BlueCross B15E $0 virtual care from Teladoc Health ® - 14002TN0400239 Health Insurance Plan
BlueCross BlueShield of Tennessee health insurance plan with the Plan ID 14002TN0400239. The plan is called BlueCross B15E $0 virtual care from Teladoc Health ®.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 | 14002TN0400239 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| 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 | 14002TN0400239-02 | ||||||||||||||||||
| Provider Network(s) | BEHAVHEALTH BLUE-NETWORK-E PHARMACY | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Sep 2025 15:17 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 14002TN0400239-00 Standard On Exchange Plan - 14002TN0400239-01 |
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| Last Plan Update Date | Wed, 02 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 16 Sep 2025 15:17 GMT |
Benefits of BlueCross B15E $0 virtual care from Teladoc Health ® Health Insurance Plan, 14002TN0400239-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: nan nan |
NO | ||
| Accidental Dental
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Acupuncture
Exclusions: nan nan |
NO | ||
| Allergy Testing
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Bariatric Surgery
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Child
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Chemotherapy
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year Exclusions: nan 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 | $0.00, 0.00% |
100.00% |
| Cosmetic Surgery
Exclusions: nan nan |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Dental Check-Up for Children
Limit: 1.0 Exam(s) per 6 Months Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Diabetes Education
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Dialysis
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Durable Medical Equipment
Exclusions: nan Durable medical equipment, Prosthetics, and Orthotics over $1000 requires prior authorization. |
YES | $0.00, 0.00% |
100.00% |
| Emergency Room Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Transportation/Ambulance
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Gender Affirming Care
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Generic Drugs
Exclusions: nan 30-day supply retail; up to 90-day supply home delivery. |
YES | $0.00, 0.00% |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Year Exclusions: nan Therapy limited to 20 visits per therapy type per year. Limits do not apply to services for treatment of autism spectrum disorders. Physical, speech or occupational therapy provided in the home does not require Prior Authorization. |
YES | $0.00, 0.00% |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years Exclusions: nan Limited to 1 per ear every 3 calendar years. |
YES | $0.00, 0.00% |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Hospice Services
Exclusions: nan Prior Authorization required for Inpatient Hospice. |
YES | $0.00, 0.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: nan Prior Authorization required for certain Advanced Radiological Imaging services. Penalties include reduced benefits or denial of claim. |
YES | $0.00, 0.00% |
100.00% |
| Infertility Treatment
Exclusions: nan nan |
NO | ||
| Infusion Therapy
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan Prior Authorization required (except maternity). Penalties include reduced benefits or denial of claim. |
YES | $0.00, 0.00% |
100.00% |
| Inpatient Physician and Surgical Services
Exclusions: nan Prior Authorization required (except maternity). Penalties include reduced benefits or denial of claim. |
YES | $0.00, 0.00% |
100.00% |
| Laboratory Outpatient and Professional Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Long-Term/Custodial Nursing Home Care
Exclusions: nan nan |
NO | ||
| Major Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Major Dental Care - Child
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Mental/Behavioral Health Inpatient Services
Exclusions: nan Prior Authorization required. Penalties include reduced benefits or denial of claim. |
YES | $0.00, 0.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
Exclusions: nan 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 | $0.00, 0.00% |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: nan 30-day supply retail; 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 | $0.00, 0.00% |
100.00% |
| Nutritional Counseling
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Orthodontia - Adult
Exclusions: nan nan |
NO | ||
| Orthodontia - Child
Exclusions: nan Prior Authorization required for Medically Necessary orthodontia. Penalties include reduced benefits or denial of claim. |
YES | $0.00, 0.00% |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan Prior Authorization required for Outpatient Facility. |
YES | $0.00, 0.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Year Exclusions: nan Therapy limited to 20 visits per therapy type per year. Cardiac and Pulmonary Rehab limited to 36 visits. The limit on the number of visits for therapy applies to all visits for that therapy type, whether received in a Practitioner's office, outpatient facility or home health setting. Limits do not apply to services for treatment of autism spectrum disorders. Prior authorization request for certain therapies. Penalties include reduced benefits or claim denial |
YES | $0.00, 0.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: nan Prior Authorization required for Outpatient Surgery. |
YES | $0.00, 0.00% |
100.00% |
| Preferred Brand Drugs
Exclusions: nan 30-day supply retail; 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 | $0.00, 0.00% |
100.00% |
| Prenatal and Postnatal Care
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: nan $0 Virtual care for telehealth services are available through Teladoc with your plan. Regular benefits apply for telehealth services provided by other network providers. |
YES | $0.00, 0.00% |
100.00% |
| Private-Duty Nursing
Exclusions: nan nan |
NO | ||
| Prosthetic Devices
Exclusions: nan Durable medical equipment, Prosthetics, and Orthotics over $1000 requires prior authorization. |
YES | $0.00, 0.00% |
100.00% |
| Radiation
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Reconstructive Surgery
Exclusions: nan Covered Services: Surgery to correct significant defects from congenital causes, (except where specifically excluded), accidents or disfigurement from a disease state. Reconstructive breast Surgery as a result of a mastectomy or partial mastectomy (other than lumpectomy). |
