BlueCross BlueShield of South Carolina

Blue Cooper Standard Gold

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Plan Overview

Combined Medical and Drug Deductible	Individual: $1,500.00 Family: $3000 Per Person: $1500
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,800.00 Family: $15600 Per Person: $7800

Office Visit

Primary Doctor	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 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.
Specialist	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 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.
Non Preferred Brand Drugs	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 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.
Generic Drugs	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 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.
Specialty Drugs	CoPay: $250.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 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.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: No Charge after deductible CoInsurance: 25.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered Benefit Explanation: An out-of-Network Provider may Balance-Bill you for the difference between the Allowed Amount we pay and their billed charge.
Urgent Care Facility	CoPay: $45.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: An out-of-Network Provider may Balance-Bill you for the difference between the Allowed Amount we pay and their billed charge.

Maternity

Labor and Delivery Hospital Stay

CoPay: No Charge after deductible
CoInsurance: 25.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: 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.

Pre and Postnatal Office Visit

CoPay: No Charge after deductible
CoInsurance: 25.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Prenatal and postnatal care will be covered after artificial insemination or in-vitro fertilization, but the actual insemination/fertilization is not covered.

Vision

Routine Eye Exams for Children

CoPay: $25.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year

Major Dental Care

Routine Dental Checkups for Children

Covered: Not Covered

BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
HealthMarkets is an authorized agent of BlueCross BlueShield of South Carolina.