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

Health Insurance Plan Details (2024 Plan)

by BlueCross BlueShield of Tennessee

Monthly Premium

EPO
$ubsidy
Gold
Deductible
$1,000 /yr
Max Out-of-Pocket
$4,800 /yr

Details

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

Plan Documents

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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