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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 Johnson 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
14002TN0400106
Coverage area
Johnson 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 0-14 309
Premium Child Age 18 368
Premium Adult Individual Age 21 404
Premium Adult Individual Age 27 423
Premium Adult Individual Age 30 458
Premium Adult Individual Age 40 516
Premium Adult Individual Age 50 721
Premium Adult Individual Age 60 1,096
Premium Couple 21 808
Premium Couple 30 917
Premium Couple 40 1,032
Premium Couple 50 1,443
Premium Couple 60 2,193
Couple+1 child, Age 21 1,117
Couple+1 child, Age 30 1,226
Couple+1 child, Age 40 1,341
Couple+1 child, Age 50 1,752
Couple+2 children, Age 21 1,426
Couple+2 children, Age 30 1,535
Couple+2 children, Age 40 1,650
Couple+2 children, Age 50 2,061
Couple+3 or more Children, Age 21 1,735
Couple+3 or more Children, Age 30 1,844
Couple+3 or more Children, Age 40 1,959
Couple+3 or more Children, Age 50 2,370
Individual+1 child, Age 21 713
Individual+1 child, Age 30 767
Individual+1 child, Age 40 825
Individual+1 child, Age 50 1,030
Individual+2 children, Age 21 1,022
Individual+2 children, Age 30 1,076
Individual+2 children, Age 40 1,134
Individual+2 children, Age 50 1,339
Individual+3 or more children, Age 21 1,331
Individual+3 or more children, Age 30 1,385
Individual+3 or more children, Age 40 1,443
Individual+3 or more children, Age 50 1,648
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