Select Plan to Review
*RX Coverage: Generic/Preferred Brand/Non-Preferred Brand Copay.
When you click on one of the View buttons below your Summary of Benefits and Coverage (SBC) will pull up in PDF format.
| Plan Number | Network | Maternity | In-Network Deductible Amount | Primary Care Practitioner/Specialist Copay | Coinsurance Percent | Out-of-Pocket Maximum | RX Coverage* | |
|---|---|---|---|---|---|---|---|---|
| View | H31 | P | No | $500 Individual/$1500 Family | Deductible/Coinsurance | 20% | $1500 Individual/$3500 Family | $10/$35/$50 Copay |
| View | H32 | P | No | $1000 Individual/$3000 Family | Deductible/Coinsurance | 20% | $2000 Individual/$5000 Family | $10/$35/$50 Copay |
| View | H32 | P | Yes | $1000 Individual/$3000 Family | Deductible/Coinsurance | 20% | $2000 Individual/$5000 Family | $10/$35/$50 Copay |
| View | H37 | P | No | $2500 Individual/$7500 Family | Deductible/Coinsurance | 20% | $3500 Individual/$9500 Family | $10/$35/$50 Copay |
| View | H37 | P | Yes | $2500 Individual/$7500 Family | Deductible/Coinsurance | 20% | $3500 Individual/$9500 Family | $10/$35/$50 Copay |
© 1998-2013 BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association.
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