Blue Pee Dee Silver 2 + Adult Vision - 26065SC0730009 Health Insurance Plan

Blue Cross and Blue Shield of South Carolina health insurance plan with the Plan ID 26065SC0730009. The plan is called Blue Pee Dee Silver 2 + Adult Vision.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.13% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.87% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.

Health Insurance Plan ID 26065SC0730009
Health Insurance Plan Year 2025
State South Carolina
Health Insurance Issuer Blue Cross and Blue Shield of South Carolina
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 26065SC0730009-03
Provider Network(s) PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT).

Providers South Carolina All US States
All 21200 27635
PCP 3630 5040
Allergy 15 22
OB/GYN 157 221
Dentists 770 875
Available Variants of the Health Plan

Standard Off Exchange Plan - 26065SC0730009-00

Standard On Exchange Plan - 26065SC0730009-01

Open to Indians below 300% FPL - 26065SC0730009-02

Open to Indians above 300% FPL - 26065SC0730009-03

73% AV Silver Plan - 26065SC0730009-04

87% AV Silver Plan - 26065SC0730009-05

94% AV Silver Plan - 26065SC0730009-06

Last Plan Update Date Fri, 25 Oct 2024 00:00 GMT
Last Import Date Thu, 21 Nov 2024 00:44 GMT

Benefits of Blue Pee Dee Silver 2 + Adult Vision Health Insurance Plan, 26065SC0730009-03

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 500.0 Dollars per Benefit Period

YES

$25.00

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care

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.

YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education

Diabetes self-management training and education will be provided on an outpatient basis when done by a registered or licensed health care professional that is certified in diabetes.

YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Dialysis
YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

A replacement DME is covered when due to a change in medical condition.

YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Emergency Room Services

An out-of-Network Provider may Balance-Bill you for the difference between the Allowed Amount we pay and their billed charge.

YES

$300.00 Copay with deductible, 50.00% Coinsurance after deductible

$300.00 Copay with deductible, 50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Frames and lenses are limited to 1 set per year.

YES

$50.00

100.00%
Gender Affirming Care
NO
Generic Drugs

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.

YES

$12.00

100.00%
Habilitation Services

Limit: 30.0 Visit(s) per Benefit Period

Habilitation services are health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Habilitative therapies are combined for a maximum 30 visits per Benefit Period.

YES

$8.00

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 60.0 Visit(s) per Benefit Period

YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Hospice Services

Limit: 6.0 Months per Episode

YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services

The cost sharing that displays applies to outpatient office visits only. All other outpatient services (e.g., intensive outpatient and partial hospitalization programs) may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

YES

$20.00

100.00%
Non-Preferred Brand Drugs

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.

YES

$320.00

100.00%
Nutritional Counseling
YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$20.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 30.0 Visit(s) per Benefit Period

Physical, speech and occupational rehabilitative therapy are combined for a maximum 30 visits per Benefit Period, other than inpatient therapy.

YES

$8.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

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.

YES

$160.00

100.00%
Prenatal and Postnatal Care

Prenatal and postnatal care will be covered after artificial insemination or in-vitro fertilization, but the actual insemination/fertilization is not covered.

YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization

As required by USPSTF, CDC and HRSA, and including OBGYN exams (limit 2 per year), mammography services, pap smear services, prostate services, and routine colorectal cancer screening/testing.

YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness

When you use your network's telehealth service, there is no charge for your first 4 telehealth office visits. Starting with the 5th visit, a copay applies. See Schedule of Benefits for details.

YES

$20.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Radiation
YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Reconstructive Surgery that is considered a Covered Expense is limited to Surgery: To correct a functional defect that results from a birth defect, disease and anomaly; or Performed to correct a seriously disfiguring condition resulting from injury; or For breast reconstruction after a mastectomy.

YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 30.0 Visit(s) per Benefit Period

Physical, speech and occupational rehabilitative therapy are combined for a maximum 30 visits per Benefit Period, other than inpatient therapy.

YES

$8.00

100.00%
Rehabilitative Speech Therapy

Limit: 30.0 Visit(s) per Benefit Period

Physical, speech and occupational rehabilitative therapy are combined for a maximum 30 visits per Benefit Period, other than inpatient therapy.

YES

$8.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)

Limit: 1.0 Exam(s) per Year

Frames and lenses are limited to 1 set per year.

YES

$25.00

100.00%
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

YES

$25.00

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 60.0 Days per Benefit Period

You must be admitted to a Skilled Nursing Facility within 14 days of discharge from an approved hospital admission.

YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$40.00

100.00%
Specialty Drugs

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.

YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$20.00

100.00%
Transplant
YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities

An out-of-Network Provider may Balance-Bill you for the difference between the Allowed Amount we pay and their billed charge.

