BlueEssentials Standard Silver – EPO

Network type: EPO
Coverage tier: Silver
Primary care visit: $40 copay
Specialist visit: $80 copay
Urgent care visit: $60 copay

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Description

Health Care Plan Details

Network type EPO
Deductible $5,900 per person $5,900 per person
Out-of-pocket max $9,100 per person $18,200 per family
Metal tier Silver

Visit Copay

Primary care visit $40 copay
Specialist visit $80 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $60 copay
Emergency room 40% coinsurance after deductible
Ambulance 40% coinsurance after deductible
Hospital stay (facility) 40% coinsurance after deductible
Hospital stay (physician) 40% coinsurance after deductible
Outpatient procedure (facility) 40% coinsurance after deductible
Outpatient procedure (physician) 40% coinsurance after deductible
Physical rehabilitation $40 copay

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 40% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic $20 copay
Brand This is the amount you will pay for a generic drug prescription.
Non-preferred Brand $80 copay after deductible
Specialty This is the amount you will pay for a generic drug prescription.

Lab Tests and Diagnostic Procedures

X-rays 40% coinsurance after deductible
Imaging (CT/PET/MRI) 40% coinsurance after deductible
Blood work 40% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services $40 copay
Psychiatric hospital stay 40% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://www.southcarolinablues.com/web/nonsecure/sc/resources/5c0c4b6b-7590-420d-80fc-c6251d5f6411/BlueEssentials+Standard+-+Silver++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