BlueCross Blue Basic (PPO)
Medicare Advantage Health Plan Details
Health insurance company offering plan: Blue Cross Blue Shield of South Carolina
- Dental
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: $30 copay
Out-of-network: $45 copay
Out-of-network: 20% coinsurance
Emergency Room
$115 copay
Ambulance Coverage
In-network: $275 copay
Out-of-network: $275 copay
Lab, X-Ray, Radiology Coverage
Diagnostic tests & procedures:
In-network: $0-$100 copay
Out-of-network: 20% coinsurance
Lab services:
In-network: $0-$10 copay
Out-of-network: 20% coinsurance
Diagnostic radiology services (e.g., CT, MRI, etc):
In-network: $0-$150 copay
Out-of-network: 20% coinsurance
Outpatient x-rays:
In-network: $10 copay
Out-of-network: 20% coinsurance
Hospital Services
Inpatient hospital coverage:
In-network:
Tier 1
$325 per day for days 1-5
$0 per day for days 6-90
$0 per stay
Out-of-network:
20% per stay
Outpatient hospital coverage:
In-network: $0-$250 copay
Out-of-network: 20% coinsurance
Rehabilitation Coverage
Occupational therapy services:
In-network: $30 copay
Out-of-network: $45 copay
Urgent Care Coverage
$115 copay
Skilled Nursing Facility (SNF)
In-network:
Tier 1
$0 per day for days 1-20
$218 per day for days 21-100
Out-of-network:
20% per stay
Mental Health Coverage
Outpatient group therapy with a psychiatrist:
In-network: $35 copay
Out-of-network: 20% coinsurance
Outpatient individual therapy with a psychiatrist:
In-network: $35 copay
Out-of-network: 20% coinsurance
Outpatient group therapy visits:
In-network: $45 copay
Out-of-network: 20% coinsurance
Outpatient individual therapy visit:
In-network: $45 copay
Out-of-network: 20% coinsurance
Dental, Vision, Hearing Benefits
Dental Services
Oral exams:
In-network: $0 copay
Out-of-network: 50% coinsurance
Prophylaxis (cleaning):
In-network: $0 copay
Out-of-network: 50% coinsurance
Dental x-rays:
In-network: $0 copay
Out-of-network: 50% coinsurance
Vision Benefits
Routine eye exams:
In-network: $0 copay
Out-of-network: 20% coinsurance
Contact Lenses:
In-network: $0 copay
Out-of-network: 20% coinsurance
Eyeglasses:
In-network: $0 copay
Out-of-network: 20% coinsurance
Hearing Benefits
Hearing exam:
In-network: $45 copay
Out-of-network: 20% coinsurance
Fitting/evaluation:
In-network: $45 copay
Out-of-network: 20% coinsurance
Hearing aids - prescription:
In-network: $699-$999 copay
Out-of-network: 20% coinsurance
Additional Added Benefits
Plan Links
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