2018 BlueEssentialsSM Gold Plans - South Carolina …30 for those 20 and over Blue CareOnDemand $5...

3
2018 BlueEssentials SM Gold Plans

Transcript of 2018 BlueEssentialsSM Gold Plans - South Carolina …30 for those 20 and over Blue CareOnDemand $5...

Page 1: 2018 BlueEssentialsSM Gold Plans - South Carolina …30 for those 20 and over Blue CareOnDemand $5 copay $5 copay 0% coinsurance after ... age, sex, gender identity, sexual orientation

2018 BlueEssentialsSM Gold Plans

Page 2: 2018 BlueEssentialsSM Gold Plans - South Carolina …30 for those 20 and over Blue CareOnDemand $5 copay $5 copay 0% coinsurance after ... age, sex, gender identity, sexual orientation

Benefi ts

GOLD 1 GOLD 2 HD GOLD 3 GOLD 4

DeductibleIndividual: $2,000Family: $4,000

Individual: $1,000Family: $2,000

Individual: $2,700Family: $5,400

Individual: $2,700Family: $5,400

Coinsurance 20% 30% 0% 20%

Out-of-Pocket MaximumIndividual: $4,500Family: $9,000

Individual: $5,000Family: $10,000

Individual: $2,700Family: $5,400*

Individual: $5,600Family: $11,200

PCP$15 copay $20 copay 0% coinsurance after

deductible is met$10 for kids up to age 20; $30 for those 20 and over

Blue CareOnDemand$5 copay $5 copay 0% coinsurance after

deductible is met$10 copay

Specialist$30 copay $40 copay 0% coinsurance after

deductible is met$40 copay

Urgent Care (other than Doctors Care)

$50 copay $50 copay 0% coinsurance after deductible is met

$40 copay

Emergency Room Services$300 copay per visit. Meet deductible, then 20% coinsurance.

$300 copay per visit. Meet deductible, then 30% coinsurance.

0% coinsurance after deductible is met

$300 copay per visit. Meet deductible, then 20% coinsurance.

Inpatient Hospitalization20% after deductible is met

30% after deductible is met

0% coinsurance after deductible is met

20% coinsurance after deductible is met

Ambulatory Surgery Center$500 copay per visit $500 copay per visit 0% coinsurance after

deductible is met$500 copay per visit

PHARMACY BENEFITS

Prescription Drugs (up to 30-day supply)

Tier 0: $0Tier 1: $12Tier 2: $35Tier 3: $100Tier 4: 30%

Tier 0: $0Tier 1: $20Tier 2: $40Tier 3: $100Tier 4: 30%

Tier 0: $0 Tier 1: 0% coinsurance

after deductible is metTier 2: 0% coinsurance

after deductible is metTier 3: 0% coinsurance

after deductible is metTier 4: 0% coinsurance

after deductible is met

Tier 0: $0Tier 1: $8Tier 2: $40Tier 3: $100Tier 4: 30%

Mail Order (up to 90-day supply)

Tier 1: $17Tier 2: $95Tier 3: $270

Tier 1: $28Tier 2: $108Tier 3: $270

Tier 1: 0% coinsurance after deductible is met

Tier 2: 0% coinsurance after deductible is met

Tier 3: 0% coinsurance after deductible is met

Tier 1: $11Tier 2: $108Tier 3: $270

* The HD Gold 3 out-of-pocket maximum for a family is $5,400 per person, or $5,400 when collectively satisfi ed by all family members.

Page 3: 2018 BlueEssentialsSM Gold Plans - South Carolina …30 for those 20 and over Blue CareOnDemand $5 copay $5 copay 0% coinsurance after ... age, sex, gender identity, sexual orientation

BlueCross BlueShield of South Carolina does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in the

administration of the plan, including enrollment and benefit determinations.

Have Questions?

Call 877-313-BLUE (2583) and an enrollment counselor can help you.

Visit a South Carolina BLUESM retail center near you.

Go towww.SouthCarolinaBlues.com

www.SCBlueRetailCenters.com

Columbia1260 Bower ParkwaySuite A4Columbia, SC855-592-BLUE (2583)

Greenville1025 Woodruff RoadSuite A105Greenville, SC855-392-BLUE (2583)

Mount PleasantTowne Centre Place1795 Highway 17 North, Unit 7Mount Pleasant, SC855-492-BLUE (2583)

Look for one of the South Carolina BLUE RVs at a location near you.

