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Silver S26S $40 PCP Copay + Free Telehealth

14002TN0400264
Silver
EPO

Silver S26S $40 PCP Copay + Free Telehealth is a Silver EPO plan by BlueCross BlueShield of Tennessee.

IMPORTANT: You are viewing the 2023 version of Silver S26S $40 PCP Copay + Free Telehealth 14002TN0400264. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Silver S26S $40 PCP Copay + Free Telehealth is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Silver S26S $40 PCP Copay + Free Telehealth 14002TN0400264.
Insurer: BlueCross BlueShield of Tennessee
Network Type: EPO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 14002TN0400264

Cost-Sharing Overview

Silver S26S $40 PCP Copay + 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 Silver S26S $40 PCP Copay + 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

Silver S26S $40 PCP Copay + 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: No
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Silver S26S $40 PCP Copay + 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

Silver S26S $40 PCP Copay + 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
Routine Eye Exam for Children
Covered
$0.00 100.00%1 Exam(s) per Benefit Period
Eye Glasses for Children
Covered
$0.00 100.00%1 Item(s) per Benefit Period
Dental Check-Up for Children
Covered
$0.00 100.00%1 Exam(s) per 6 Months
Rehabilitative Speech Therapy
Covered
$40.00 100.00%20 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
$40.00 100.00%20 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
40.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
40.00% Coinsurance after deductible 100.00%
Basic Dental Care – Child
Covered
20.00% 100.00%
Orthodontia – Child
Covered
40.00% Coinsurance after deductible 100.00%
Primary Care Visit to Treat an Injury or Illness
Covered
$40.00 100.00% PCP copay. Telehealth services are available through PhysicianNow with your plan.
Specialist Visit
Covered
$80.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$40.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
40.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
40.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
0.00% 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
$60.00 100.00%
Home Health Care Services
Covered
40.00% Coinsurance after deductible 100.00%60 Visit(s) per Year
Emergency Room Services
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
40.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
40.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Covered
40.00% Coinsurance after deductible 100.00%60 Days per Year Skilled Nursing and Rehabilitation Facility limited to 60 days/year combined.
Prenatal and Postnatal Care
Covered
40.00% Coinsurance after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
40.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$40.00 100.00% 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
40.00% Coinsurance after deductible 100.00% Prior Authorization required. Penalties include reduced benefits or denial of claim.
Substance Abuse Disorder Outpatient Services
Covered
$40.00 100.00% 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
40.00% Coinsurance after deductible 100.00% Prior Authorization required. Penalties include reduced benefits or denial of claim.
Generic Drugs
Covered
$20.00 100.00% $20 copay applies per 30 day supply and $50.00 copay applies per 90 day supply home delivery for Generic Drugs.
Preferred Brand Drugs
Covered
$40.00 100.00% $40 copay applies per 30 day supply and $100.00 copay applies per 90 day supply home delivery.
Non-Preferred Brand Drugs
Covered
$80.00 Copay after deductible 100.00% $80 copay applies after deductible per 30 day supply and $200 copay applies after deductible per 90 day supply home delivery.
Specialty Drugs
Covered
$350.00 Copay after deductible 100.00% Up to a 30-day supply. Must use a pharmacy in the preferred specialty pharmacy network.
Outpatient Rehabilitation Services
Covered
40.00% Coinsurance 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
40.00% Coinsurance 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
40.00% Coinsurance 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 therapy, whether received in a Practitioner’s office, outpatient facility or home health setting.
Durable Medical Equipment
Covered
40.00% Coinsurance after deductible 100.00% Durable medical equipment over $500 requires prior authorization.
Hearing Aids
Covered
40.00% Coinsurance after deductible 100.00%1 Item(s) per 3 Years
Imaging (CT/PET Scans, MRIs)
Covered
40.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
0.00% 100.00%
Routine Foot Care
Acupuncture
Weight Loss Programs
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
40.00% Coinsurance after deductible 100.00% Transplant services or supplies that have not received Prior Authorization will not be Covered.
Accidental Dental
Covered
40.00% Coinsurance after deductible 100.00%
Dialysis
Covered
40.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
40.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
40.00% Coinsurance after deductible 100.00%
Radiation
Covered
40.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
40.00% Coinsurance after deductible 100.00%
Prosthetic Devices
Covered
40.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
40.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
40.00% Coinsurance after deductible 100.00%
Nutritional Counseling
Covered
40.00% Coinsurance after deductible 100.00%
Reconstructive Surgery
Covered
40.00% Coinsurance after deductible 100.00%
Gender Affirming Care
Covered
40.00% Coinsurance after deductible 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Silver S26S $40 PCP Copay + 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 Silver S26S $40 PCP Copay + 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 Silver S26S $40 PCP Copay + 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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