BlueEssentials Silver 39 – EPO
94% cost sharing reduction [Popular Plan]
Network type: EPO
Coverage tier: Silver
Primary care visit: $8 copay
Specialist visit: $9 copay
Urgent care visit: $9 copay
Description
This plan has 94% 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 | $8 copay |
| Specialist visit | $9 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $9 copay |
| Emergency room | $130 copay |
| Ambulance | $12 copay |
| Hospital stay (facility) | $250 copay per Day |
| Hospital stay (physician) | $9 copay |
| Outpatient procedure (facility) | $12 copay |
| Outpatient procedure (physician) | $5 copay |
| Physical rehabilitation | $20 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 20% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $2 copay |
| Brand | This is the amount you will pay for a generic drug prescription. |
| Non-preferred Brand | 50% coinsurance |
| Specialty | This is the amount you will pay for a generic drug prescription. |
Lab Tests and Diagnostic Procedures
| X-rays | $10 copay |
| Imaging (CT/PET/MRI) | $29 copay |
| Blood work | $2 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $8 copay |
| Psychiatric hospital stay | $250 copay per Day |
Health Plan Provider Information
| Health Plan Benefits | https://www.southcarolinablues.com/web/nonsecure/sc/resources/cbbebebb-6e89-43b2-ac6b-ea28a8b87e60/BCBS+Individual+-+Silver+39+-+FPL+100-150+%28CS3%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 |
