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2018 BlueEssentials SM Silver Plans

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Page 1: 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

Page 2: 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

Benefi ts

SILVER 1 SILVER 2 SILVER 3

DeductibleIndividual: $690Family: $1,380

Individual: $3,000Family: $6,000

Individual: $3,500Family: $7,000

Coinsurance 50% 40% 25%

Out-of-Pocket MaximumIndividual: $7,350Family: $14,700

Individual: $6,600Family: $13,200

Individual: $6,500Family: $13,000

PCP $30 copay $25 copay $30 copay

Blue CareOnDemand $20 copay $15 copay $20 copay

Specialist $60 copay $50 copay $60 copay

Urgent Care (other than Doctors Care)

$60 copay $50 copay $60 copay

Emergency Room Services$300 copay per visit. Meet deductible, then 50% coinsurance.

40% coinsurance after deductible is met

$300 copay per visit. Meet deductible, then 25% coinsurance.

Inpatient Hospitalization50% coinsurance after deductible is met

40% coinsurance after deductible is met

25% coinsurance after deductible is met

Ambulatory Surgery Center $500 copay per visit $500 copay per visit $500 copay per visit

PHARMACY BENEFITS

Prescription Drugs (up to 30-day supply)

Tier 0: $0Tier 1: $30Tier 2: $60Tier 3: $100Tier 4: 30%

Tier 0: $0Tier 1: $10Tier 2: 40% coinsurance

after deductible is metTier 3: 40% coinsurance

after deductible is metTier 4: 40% coinsurance

after deductible is met

Tier 0: $0Tier 1: $12Tier 2: $40Tier 3: $125Tier 4: 30%

Mail Order (up to 90-day supply)

Tier 1: $42Tier 2: $162Tier 3: $270

Tier 1: $14Tier 2: 40% coinsurance

after deductible is metTier 3: 40% coinsurance

after deductible is met

Tier 1: $17Tier 2: $108Tier 3: $338

Page 3: 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

Benefi ts

SILVER 4 HD SILVER 5 HD SILVER 6

DeductibleIndividual: $3,100Family: $6,200

Individual: $3,300Family: $6,600

Individual: $4,300Family: $8,600

Coinsurance 30% 20% 0%

Out-of-Pocket MaximumIndividual: $7,350Family: $14,700

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

Individual: $4,300Family: $8,600

PCP$30 copay 20% coinsurance after

deductible is met0% coinsurance after deductible is met

Blue CareOnDemand$20 copay 20% coinsurance after

deductible is met0% coinsurance after deductible is met

Specialist$60 copay 20% coinsurance after

deductible is met0% coinsurance after deductible is met

Urgent Care (other than Doctors Care)

$60 copay 20% coinsurance after deductible is met

0% coinsurance after deductible is met

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

20% coinsurance after deductible is met

0% coinsurance after deductible is met

Inpatient Hospitalization30% coinsurance after deductible is met

20% coinsurance after deductible is met

0% coinsurance after deductible is met

Ambulatory Surgery Center$500 copay per visit 20% coinsurance after

deductible is met0% coinsurance after deductible is met

PHARMACY BENEFITS

Prescription Drugs (up to 30-day supply)

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

Tier 0: $0Tier 1: 20% coinsurance

after deductible is metTier 2: 20% coinsurance

after deductible is metTier 3: 20% coinsurance

after deductible is metTier 4: 20% coinsurance

after deductible is met

Tier 0: $0Tier 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

Mail Order (up to 90-day supply)

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

Tier 1: 20% coinsurance after deductible is met

Tier 2: 20% coinsurance after deductible is met

Tier 3: 20% coinsurance after deductible is met

Tier 1: 0% coinsurance after deductible is met

Tier 2: 0% coinsurance after deductible is met

Tier 3: 0% coinsurance after deductible is met

Page 4: 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

Benefi ts

SILVER 7 SILVER 8 SILVER 9

DeductibleIndividual: $6,400Family: $12,800

Individual: $5,250Family: $10,500

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

Coinsurance 25% 15% 50%

Out-of-Pocket MaximumIndividual: $7,150Family: $14,300

Individual: $6,700Family: $13,400

Individual: $6,850Family: $13,700

PCP$25 copay $10 for kids up to age 20;

$25 for those 20 and over$30 copay

Blue CareOnDemand $20 copay $10 copay $20 copay

Specialist $55 copay $40 copay $60 copay

Urgent Care (other than Doctors Care)

$55 copay $50 copay $60 copay

Emergency Room Services$300 copay per visit. Meet deductible, then 25% coinsurance.

