|
Plan Code
|
Deductible
|
Coinsurance
|
Out-of-Pocket Maximum
|
||||
|---|---|---|---|---|---|---|---|
|
Self-only
|
Family
|
Self-only
|
Family
|
Plan Pays
|
You Pay
|
Self-only
|
Family
|
|
S5S
|
S5F
|
$1,000
|
$2,000
|
80%
|
20%
|
$6,000
|
$12,000
|
|
S6S
|
S6F
|
$1,500
|
$3,000
|
80%
|
20%
|
$6,500
|
$13,000
|
|
S7S
|
S7F
|
$2,500
|
$5,000
|
100%
|
0%
|
$2,500
|
$5,000
|
|
S8S
|
S8F
|
$3,500
|
$7,000
|
100%
|
0%
|
$3,500
|
$7,000
|
Each plan features the doctors, hospitals and other health care providers who participate in BlueNetwork S. Please use the Find A Doctor tool on this site to see if your doctors participate in BlueNetwork S before applying for one of the plans above.
*Out-of-Pocket Max includes deductible
Coinsurance applies to maximum allowable charges. Out-of-pocket maximums for in-network and out-of-network covered services are separate and do not combine. Lifetime maximum benefit - $5,000,000. Any balance of charges (between billed charges and maximum allowable charge) does not apply toward your deductible or out-of-pocket maximum.
SimplyBluePlus Offers Additional Benefits
In addition to the benefits offered by SimplyBlue plans, SimplyBluePlus plan options offer you more benefits to help you stay well and budget your health care dollars.
$30 Copay for Office Visits
$15 Copay for Generic Prescription Drugs
Covered Wellness and Preventive Services for Adults and Children Age Six and Older (Subject to $30 copay and $300 annual payment limit). Well care exams are covered including the following services:
Exclusions are those wellness services not recommended by the guidelines of the
U.S. Task Force on Preventive Care and the medical policy of BlueCross BlueShield
of Tennessee.