2020 INDIVIDUAL AND FAMILY PLANS - BlueCross BlueShield …...4 $0 cost preventive services. All BlueEssentialsSM plans from BlueCross BlueShield of South Carolina provide preventive

Only insurance company in the state that has allof South Carolina’s Hospitals in our network.

2020 INDIVIDUAL AND FAMILY PLANS

PLANS ASLOW AS

$0

PER MONTH

1

THE POWER OF BLUE®

Our goal is to provide the highest quality affordable health care solutions for all individuals and families within our communities.

1 in 3more than

1,000,000

$0

95 %

*Rating as of Dec. 18, 2018. For latest rating, access ambest.com.

A+

Financial Security And Best In Class Offering A+ (Superior)* rating by A.M. Best for the 17th consecutive year — making us the only insurance company in South Carolina with that rating.

Low-Cost Plan Options High-quality health coverage can be affordable — and we’re here to prove it. We offer numerous low-cost options — with plans as low as $0 a month — to ensure you have the right plan for your needs and budget.

Award-Winning Customer ServiceWe provide first-class, superior service to our members when they need us most.

Ninety-five percent of all customer inquiries are resolved within 24 hours.

The Largest Provider Network We have an extensive network of doctors, hospitals, specialists, pharmacies and other health care providers throughout the state.

1 in 3 Americans rely on Blue

We insure more than 1 million South Carolinians

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Health has its rewards. We reward our members with up to $150 each year for completing various wellness activities through our Blue RewardsSM program. Reward dollars can be used toward copays, deductibles and coinsurance, based on covered medical services.*

Wellness Activity RewardAnnual Flu Shot $60

Annual Wellness Exam $60

Blue CareOnDemandSM Registration $30

Total $150

Once each activity is completed, reward dollars are loaded on a reloadable, prepaid Visa card. All wellness criteria will be verified before distribution of rewards. All members are eligible for each reward, one time per benefit year. *Rewards cannot be used for drug copays or premiums.

See a doctor whenever, wherever through virtual video consults provided by Blue CareOnDemand. Use your smartphone, tablet or computer to access faster, easier, on-the-go care for minor health conditions, including cold and flu symptoms, fevers, rashes and more.

It’s free to enroll — with a low out-of-pocket cost — so what are you waiting for? Download the mobile app today or visit www.BlueCareOnDemandSC.com.

THE VALUE OF WELLNESSUsing research and data insights, BlueCross BlueShield of South Carolina continues to push for innovative, healthy ways to provide better health care solutions and benefits for our members.

Care when you need it, 24/7

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Savings at the pharmacy. The BlueCross network saves you money on prescription drugs by giving you access to a vast array of generic drugs at pharmacies including CVS, Walmart, Sam’s Club, Costco, Kroger, Publix, Kmart, Bi-Lo and Winn-Dixie.

PRESCRIPTION DRUG TIERS

Tier 0 Drugs Tier 1 Drugs Tier 2 Drugs Tier 3 Drugs Tier 4 Drugs

Considered preventive medications under the Affordable Care Act (ACA) and covered at no cost to the member.

Usually generic medications and will generally cost a member the least amount out of pocket.

Most often brand-name drugs, some-times referred to as “preferred” drugs, as these cost less than other brand-name drugs.

Most often brand drugs, sometimes referred to as “non-preferred” drugs, as they usually cost more than other brand drugs. These drugs may have generic equivalents.

Drugs that treat complex conditions. Members tend to pay more for drugs in this tier.

Find a network pharmacy in your area by visiting www.SouthCarolinaBlues.com/links/pharmacy/BlueEssentials.

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$0 cost preventive services.

All BlueEssentialsSM plans from BlueCross BlueShield of South Carolina provide preventive services at zero cost for members. These include:

n Mammograms

n Prostate Screenings (PSA) and Lab Work (in accordance with the American Cancer Society)

n Contraceptive Devices

n Wellness Exams

n Immunizations

n Flu Shots

For a clearer tomorrow.All BlueEssentials plans also include vision benefits for members ages 18 or younger, including low copayments on vision exams, discounts on lenses, frames and contacts. Benefits include:

n One exam per benefit period with a $25 copayment n $50 copayment on lenses and frames limited to once every benefit period

WHAT YOU GET WITH BLUE

All BlueEssentials plans also include an unlimited lifetime benefit maximum.

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Tools to manage your health.Making the right health care decisions is easy using My Health Toolkit®. An online information and customer service center, My Health Toolkit gives you access to important information about plan benefits at your fingertips.

My Health Toolkit provides access to:

n Claims, Eligibility, Benefits

n Contact Preferences

n Authorization Status

n ID Card — save a digital version of your ID card for faster access

n And more!

Start making informed health care decisions now by visiting www.SouthCarolinaBlues.com or downloading the free mobile app in the App Store or Google Play.

THE VALUE OF BLUEWe work hard to ensure our members’ health coverage benefits remain relevant and provide value with member perks, discounts and value-added programs, such as:

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Staying healthy means taking care of your mind and body on a regular basis. Our members enjoy discounts and value-added programs at no additional cost!

Discounts and programs include:

n Fitness Center Memberships

n Weight Management

n Allergy Relief

n Alternative Health Care

n Laser Vision Correction

n Hearing Care

n Hair Restoration

n And more!

BlueCross members have access to Blue365®, a website with discounts on everyday products that can help individuals and families live healthier, happier lives.

Visit www.Blue365Deals.com/BCBSSC to view deals.

Time for a tuneup.

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FINANCIAL ASSISTANCEOur members have access to federal government assistance that can help make health insurance (even more!) affordable. These savings are provided to members either through an Advance Premium Tax Credit (APTC), Cost Sharing Reduction (CSR), or both.

