Silver S21S $10 PCP Copay + Free Telehealth - 14002TN0400124 Health Insurance Plan

BlueCross BlueShield of Tennessee health insurance plan with the Plan ID 14002TN0400124. The plan is called Silver S21S $10 PCP Copay + Free Telehealth.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 66.04% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 33.96% of the costs of all covered benefits (according to the Issuer).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 66.19% (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 33.81% 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 14002TN0400124
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 14002TN0400124-00
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 - 14002TN0400124-00

Standard On Exchange Plan - 14002TN0400124-01

Open to Indians below 300% FPL - 14002TN0400124-02

Open to Indians above 300% FPL - 14002TN0400124-03

73% AV Silver Plan - 14002TN0400124-04

87% AV Silver Plan - 14002TN0400124-05

94% AV Silver Plan - 14002TN0400124-06

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

Silver S21S $10 PCP Copay + Free Telehealth Health Insurance Plan Variant 14002TN0400124-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.661943945
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 Silver Off Exchange Plan
Dental Only Plan No
Disease Management Programs Offered Asthma, Heart Disease, Diabetes
EHB Percent of Total Premium 1
First Tier Utilization 20%
Formulary ID TNF007
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 Actuarial Value 66.04%
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 Silver
Multiple In Network Tiers Yes
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) 14002TN0400124-00
Plan Marketing Name Silver S21S $10 PCP Copay + Free Telehealth
Plan Type EPO
Plan Variant Marketing Name Silver S21S $10 PCP Copay + Free Telehealth
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,000
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $3,900
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $3,900
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,800
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 80%
Service Area ID TNS004
Source Name HIOS
Plan ID 14002TN0400124
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 50.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $7800 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $3900 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $3,900
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 50.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group $7800 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $3900 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $3,900
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 $14200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7100 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,100
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $14200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $7100 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $7,100
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 Yes
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Silver S21S $10 PCP Copay + Free Telehealth Health Insurance Plan, 14002TN0400124

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

Frequently Asked Questions(FAQ) about Silver S21S $10 PCP Copay + Free Telehealth, 14002TN0400124 Health Insurance Plan, 14002TN0400124

  • Does Silver S21S $10 PCP Copay + Free Telehealth Health Insurance Plan, 14002TN0400124 support Mail Ordering?

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

  • Does (14002TN0400124) Health Insurance Plan, Variant (14002TN0400124-00) offer Disease Management Programs?

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

    Does (14002TN0400124) Health Insurance Plan, Variant (14002TN0400124-00) have Out Of Country Coverage?

    Yes. Details: Blue Cross Blue Shield Global Core

    Does (14002TN0400124) Health Insurance Plan, Variant (14002TN0400124-00) have Out of Service Area Coverage?

    Yes. Details: BlueCard PPO

    Does (14002TN0400124) Health Insurance Plan, Variant (14002TN0400124-00) offer Disease Management Programs?

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

    Does Silver S21S $10 PCP Copay + Free Telehealth Health Insurance Plan, Variant (14002TN0400124-00) offer Disease Management Programs for Asthma?

    Yes, the Silver S21S $10 PCP Copay + Free Telehealth Health Insurance Plan Variant 14002TN0400124-00 offers Disease Management Program for Asthma.

    Does Silver S21S $10 PCP Copay + Free Telehealth Health Insurance Plan, Variant (14002TN0400124-00) offer Disease Management Programs for Heart disease?

    Yes, the Silver S21S $10 PCP Copay + Free Telehealth Health Insurance Plan Variant 14002TN0400124-00 offers Disease Management Program for Heart disease.

    Does Silver S21S $10 PCP Copay + Free Telehealth Health Insurance Plan, Variant (14002TN0400124-00) offer Disease Management Programs for Diabetes?

    Yes, the Silver S21S $10 PCP Copay + Free Telehealth Health Insurance Plan Variant 14002TN0400124-00 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