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Blue Pee Dee Standard Gold

26065SC0730005
Gold
HMO

Blue Pee Dee Standard Gold is a Gold HMO plan by BlueCross BlueShield of South Carolina.

IMPORTANT: You are viewing the 2024 version of Blue Pee Dee Standard Gold 26065SC0730005. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Blue Pee Dee Standard Gold is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Blue Pee Dee Standard Gold 26065SC0730005.
Insurer: BlueCross BlueShield of South Carolina
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 26065SC0730005

Cost-Sharing Overview

Blue Pee Dee Standard Gold offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Blue Pee Dee Standard Gold?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Blue Pee Dee Standard Gold offers the following features and referral requirements.

Wellness Program: No
Disease Program:
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Blue Pee Dee Standard Gold covers when you are out of the service area or out of the country.

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.
National Network: No

Additional Benefits and Cost-Sharing

Blue Pee Dee Standard Gold includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Specialist Visit
Covered
$60.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Facility charges for approved surgeries performed at designated Ambulatory Surgical Centers (ASC) are subject only to a $500 copay; deductible and coinsurance will not apply to the ASC facility charge.
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
No Charge after deductible 25.00% Coinsurance after deductibleNot Applicable 100.00%6.0 Months per Episode
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
$45.00 Not ApplicableNot Applicable 100.00% An out-of-Network Provider may Balance-Bill you for the difference between the Allowed Amount we pay and their billed charge.
Home Health Care Services
Covered
No Charge after deductible 25.00% Coinsurance after deductibleNot Applicable 100.00%60.0 Visit(s) per Benefit Period
Emergency Room Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 25.00% Coinsurance after deductible An out-of-Network Provider may Balance-Bill you for the difference between the Allowed Amount we pay and their billed charge.
Emergency Transportation/Ambulance
Covered
No Charge after deductible 25.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
No Charge after deductible 25.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%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.
Prenatal and Postnatal Care
Covered
No Charge after deductible 25.00% Coinsurance after deductibleNot Applicable 100.00% Prenatal and postnatal care will be covered after artificial insemination or in-vitro fertilization, but the actual insemination/fertilization is not covered.
Delivery and All Inpatient Services for Maternity Care
Covered
No Charge after deductible 25.00% Coinsurance after deductibleNot Applicable 100.00% 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.
Mental/Behavioral Health Outpatient Services
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
$15.00 Not ApplicableNot Applicable 100.00% 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.
Preferred Brand Drugs
Covered
$30.00 Not ApplicableNot Applicable 100.00% 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.
Non-Preferred Brand Drugs
Covered
$60.00 Not ApplicableNot Applicable 100.00% 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.
Specialty Drugs
Covered
$250.00 Not ApplicableNot Applicable 100.00% 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.
Outpatient Rehabilitation Services
Covered
$30.00 Not ApplicableNot Applicable 100.00%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.
Habilitation Services
Covered
No Charge after deductible 25.00% Coinsurance after deductibleNot Applicable 100.00%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.
Chiropractic Care
Not Covered
Coverage for chiropractic services can be purchased separately. If you?re interested in further details, you may call 855-404-6752.
Durable Medical Equipment
Covered
No Charge after deductible 25.00% Coinsurance after deductibleNot Applicable 100.00% A replacement DME is covered when due to a change in medical condition.
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
Not Applicable 0.00%Not Applicable 100.00% 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.
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Covered
$25.00 Not ApplicableNot Applicable 100.00%1.0 Exam(s) per Year
Eye Glasses for Children
Covered
$50.00 Not ApplicableNot Applicable 100.00%1.0 Item(s) per Year Frames and lenses are limited to 1 set per year.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$30.00 Not ApplicableNot Applicable 100.00%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.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 Not ApplicableNot Applicable 100.00%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.
Well Baby Visits and Care
Covered
No Charge No ChargeNot Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Orthodontia – Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Transplant
Covered
No Charge after deductible 25.00% Coinsurance after deductibleNot Applicable 100.00%
Accidental Dental
Covered
No Charge after deductible 25.00% Coinsurance after deductibleNot Applicable 100.00%
Dialysis
Covered
No Charge after deductible 25.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
No Charge after deductible 25.00% Coinsurance after deductibleNot Applicable 100.00%
Chemotherapy
Covered
No Charge after deductible 25.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
No Charge after deductible 25.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
No Charge after deductible 25.00% Coinsurance after deductibleNot Applicable 100.00% 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.
Prosthetic Devices
Covered
No Charge after deductible 25.00% Coinsurance after deductibleNot Applicable 100.00%
Infusion Therapy
Covered
No Charge after deductible 25.00% Coinsurance after deductibleNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Nutritional Counseling
Covered
No Charge after deductible 25.00% Coinsurance after deductibleNot Applicable 100.00%
Reconstructive Surgery
Covered
No Charge after deductible 25.00% Coinsurance after deductibleNot Applicable 100.00% 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.
Gender Affirming Care

Free Preventive Services

There is no copayment or coinsurance for any of the following Blue Pee Dee Standard Gold preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Blue Pee Dee Standard Gold including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Blue Pee Dee Standard Gold?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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