BlueEssentials HD Bronze 3 – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$5,400 per person $5,400 per person
Out-of-pocket max	$7,500 per person $15,000 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	30% coinsurance after deductible
Specialist visit	30% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	30% coinsurance after deductible
Emergency room	30% coinsurance after deductible
Ambulance	30% coinsurance after deductible
Hospital stay (facility)	30% coinsurance after deductible
Hospital stay (physician)	30% coinsurance after deductible
Outpatient procedure (facility)	30% coinsurance after deductible
Outpatient procedure (physician)	30% coinsurance after deductible
Physical rehabilitation	30% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	30% coinsurance after deductible
Brand	This is the amount you will pay for a generic drug prescription.
Non-preferred Brand	30% coinsurance after deductible
Specialty	This is the amount you will pay for a generic drug prescription.

Lab Tests and Diagnostic Procedures

X-rays	30% coinsurance after deductible
Imaging (CT/PET/MRI)	30% coinsurance after deductible
Blood work	30% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	30% coinsurance after deductible
Psychiatric hospital stay	30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.southcarolinablues.com/web/nonsecure/sc/resources/10c3834b-df4b-4c83-9ff3-4de380f30cb5/BCBS%2520Individual%2520-%2520HD%2520Bronze%25203%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