Bronze B15L + Free Telehealth

14002TN0400099
Bronze
EPO

Bronze B15L + Free Telehealth is a Bronze EPO plan by BlueCross BlueShield of Tennessee.

IMPORTANT: You are viewing the 2023 version of Bronze B15L + Free Telehealth 14002TN0400099. You can enroll in this plan during open enrollment 2023, which started November 1st and ends January 15th, 2023, in most states.

Locations

Bronze B15L + Free Telehealth is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Bronze B15L + Free Telehealth 14002TN0400099.
Insurer: BlueCross BlueShield of Tennessee
Network Type: EPO
Metal Type: Bronze
HSA Eligible?: No
Plan ID: 14002TN0400099

Cost-Sharing Overview

Bronze B15L + Free Telehealth 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 Bronze B15L + Free Telehealth?

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

Bronze B15L + Free Telehealth 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:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Bronze B15L + Free Telehealth 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

Bronze B15L + Free Telehealth 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
No Charge after deductible 100.00% Telehealth services are available through PhysicianNow with your plan.
Specialist Visit
Covered
No Charge after deductible 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
No Charge after deductible 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
No Charge after deductible 100.00% Prior Authorization required for Outpatient Facility.
Outpatient Surgery Physician/Surgical Services
Covered
No Charge after deductible 100.00% Prior Authorization required for Outpatient Surgery.
Hospice Services
Covered
0.00% 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
No Charge after deductible 100.00%
Home Health Care Services
Covered
No Charge after deductible 100.00%
Emergency Room Services
Covered
No Charge after deductible No Charge after deductible
Emergency Transportation/Ambulance
Covered
No Charge after deductible No Charge after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
No Charge after deductible 100.00% Prior Authorization required (except maternity). Penalties included reduced benefits or denial of claim.
Inpatient Physician and Surgical Services
Covered
No Charge after deductible 100.00% Prior Authorization required (except maternity). Penalties included reduced benefits or denial of claim.
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Covered
No Charge after deductible 100.00%60 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
No Charge after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
No Charge after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
No Charge after deductible 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
No Charge after deductible 100.00% Prior Authorization required. Penalties include reduced benefits or denial of claim.
Substance Abuse Disorder Outpatient Services
Covered
No Charge after deductible 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
No Charge after deductible 100.00% Prior Authorization required. Penalties include reduced benefits or denial of claim.
Generic Drugs
Covered
No Charge after deductible 100.00% 30-day supply retail; up to 90-day supply home delivery.
Preferred Brand Drugs
Covered
No Charge after deductible 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.
Non-Preferred Brand Drugs
Covered
No Charge after deductible 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.
Specialty Drugs
Covered
No Charge after deductible 100.00% Up to a 30-day supply. Must use a pharmacy in the preferred specialty pharmacy network.
Outpatient Rehabilitation Services
Covered
No Charge after deductible 100.00%20 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
No Charge after deductible 100.00%20 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
No Charge after deductible 100.00%20 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
No Charge after deductible 100.00% Durable medical equipment over $500 requires prior authorization.
Hearing Aids
Covered
No Charge after deductible 100.00%1 Item(s) per 3 Years
Imaging (CT/PET Scans, MRIs)
Covered
No Charge after deductible 100.00% Prior Authorization required for certain Advanced Radiological Imaging services. Penalties include reduced benefits or denial of claim.
Preventive Care/Screening/Immunization
Covered
0.00% 100.00%
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Covered
$0.00 100.00%1 Visit(s) per Year
Eye Glasses for Children
Covered
$0.00 100.00%1 Visit(s) per Year
Dental Check-Up for Children
Covered
$0.00 100.00%1 Visit(s) per 6 Months
Rehabilitative Speech Therapy
Covered
No Charge after deductible 100.00%20 Visit(s) per Year Prior Authorization required for certain therapies. Penalties include reduced benefits or denial of claim.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
No Charge after deductible 100.00%40 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
0.00% 100.00%
Laboratory Outpatient and Professional Services
Covered
No Charge after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
No Charge after deductible 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
20.00% 100.00%
Orthodontia – Child
Covered
No Charge after deductible 100.00% Prior Authorization required for Medically Necessary orthodontia. Penalties include reduced benefits or denial of claim.
Major Dental Care – Child
Covered
50.00% 100.00%
Basic Dental Care – Adult
Orthodontia – Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Transplant
Covered
No Charge after deductible 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
No Charge after deductible 100.00%
Dialysis
Covered
No Charge after deductible 100.00%
Allergy Testing
Covered
No Charge after deductible 100.00%
Chemotherapy
Covered
No Charge after deductible 100.00%
Radiation
Covered
No Charge after deductible 100.00%
Diabetes Education
Covered
No Charge after deductible 100.00%
Prosthetic Devices
Covered
No Charge after deductible 100.00%
Infusion Therapy
Covered
No Charge after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
No Charge after deductible 100.00%
Nutritional Counseling
Covered
No Charge after deductible 100.00%
Reconstructive Surgery
Covered
No Charge after deductible 100.00%
Gender Affirming Care
Covered
No Charge after deductible 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Bronze B15L + Free Telehealth 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 Bronze B15L + Free Telehealth 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 Bronze B15L + Free Telehealth?

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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