BlueCross BlueShield of Tennessee health insurance plan with the Plan ID 14002TN0400228. The plan is called Gold G08S $30 PCP Copay + Free Telehealth.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.00% (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 22.00% 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 | 14002TN0400228 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
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 | 14002TN0400228-01 | ||||||||||||||||||
Provider Network(s) | ['TNN001'] | ||||||||||||||||||
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 - 14002TN0400228-00 Standard On Exchange Plan - 14002TN0400228-01 |
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Last Plan Update Date | Fri, 02 Dec 2022 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 20 Aug 2024 06:14 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
YES | 20.00% |
100.00% |
Chemotherapy
|
YES | 25.00% 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 | 25.00% Coinsurance after deductible |
100.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Dental Check-Up for Children
Limit: 1.0 Exam(s) per 6 Months |
YES | $0.00 |
100.00% |
Diabetes Education
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Dialysis
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Durable Medical Equipment
Durable medical equipment over $500 requires prior authorization. |
YES | 25.00% Coinsurance after deductible |
100.00% |
Emergency Room Services
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
Emergency Transportation/Ambulance
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period |
YES | $0.00 |
100.00% |
Gender Affirming Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Generic Drugs
$15.00 copay 30-day supply retail; $37.50 copay up to 90-day supply home delivery for Generic. |
YES | $15.00 |
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 | 25.00% Coinsurance after deductible |
100.00% |
Hearing Aids
Limit: 1.0 Item(s) per 3 Years |
YES | 25.00% Coinsurance after deductible |
100.00% |
Home Health Care Services
Limit: 60.0 Visit(s) per Year |
YES | 25.00% Coinsurance after deductible |
100.00% |
Hospice Services
Prior Authorization required for Inpatient Hospice. |
YES | 0.00% |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Infertility Treatment
|
NO | ||
Infusion Therapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Laboratory Outpatient and Professional Services
|
YES | 25.00% Coinsurance after deductible |
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 | 25.00% 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 outpatient services. Prior Authorization required for certain outpatient procedures. Penalties include reduced benefits or denial of claim. |
YES | $30.00 |
100.00% |
Non-Preferred Brand Drugs
$60.00 copay 30-day supply retail; $150.00 copay 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 | $60.00 |
100.00% |
Nutritional Counseling
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% Coinsurance after deductible |
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 | 25.00% Coinsurance after deductible |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Preferred Brand Drugs
$30.00 copay 30-day supply retail; $75.00 copay 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 | $30.00 |
100.00% |
Prenatal and Postnatal Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
Primary Care Visit to Treat an Injury or Illness
$30 copay. Telehealth services are available through PhysicianNow with your plan. |
YES | $30.00 |
100.00% |
Private-Duty Nursing
|
NO | ||
Prosthetic Devices
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Radiation
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Reconstructive Surgery
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year Therapy limited to 20 visits per type per year. Physical, speech or occupational therapy provided in the home does not require Prior Authorization. |
YES | $30.00 |
100.00% |
Rehabilitative Speech Therapy
Limit: 20.0 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 | $30.00 |
100.00% |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
|
NO | ||
Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Benefit Period |
YES | $0.00 |
100.00% |
Routine Foot Care
|
NO | ||
Skilled Nursing Facility
Limit: 60.0 Days per Year Skilled Nursing and Rehabilitation Facility limited to 60 days/year combined. |
YES | 25.00% Coinsurance after deductible |
100.00% |
Specialist Visit
|
YES | $60.00 |
100.00% |
Specialty Drugs
Up to a 30-day supply. Must use a pharmacy in specialty pharmacy network. |
YES | $250.00 |
100.00% |
Substance Abuse Disorder Inpatient Services
Prior Authorization required. Penalties include reduced benefits or denial of claim. |
YES | 25.00% 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 outpatient services. Prior Authorization required for certain outpatient procedures. Penalties include reduced benefits or denial of claim. |
YES | $30.00 |
100.00% |
Transplant
Transplant services or supplies that have not received Prior Authorization will not be Covered. |
YES | 25.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Urgent Care Centers or Facilities
|
YES | $45.00 |
100.00% |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
|
YES | 0.00% |
100.00% |
X-rays and Diagnostic Imaging
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.780017779 |
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2023 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | Standard Gold On Exchange Plan |
Dental Only Plan | No |
Design Type | Design 1 |
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 |
First Tier Utilization | 100% |
Formulary ID | TNF009 |
Formulary URL | URL |
HIOS Product ID | 14002TN040 |
Import Date | 12/2/2022 1:01 |
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 | Gold |
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 | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 14002TN0400228-01 |
Plan Level Exclusions | No |
Plan Marketing Name | Gold G08S $30 PCP Copay + Free Telehealth |
Plan Type | EPO |
Plan Variant Marketing Name | Gold G08S $30 PCP Copay + Free Telehealth |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $2,700 |
SBC Scenario, Having a Baby, Copayment | $10 |
SBC Scenario, Having a Baby, Deductible | $2,000 |
SBC Scenario, Having a Baby, Limit | $0 |
SBC Scenario, Having Diabetes, Coinsurance | $500 |
SBC Scenario, Having Diabetes, Copayment | $500 |
SBC Scenario, Having Diabetes, Deductible | $2,000 |
SBC Scenario, Having Diabetes, Limit | $0 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,000 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | TNS007 |
Source Name | HIOS |
Plan ID | 14002TN0400228 |
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 | 25.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $4000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $2000 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $2,000 |
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 | $17400 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
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 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