Blue Cross Blue Shield BlueCross Silver S04S TN

Plan Information
Company BlueCross BlueShield of Tennessee
State TN
Metal Tier Silver
Plan Type PPO

Cost Sharing Benefits

These details are for the standard Silver plan. For reduced Cost Sharing versions scroll down below

Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $2,000 $4,000
Deductible (Family) $4,000 $8,000
Coinsurance 50% 50%
Out of Pocket Maximum (Individual) $4,000 $12,000
Out of Pocket Maximum (Family) $8,000 $24,000
Services In Network Out of Network
Primary Care Visit 50% Coinsurance after deductible 50% coinsurance
Specialist Visit 50% Coinsurance after deductible 50% coinsurance
In Patient Hospital Services 50% Coinsurance after deductible 50% coinsurance
Emergency Room Services 50% Coinsurance after deductible 50% coinsurance
Mental / Behavioral Health 50% coinsurance 50% coinsurance
Imaging (CT/PET Scans, MRIs) 50% coinsurance 50% coinsurance
Rehabilitative Speech Therapy 50% coinsurance 50% coinsurance
Rehabilitative Occupational & Physical Therapy 50% coinsurance 50% coinsurance
Preventative Care $0 50% coinsurance
Laboratory Outpatient and Professional Services 50% coinsurance 50% coinsurance
X-ray and Diagnostic Imaging 50% coinsurance 50% coinsurance
Outpatient Facility 50% coinsurance 50% coinsurance
Outpatient Surgery 50% coinsurance 50% coinsurance
Prescription Drugs In Network Out of Network
Generic Rx 50% Coinsurance after deductible
Preferred Brand Rx 50% Coinsurance after deductible
Non Preferred Brand Rx 50% Coinsurance after deductible
Specialty Drugs 50% Coinsurance after deductible

73% Cost Sharing Benefits

Households with incomes between 200% to 250% of FPL qualify for the following cost sharing benefits for this silver plan. To understand how cost sharing reductions work and how they work for you see our article about Obamacare Cost Sharing Reduction Discounts

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $1,000.00
Deductible (Family) $2,000.00
Out of Pocket Maximum (Individual) $3,650.00
Out of Pocket Maximum (Family) $7,300.00
Services In Network Out of Network
Primary Care Physician 50% Coinsurance after deductible
Specialists 50% Coinsurance after deductible
Emergency Room 50% Coinsurance after deductible
Inpatient Facility 50% Coinsurance after deductible
Inpatient Physician 50% Coinsurance after deductible
Prescription Drugs In Network Out of Network
Generic Rx 50% Coinsurance after deductible
Preferred Brand Rx 50% Coinsurance after deductible
Non Preferred Brand Rx 50% Coinsurance after deductible
Specialty Drugs 50% Coinsurance after deductible

87% Cost Sharing Benefits

Households with incomes between 150% to 200% of FPL qualify for the following cost sharing benefits for this silver plan.

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $0.00
Deductible (Family) $0.00
Out of Pocket Maximum (Individual) $1,450.00
Out of Pocket Maximum (Family) $2,900.00
Services In Network Out of Network
Primary Care Physician 50% Coinsurance after deductible
Specialists 50% Coinsurance after deductible
Emergency Room 50% Coinsurance after deductible
Inpatient Facility 50% Coinsurance after deductible
Inpatient Physician 50% Coinsurance after deductible
Prescription Drugs In Network Out of Network
Generic Rx 50% Coinsurance after deductible
Preferred Brand Rx 50% Coinsurance after deductible
Non Preferred Brand Rx 50% Coinsurance after deductible
Specialty Drugs 50% Coinsurance after deductible

94% Cost Sharing Benefits

Households with incomes between 138% to 150% of FPL qualify for the following cost sharing benefits for this silver plan.

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $0.00
Deductible (Family) $0.00
Out of Pocket Maximum (Individual) $550.00
Out of Pocket Maximum (Family) $1,100.00
Services In Network Out of Network
Primary Care Physician 50% Coinsurance after deductible
Specialists 50% Coinsurance after deductible
Emergency Room 50% Coinsurance after deductible
Inpatient Facility 50% Coinsurance after deductible
Inpatient Physician 50% Coinsurance after deductible
Prescription Drugs In Network Out of Network
Generic Rx 50% Coinsurance after deductible
Preferred Brand Rx 50% Coinsurance after deductible
Non Preferred Brand Rx 50% Coinsurance after deductible
Specialty Drugs 50% Coinsurance after deductible

Other Plans

Other plans that are available in the state.

Plan Name
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