Blue Cooper Silver 1 – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$7,000 per person $7,000 per person
Out-of-pocket max	$9,300 per person $18,600 per family
Metal tier	Silver

Visit Copay

Primary care visit	$30 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	$150 copay 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	$30 copay
Psychiatric hospital stay	50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.southcarolinablues.com/web/nonsecure/sc/resources/24d4650b-7477-4bff-a760-d28d8544bda8/BCBS%2520Blue%2520Cooper%2520-%2520Silver%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