March 19, 2010

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BlueCross BlueShield of Tennessee – PremierBlue A31S – TENNESSEE

A comparison of the PremierBlue A31S offered by BlueCross BlueShield of Tennessee is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
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Network See Provider See Provider
Application PremierBlue A31S Application PremierBlue A31S Application
Brochure PremierBlue A31S Brochure PremierBlue A31S Brochure
Copay
  • Office Visit for Diagnosis and Treatment of Illness or Injury: $25
  • Primary Care Practitioners (PCP/Specialist): $40
    		•  N/A
    Office Visit Practitioner Office Services -
    • Office Visit for Diagnosis and Treatment of Illness or Injury: $25
    • Primary Care Practitioners (PCP/Specialist: $40
    		 Practitioner Office Services -
    • Office Visit for Diagnosis and Treatment of Illness or Injury: Deductible and 60%
    • Primary Care Practitioners (PCP/Specialist: Deductible and 60%
    Deductible Individual: $500, Family: $1,500 Individual: $1,000, Family: $3,000
    Coinsurance 80% 60%
    Coinsurance Limit Individual: $3,000, Family: $6,000 Individual: $9,000, Family: $18,000
    Out-of-Pocket Maximum Individual: $3,500, Family: $7,500 (Includes deductible) Individual: $10,000, Family: $21,000 (Includes deductible)
    Lifetime Maximum $5 million $5 million
    Prescription Drugs Prescription Drugs -
    • Generic Drugs: $10 Copay
    • Preferred Brand Name Drugs: $35 Copay
    • Brand Name Drugs: $50 Copay
    		 Reimbursement based on Maximum Allowable Charge, less the in-network copayments and drug deductible
    Emergency Room PremierBlue A31S PremierBlue A31S
    Adult Preventative Care Preventive Health Care Services -
    • Annual Well Woman Exam: 100% after PCP Copay
    • Annual Well Woman Exam (Ages 6 and up; limited to $300 per calendar year): 100% after PCP Copay
    • Annual Mammography Screening: 100%
    • Annual Cervical Cancer Screening: 100%
    • Prostate Cancer Screening: 100%
    		 Preventive Health Care Services -
    • Well Child Care and Immunizations (To age 6): Deductible then 60%
    • Annual Well Care (Ages 6 and up; limited to $300 per calendar year): Deductible then 60%
    Child Preventative Care Preventive Health Care Services -
    • Well Child Care and Immunizations (To age 6): 100% after PCP Copay
    • Annual Well Care (Ages 6 and up; limited to $300 per calendar year): 100% after PCP Copay
    		 Preventive Health Care Services -
    • Well Child Care and Immunizations (To age 6): Deductible then 60%
    • Annual Well Care (Ages 6 and up; limited to $300 per calendar year): Deductible then 60%
    Lab / X-Ray
  • Routine Diagnostic Lab, X-Ray, Injections Allergy Testing: 100%
  • Non-Routine Diagnostic Services (CAT scans, MRI's, PET scans, nuclear medicine and other similar technologies): Deductible then 80%
    		•
  • Routine Diagnostic Lab, X-Ray, Injections Allergy Testing: Deductible then 60%
  • Non-Routine Diagnostic Services (CAT scans, MRI's, PET scans, nuclear medicine and other similar technologies): Deductible then 60%
    		•
    Maternity Not covered Not covered
    Physical Therapy Therapy Services (Physical, speech, occupational, and manipulative limited to 20 visits per therapy type per Calendar Year; Cardiac and pulmonary rehab therapy limited to 36 visits per therapy type per Calendar Year): Deductible then 80% Therapy Services (Physical, speech, occupational, and manipulative limited to 20 visits per therapy type per Calendar Year; Cardiac and pulmonary rehab therapy limited to 36 visits per therapy type per Calendar Year): Deductible then 60%
    Skilled Nursing Skilled Nursing or Rehabilitation (30 days per calendar year): Deductible then 80% Skilled Nursing or Rehabilitation (30 days per calendar year): Deductible then 60%
    Home Health Care
  • Home Health Care Services (40 per year): Deductible then 80%
  • Hospice Care: 100%
    		•
  • Home Health Care Services (40 per year): Deductible then 60%
  • Hospice Care: Deductible then 60%
    		•
    Mental Health Behavioral Health Services (Limited to $20,000 per lifetime; coinsurance amounts do not apply to the out-of-pocket maximum) -
    • Inpatient Services (Limited to 20 days per calendar year): 60% after deductible
    • Outpatient Services (Limited to $1,000 per calendar year): 50% after deductible
    		 Behavioral Health Services (Limited to $20,000 per lifetime; coinsurance amounts do not apply to the out-of-pocket maximum) -
    • Inpatient Services (Limited to 20 days per calendar year): 60% after deductible
    • Outpatient Services (Limited to $1,000 per calendar year): 50% after deductible
    Hospital Care
  • Inpatient Services: Deductible then 80%
  • Outpatient Facility Services: Deductible then 80%
  • Outpatient Surgery: Deductible then 80%
  • Other Outpatient Services: Deductible then 80%
    		•
  • Inpatient Services: Deductible then 60%
  • Outpatient Facility Services: Deductible then 60%
  • Outpatient Surgery: Deductible then 60%
  • Other Outpatient Services: Deductible then 60%
    		•
    Optional Benefits
  • Deductible on Brand Name Drugs, separate from Medical Deductible
  • Maternity Benefits
  • Dental Benefits
    		•
  • Deductible on Brand Name Drugs, separate from Medical Deductible
  • Maternity Benefits
  • Dental Benefits
    		•