Blue Cooper Bronze 1 – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$7,900 per person $7,900 per person
Out-of-pocket max	$8,850 per person $17,700 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	$48 copay
Specialist visit	$96 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$60 copay
Emergency room	$300 copay after deductible, 45% coinsurance after deductible
Ambulance	45% coinsurance after deductible
Hospital stay (facility)	45% coinsurance after deductible
Hospital stay (physician)	45% coinsurance after deductible
Outpatient procedure (facility)	45% coinsurance after deductible
Outpatient procedure (physician)	45% coinsurance after deductible
Physical rehabilitation	45% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	45% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$29 copay
Brand	This is the amount you will pay for a generic drug prescription.
Non-preferred Brand	45% coinsurance after deductible
Specialty	This is the amount you will pay for a generic drug prescription.

Lab Tests and Diagnostic Procedures

X-rays	45% coinsurance after deductible
Imaging (CT/PET/MRI)	45% coinsurance after deductible
Blood work	45% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$48 copay
Psychiatric hospital stay	45% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.southcarolinablues.com/web/nonsecure/sc/resources/dcc96473-a59e-4e35-b54b-e6e2e564323b/BCBS%2520Blue%2520Cooper%2520-%2520Bronze%25201%25202024.pdf
Drug and medication plan formulary	https://www.southcarolinablues.com/links/2024/pharmacy/Individual
Search doctor list	https://www.southcarolinablues.com/links/2024/provider/bluecooper