$300 copay per visit. Meet deductible, then 15% coinsurance.

50% coinsurance after deductible is met

Inpatient Hospitalization25% coinsurance after deductible is met

15% coinsurance after deductible is met

50% coinsurance after deductible is met

Ambulatory Surgery Center $500 copay per visit $500 copay per visit $500 copay per visit

PHARMACY BENEFITS

Prescription Drugs (up to 30-day supply)

Tier 0: $0Tier 1: $7Tier 2: $45Tier 3: $150Tier 4: 25% coinsurance

after deductible is met

Tier 0: $0Tier 1: $10Tier 2: $30Tier 3: $100Tier 4: 30%

Tier 0: $0Tier 1: $20Tier 2: $50Tier 3: $100Tier 4: 30%

Mail Order (up to 90-day supply)

Tier 1: $10Tier 2: $122Tier 3: $405

Tier 1: $14Tier 2: $81Tier 3: $270

Tier 1: $28Tier 2: $135Tier 3: $270

Second-lowest cost Silver plan

Page 5: 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

Benefi ts

SILVER 10 SILVER 11 SILVER 12

DeductibleIndividual: $7,150Family: $14,300

Individual: $5,500Family: $11,000

Individual: $4,800Family: $9,600

Coinsurance 0% 20% 30%

Out-of-Pocket MaximumIndividual: $7,150Family: $14,300

Individual: $7,150Family: $14,300

Individual: $7,350Family: $14,700

PCP

$0 copay per visit on fi rst four visits, then 0% coinsurance after deductible is met

$15 copay $15 copay

Blue CareOnDemand0% coinsurance after deductible is met

$5 copay $5 copay

Specialist0% coinsurance after deductible is met

20% coinsurance after deductible is met

30% coinsurance after deductible is met

Urgent Care (other than Doctors Care)

0% coinsurance after deductible is met

20% coinsurance after deductible is met

30% coinsurance after deductible is met

Emergency Room Services0% coinsurance after deductible is met

20% coinsurance after deductible is met

30% coinsurance after deductible is met

Inpatient Hospitalization0% coinsurance after deductible is met

20% coinsurance after deductible is met

30% coinsurance after deductible is met

Ambulatory Surgery Center $500 copay per visit $500 copay per visit $500 copay per visit

PHARMACY BENEFITS

Prescription Drugs (up to 30-day supply)

Tier 0: $0Tier 1: $5Tier 2: $50Tier 3: $100Tier 4: 30%

Tier 0: $0Tier 1: $5Tier 2: $50Tier 3: $100Tier 4: 30%

Tier 0: $0Tier 1: $10Tier 2: $50Tier 3: $100Tier 4: 30%

Mail Order (up to 90-day supply)

Tier 1: $7Tier 2: $135Tier 3: $270

Tier 1: $7Tier 2: $135Tier 3: $270

Tier 1: $14Tier 2: $135Tier 3: $270

Lowest cost Silver plan

Page 6: 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

Benefi ts

HD SILVER 13 SILVER 14

DeductibleIndividual: $4,550Family: $9,100

Individual: $6,650Family: $13,300

Coinsurance 0% 15%

Out-of-Pocket MaximumIndividual: $4,550Family: $9,100

Individual: $7,150Family: $14,300

PCP0% coinsurance after deductible is met

$20 copay

Blue CareOnDemand0% coinsurance after deductible is met

$20 copay

Specialist0% coinsurance after deductible is met

$50 copay

Urgent Care (other than Doctors Care)

0% coinsurance after deductible is met

$50 copay

Emergency Room Services0% coinsurance after deductible is met

$300 copay per visit. Meet deductible, then 15% coinsurance.

Inpatient Hospitalization0% coinsurance after deductible is met

15% coinsurance after deductible is met

Ambulatory Surgery Center0% coinsurance after deductible is met

$500 copay per visit

PHARMACY BENEFITS

Prescription Drugs (up to 30-day supply)

Tier 0: $0Tier 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: $10Tier 2: $40Tier 3: 15% coinsurance

after deductible is metTier 4: 15% coinsurance

after deductible is met

Mail Order (up to 90-day supply)

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: $14Tier 2: $108Tier 3: 15% coinsurance

after deductible is met

Page 7: 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

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


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