BlueEssentials Gold 4 – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $30 copay
Specialist visit: $55 copay
Urgent care visit: $55 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $3,000 per person $3,000 per person |
| Out-of-pocket max | $6,600 per person $13,200 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $30 copay |
| Specialist visit | $55 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $55 copay |
| Emergency room | $300 copay after deductible, 35% coinsurance after deductible |
| Ambulance | 35% coinsurance after deductible |
| Hospital stay (facility) | 35% coinsurance after deductible |
| Hospital stay (physician) | 35% coinsurance after deductible |
| Outpatient procedure (facility) | 35% coinsurance after deductible |
| Outpatient procedure (physician) | 35% coinsurance after deductible |
| Physical rehabilitation | 35% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 35% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | This is the amount you will pay for a generic drug prescription. |
| Non-preferred Brand | $100 copay |
| Specialty | This is the amount you will pay for a generic drug prescription. |
Lab Tests and Diagnostic Procedures
| X-rays | 35% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 35% coinsurance after deductible |
| Blood work | 35% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $30 copay |
| Psychiatric hospital stay | 35% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.southcarolinablues.com/web/nonsecure/sc/resources/22d30043-a9a1-4239-9145-5e8a4394a32d/BCBS%2520Individual%2520-%2520Gold%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 |
