BlueEssentials Silver 14 – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$6,900 per person $6,900 per person
Out-of-pocket max	$9,400 per person $18,800 per family
Metal tier	Silver

Visit Copay

Primary care visit	$25 copay
Specialist visit	$60 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$60 copay
Emergency room	$300 copay after deductible, 50% coinsurance after deductible
Ambulance	50% coinsurance after deductible
Hospital stay (facility)	50% coinsurance after deductible
Hospital stay (physician)	50% coinsurance after deductible
Outpatient procedure (facility)	50% coinsurance after deductible
Outpatient procedure (physician)	50% coinsurance after deductible
Physical rehabilitation	50% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$20 copay
Brand	This is the amount you will pay for a generic drug prescription.
Non-preferred Brand	50% coinsurance after deductible
Specialty	This is the amount you will pay for a generic drug prescription.

Lab Tests and Diagnostic Procedures

X-rays	50% coinsurance after deductible
Imaging (CT/PET/MRI)	50% coinsurance after deductible
Blood work	50% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$25 copay
Psychiatric hospital stay	50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.southcarolinablues.com/web/nonsecure/sc/resources/5a7ece79-8752-46e5-9822-182503e8c9b9/BCBS%2520Individual%2520-%2520Silver%252014%25202024.pdf
Drug and medication plan formulary	https://www.southcarolinablues.com/links/2024/pharmacy/Individual
Search doctor list	https://www.southcarolinablues.com/links/2024/providers/EPO