BlueEssentials Bronze 4 – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$7,200 per person $7,200 per person
Out-of-pocket max	$9,450 per person $18,900 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	$40 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	$29 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	$40 copay
Psychiatric hospital stay	50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.southcarolinablues.com/web/nonsecure/sc/resources/e693b1d7-1da9-4335-b654-70f435345d8d/BCBS%2520Individual%2520-%2520Bronze%25204%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