SC Blue RVs 855-382-BLUE (2583) | [email protected]

114950-10-17


Blue Care Elect Preferred 90 Copay (PPO)...If you need immediate medical attention Urgent care $20 / visit 20% coinsurance Deductible applies first for out-of-network Facility fee

Blue Care Elect Preferred 90 Copay (PPO)...If you need immediate medical attention Urgent care $20 / visit 20% coinsurance Deductible applies first for out-of-network Facility fee

Extra Benefits · Diagnostic Services: $0 copay Restorative Services: $0 copay Endodontic services: $0 copay Periodontics: $0 copay Extractions: $0 copay Prosthodontics: $0 copay

Extra Benefits · Diagnostic Services: $0 copay Restorative Services: $0 copay Endodontic services: $0 copay Periodontics: $0 copay Extractions: $0 copay Prosthodontics: $0 copay

DrCare DrExtra · Emergency Coverage $75 copay, waived if admitted Urgent Care Facility $0 copay Worldwide Emergency and Urgent Care coverage $125 copay ER and $25 copay UC, up to

DrCare DrExtra · Emergency Coverage $75 copay, waived if admitted Urgent Care Facility $0 copay Worldwide Emergency and Urgent Care coverage $125 copay ER and $25 copay UC, up to

ENEFITS OOKLET - Maine€¦ · -Day Supply 90-Day Supply Generic copay $10 $15 Preferred brand copay $30 $45 -preferred brand copay $45 $70 Specialty coinsurance 25% ($150 max) 25%

ENEFITS OOKLET - Maine€¦ · -Day Supply 90-Day Supply Generic copay $10 $15 Preferred brand copay $30 $45 -preferred brand copay $45 $70 Specialty coinsurance 25% ($150 max) 25%

Vilhauer Enterprises...(MRI, MRA, Pet Scans, CT Scans, etc.) 30% coinsurance, after deductible 25% coinsurance, Hospital Services 30% coinsurance, after deductible 25% coinsurance,

Vilhauer Enterprises...(MRI, MRA, Pet Scans, CT Scans, etc.) 30% coinsurance, after deductible 25% coinsurance, Hospital Services 30% coinsurance, after deductible 25% coinsurance,

Formulary Access for Patients with Diabetesphrma-docs.phrma.org/.../files/pdf/burden-diabetes-2016.pdfAntidiabetics=Antidiabetic Agents 2016 Copay 2016 Coinsurance Maximum 70% $53

Formulary Access for Patients with Diabetesphrma-docs.phrma.org/.../files/pdf/burden-diabetes-2016.pdfAntidiabetics=Antidiabetic Agents 2016 Copay 2016 Coinsurance Maximum 70% $53

Maine Bureau of Insurance€¦  · Web viewCoverage that supplements employer group major medical coverage by providing coverage of deductible, coinsurance or copay must …

Maine Bureau of Insurance€¦  · Web viewCoverage that supplements employer group major medical coverage by providing coverage of deductible, coinsurance or copay must …

Summary of Benefits and Coverage - WordPress.com · Specialist visit 20% coinsurance 40% coinsurance None Preventive care/screening/ immunization No charge 40% coinsurance You may

Summary of Benefits and Coverage - WordPress.com · Specialist visit 20% coinsurance 40% coinsurance None Preventive care/screening/ immunization No charge 40% coinsurance You may

VFC VFC DESC PROV TXT MEM TXT LENGTH OF 0001 SVCS … · 2020. 10. 1. · VFC VFC_DESC PROV_TXT MEM_TXT LENGTH OF MEMBER TEXT 0000 $15.00 + 30% NPAR COPAY A $15 and 30% coinsurance

VFC VFC DESC PROV TXT MEM TXT LENGTH OF 0001 SVCS … · 2020. 10. 1. · VFC VFC_DESC PROV_TXT MEM_TXT LENGTH OF MEMBER TEXT 0000 $15.00 + 30% NPAR COPAY A $15 and 30% coinsurance

Summary of Benefits and Coverage: What this Covers & What ...williamstanklines.com/careers/anthemSBC.pdf20% coinsurance 40% coinsurance -----none-----Specialist visit 20% coinsurance

Summary of Benefits and Coverage: What this Covers & What ...williamstanklines.com/careers/anthemSBC.pdf20% coinsurance 40% coinsurance -----none-----Specialist visit 20% coinsurance

CALCPA HEALTH PLAN EZ GUIDE€¦ · The Group Insurance Trust of the California Society of CPA’s is a ... 24 hours a day ... • 35/1000/40% $35 copay, 40% coinsurance, ...

