BlueEssentials Silver 39 – EPO
87% cost sharing reduction [Popular Plan]
Network type: EPO
Coverage tier: Silver
Primary care visit: $30 copay
Specialist visit: $55 copay
Urgent care visit: $55 copay
Description
This plan has 87% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | EPO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $3,150 per person $6,300 per family |
| Metal tier | Silver |
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 | $900 copay |
| Ambulance | $68 copay |
| Hospital stay (facility) | $1500 copay per Day |
| Hospital stay (physician) | $55 copay |
| Outpatient procedure (facility) | $68 copay |
| Outpatient procedure (physician) | $35 copay |
| Physical rehabilitation | $35 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 20% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $12 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 | $68 copay |
| Imaging (CT/PET/MRI) | $200 copay |
| Blood work | $19 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $30 copay |
| Psychiatric hospital stay | $1500 copay per Day |
Health Plan Provider Information
| Health Plan Benefits | https://www.southcarolinablues.com/web/nonsecure/sc/resources/577dc8ee-9603-45a7-8940-a1b4a3a6c052/BCBS+Individual+-+Silver+39+-+FPL+151-200+%28CS2%29+2024.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 |
