BlueCross BlueShield of South Carolina

BlueEssentials Gold 4

Plan Overview

Medical Deductible
  • Individual: $3,000
  • Family: $6,000
  • Per Person: $3,000
Prescription Drug Deductible
  • Individual: $0
  • Family: $0
  • Per Person: $0
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $7,000
  • Family: $14,000
  • Per Person: $7,000

Office Visit

Primary Doctor
  • CoPay: $30.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: You can save time and reduce your copay by consulting a physician using the telehealth service, Blue CareOnDemand. See our brochure or visit www.BlueCareOnDemandSC.com for more details.
Specialist
  • CoPay: $55.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: $40.00
  • CoInsurance: Not Applicable
  • Covered: Covered
Non Preferred Brand Drugs
  • CoPay: $100.00
  • CoInsurance: Not Applicable
  • Covered: Covered
Generic Drugs
  • CoPay: $10.00
  • CoInsurance: Not Applicable
  • Covered: Covered
Specialty Drugs
  • CoPay: No Charge after deductible
  • CoInsurance: 35.00% Coinsurance after deductible
  • Covered: Covered

Inpatient Coverage

Hospital Services
  • CoPay: No Charge after deductible
  • CoInsurance: 35.00% Coinsurance after deductible
  • Covered: Covered
Inpatient Services
  • CoPay: No Charge after deductible
  • CoInsurance: 35.00% Coinsurance after deductible
  • Covered: Covered

Emergency and Urgent Care

Emergency Room
  • CoPay: $300.00 Copay with deductible
  • CoInsurance: 35.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: An out-of-Network Provider may Balance-Bill you for the difference between the Allowed Amount we pay and their billed charge.
Urgent Care Facility
  • CoPay: $55.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Services rendered at Doctors Care facilities are provided at in-network Primary Care benefits. An out-of-Network Provider may Balance-Bill you for the difference between the Allowed Amount we pay and their billed charge.

Maternity

Labor and Delivery Hospital Stay
  • CoPay: No Charge after deductible
  • CoInsurance: 35.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: No Preauthorization is required for the mother's hospitalization related to the delivery of a newborn child when the mother's hospital stay is 48 hours or less for a vaginal birth or 96 hours or less for a cesarean section. Confinements exceeding these limits require Preauthorization.
Pre and Postnatal Office Visit
  • CoPay: No Charge after deductible
  • CoInsurance: 35.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Prenatal and postnatal care will be covered after artificial insemination or in-vitro fertilization, but the actual insemination/fertilization is not covered.

Vision

Routine Eye Exams For Children
  • CoPay: $25.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Exam(s) per Year

Major Dental Care

Routine Dental Checkups for Children
  • Covered: Not Covered
Basic Dental Care - Child
  • Covered: Not Covered
Major Dental Care - Child
  • Covered: Not Covered
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
HealthMarkets is an authorized agent of BlueCross BlueShield of South Carolina.
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We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN26065SC0380021ACA1

© 2024 HealthMarkets Insurance Agency. All rights reserved.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN26065SC0380021ACA1

© 2024 HealthMarkets Insurance Agency. All rights reserved.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN26065SC0380021ACA1