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Silver S04S, Network S
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Silver S04S, Network S

Overview
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Silver S04S, Network S is an individual health health plan issued by BlueCross BlueShield of Tennessee and is available for the year 2019. This health plan is offered by the federal government through HealthCare.gov and the Affordable Care Act (ACA).

Where Do I Need to Live to Quality for this Plan?

This plan is available for qualifying individuals who live in Knox county, Tennessee.

What Type of Health Plan Is This?

This plan is an EPO plan, which is also known as an "Exclusive Provider Organization." An EPO is a managed care plan where services are covered so long as the the hospitals, dentists, and other health providers in the plan's network are used.

Where Can I Buy This Plan?

You can purchase this plan at HealthCare.gov.

About
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Issuer
BlueCross BlueShield of Tennessee
Plan ID
14002TN0400107
Coverage area
Knox County, Tennessee
Phone
Local Phone: 1-423-535-5600
Toll-Free: 1-800-565-9140
TTY:
Plan type
EPO
Coverage type
Medical deductible
$2,500
Out-of-pocket maximum
$7,700
Generic drug co-pay
50% Coinsurance after deductible
Preferred brand drug co-pay
50% Coinsurance after deductible
Primary care physician visit cost
50% Coinsurance after deductible
Specialist doctor visit cost
50% Coinsurance after deductible
Doctor Visits
Primary Care Visit 50% Coinsurance after deductible
Specialist Visit 50% Coinsurance after deductible
Emergency Room Visit 50% Coinsurance after deductible
Inpatient Facility Visit 50% Coinsurance after deductible
Inpatient Physician Visit 50% Coinsurance after deductible
Prescription Drugs
Generic Drugs 50% Coinsurance after deductible
Preferred Brand Drugs 50% Coinsurance after deductible
Non-preferred Brand Drugs 50% Coinsurance after deductible
Specialty Drugs 50% Coinsurance after deductible
Medical Deductible
Medical Deductible (Individual) $2,500
Medical Maximum Out Of Pocket (Individual) $7,700
Medical Deductible (Family) $5,000
Medical Maximum Out Of Pocket (Family) $15,400
Drug Deductible
Drug Deductible (Individual) Included in Medical
Drug Maximum Out Of Pocket (Individual) Included in Medical
Drug Deductible (Family) Included in Medical
Drug Maximum Out Of Pocket (Family) Included in Medical
Premium Rates
EHB Percent of Total Premium 100.00%
Premium Child Age 0-14 286
Premium Child Age 18 342
Premium Adult Individual Age 21 374
Premium Adult Individual Age 27 392
Premium Adult Individual Age 30 425
Premium Adult Individual Age 40 479
Premium Adult Individual Age 50 669
Premium Adult Individual Age 60 1,017
Premium Couple 21 749
Premium Couple 30 851
Premium Couple 40 958
Premium Couple 50 1,339
Premium Couple 60 2,035
Couple+1 child, Age 21 1,036
Couple+1 child, Age 30 1,137
Couple+1 child, Age 40 1,245
Couple+1 child, Age 50 1,626
Couple+2 children, Age 21 1,323
Couple+2 children, Age 30 1,424
Couple+2 children, Age 40 1,531
Couple+2 children, Age 50 1,912
Couple+3 or more Children, Age 21 1,610
Couple+3 or more Children, Age 30 1,711
Couple+3 or more Children, Age 40 1,818
Couple+3 or more Children, Age 50 2,199
Individual+1 child, Age 21 661
Individual+1 child, Age 30 712
Individual+1 child, Age 40 765
Individual+1 child, Age 50 956
Individual+2 children, Age 21 948
Individual+2 children, Age 30 999
Individual+2 children, Age 40 1,052
Individual+2 children, Age 50 1,243
Individual+3 or more children, Age 21 1,235
Individual+3 or more children, Age 30 1,286
Individual+3 or more children, Age 40 1,339
Individual+3 or more children, Age 50 1,530
Reference
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  • HealthCare.gov. U.S. Centers for Medicare and Medicaid. Accessed June 11, 2019. https://www.healthcare.gov
  • The 'metal' categories: Bronze, Silver, Gold & Platinum. U.S. Centers for Medicare and Medicaid. Accessed June 11, 2019. https://www.healthcare.gov/choose-a-plan/plans-categories
  • Health insurance plan & network types: HMOs, PPOs, and more. U.S. Centers for Medicare and Medicaid. Accessed June 11, 2019. https://www.healthcare.gov/choose-a-plan/plan-types