BlueCross S24E $35 PCP Copay + $0 Virtual Care for Medical & Mental Health

Health Insurance Plan Details (2024 Plan)

by BlueCross BlueShield of Tennessee

Monthly Premium

EPO
$ubsidy
Silver
Deductible
$5,450 /yr
Max Out-of-Pocket
$8,900 /yr

Details

Deductible (per individual) $5,450 /yr
Deductible (per family) $10,900 /yr
Max Out-of-Pocket (per individual) $8,900 /yr
Max Out-of-Pocket (per family) $17,800 /yr
Drug Deductible (per individual) $0
Drug Deductible (per family) $0
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 $35 Copay
Specialist Visit $75 Copay
Emergency Room $750 Copay with deductible and 50% Coinsurance after deductible
Inpatient Facility $2000 Copay per Stay with deductible and 50% Coinsurance after deductible
Inpatient Physician 50% Coinsurance after deductible
Drug Costs
Generic Drugs $60 Copay
Preferred Brand Drugs $100 Copay
Non-preferred Brand Drugs $250 Copay
Specialty Drugs 50% Coinsurance

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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