BlueCross BlueShield of South Carolina

BlueEssentials Bronze 4

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Plan Overview

Combined Medical and Drug Deductible	Individual: $7,200.00 Family: $14400 Per Person: $7200
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,200.00 Family: $18400 Per Person: $9200

Office Visit

Primary Doctor	CoPay: $43.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: You can save time and reduce your copay by consulting a physician using the telehealth service, Blue CareOnDemand. See our brochure or visit www.BlueCareOnDemandSC.com for more details.
Specialist	CoPay: $65.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: No Charge after deductible CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits or prior authorization are required for some covered drugs. See Covered Drugs List for details.
Non Preferred Brand Drugs	CoPay: No Charge after deductible CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits or prior authorization are required for some covered drugs. See Covered Drugs List for details.
Generic Drugs	CoPay: $29.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits or prior authorization are required for some covered drugs. See Covered Drugs List for details.
Specialty Drugs	CoPay: No Charge after deductible CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits or prior authorization are required for some covered drugs. See Covered Drugs List for details.

Inpatient Coverage

Hospital Services	CoPay: No Charge after deductible CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: No Charge after deductible CoInsurance: 50.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $300.00 Copay with deductible CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: An out-of-Network Provider may Balance-Bill you for the difference between the Allowed Amount we pay and their billed charge.
Urgent Care Facility	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Services rendered at Doctors Care facilities are provided at in-network Primary Care benefits. An out-of-Network Provider may Balance-Bill you for the difference between the Allowed Amount we pay and their billed charge.

Maternity

Labor and Delivery Hospital Stay

CoPay: No Charge after deductible
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: No Preauthorization is required for the mother's hospitalization related to the delivery of a newborn child when the mother's hospital stay is 48 hours or less for a vaginal birth or 96 hours or less for a cesarean section. Confinements exceeding these limits require Preauthorization.

Pre and Postnatal Office Visit

CoPay: No Charge after deductible
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Prenatal and postnatal care will be covered after artificial insemination or in-vitro fertilization, but the actual insemination/fertilization is not covered.

Vision

Routine Eye Exams for Children

CoPay: $25.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year

Major Dental Care

Routine Dental Checkups for Children

Covered: Not Covered

BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
HealthMarkets is an authorized agent of BlueCross BlueShield of South Carolina.