BlueEssentials Silver 39 - 26065SC0380050 Health Insurance Plan
Blue Cross and Blue Shield of South Carolina health insurance plan with the Plan ID 26065SC0380050. The plan is called BlueEssentials Silver 39.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 73.49% (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 26.51% 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 | 26065SC0380050 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| 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 | 26065SC0380050-04 | ||||||||||||||||||
| 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). |
|
||||||||||||||||||
| Available Variants of the Health Plan | Standard Off Exchange Plan - 26065SC0380050-00 Standard On Exchange Plan - 26065SC0380050-01 Open to Indians below 300% FPL - 26065SC0380050-02 Open to Indians above 300% FPL - 26065SC0380050-03 73% AV Silver Plan - 26065SC0380050-04 |
||||||||||||||||||
| Last Plan Update Date | Tue, 19 Dec 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of BlueEssentials Silver 39 Health Insurance Plan, 26065SC0380050-04
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | No Charge, 20.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge, 20.00% |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | No Charge, 20.00% |
100.00% |
| Chiropractic Care
Coverage for chiropractic services can be purchased separately. If you?re interested in further details, you may call 855-404-6752. |
NO | ||
| 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, 20.00% |
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, 20.00% |
100.00% |
| Dialysis
|
YES | No Charge, 20.00% |
100.00% |
| Durable Medical Equipment
A replacement DME is covered when due to a change in medical condition. |
YES | $140.00 |
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 | $1,600.00 |
$1,600.00 |
| Emergency Transportation/Ambulance
|
YES | $140.00 |
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. Six tier levels apply to prescription drug coverage. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits may apply. See Covered Drugs List. |
YES | $28.00 |
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 | $90.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 60.0 Visit(s) per Benefit Period |
YES | No Charge, 20.00% |
100.00% |
| Hospice Services
Limit: 6.0 Months per Episode |
YES | No Charge, 20.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $400.00 |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | No Charge, 20.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $1900.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | $90.00 |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $40.00 |
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 | $1900.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $30.00 |
100.00% |
| Non-Preferred Brand Drugs
Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. Six tier levels apply to prescription drug coverage. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits may apply. See Covered Drugs List. |
YES | No Charge after deductible, 50.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | No Charge, 20.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Facility charges for approved surgeries performed at designated Ambulatory Surgical Centers (ASC) are subject only to a copay; deductible and coinsurance will not apply to the ASC facility charge. |
YES | $140.00 |
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 | $90.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $100.00 |
100.00% |
| Preferred Brand Drugs
Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. Six tier levels apply to prescription drug coverage. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits may apply. See Covered Drugs List. |
YES | $125.00 |
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, 20.00% |
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
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. |
YES | $30.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | No Charge, 20.00% |
100.00% |
| Radiation
|
YES | No Charge, 20.00% |
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, 20.00% |
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 | $90.00 |
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 | $90.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| 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 | $1900.00 Copay per Day |
100.00% |
| Specialist Visit
|
YES | $90.00 |
100.00% |
| Specialty Drugs
Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. Six tier levels apply to prescription drug coverage. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits may apply. See Covered Drugs List. |
YES | No Charge after deductible, 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $1900.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $30.00 |
100.00% |
| Transplant
|
YES | No Charge, 20.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
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. |
YES | $90.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $130.00 |
100.00% |
BlueEssentials Silver 39 Health Insurance Plan Variant 26065SC0380050-04 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7349097035360551 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | 73% AV Level Silver Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $1000 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $500 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $500 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | SCF012 |
| Formulary URL | URL |
| HIOS Product ID | 26065SC038 |
| Import Date | 2023-12-19 01:01:03 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 2 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| 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 | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 20.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | SCN001 |
| 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 |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 26065SC0380050-04 |
| Plan Marketing Name | BlueEssentials Silver 39 |
| Plan Type | EPO |
| Plan Variant Marketing Name | BlueEssentials Silver 39 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $500 |
| SBC Scenario, Having a Baby, Copayment | $2,700 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $1,300 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $500 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $80 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | SCS001 |
| Source Name | HIOS |
| Plan ID | 26065SC0380050 |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $13000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,500 |
| 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 | No |
Copay & Coinsurance of BlueEssentials Silver 39 Health Insurance Plan, 26065SC0380050
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about BlueEssentials Silver 39, 26065SC0380050 Health Insurance Plan, 26065SC0380050
-
Does BlueEssentials Silver 39 Health Insurance Plan, 26065SC0380050 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (26065SC0380050) Health Insurance Plan, Variant (26065SC0380050-04) have Out Of Country Coverage?
Does (26065SC0380050) Health Insurance Plan, Variant (26065SC0380050-04) have Out of Service Area Coverage?
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