BlueCross S25E $55 PCP Copay + $0 virtual care from Teladoc Health ®
14002TN0400256
Silver
EPO
BlueCross S25E $55 PCP Copay + $0 virtual care from Teladoc Health ® is a Silver EPO plan by BlueCross BlueShield of Tennessee.
Locations
BlueCross S25E $55 PCP Copay + $0 virtual care from Teladoc Health ® is offered in the following counties.
Plan Overview
This is a plan overview for 2025 version of BlueCross S25E $55 PCP Copay + $0 virtual care from Teladoc Health ® 14002TN0400256.
| Insurer: | BlueCross BlueShield of Tennessee |
| Network Type: | EPO |
| Metal Type: | Silver |
| HSA Eligible?: | No |
| Plan ID: | 14002TN0400256 |
Cost-Sharing Overview
BlueCross S25E $55 PCP Copay + $0 virtual care from Teladoc Health ® offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for BlueCross S25E $55 PCP Copay + $0 virtual care from Teladoc Health ® includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $8900 per person | $17800 per group |
| Deductible: | $0 per person | $0 per group |
| Coinsurance: | $0 per group | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for BlueCross S25E $55 PCP Copay + $0 virtual care from Teladoc Health ® will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | per person not applicable | per group not applicable |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $70 |
| Copayment: | $0 |
| Coinsurance: | $6,300 |
| Limit: | $0 |
| Deductible: | $4,300 |
| Copayment: | $500 |
| Coinsurance: | $100 |
| Limit: | $0 |
| Deductible: | $5 |
| Copayment: | $900 |
| Coinsurance: | $1,000 |
| Limit: | $0 |
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 S25E $55 PCP Copay + $0 virtual care from Teladoc 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 S25E $55 PCP Copay + $0 virtual care from Teladoc 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, Pregnancy |
| Notice Pregnancy: | No |
| Referral Specialist: | No |
| Specialist Requiring Referral: | |
| Plan Exclusions: | |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what BlueCross S25E $55 PCP Copay + $0 virtual care from Teladoc 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 S25E $55 PCP Copay + $0 virtual care from Teladoc 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 | $55.00 Not Applicable | Not Applicable 100.00% | $0 Virtual care for telehealth services are available through Teladoc with your plan. Regular benefits apply for telehealth services provided by other network providers. |
| Specialist Visit Covered | $100.00 Not Applicable | Not Applicable 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $55.00 Not Applicable | Not Applicable 100.00% | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | $1,500.00 50.00% | Not Applicable 100.00% | Prior Authorization required for Outpatient Facility. |
| Outpatient Surgery Physician/Surgical Services Covered | Not Applicable 50.00% | Not Applicable 100.00% | Prior Authorization required for Outpatient Surgery. |
| Hospice Services Covered | Not Applicable No Charge | Not Applicable 100.00% | Prior Authorization required for Inpatient Hospice. |
| 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 | Not Applicable 50.00% | Not Applicable 100.00% | |
| Home Health Care Services Covered | Not Applicable 50.00% | Not Applicable 100.00% | 60.0 Visit(s) per Year |
| Emergency Room Services Covered | $750.00 50.00% | $750.00 50.00% | |
| Emergency Transportation/Ambulance Covered | Not Applicable 50.00% | Not Applicable 50.00% | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | $2000.00 Copay per Stay 50.00% | Not Applicable 100.00% | Prior Authorization required (except maternity). Penalties include reduced benefits or denial of claim. |
| Inpatient Physician and Surgical Services Covered | Not Applicable 50.00% | Not Applicable 100.00% | Prior Authorization required (except maternity). Penalties include reduced benefits or denial of claim. |
| Bariatric Surgery | |||
| Cosmetic Surgery | |||
| Skilled Nursing Facility Covered | Not Applicable 50.00% | Not Applicable 100.00% | 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. |
| Prenatal and Postnatal Care Covered | $55.00 Not Applicable | Not 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. |
| Delivery and All Inpatient Services for Maternity Care Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| Mental/Behavioral Health Outpatient Services Covered | $55.00 Not Applicable | Not 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 other 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 50.00% | Not Applicable 100.00% | |
| Substance Abuse Disorder Outpatient Services Covered | $55.00 Not Applicable | Not 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 other 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 50.00% | Not Applicable 100.00% | |
| Generic Drugs Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | 30-day supply retail; up to 90-day supply home delivery. Drug deductible applies. |
