BlueCross BlueShield of Tennessee

Gold G07L $10 PCP Copay + Free Telehealth

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Plan Overview

Combined Medical and Drug Deductible	Individual: $1,000 Family: $2,000 Per Person: $1,000
Combined Medical and Drug Out of Pocket Maximum	Individual: $5,500 Family: $11,000 Per Person: $5,500

Office Visit

Primary Doctor	CoPay: $10.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: $10 copay only applicable at Sanitas Centers. Telehealth services are available through PhysicianNow with your plan.
Specialist	CoPay: Not Applicable CoInsurance: 45.00% Coinsurance after deductible Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 45.00% Coinsurance after deductible Covered: Covered Benefit Explanation: $50 co-pay applies per 30 day supply and $125 co-pay applies per 90 day supply for Preferred Brand Drugs on Preventive Drug List. Deductible/Coinsurance for other Preferred Brand Drugs, 30-day supply retail; up to 90-day supply home delivery or Plus90 Retail 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: Not Applicable CoInsurance: 45.00% Coinsurance after deductible Covered: Covered Benefit Explanation: $100 co-pay applies per 30 day supply and $250 co-pay applies for 90 day supply for Non-Preferred Brand Drugs on Preventive Drug List. Deductible/Coinsurance for other Non-Preferred Brand Drugs, 30-day supply retail; up to 90-day supply home delivery or Plus90 Retail 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: Not Applicable CoInsurance: 45.00% Coinsurance after deductible Covered: Covered Benefit Explanation: $20 co-pay applies per 30 day supply and $50 co-pay applies per 90 day supply for Generic Drugs on Preventive Drug List. Deductible/Coinsurance for other Generic Drugs, 30-day supply retail; up to 90-day supply home delivery or Plus90 Retail Network.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 45.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Up to a 30-day supply. Must use a pharmacy in the preferred specialty pharmacy network.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 45.00% 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: 45.00% 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: 45.00% 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: 45.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 45.00% Coinsurance after deductible 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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