Gold G08S $30 PCP Copay + Free Telehealth - 14002TN0400225 Health Insurance Plan

BlueCross BlueShield of Tennessee health insurance plan with the Plan ID 14002TN0400225. 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 14002TN0400225
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 14002TN0400225-00
Provider Network(s) ['TNN001']
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 - 14002TN0400225-00

Standard On Exchange Plan - 14002TN0400225-01

Open to Indians below 300% FPL - 14002TN0400225-02

Open to Indians above 300% FPL - 14002TN0400225-03

Last Plan Update Date Fri, 02 Dec 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Gold G08S $30 PCP Copay + Free Telehealth Health Insurance Plan, 14002TN0400225-00

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%

Gold G08S $30 PCP Copay + Free Telehealth Health Insurance Plan Variant 14002TN0400225-00 Attributes

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 Off 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) 14002TN0400225-00
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 TNS004
Source Name HIOS
Plan ID 14002TN0400225
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

Copay & Coinsurance of Gold G08S $30 PCP Copay + Free Telehealth Health Insurance Plan, 14002TN0400225

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

Frequently Asked Questions(FAQ) about Gold G08S $30 PCP Copay + Free Telehealth, 14002TN0400225 Health Insurance Plan, 14002TN0400225

  • Does Gold G08S $30 PCP Copay + Free Telehealth Health Insurance Plan, 14002TN0400225 support Mail Ordering?

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

  • Does (14002TN0400225) Health Insurance Plan, Variant (14002TN0400225-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does (14002TN0400225) Health Insurance Plan, Variant (14002TN0400225-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (14002TN0400225) Health Insurance Plan, Variant (14002TN0400225-00) have Out of Service Area Coverage?

    Yes. Details: Network Providers Statewide, Emergency Services Only out of state

    Does (14002TN0400225) Health Insurance Plan, Variant (14002TN0400225-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does Gold G08S $30 PCP Copay + Free Telehealth Health Insurance Plan, Variant (14002TN0400225-00) offer Disease Management Programs for Asthma?

    Yes, the Gold G08S $30 PCP Copay + Free Telehealth Health Insurance Plan Variant 14002TN0400225-00 offers Disease Management Program for Asthma.

    Does Gold G08S $30 PCP Copay + Free Telehealth Health Insurance Plan, Variant (14002TN0400225-00) offer Disease Management Programs for Heart disease?

    Yes, the Gold G08S $30 PCP Copay + Free Telehealth Health Insurance Plan Variant 14002TN0400225-00 offers Disease Management Program for Heart disease.

    Does Gold G08S $30 PCP Copay + Free Telehealth Health Insurance Plan, Variant (14002TN0400225-00) offer Disease Management Programs for Depression?

    Yes, the Gold G08S $30 PCP Copay + Free Telehealth Health Insurance Plan Variant 14002TN0400225-00 offers Disease Management Program for Depression.

    Does Gold G08S $30 PCP Copay + Free Telehealth Health Insurance Plan, Variant (14002TN0400225-00) offer Disease Management Programs for Diabetes?

    Yes, the Gold G08S $30 PCP Copay + Free Telehealth Health Insurance Plan Variant 14002TN0400225-00 offers Disease Management Program for Diabetes.

    Does Gold G08S $30 PCP Copay + Free Telehealth Health Insurance Plan, Variant (14002TN0400225-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Gold G08S $30 PCP Copay + Free Telehealth Health Insurance Plan Variant 14002TN0400225-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Gold G08S $30 PCP Copay + Free Telehealth Health Insurance Plan, Variant (14002TN0400225-00) offer Disease Management Programs for Low back pain?

    Yes, the Gold G08S $30 PCP Copay + Free Telehealth Health Insurance Plan Variant 14002TN0400225-00 offers Disease Management Program for Low back pain.

    Does Gold G08S $30 PCP Copay + Free Telehealth Health Insurance Plan, Variant (14002TN0400225-00) offer Disease Management Programs for Pregnancy?

    Yes, the Gold G08S $30 PCP Copay + Free Telehealth Health Insurance Plan Variant 14002TN0400225-00 offers Disease Management Program for Pregnancy.

    Does Gold G08S $30 PCP Copay + Free Telehealth Health Insurance Plan, Variant (14002TN0400225-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Gold G08S $30 PCP Copay + Free Telehealth Health Insurance Plan Variant 14002TN0400225-00 offers Disease Management Program for Weight loss programs.

 

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