BlueCross G07S $10 PCP Copay at Blue of TN + $0 Virtual Care for Medical & Mental Health – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $10 copay
Specialist visit: 30% coinsurance after deductible
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $1,000 per person $1,000 per person |
| Out-of-pocket max | $4,800 per person $9,600 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $10 copay |
| Specialist visit | 30% coinsurance after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $750 copay after deductible, 30% coinsurance after deductible |
| Ambulance | 30% coinsurance after deductible |
| Hospital stay (facility) | 30% coinsurance after deductible |
| Hospital stay (physician) | 30% coinsurance after deductible |
| Outpatient procedure (facility) | 30% coinsurance after deductible |
| Outpatient procedure (physician) | 30% coinsurance after deductible |
| Physical rehabilitation | 30% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 30% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | 30% coinsurance after deductible |
| Brand | 30% coinsurance after deductible |
| Non-preferred Brand | 30% coinsurance after deductible |
| Specialty | 30% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | No charge |
| Imaging (CT/PET/MRI) | 30% coinsurance after deductible |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $10 copay |
| Psychiatric hospital stay | 30% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.bcbst.com/sbc/2024/127600/G07S_SBC.pdf |
| Drug and medication plan formulary | https://www.bcbst.com/docs/providers/2024-essential-plus-formulary.pdf |
| Search doctor list | https://www.bcbst.com/network-s |