CALCPA HEALTH PLAN EZ GUIDE€¦ · The Group Insurance Trust of the California Society of CPA’s is a ... 24 hours a day ... • 35/1000/40% $35 copay, 40% coinsurance, ...

2018 BlueEssentialsSM Silver Plans - South Carolina … $30 copay $25 copay $30 copay Blue CareOnDemand $20 copay $15 copay $20 copay ... age, sex, gender identity, sexual orientation

2018 BlueEssentialsSM Silver Plans - South Carolina … $30 copay $25 copay $30 copay Blue CareOnDemand $20 copay $15 copay $20 copay ... age, sex, gender identity, sexual orientation

Extra Benefits - AR Health & Wellness...Diagnostic services: $0 copay Restorative services: 20% coinsurance Endodontic services: 20% coinsurance Periodontics: 20% - 50% coinsurance

Extra Benefits - AR Health & Wellness...Diagnostic services: $0 copay Restorative services: 20% coinsurance Endodontic services: 20% coinsurance Periodontics: 20% - 50% coinsurance

Extra Benefits - Peach State Health Plan Inc...Diagnostic services: $0 copay Restorative services: $0 copay Endodontics: $0 copay Periodontics: $0 copay Extractions: $0 copay Prosthodontics:

Extra Benefits - Peach State Health Plan Inc...Diagnostic services: $0 copay Restorative services: $0 copay Endodontics: $0 copay Periodontics: $0 copay Extractions: $0 copay Prosthodontics:

deductible? network providers: $6,700 meet their own ...$750 Copay per day with deductible 50% Coinsurance Prior authorization may be required. Physician/surgeon fees No charge 50%

deductible? network providers: $6,700 meet their own ...$750 Copay per day with deductible 50% Coinsurance Prior authorization may be required. Physician/surgeon fees No charge 50%

FSSA OMPP PPT Template - IN.gov secondary... · 2019. 5. 31. · • When TPL has applied the entire amount to the copay, coinsurance, or deductible, and no ... 38 Residential substance

FSSA OMPP PPT Template - IN.gov secondary... · 2019. 5. 31. · • When TPL has applied the entire amount to the copay, coinsurance, or deductible, and no ... 38 Residential substance

Extra Benefits - Health Net · Diagnostic services: $0 -$15 copay Restorative services: $0 - $300 copay Endodontics: $5 - $275 copay Periodontics: $0 - $375 copay Extractions: $15

Extra Benefits - Health Net · Diagnostic services: $0 -$15 copay Restorative services: $0 - $300 copay Endodontics: $5 - $275 copay Periodontics: $0 - $375 copay Extractions: $15

837 MOOP Reporting Hands On - etouches · MOOP Reporting 1. Member Out Of Pocket (MOOP) reporting requirement is mandated by the Affordable Care Act. 2. Copay + Coinsurance + Deductible

837 MOOP Reporting Hands On - etouches · MOOP Reporting 1. Member Out Of Pocket (MOOP) reporting requirement is mandated by the Affordable Care Act. 2. Copay + Coinsurance + Deductible

Short Term Medical Plans - Health Insurance Plans ...Highlights of Network Covered Expenses 1 For copay plans, non-network office visits subject to deductible and coinsurance, $50

Short Term Medical Plans - Health Insurance Plans ...Highlights of Network Covered Expenses 1 For copay plans, non-network office visits subject to deductible and coinsurance, $50

NEED MORE? GET MORE....dentist not in the Cigna network, you may need to submit the claim yourself. We review the claim and will refund your copay or coinsurance for eligible dental

NEED MORE? GET MORE....dentist not in the Cigna network, you may need to submit the claim yourself. We review the claim and will refund your copay or coinsurance for eligible dental