BlueCross BlueShield of South Carolina

BlueEssentials Gold 4

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Plan Overview

Medical Deductible	Individual: $3,000 Family: $6,000 Per Person: $3,000
Prescription Drug Deductible	Individual: $0 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,000 Family: $14,000 Per Person: $7,000

Office Visit

Primary Doctor	CoPay: $30.00 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: $55.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $100.00 CoInsurance: Not Applicable Covered: Covered
Generic Drugs	CoPay: $10.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: No Charge after deductible CoInsurance: 35.00% Coinsurance after deductible Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: No Charge after deductible CoInsurance: 35.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: No Charge after deductible CoInsurance: 35.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $300.00 Copay with deductible CoInsurance: 35.00% 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: $55.00 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: 35.00% 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: 35.00% 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
Basic Dental Care - Child	Covered: Not Covered
Major Dental Care - Child	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.

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