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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 Lake 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
14002TN0400109
Coverage area
Lake 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 0-14 348.01
Premium Child Age 18 415.34
Premium Adult Individual Age 21 454.92
Premium Adult Individual Age 27 476.76
Premium Adult Individual Age 30 516.33
Premium Adult Individual Age 40 581.39
Premium Adult Individual Age 50 812.49
Premium Adult Individual Age 60 1,234.65
Premium Couple 21 909.84
Premium Couple 30 1,032.66
Premium Couple 40 1,162.78
Premium Couple 50 1,624.98
Premium Couple 60 2,469.3
Couple+1 child, Age 21 1,257.85
Couple+1 child, Age 30 1,380.67
Couple+1 child, Age 40 1,510.79
Couple+1 child, Age 50 1,972.99
Couple+2 children, Age 21 1,605.86
Couple+2 children, Age 30 1,728.68
Couple+2 children, Age 40 1,858.8
Couple+2 children, Age 50 2321
Couple+3 or more Children, Age 21 1,953.87
Couple+3 or more Children, Age 30 2,076.69
Couple+3 or more Children, Age 40 2,206.81
Couple+3 or more Children, Age 50 2,669.01
Individual+1 child, Age 21 802.93
Individual+1 child, Age 30 864.34
Individual+1 child, Age 40 929.4
Individual+1 child, Age 50 1,160.5
Individual+2 children, Age 21 1,150.94
Individual+2 children, Age 30 1,212.35
Individual+2 children, Age 40 1,277.41
Individual+2 children, Age 50 1,508.51
Individual+3 or more children, Age 21 1,498.95
Individual+3 or more children, Age 30 1,560.36
Individual+3 or more children, Age 40 1,625.42
Individual+3 or more children, Age 50 1,856.52
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