BlueExtend PPO Standard Silver
BlueCross BlueShield of South Carolina
Plan overview
Medical deductible
Individual: $6000
Family: $12000
Per Person: $6000
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $8900
Family: $17800
Per Person: $8900
Office visit
Primary Doctor
CoPay: $40.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: You can save time by consulting a physician using the telehealth service, Blue CareOnDemand. See our brochure or visit www.BlueCareOnDemandSC.com for more details.
Specialist
CoPay: $80.00
CoInsurance: Not Applicable
Covered: Covered
Prescription drug information
Preferred brand drugs
CoPay: $40.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits or prior authorization are required for some covered drugs. See Covered Drugs List for details.
Non preferred brand drugs
CoPay: $80.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits or prior authorization are required for some covered drugs. See Covered Drugs List for details.
Generic drugs
CoPay: $20.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits or prior authorization are required for some covered drugs. See Covered Drugs List for details.
Specialty drugs
CoPay: $350.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits or prior authorization are required for some covered drugs. See Covered Drugs List for details.
Inpatient coverage
Hospital services
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Inpatient services
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Emergency and urgent care
Emergency room
CoPay: Not Applicable
CoInsurance: 40.00% 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: $60.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Out-of-Network Providers may Balance-Bill you for the difference between the Allowed Amount we pay and their billed charge.
Maternity
Labor and delivery hospital stay
CoPay: Not Applicable
CoInsurance: 40.00% 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: Not Applicable
CoInsurance: 40.00% 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
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).
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