BlueCross BlueShield of Tennessee

Gold G06S $35 PCP Copay + Free Telehealth + Rx Copays

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Plan Overview

Medical Deductible	Individual: $2,750 Family: $5,500 Per Person: $2,750
Prescription Drug Deductible	Individual: $0 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $6,350 Family: $12,700 Per Person: $6,350

Office Visit

Primary Doctor	CoPay: $35.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Telehealth services are available through PhysicianNow with your plan.
Specialist	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $35.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 30-day supply retail; up to 90-day supply home delivery or Plus90 network. 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	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 30-day supply retail; up to 90-day supply home delivery or Plus90 network. 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.
Generic Drugs	CoPay: $8.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 30-day supply retail; up to 90-day supply home delivery or Plus90 network.
Specialty Drugs	CoPay: $120.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Up to a 30-day supply. Must use a pharmacy in specialty pharmacy network.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Prior Authorization required (except maternity). Penalties included reduced benefits or denial of claim.
Inpatient Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Prior Authorization required (except maternity). Penalties included reduced benefits or denial of claim.

Emergency and Urgent Care

Emergency Room	CoPay: $500.00 Copay with deductible CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: $35.00 CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: $0.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Year

Major Dental Care

Routine Dental Checkups for Children	CoPay: Not Applicable CoInsurance: 0.00% Covered: Covered Limit Quantity: 1 Limit Unit : Visit(s) per 6 Months
Basic Dental Care - Child	CoPay: Not Applicable CoInsurance: 20.00% Covered: Covered
Major Dental Care - Child	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered

©1998-2015 BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association. BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace. 1 Cameron Hill Circle, Chattanooga TN 37402-0001

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