Benefi ts
GOLD 1 GOLD 2 HD GOLD 3 GOLD 4
DeductibleIndividual: $2,000Family: $4,000
Individual: $1,000Family: $2,000
Individual: $2,700Family: $5,400
Individual: $2,700Family: $5,400
Coinsurance 20% 30% 0% 20%
Out-of-Pocket MaximumIndividual: $4,500Family: $9,000
Individual: $5,000Family: $10,000
Individual: $2,700Family: $5,400*
Individual: $5,600Family: $11,200
PCP$15 copay $20 copay 0% coinsurance after
deductible is met$10 for kids up to age 20; $30 for those 20 and over
Blue CareOnDemand$5 copay $5 copay 0% coinsurance after
deductible is met$10 copay
Specialist$30 copay $40 copay 0% coinsurance after
deductible is met$40 copay
Urgent Care (other than Doctors Care)
$50 copay $50 copay 0% coinsurance after deductible is met
$40 copay
Emergency Room Services$300 copay per visit. Meet deductible, then 20% coinsurance.
$300 copay per visit. Meet deductible, then 30% coinsurance.
0% coinsurance after deductible is met
$300 copay per visit. Meet deductible, then 20% coinsurance.
Inpatient Hospitalization20% after deductible is met
30% after deductible is met
0% coinsurance after deductible is met
20% coinsurance after deductible is met
Ambulatory Surgery Center$500 copay per visit $500 copay per visit 0% coinsurance after
deductible is met$500 copay per visit
PHARMACY BENEFITS
Prescription Drugs (up to 30-day supply)
Tier 0: $0Tier 1: $12Tier 2: $35Tier 3: $100Tier 4: 30%
Tier 0: $0Tier 1: $20Tier 2: $40Tier 3: $100Tier 4: 30%
Tier 0: $0 Tier 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: $8Tier 2: $40Tier 3: $100Tier 4: 30%
Mail Order (up to 90-day supply)
Tier 1: $17Tier 2: $95Tier 3: $270
Tier 1: $28Tier 2: $108Tier 3: $270
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: $11Tier 2: $108Tier 3: $270
* The HD Gold 3 out-of-pocket maximum for a family is $5,400 per person, or $5,400 when collectively satisfi ed by all family members.
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