BlueCross G08L $30 PCP Copay + $0 Virtual Care for Medical & Mental Health

14002TN0400230
Gold
EPO

BlueCross G08L $30 PCP Copay + $0 Virtual Care for Medical & Mental Health is a Gold EPO plan by BlueCross BlueShield of Tennessee.

IMPORTANT: You are viewing the 2024 version of BlueCross G08L $30 PCP Copay + $0 Virtual Care for Medical & Mental Health 14002TN0400230. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

BlueCross G08L $30 PCP Copay + $0 Virtual Care for Medical & Mental Health is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of BlueCross G08L $30 PCP Copay + $0 Virtual Care for Medical & Mental Health 14002TN0400230.
Insurer: BlueCross BlueShield of Tennessee
Network Type: EPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 14002TN0400230

Cost-Sharing Overview

BlueCross G08L $30 PCP Copay + $0 Virtual Care for Medical & Mental Health offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for BlueCross G08L $30 PCP Copay + $0 Virtual Care for Medical & Mental Health?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

BlueCross G08L $30 PCP Copay + $0 Virtual Care for Medical & Mental Health offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions: No
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what BlueCross G08L $30 PCP Copay + $0 Virtual Care for Medical & Mental Health covers when you are out of the service area or out of the country.

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
National Network: No

Additional Benefits and Cost-Sharing

BlueCross G08L $30 PCP Copay + $0 Virtual Care for Medical & Mental Health includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$30.00 Not ApplicableNot Applicable 100.00% $30 copay. Telehealth services are available through Teladoc with your plan.
Specialist Visit
Covered
$60.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable No ChargeNot Applicable 100.00% Prior Authorization required for Inpatient Hospice. Penalties include reduced benefits or denial of claim.
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
$45.00 Not ApplicableNot Applicable 100.00%
Home Health Care Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%60.0 Visit(s) per Year
Emergency Room Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 25.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%60.0 Days per Year Skilled Nursing and Rehabilitation Facility limited to 60 days/year combined.
Prenatal and Postnatal Care
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$30.00 Not ApplicableNot Applicable 100.00% 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.
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Prior Authorization required. Penalties include reduced benefits or denial of claim.
Substance Abuse Disorder Outpatient Services
Covered
$30.00 Not ApplicableNot Applicable 100.00% 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.
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Prior Authorization required. Penalties include reduced benefits or denial of claim.
Generic Drugs
Covered
$15.00 Not ApplicableNot Applicable 100.00% $15.00 copay 30-day supply retail; $37.50 copay up to 90-day supply home delivery for Generic.
Preferred Brand Drugs
Covered
$30.00 Not ApplicableNot Applicable 100.00% $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.
Non-Preferred Brand Drugs
Covered
$60.00 Not ApplicableNot Applicable 100.00% $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.
Specialty Drugs
Covered
$250.00 Not ApplicableNot Applicable 100.00% Up to a 30-day supply. Must use a pharmacy in specialty pharmacy network.
Outpatient Rehabilitation Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%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.
Habilitation Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%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.
Chiropractic Care
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%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.
Durable Medical Equipment
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Durable medical equipment over $500 requires prior authorization.
Hearing Aids
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%1.0 Item(s) per 3 Years
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
Not Applicable 0%Not Applicable 100.00%
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%1.0 Exam(s) per Benefit Period
Eye Glasses for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%1.0 Item(s) per Benefit Period
Dental Check-Up for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%1.0 Exam(s) per 6 Months
Rehabilitative Speech Therapy
Covered
$30.00 Not ApplicableNot Applicable 100.00%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.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 Not ApplicableNot Applicable 100.00%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.
Well Baby Visits and Care
Covered
Not Applicable No ChargeNot Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Basic Dental Care – Child
Covered
Not Applicable 20.00%Not Applicable 100.00%
Orthodontia – Child
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Major Dental Care – Child
Covered
Not Applicable 50.00%Not Applicable 100.00%
Basic Dental Care – Adult
Orthodontia – Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Transplant
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Transplant services or supplies that have not received Prior Authorization will not be Covered.
Accidental Dental
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Dialysis
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Chemotherapy
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Infusion Therapy
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Nutritional Counseling
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Reconstructive Surgery
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Gender Affirming Care
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following BlueCross G08L $30 PCP Copay + $0 Virtual Care for Medical & Mental Health preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for BlueCross G08L $30 PCP Copay + $0 Virtual Care for Medical & Mental Health including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for BlueCross G08L $30 PCP Copay + $0 Virtual Care for Medical & Mental Health?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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