BlueEssentials Gold 5 – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $20 copay
Specialist visit: $40 copay
Urgent care visit: $40 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $250 per person $250 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $20 copay |
| Specialist visit | $40 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $40 copay |
| Emergency room | 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 | $10 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 | $20 copay |
| Psychiatric hospital stay | 50% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.southcarolinablues.com/web/nonsecure/sc/resources/b508d559-a3d2-4206-8196-47605712b226/BCBS%2520Individual%2520-%2520Gold%25205%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 |