| Preferred Brand Drugs Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | 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. Drug deductible applies. |
| Non-Preferred Brand Drugs Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | 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. Drug deductible applies. |
| Specialty Drugs Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | Up to a 30-day supply. Must use a pharmacy in the preferred specialty pharmacy network. Drug deductible applies. |
| Outpatient Rehabilitation Services Covered | Not Applicable 50.00% | Not Applicable 100.00% | 20.0 Visit(s) per Year 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. |
| Habilitation Services Covered | Not Applicable 50.00% | Not Applicable 100.00% | 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. |
| Chiropractic Care Covered | Not Applicable 50.00% | Not 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 therapy, whether received in a Practitioner’s office, outpatient facility or home health setting. |
| Durable Medical Equipment Covered | Not Applicable 50.00% | Not Applicable 100.00% | Durable medical equipment, Prosthetics, and Orthotics over $1000 requires prior authorization. |
| Hearing Aids Covered | Not Applicable 50.00% | Not Applicable 100.00% | 1.0 Item(s) per 3 Years Limited to 1 per ear every 3 calendar years. |
| Imaging (CT/PET Scans, MRIs) Covered | Not Applicable 50.00% | Not Applicable 100.00% | Prior Authorization required for certain Advanced Radiological Imaging services. Penalties include reduced benefits or denial of claim. |
| Preventive Care/Screening/Immunization Covered | Not Applicable No Charge | Not Applicable 100.00% | |
| Routine Foot Care | |||
| Acupuncture | |||
| Weight Loss Programs | |||
| Routine Eye Exam for Children Covered | Not Applicable No Charge | Not Applicable 100.00% | 1.0 Exam(s) per Benefit Period |
| Eye Glasses for Children Covered | Not Applicable No Charge | Not Applicable 100.00% | 1.0 Item(s) per Benefit Period |
| Dental Check-Up for Children Covered | Not Applicable No Charge | Not Applicable 100.00% | 1.0 Exam(s) per 6 Months |
| Rehabilitative Speech Therapy Covered | Not Applicable 50.00% | Not Applicable 100.00% | 20.0 Visit(s) per Year Therapy limited to 20 visits per year. The limit on 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 auth request for certain therapies. Penalties include reduced benefits or claim denial. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | Not Applicable 50.00% | Not Applicable 100.00% | 20.0 Visit(s) per Year Therapy limited to 20 visits per therapy type per year. The limit on 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 auth request for certain therapies. Penalties include reduced benefits or claim denial. |
| Well Baby Visits and Care Covered | Not Applicable No Charge | Not Applicable 100.00% | |
| Laboratory Outpatient and Professional Services Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| X-rays and Diagnostic Imaging Covered | Not Applicable 50.00% | Not Applicable 100.00% | 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. |
| Basic Dental Care – Child Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| Orthodontia – Child Covered | Not Applicable 50.00% | Not Applicable 100.00% | Prior Authorization required for Medically Necessary orthodontia. Penalties include reduced benefits or denial of claim. |
| 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 50.00% | Not Applicable 100.00% | 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. |
| Accidental Dental Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| Dialysis Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| Allergy Testing Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| Chemotherapy Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| Radiation Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| Diabetes Education Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| Prosthetic Devices Covered | Not Applicable 50.00% | Not Applicable 100.00% | Durable medical equipment, Prosthetics, and Orthotics over $1000 requires prior authorization. |
| Infusion Therapy Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| Treatment for Temporomandibular Joint Disorders Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| Nutritional Counseling Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| Reconstructive Surgery Covered | Not Applicable 50.00% | Not Applicable 100.00% | 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). |
| Gender Affirming Care Covered | Not Applicable 50.00% | Not Applicable 100.00% |
Free Preventive Services
There is no copayment or coinsurance for any of the following BlueCross S25E $55 PCP Copay + $0 virtual care from Teladoc 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.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for BlueCross S25E $55 PCP Copay + $0 virtual care from Teladoc 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 S25E $55 PCP Copay + $0 virtual care from Teladoc 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