YES | $0.00, 0.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year Exclusions: nan Therapy limited to 20 visits per therapy type per year. The limit on the number of visits for therapy applies to all visits for that therapy type, whether received in a Practitioner's office, outpatient facility or home health setting. Limits do not apply to services for treatment of autism spectrum disorders. Prior authorization request for certain therapies. Penalties include reduced benefits or claim denial. |
YES | $0.00, 0.00% |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Exclusions: nan Therapy limited to 20 visits per year. The limit on the number of visits for therapy applies to all visits for that therapy type, whether received in a Practitioner's office, outpatient facility or home health setting. Limits do not apply to services for treatment of autism spectrum disorders. Prior authorization request for certain therapies. Penalties include reduced benefits or claim denial. |
YES | $0.00, 0.00% |
100.00% |
| Routine Dental Services (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Benefit Period Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Routine Foot Care
Exclusions: nan nan |
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Days per Year Exclusions: nan Medically Necessary and Appropriate inpatient care requiring medical, rehabilitative or nursing care in a restorative setting. Prior Authorization required. Penalties included reduced benefits or denial of claim. |
YES | $0.00, 0.00% |
100.00% |
| Specialist Visit
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Specialty Drugs
Exclusions: nan Up to a 30-day supply. Must use a pharmacy in the preferred specialty pharmacy network. |
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: nan Prior Authorization required. Penalties include reduced benefits or denial of claim. |
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
Exclusions: nan 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 | $0.00, 0.00% |
100.00% |
| Transplant
Exclusions: nan All transplants require Prior Authorization or benefits will be denied. Call our consumer advisors before any pre-transplant evaluation or other transplant service is performed to request Prior Authorization and to obtain information about Transplant Network Providers. |
YES | $0.00, 0.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Urgent Care Centers or Facilities
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Weight Loss Programs
Exclusions: nan nan |
NO | ||
| Well Baby Visits and Care
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
Exclusions: nan Medically Necessary and Appropriate diagnostic radiology services, including x-rays, ultrasounds and bone density tests. Advanced Radiological Imaging services including MRIs, CT scans, PET scans and nuclear cardiac imaging are covered services, but are subject to different benefits than displayed here. Please refer to the Imaging (CT/PET scans, MRIs) benefit category on healthcare.gov or in the SBC for the appropriate benefits associated with those covered services. |
YES | $0.00, 0.00% |
100.00% |
BlueCross B15E $0 virtual care from Teladoc Health ® Health Insurance Plan Variant 14002TN0400239-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1.0 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Zero Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | TNF004 |
| Formulary URL | URL |
| HIOS Product ID | 14002TN040 |
| Import Date | 2024-10-02 01:01:28 |
| 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 | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | TNN003 |
| 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 | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 14002TN0400239-02 |
| Plan Marketing Name | BlueCross B15E $0 virtual care from Teladoc Health ® |
| Plan Type | EPO |
| Plan Variant Marketing Name | BlueCross B15E $0 virtual care from Teladoc Health ® |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| 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 | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | TNS004 |
| Source Name | HIOS |
| Plan ID | 14002TN0400239 |
| State Code | TN |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $0 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of BlueCross B15E $0 virtual care from Teladoc Health ® Health Insurance Plan, 14002TN0400239
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about BlueCross B15E $0 virtual care from Teladoc Health ®, 14002TN0400239 Health Insurance Plan, 14002TN0400239
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Does BlueCross B15E $0 virtual care from Teladoc Health ® Health Insurance Plan, 14002TN0400239 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (14002TN0400239) Health Insurance Plan, Variant (14002TN0400239-02) offer Disease Management Programs?
Does (14002TN0400239) Health Insurance Plan, Variant (14002TN0400239-02) have Out Of Country Coverage?
Does (14002TN0400239) Health Insurance Plan, Variant (14002TN0400239-02) have Out of Service Area Coverage?
Does (14002TN0400239) Health Insurance Plan, Variant (14002TN0400239-02) offer Disease Management Programs?
Does BlueCross B15E $0 virtual care from Teladoc Health ® Health Insurance Plan, Variant (14002TN0400239-02) offer Disease Management Programs for Asthma?
Does BlueCross B15E $0 virtual care from Teladoc Health ® Health Insurance Plan, Variant (14002TN0400239-02) offer Disease Management Programs for Heart disease?
Does BlueCross B15E $0 virtual care from Teladoc Health ® Health Insurance Plan, Variant (14002TN0400239-02) offer Disease Management Programs for Depression?
Does BlueCross B15E $0 virtual care from Teladoc Health ® Health Insurance Plan, Variant (14002TN0400239-02) offer Disease Management Programs for Diabetes?
Does BlueCross B15E $0 virtual care from Teladoc Health ® Health Insurance Plan, Variant (14002TN0400239-02) offer Disease Management Programs for High blood pressure & high cholesterol?
Does BlueCross B15E $0 virtual care from Teladoc Health ® Health Insurance Plan, Variant (14002TN0400239-02) offer Disease Management Programs for Low back pain?
Does BlueCross B15E $0 virtual care from Teladoc Health ® Health Insurance Plan, Variant (14002TN0400239-02) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 16 Sep 2025 15:17 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