BlueExtend PPO HD Silver 1 - 26065SC0750003 Health Insurance Plan
Blue Cross and Blue Shield of South Carolina health insurance plan with the Plan ID 26065SC0750003. The plan is called BlueExtend PPO HD Silver 1.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.81% (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 28.19% 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 | 26065SC0750003 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 26065SC0750003-00 | ||||||||||||||||||
| 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). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 26065SC0750003-00 Standard On Exchange Plan - 26065SC0750003-01 Open to Indians below 300% FPL - 26065SC0750003-02 Open to Indians above 300% FPL - 26065SC0750003-03 73% AV Silver Plan - 26065SC0750003-04 |
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| Last Plan Update Date | Fri, 25 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of BlueExtend PPO HD Silver 1 Health Insurance Plan, 26065SC0750003-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| Chiropractic Care
Limit: 500.0 Dollars per Benefit Period |
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| 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, 0.00% Coinsurance after deductible |
75.00% |
| 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, 0.00% Coinsurance after deductible |
75.00% |
| Dialysis
|
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| Durable Medical Equipment
A replacement DME is covered when due to a change in medical condition. |
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| 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 | No Charge after deductible, 0.00% Coinsurance after deductible |
No Charge after deductible, 0.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Frames and lenses are limited to 1 set per year. |
YES | $50.00 |
75.00% |
| 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 | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| 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 | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 60.0 Visit(s) per Benefit Period |
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| Hospice Services
Limit: 6.0 Months per Episode |
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| Laboratory Outpatient and Professional Services
|
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| 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, 0.00% Coinsurance after deductible |
75.00% |
| 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 | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| 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 | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| Nutritional Counseling
|
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| 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 | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| 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 | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| 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, 0.00% Coinsurance after deductible |
75.00% |
| 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 |
75.00% |
| Primary Care Visit to Treat an Injury or Illness
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. |
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| Radiation
|
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| 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, 0.00% Coinsurance after deductible |
75.00% |
| 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 | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| 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 | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| 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 |
75.00% |
| 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, 0.00% Coinsurance after deductible |
75.00% |
| Specialist Visit
|
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| 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, 0.00% Coinsurance after deductible |
75.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| Transplant
|
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| 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 | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
75.00% |
| X-rays and Diagnostic Imaging
|
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
75.00% |
BlueExtend PPO HD Silver 1 Health Insurance Plan Variant 26065SC0750003-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7181104387583751 |
| 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 | Standard Silver Off Exchange Plan |
| 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 | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | SCF006 |
| Formulary URL | URL |
| HIOS Product ID | 26065SC075 |
| 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 | Yes |
| 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 | Yes |
| 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 | Yes |
| Out of Service Area Coverage Description | Benefits are available outside South Carolina when consulting BlueCard Program providers. Outside both SC and the BlueCard Program, 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; balance-billing may apply. |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 26065SC0750003-00 |
| Plan Marketing Name | BlueExtend PPO HD Silver 1 |
| Plan Type | PPO |
| Plan Variant Marketing Name | BlueExtend PPO HD Silver 1 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $4,950 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $4,950 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | SCS001 |
| Source Name | HIOS |
| Plan ID | 26065SC0750003 |
| 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 | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $9900 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $4950 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $4,950 |
| 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 | $9900 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $4950 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $4,950 |
| 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 BlueExtend PPO HD Silver 1 Health Insurance Plan, 26065SC0750003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about BlueExtend PPO HD Silver 1, 26065SC0750003 Health Insurance Plan, 26065SC0750003
-
Does BlueExtend PPO HD Silver 1 Health Insurance Plan, 26065SC0750003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (26065SC0750003) Health Insurance Plan, Variant (26065SC0750003-00) offer Disease Management Programs?
Does (26065SC0750003) Health Insurance Plan, Variant (26065SC0750003-00) have Out Of Country Coverage?
Does (26065SC0750003) Health Insurance Plan, Variant (26065SC0750003-00) have Out of Service Area Coverage?
Does (26065SC0750003) Health Insurance Plan, Variant (26065SC0750003-00) offer Disease Management Programs?
Does BlueExtend PPO HD Silver 1 Health Insurance Plan, Variant (26065SC0750003-00) offer Disease Management Programs for Asthma?
Does BlueExtend PPO HD Silver 1 Health Insurance Plan, Variant (26065SC0750003-00) offer Disease Management Programs for Heart disease?
Does BlueExtend PPO HD Silver 1 Health Insurance Plan, Variant (26065SC0750003-00) offer Disease Management Programs for Depression?
Does BlueExtend PPO HD Silver 1 Health Insurance Plan, Variant (26065SC0750003-00) offer Disease Management Programs for Diabetes?
Does BlueExtend PPO HD Silver 1 Health Insurance Plan, Variant (26065SC0750003-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does BlueExtend PPO HD Silver 1 Health Insurance Plan, Variant (26065SC0750003-00) offer Disease Management Programs for Low back pain?
Does BlueExtend PPO HD Silver 1 Health Insurance Plan, Variant (26065SC0750003-00) offer Disease Management Programs for Pregnancy?
Does BlueExtend PPO HD Silver 1 Health Insurance Plan, Variant (26065SC0750003-00) offer Disease Management Programs 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