BlueEssentials Gold 4
26065SC0380021
Gold
EPO
BlueEssentials Gold 4 is a Gold EPO plan by BlueCross BlueShield of South Carolina.
IMPORTANT: You are viewing the 2024 version of BlueEssentials Gold 4 26065SC0380021. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.
Locations
BlueEssentials Gold 4 is offered in the following counties.
Plan Overview
This is a plan overview for 2024 version of BlueEssentials Gold 4 26065SC0380021.
| Insurer: | BlueCross BlueShield of South Carolina |
| Network Type: | EPO |
| Metal Type: | Gold |
| HSA Eligible?: | No |
| Plan ID: | 26065SC0380021 |
Cost-Sharing Overview
BlueEssentials Gold 4 offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for BlueEssentials Gold 4 includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $6600 per person | $13200 per group |
| Deductible: | $3000 per person | $6000 per group |
| Coinsurance: | $6000 per group | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for BlueEssentials Gold 4 will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | per person not applicable | per group not applicable |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $3,000.00 |
| Copayment: | $10.00 |
| Coinsurance: | $3,300.00 |
| Limit: | $60.00 |
| Deductible: | $900.00 |
| Copayment: | $1,800.00 |
| Coinsurance: | $0.00 |
| Limit: | $20.00 |
| Deductible: | $2,500.00 |
| Copayment: | $200.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
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 BlueEssentials Gold 4?
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
BlueEssentials Gold 4 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 BlueEssentials Gold 4 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
BlueEssentials Gold 4 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 Applicable | Not Applicable 100.00% | 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. |
| Specialist Visit Covered | $55.00 Not Applicable | Not Applicable 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $30.00 Not Applicable | Not Applicable 100.00% | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | No Charge after deductible 35.00% Coinsurance after deductible | Not 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 | No Charge after deductible 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Hospice Services Covered | No Charge after deductible 35.00% Coinsurance after deductible | Not 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 | $55.00 Not Applicable | Not Applicable 100.00% | 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. |
| Home Health Care Services Covered | No Charge after deductible 35.00% Coinsurance after deductible | Not Applicable 100.00% | 60.0 Visit(s) per Benefit Period |
| Emergency Room Services Covered | $300.00 Copay with deductible 35.00% Coinsurance after deductible | $300.00 Copay with deductible 35.00% 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 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | No Charge after deductible 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Inpatient Physician and Surgical Services Covered | No Charge after deductible 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Bariatric Surgery | |||
| Cosmetic Surgery | |||
| Skilled Nursing Facility Covered | No Charge after deductible 35.00% Coinsurance after deductible | Not 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 35.00% Coinsurance after deductible | Not 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 35.00% Coinsurance after deductible | Not 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 Applicable | Not Applicable 100.00% | |
| Mental/Behavioral Health Inpatient Services Covered | No Charge after deductible 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Substance Abuse Disorder Outpatient Services Covered | $30.00 Not Applicable | Not Applicable 100.00% | |
| Substance Abuse Disorder Inpatient Services Covered | No Charge after deductible 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Generic Drugs Covered | $10.00 Not Applicable | Not 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 | $40.00 Not Applicable | Not 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 | $100.00 Not Applicable | Not 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 | Not Applicable 35.00% | Not 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 | No Charge after deductible 35.00% Coinsurance after deductible | Not 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 35.00% Coinsurance after deductible | Not 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 35.00% Coinsurance after deductible | Not Applicable 100.00% | A replacement DME is covered when due to a change in medical condition. |
| Hearing Aids | |||
| Imaging (CT/PET Scans, MRIs) Covered | No Charge after deductible 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Preventive Care/Screening/Immunization Covered | No Charge No Charge | 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 Applicable | Not Applicable 100.00% | 1.0 Exam(s) per Year |
| Eye Glasses for Children Covered | $50.00 Not Applicable | Not Applicable 100.00% | 1.0 Exam(s) per Year Frames and lenses are limited to 1 set per year. |
| Dental Check-Up for Children Not Covered | |||
| Rehabilitative Speech Therapy Covered | No Charge after deductible 35.00% Coinsurance after deductible | Not 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 | No Charge after deductible 35.00% Coinsurance after deductible | Not 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 Charge | Not Applicable 100.00% | |
| Laboratory Outpatient and Professional Services Covered | No Charge after deductible 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| X-rays and Diagnostic Imaging Covered | No Charge after deductible 35.00% Coinsurance after deductible | Not 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 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Accidental Dental Covered | No Charge after deductible 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Dialysis Covered | No Charge after deductible 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Allergy Testing Covered | No Charge after deductible 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Chemotherapy Covered | No Charge after deductible 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Radiation Covered | No Charge after deductible 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Diabetes Education Covered | No Charge after deductible 35.00% Coinsurance after deductible | Not 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 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Infusion Therapy Covered | No Charge after deductible 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Treatment for Temporomandibular Joint Disorders | |||
| Nutritional Counseling Covered | No Charge after deductible 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Reconstructive Surgery Covered | No Charge after deductible 35.00% Coinsurance after deductible | Not 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 BlueEssentials Gold 4 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.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for BlueEssentials Gold 4 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 BlueEssentials Gold 4?
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