BlueCross G07S $10 PCP Copay at Blue of TN + $0 Virtual Care for Medical & Mental Health

Health Insurance Plan Details (2024 Plan)

SBC doc

doctor lookup

drug list

EPO

Gold

Deductible (per individual)	$1,000 /yr
Deductible (per family)	$2,000 /yr
Max Out-of-Pocket (per individual)	$4,800 /yr
Max Out-of-Pocket (per family)	$9,600 /yr
Drug Deductible (per individual)	Included in Medical
Drug Deductible (per family)	Included in Medical
Drug Max Out-of-Pocket (per individual)	Included in Medical
Drug Max Out-of-Pocket (per family)	Included in Medical
Plan Type	EPO
Includes Child Dental?	Yes
Includes Adult Dental?	No

Medical Services
Preventive Care	No Charge
Primary Care Visit	$10 Copay
Specialist Visit	30% Coinsurance after deductible
Emergency Room	$750 Copay with deductible and 30% Coinsurance after deductible
Inpatient Facility	30% Coinsurance after deductible
Inpatient Physician	30% Coinsurance after deductible

Drug Costs
Generic Drugs	30% Coinsurance after deductible
Preferred Brand Drugs	30% Coinsurance after deductible
Non-preferred Brand Drugs	30% Coinsurance after deductible
Specialty Drugs	30% Coinsurance after deductible

Summary of Benefits and Coverage	SBC doc
Provider Directory	Doctor lookup
Drug Formulary List	drug list

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible

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