BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ® - 14002TN0400244 Health Insurance Plan

BlueCross BlueShield of Tennessee health insurance plan with the Plan ID 14002TN0400244. The plan is called BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ®.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 63.81% (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 36.19% 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 14002TN0400244
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 14002TN0400244-00
Provider Network(s) BEHAVHEALTH DENTALBLUE PHARMACY BLUE-NETWORK-S
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT).

Providers Tennessee All US States
All 37845 97210
PCP 4422 5035
Allergy 21 24
OB/GYN 179 212
Dentists 1510 1746
Available Variants of the Health Plan

Standard Off Exchange Plan - 14002TN0400244-00

Standard On Exchange Plan - 14002TN0400244-01

Open to Indians below 300% FPL - 14002TN0400244-02

Open to Indians above 300% FPL - 14002TN0400244-03

Last Plan Update Date Wed, 02 Oct 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ® Health Insurance Plan, 14002TN0400244-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

50.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

50.00% Coinsurance after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
YES

50.00%

100.00%
Chemotherapy
YES

50.00% 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

50.00% Coinsurance after deductible

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

50.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children

Limit: 1.0 Exam(s) per 6 Months

YES

No Charge

100.00%
Diabetes Education
YES

50.00% Coinsurance after deductible

100.00%
Dialysis
YES

50.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

Durable medical equipment, Prosthetics, and Orthotics over $1000 requires prior authorization.

YES

50.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

YES

No Charge

100.00%
Gender Affirming Care
YES

50.00% Coinsurance after deductible

100.00%
Generic Drugs

$25 co-pay applies per 30-day supply and $62.50 co-pay applies per 90-day supply home delivery for Generic Drugs.

YES

$25.00

100.00%
Habilitation Services

Limit: 20.0 Visit(s) per Year

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

$50.00

100.00%
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

Limited to 1 per ear every 3 calendar years.

YES

50.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 60.0 Visit(s) per Year

YES

50.00% Coinsurance after deductible

100.00%
Hospice Services

Prior Authorization required for Inpatient Hospice.

YES

No Charge

100.00%
Imaging (CT/PET Scans, MRIs)

Prior Authorization required for certain Advanced Radiological Imaging services. Penalties include reduced benefits or denial of claim.

YES

50.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

50.00% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)

Prior Authorization required (except maternity). Penalties include reduced benefits or denial of claim.

YES

50.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services

Prior Authorization required (except maternity). Penalties include reduced benefits or denial of claim.

YES

50.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

50.00% 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

50.00% 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

$50.00

100.00%
Non-Preferred Brand Drugs

$100 co-pay applies per 30 day supply and $250 co-pay applies for 90 day supply for Non-Preferred Brand Drugs on Preventive Drug List. Deductible/Coinsurance for other Non-Preferred Brand Drugs, 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

$100.00 Copay after deductible

100.00%
Nutritional Counseling
YES

50.00% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

Prior Authorization required for Medically Necessary orthodontia. Penalties include reduced benefits or denial of claim.

YES

50.00% Coinsurance after deductible

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$50.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

Prior Authorization required for Outpatient Facility.

YES

50.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 20.0 Visit(s) per Year

PCP copay for Physical, Speech, Occupational Therapy. Deductible/coinsurance for other outpatient services. 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

50.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services

Prior Authorization required for Outpatient Surgery.

YES

50.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

$50 co-pay applies after deductible per 30-day supply and $125 co-pay applies after deductible per 90-day supply home delivery.

YES

$50.00 Copay after deductible

100.00%
Prenatal and Postnatal Care
YES

$50.00

100.00%
Preventive Care/Screening/Immunization
YES

0.00%

100.00%
Primary Care Visit to Treat an Injury or Illness

$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

$50.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices

Durable medical equipment, Prosthetics, and Orthotics over $1000 requires prior authorization.

YES

50.00% Coinsurance after deductible

100.00%
Radiation
YES

50.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

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

50.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 20.0 Visit(s) per Year

PCP copay for Physical and Occupational Therapy. 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

$50.00

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Year

PCP copay for Speech Therapy. 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

$50.00

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

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 60.0 Days per Year

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

50.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$100.00

100.00%
Specialty Drugs

Up to a 30-day supply. Must use a pharmacy in the preferred specialty pharmacy network.

YES

$500.00 Copay after deductible

100.00%
Substance Abuse Disorder Inpatient Services

Prior Authorization required. Penalties include reduced benefits or denial of claim.

YES

50.00% 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

$50.00

100.00%
Transplant

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

50.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

50.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$75.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging

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

50.00% Coinsurance after deductible

100.00%

BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ® Health Insurance Plan Variant 14002TN0400244-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.638091065338329
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 Standard Bronze 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, Pregnancy
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID TNF005
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 Expanded Bronze
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 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 14002TN0400244-00
Plan Marketing Name BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ®
Plan Type EPO
Plan Variant Marketing Name BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ®
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,700
SBC Scenario, Having a Baby, Copayment $50
SBC Scenario, Having a Baby, Deductible $7,500
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,950
SBC Scenario, Having Diabetes, Deductible $800
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $500
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,100
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID TNS004
Source Name HIOS
Plan ID 14002TN0400244
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 $15000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $7500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $7,500
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 $18400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9200 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,200
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 Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ® Health Insurance Plan, 14002TN0400244

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

Frequently Asked Questions(FAQ) about BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ®, 14002TN0400244 Health Insurance Plan, 14002TN0400244

  • Does BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ® Health Insurance Plan, 14002TN0400244 support Mail Ordering?

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

  • Does (14002TN0400244) Health Insurance Plan, Variant (14002TN0400244-00) 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, Pregnancy

    Does (14002TN0400244) Health Insurance Plan, Variant (14002TN0400244-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (14002TN0400244) Health Insurance Plan, Variant (14002TN0400244-00) have Out of Service Area Coverage?

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

    Does (14002TN0400244) Health Insurance Plan, Variant (14002TN0400244-00) 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, Pregnancy

    Does BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ® Health Insurance Plan, Variant (14002TN0400244-00) offer Disease Management Programs for Asthma?

    Yes, the BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ® Health Insurance Plan Variant 14002TN0400244-00 offers Disease Management Program for Asthma.

    Does BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ® Health Insurance Plan, Variant (14002TN0400244-00) offer Disease Management Programs for Heart disease?

    Yes, the BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ® Health Insurance Plan Variant 14002TN0400244-00 offers Disease Management Program for Heart disease.

    Does BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ® Health Insurance Plan, Variant (14002TN0400244-00) offer Disease Management Programs for Depression?

    Yes, the BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ® Health Insurance Plan Variant 14002TN0400244-00 offers Disease Management Program for Depression.

    Does BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ® Health Insurance Plan, Variant (14002TN0400244-00) offer Disease Management Programs for Diabetes?

    Yes, the BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ® Health Insurance Plan Variant 14002TN0400244-00 offers Disease Management Program for Diabetes.

    Does BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ® Health Insurance Plan, Variant (14002TN0400244-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ® Health Insurance Plan Variant 14002TN0400244-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ® Health Insurance Plan, Variant (14002TN0400244-00) offer Disease Management Programs for Low back pain?

    Yes, the BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ® Health Insurance Plan Variant 14002TN0400244-00 offers Disease Management Program for Low back pain.

    Does BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ® Health Insurance Plan, Variant (14002TN0400244-00) offer Disease Management Programs for Pregnancy?

    Yes, the BlueCross B16S $50 PCP Copay + $0 virtual care from Teladoc Health ® Health Insurance Plan Variant 14002TN0400244-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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