country Coverage Description | Blue Cross Blue Shield Global Core |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | BlueCard PPO |
Plan Effective Date | 1/1/2022 |
Plan Expiration Date | 12/31/2022 |
Plan ID (Standard Component ID with Variant) | 14002TN0400212-01 |
Plan Marketing Name | Gold G07S $10 PCP Copay + Free Telehealth |
Plan Type | EPO |
Plan Variant Marketing Name | Gold G07S $10 PCP Copay + Free Telehealth |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $4,500 |
SBC Scenario, Having a Baby, Copayment | $0 |
SBC Scenario, Having a Baby, Deductible | $1,000 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $2,000 |
SBC Scenario, Having Diabetes, Copayment | $0 |
SBC Scenario, Having Diabetes, Deductible | $1,000 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $500 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $700 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,000 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Second Tier Utilization | 80% |
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 | 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 | 45.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $2000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1000 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,000 |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 45.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $2000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $1000 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $1,000 |
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 | $11000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $5500 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,500 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $11000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $5500 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $5,500 |
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 | Yes |
URL for Summary of Benefits & Coverage | URL |
Wellness Program Offered | No |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 20 Aug 2024 06:14 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