BlueCross S34E $45 PCP Copay + $0 virtual care from Teladoc Health®

BlueCross BlueShield of Tennessee

Silver

Ind. deductible: $8,100
Family deductible: $8,100
Ind. OOP max: $8,100
Family OOP max: $8,100

Other cost-sharing reduction variants for this plan:

73% AV Level Silver Plan 87% AV Level Silver Plan 94% AV Level Silver Plan Limited Cost Sharing Plan Variation Standard Silver Off Exchange Plan Zero Cost Sharing Plan Variation

Monthly premiums by age

Age	Individual	Individual + tobacco
21	$608	—
30	$690	—
40	$776	—
50	$1,085	—
60	$1,649	—

Live premium estimate

Benefits & cost sharing

Primary Care

Benefit	In-network
Preventive Care/Screening/Immunization	No charge
Primary Care Visit to Treat an Injury or Illness	$45.00

Specialist

Benefit	In-network
Specialist Visit	$90.00

Hospital

Benefit	In-network
Emergency Room Services	No Charge after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	No Charge after deductible
Outpatient Surgery Physician/Surgical Services	No Charge after deductible
Urgent Care Centers or Facilities	$90.00

Pharmacy

Benefit	In-network
Generic Drugs	$10.00
Non-Preferred Brand Drugs	No Charge after deductible
Preferred Brand Drugs	No Charge after deductible
Specialty Drugs	No Charge after deductible

Mental Health

Benefit	In-network
Mental/Behavioral Health Inpatient Services	No Charge after deductible
Mental/Behavioral Health Outpatient Services	$5.00

Other

Benefit	In-network
Abortion for Which Public Funding is Prohibited	Not covered
Accidental Dental	No Charge after deductible
Acupuncture	Not covered
Allergy Testing	No Charge after deductible
Bariatric Surgery	Not covered
Basic Dental Care - Adult	Not covered
Basic Dental Care - Child	50.00%
Chemotherapy	No Charge after deductible
Routine Eye Exam for Children	No charge
Routine Foot Care	Not covered
Chiropractic Care	No Charge after deductible
Cosmetic Surgery	Not covered
Delivery and All Inpatient Services for Maternity Care	0.00%
Dental Check-Up for Children	No charge
Diabetes Education	0.00%
Dialysis	No Charge after deductible
Durable Medical Equipment	No Charge after deductible
Emergency Transportation/Ambulance	No Charge after deductible
Eye Glasses for Children	0.00%
Gender Affirming Care	0.00%
Habilitation Services	No Charge after deductible
Hearing Aids	No Charge after deductible
Home Health Care Services	No Charge after deductible
Hospice Services	No Charge after deductible
Imaging (CT/PET Scans, MRIs)	No Charge after deductible
Infertility Treatment	Not covered
Infusion Therapy	No Charge after deductible
Inpatient Physician and Surgical Services	No Charge after deductible
Laboratory Outpatient and Professional Services	0.00%
Long-Term/Custodial Nursing Home Care	Not covered
Major Dental Care - Adult	Not covered
Major Dental Care - Child	50.00%
Nutritional Counseling	No Charge after deductible
Orthodontia - Adult	Not covered
Orthodontia - Child	0.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)	$5.00
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	No Charge after deductible
Outpatient Rehabilitation Services	No Charge after deductible
Prenatal and Postnatal Care	$5.00
Private-Duty Nursing	Not covered
Prosthetic Devices	0.00%
Radiation	0.00%
Reconstructive Surgery	No Charge after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy	No Charge after deductible
Rehabilitative Speech Therapy	No Charge after deductible
Routine Dental Services (Adult)	Not covered
Routine Eye Exam (Adult)	Not covered
Skilled Nursing Facility	No Charge after deductible
Substance Abuse Disorder Inpatient Services	0.00%
Substance Abuse Disorder Outpatient Services	$0.00
Transplant	No Charge after deductible
Treatment for Temporomandibular Joint Disorders	No Charge after deductible
Weight Loss Programs	Not covered
Well Baby Visits and Care	No charge
X-rays and Diagnostic Imaging	No Charge after deductible

Plan rules

Service area

This plan covers 14 geographic areas.