YES

$40.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

No Charge after deductible, 50.00% Coinsurance after deductible

100.00%

Blue Pee Dee Silver 2 + Adult Vision Health Insurance Plan Variant 26065SC0730009-03 Attributes

Plan Attribute Value
AV Calculator Output Number 0.7113492533434971
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2025
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Limited Cost Sharing Plan Variation
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 0.9962
First Tier Utilization 100%
Formulary ID SCF014
Formulary URL URL
HIOS Product ID 26065SC073
Import Date 2024-10-25 01:01:42
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan New
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 26065
Issuer Marketplace Marketing Name BlueCross BlueShield of South Carolina
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Silver
Multiple In Network Tiers No
National Network No
Network ID SCN006
Out of Country Coverage No
Out of Country Coverage Description Benefits are available only for emergency medical conditions. Special pricing may be available through a Blue Cross Blue Shield Global Core provider.
Out of Service Area Coverage No
Out of Service Area Coverage Description Benefits are available only for emergency medical conditions when treated in an outpatient hospital emergency room or urgent treatment center, or for urgent conditions when treated in an urgent treatment center. Special pricing may be available through a BlueCard provider.
Plan Brochure URL
Plan Effective Date 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 26065SC0730009-03
Plan Marketing Name Blue Pee Dee Silver 2 + Adult Vision
Plan Type HMO
Plan Variant Marketing Name Blue Pee Dee Silver 2 + Adult Vision
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $900
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $7,900
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $3,500
SBC Scenario, Having Diabetes, Deductible $900
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $200
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,100
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID SCS005
Source Name HIOS
Plan ID 26065SC0730009
State Code SC
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 50.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $15800 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $7900 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $7,900
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Individual Not Applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $17600 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8800 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,800
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual Not Applicable
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered Yes

Copay & Coinsurance of Blue Pee Dee Silver 2 + Adult Vision Health Insurance Plan, 26065SC0730009

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Blue Pee Dee Silver 2 + Adult Vision, 26065SC0730009 Health Insurance Plan, 26065SC0730009

  • Does Blue Pee Dee Silver 2 + Adult Vision Health Insurance Plan, 26065SC0730009 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (26065SC0730009) Health Insurance Plan, Variant (26065SC0730009-03) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pregnancy, Weight Loss Programs

    Does (26065SC0730009) Health Insurance Plan, Variant (26065SC0730009-03) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan). Details: Benefits are available only for emergency medical conditions. Special pricing may be available through a Blue Cross Blue Shield Global Core provider.

    Does (26065SC0730009) Health Insurance Plan, Variant (26065SC0730009-03) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan). Details: Benefits are available only for emergency medical conditions when treated in an outpatient hospital emergency room or urgent treatment center, or for urgent conditions when treated in an urgent treatment center. Special pricing may be available through a BlueCard provider.

    Does (26065SC0730009) Health Insurance Plan, Variant (26065SC0730009-03) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pregnancy, Weight Loss Programs

    Does Blue Pee Dee Silver 2 + Adult Vision Health Insurance Plan, Variant (26065SC0730009-03) offer Disease Management Programs for Asthma?

    Yes, the Blue Pee Dee Silver 2 + Adult Vision Health Insurance Plan Variant 26065SC0730009-03 offers Disease Management Program for Asthma.

    Does Blue Pee Dee Silver 2 + Adult Vision Health Insurance Plan, Variant (26065SC0730009-03) offer Disease Management Programs for Heart disease?

    Yes, the Blue Pee Dee Silver 2 + Adult Vision Health Insurance Plan Variant 26065SC0730009-03 offers Disease Management Program for Heart disease.

    Does Blue Pee Dee Silver 2 + Adult Vision Health Insurance Plan, Variant (26065SC0730009-03) offer Disease Management Programs for Depression?

    Yes, the Blue Pee Dee Silver 2 + Adult Vision Health Insurance Plan Variant 26065SC0730009-03 offers Disease Management Program for Depression.

    Does Blue Pee Dee Silver 2 + Adult Vision Health Insurance Plan, Variant (26065SC0730009-03) offer Disease Management Programs for Diabetes?

    Yes, the Blue Pee Dee Silver 2 + Adult Vision Health Insurance Plan Variant 26065SC0730009-03 offers Disease Management Program for Diabetes.

    Does Blue Pee Dee Silver 2 + Adult Vision Health Insurance Plan, Variant (26065SC0730009-03) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Blue Pee Dee Silver 2 + Adult Vision Health Insurance Plan Variant 26065SC0730009-03 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Blue Pee Dee Silver 2 + Adult Vision Health Insurance Plan, Variant (26065SC0730009-03) offer Disease Management Programs for Low back pain?

    Yes, the Blue Pee Dee Silver 2 + Adult Vision Health Insurance Plan Variant 26065SC0730009-03 offers Disease Management Program for Low back pain.

    Does Blue Pee Dee Silver 2 + Adult Vision Health Insurance Plan, Variant (26065SC0730009-03) offer Disease Management Programs for Pregnancy?

    Yes, the Blue Pee Dee Silver 2 + Adult Vision Health Insurance Plan Variant 26065SC0730009-03 offers Disease Management Program for Pregnancy.

    Does Blue Pee Dee Silver 2 + Adult Vision Health Insurance Plan, Variant (26065SC0730009-03) offer Disease Management Programs for Weight loss programs?

    Yes, the Blue Pee Dee Silver 2 + Adult Vision Health Insurance Plan Variant 26065SC0730009-03 offers Disease Management Program for Weight loss programs.

 

Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API