Gold G06S $35 PCP Copay + Free Telehealth + Rx Copays - 14002TN0400207 Health Insurance Plan

BlueCross BlueShield of Tennessee health insurance plan with the Plan ID 14002TN0400207. The plan is called Gold G06S $35 PCP Copay + Free Telehealth + Rx Copays.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.68% (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 18.32% 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 14002TN0400207
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 14002TN0400207-00
Provider Network(s) ['TNN002']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Tennessee All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 14002TN0400207-00

Standard On Exchange Plan - 14002TN0400207-01

Open to Indians below 300% FPL - 14002TN0400207-02

Open to Indians above 300% FPL - 14002TN0400207-03

Last Plan Update Date Sat, 14 Aug 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Gold G06S $35 PCP Copay + Free Telehealth + Rx Copays Health Insurance Plan Variant 14002TN0400207-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.816775661
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 Off Exchange Plan
Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 0.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Drug EHB Deductible, In Network (Tier 1), Individual $0
Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Out of Network, Individual Not Applicable
Dental Only Plan No
Disease Management Programs Offered Asthma, Heart Disease, Diabetes
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID TNF002
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 Existing
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 No
Medical Drug Maximum Out of Pocket Integrated Yes
Medical EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance 20.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $5500 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $2750 per person
Medical EHB Deductible, In Network (Tier 1), Individual $2,750
Medical EHB Deductible, Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Out of Network, Individual Not Applicable
Metal Level Gold
Multiple In Network Tiers No
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) 14002TN0400207-00
Plan Marketing Name Gold G06S $35 PCP Copay + Free Telehealth + Rx Copays
Plan Type EPO
Plan Variant Marketing Name Gold G06S $35 PCP Copay + Free Telehealth + Rx Copays
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,000
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $2,750
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $500
SBC Scenario, Having Diabetes, Copayment $100
SBC Scenario, Having Diabetes, Deductible $2,750
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $40
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,750
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID TNS006
Source Name HIOS
Plan ID 14002TN0400207
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
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $12700 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $6350 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $6,350
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

Copay & Coinsurance of Gold G06S $35 PCP Copay + Free Telehealth + Rx Copays Health Insurance Plan, 14002TN0400207

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Gold G06S $35 PCP Copay + Free Telehealth + Rx Copays, 14002TN0400207 Health Insurance Plan, 14002TN0400207

  • Does Gold G06S $35 PCP Copay + Free Telehealth + Rx Copays Health Insurance Plan, 14002TN0400207 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (14002TN0400207) Health Insurance Plan, Variant (14002TN0400207-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes

    Does (14002TN0400207) Health Insurance Plan, Variant (14002TN0400207-00) have Out Of Country Coverage?

    Yes. Details: Blue Cross Blue Shield Global Core

    Does (14002TN0400207) Health Insurance Plan, Variant (14002TN0400207-00) have Out of Service Area Coverage?

    Yes. Details: BlueCard PPO

    Does (14002TN0400207) Health Insurance Plan, Variant (14002TN0400207-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes

    Does Gold G06S $35 PCP Copay + Free Telehealth + Rx Copays Health Insurance Plan, Variant (14002TN0400207-00) offer Disease Management Programs for Asthma?

    Yes, the Gold G06S $35 PCP Copay + Free Telehealth + Rx Copays Health Insurance Plan Variant 14002TN0400207-00 offers Disease Management Program for Asthma.

    Does Gold G06S $35 PCP Copay + Free Telehealth + Rx Copays Health Insurance Plan, Variant (14002TN0400207-00) offer Disease Management Programs for Heart disease?

    Yes, the Gold G06S $35 PCP Copay + Free Telehealth + Rx Copays Health Insurance Plan Variant 14002TN0400207-00 offers Disease Management Program for Heart disease.

    Does Gold G06S $35 PCP Copay + Free Telehealth + Rx Copays Health Insurance Plan, Variant (14002TN0400207-00) offer Disease Management Programs for Diabetes?

    Yes, the Gold G06S $35 PCP Copay + Free Telehealth + Rx Copays Health Insurance Plan Variant 14002TN0400207-00 offers Disease Management Program for Diabetes.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 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