BlueEssentials Silver 14 – EPO
73% cost sharing reduction [Popular Plan]
Network type: EPO
Coverage tier: Silver
Primary care visit: $15 copay
Specialist visit: $50 copay
Urgent care visit: $50 copay
Description
This plan has 73% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | EPO |
| Deductible | $4,200 per person $4,200 per person |
| Out-of-pocket max | $7,550 per person $15,100 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $300 copay after deductible, 20% coinsurance after deductible |
| Ambulance | 20% coinsurance after deductible |
| Hospital stay (facility) | 20% coinsurance after deductible |
| Hospital stay (physician) | 20% coinsurance after deductible |
| Outpatient procedure (facility) | 20% coinsurance after deductible |
| Outpatient procedure (physician) | 20% coinsurance after deductible |
| Physical rehabilitation | 20% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 20% 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 | 20% coinsurance after deductible |
| Specialty | This is the amount you will pay for a generic drug prescription. |
Lab Tests and Diagnostic Procedures
| X-rays | 20% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 20% coinsurance after deductible |
| Blood work | 20% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $15 copay |
| Psychiatric hospital stay | 20% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.southcarolinablues.com/web/nonsecure/sc/resources/ebe4eeb0-bd24-4b4d-9587-27e91a7d74f1/BCBS+Individual+-+Silver+14+-+FPL+201-250+%28CS1%29+2024.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 |
