March 14, 2010

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BlueCross BlueShield of Tennessee – PremierBlue A52S – TENNESSEE

A comparison of the PremierBlue A52S 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 A52S Application PremierBlue A52S Application
Brochure PremierBlue A52S Brochure PremierBlue A52S Brochure
Copay N/A N/A
Office Visit Practitioner Office Services - Office Visit for Diagnosis and Treatment of Illness or Injury: Deductible then 80% Practitioner Office Services - Office Visit for Diagnosis and Treatment of Illness or Injury: Deductible then 60%
Deductible Individual: $1,000, Family: $3,000 Individual: $2,000, Family: $6,000
Coinsurance 80% 60%
Coinsurance Limit Individual: $3,000, Family: $6,000 Individual: $9,000, Family: $18,000
Out-of-Pocket Maximum Individual: $4,000, Family: $9,000 (Includes deductible) Individual: $11,000, Family: $24,000 (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 Hospital Emergency Care -
  • Facility Charges: $100 Copay then deductible and 80%
  • Practitioner Charges: Deductible then 80%
  • Ambulance: 80% after deductible
 Hospital Emergency Care -
  • Facility Charges: Deductible then 60%
  • Practitioner Charges: Deductible then 60%
  • Ambulance: 60% after deductible
Adult Preventative Care Preventive Health Care Services -
  • Annual Well Woman Exam: Deductible then 80%
  • Annual Well Care (Ages 6 and up; limited to $300 per calendar year): Deductible then 80%
  • Annual Mammography Screening: Deductible then 80%
  • Annual Cervical Cancer Screening: Deductible then 80%
  • Prostate Cancer Screening: Deductible and 80%
 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): Deductible then 80%
  • Annual Well Care (Ages 6 and up; limited to $300 per calendar year): Deductible then 80%
 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: Deductible and 80%
  • 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 and 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 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% 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): 80% after deductible
  • Hospice Care: 100%
    		•
  • Home Health Care Services (40 per year): 60% after deductible
  • Hospice Care: 60% after deductible
    		•
    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
  • Prescription Drug (Deductible on Brand Name Drugs, separate from Medical Deductible)
  • Maternity Benefits
  • Dental Benefits
    		•
  • Prescription Drug (Deductible on Brand Name Drugs, separate from Medical Deductible)
  • Maternity Benefits
  • Dental Benefits
    		•