What is an APTC?An APTC is a federal subsidy that assists qualified individuals and families by reducing their monthly premiums.

What is a CSR?Members who qualify for an APTC also may be eligible for even lower out-of-pocket costs through a CSR. These savings only apply to a BlueEssentials Silver plan and vary based on the individual’s or family’s income.

2019 Poverty Guidelines – Annual Household IncomeCost Share 3 Cost Share 2 Cost Share 1

Family Size 100% 133% 150% 151% 200% 201% 250% 300% 400%

1 $12,490 $16,612 $18,735 $18,736 $24,980 $24,981 $31,225 $37,470 $49,960

2 $16,910 $22,490 $25,365 $25,366 $33,820 $33,821 $42,275 $50,730 $67,640

3 $21,330 $28,369 $31,995 $31,996 $42,660 $42,661 $53,325 $63,990 $85,320

4 $25,750 $34,248 $38,625 $38,626 $51,500 $51,501 $64,375 $77,250 $103,000

5 $30,170 $40,126 $45,255 $45,256 $60,340 $60,341 $75,425 $90,510 $120,680

6 $34,590 $46,005 $51,885 $51,886 $69,180 $69,181 $86,475 $103,770 $138,360

7 $39,010 $51,883 $58,515 $58,516 $78,020 $78,021 $97,525 $117,030 $156,040

8 $43,430 $57,762 $65,145 $65,146 $86,860 $86,861 $108,575 $130,290 $173,720

9 $47,850 $63,641 $71,775 $71,776 $95,700 $95,701 $119,625 $143,550 $191,400

10 $52,270 $69,519 $78,405 $78,406 $104,540 $104,541 $130,675 $156,810 $209,080

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SILVER COST-SHARING PLANSSee the FPL chart to determine your cost-sharing level

COST-SHARING PLANS

PLAN NAME BASE PLAN COST SHARE 1 201 – 250 percent FPL

COST SHARE 2 151 – 200 percent FPL


SILVER 1

Copay (PCP/Specialist/Blue CareOnDemand) $30/$60/$20 $30/$60/$5 $10/$60/$5 $10/$25/$5

Coinsurance 50 percent 50 percent 20 percent 5 percent

Deductible (Single/Family) $1,200/$2,400 $1,200/$2,400 $0/$0 $0/$0

Out-of-pocket limit (Single/Family) $8,150/$16,300 $6,500/$13,000 $2,350/$4,700 $2,250/$4,500

Pharmacy Benefits Prescription Drugs

Tier 1: $30Tier 2: $80Tier 3: $100

Tier 4: 30 percent

Tier 1: $30Tier 2: $80Tier 3: $100

Tier 4: 30 percent

Tier 1: $30Tier 2: $60Tier 3: $100

Tier 4: 30 percent

Tier 1: $10Tier 2: $25Tier 3: $100

Tier 4: 30 percent

SILVER 2






Tier 1: $10Tier 2: Deductible and

coinsuranceTier 3: Deductible and

coinsuranceTier 4: Deductible and

coinsurance

Tier 1: $10Tier 2: Deductible and coinsuranceTier 3: Deductible and coinsuranceTier 4: Deductible and coinsurance



SILVER 3






Tier 1: $15Tier 2: $40Tier 3: $125

Tier 4: 30 percent

Tier 1: $15Tier 2: $40Tier 3: $125

Tier 4: 30 percent

Tier 1: $10Tier 2: $35Tier 3: $125

Tier 4: 30 percent

Tier 1: $10Tier 2: $30Tier 3: $100

Tier 4: 30 percent

SILVER 4






Tier 1: $30Tier 2: $50 Tier 3: $100

Tier 4: 30 percent

Tier 1: $30Tier 2: $50 Tier 3: $100

Tier 4: 30 percent

Tier 1: $12Tier 2: $35 Tier 3: $100

Tier 4: 30 percent

Tier 1: $10Tier 2: $30 Tier 3: $100

Tier 4: 30 percent

The pharmacy benefits listed are Retail (up to 31-day) supply.

9

*For the HD Silver 5 plan, cost share variants 1, 2 and 3 are not HD qualified.**For the HD Silver 6 plan, cost share variants 2 and 3 are not HD qualified.

COST-SHARING PLANS




HD SILVER 5*

Copay (PCP/Specialist/Blue CareOnDemand) Deductible and coinsurance

Deductible and coinsurance







Tier 1, 2, 3 and 4: Deductible and

coinsurance


coinsurance


coinsurance


coinsurance

HD SILVER 6**






Deductible (Single/Family) $4,300/$8,600 $3,600/$7,200 $1,300/$2,600 $500/$1,000

Out-of-pocket limit (Single/Family) $4,300/$8,600 $3,600/$7,200 $1,300/$2,600 $500/$1,000



coinsurance


coinsurance


coinsurance


coinsurance

SILVER 7 NOT available in the following counties: Berkeley, Dorchester, Charleston and Colleton.



Deductible (Single/Family) $6,400/$12,800 $4,500/$9,000 $1,000/$2,000 $200/$400



Tier 1: $15Tier 2: $45Tier 3: $150

Tier 4: Deductible and coinsurance

Tier 1: $15Tier 2: $30Tier 3: $100


Tier 1: $7Tier 2: $30Tier 3: $100


Tier 1: $7Tier 2: $30Tier 3: $100


SILVER 8

Copay (PCP/Specialist/Blue CareOnDemand)$10 for kids under

age 20, $25 for adults 20+/$40/$10

$10 for kids under age 20, $20 for adults

20+/$30/$6


20+/$30/$6


20+/$30/$6Coinsurance 25 percent 25 percent 20 percent 5 percent

Deductible (Single/Family) $5,250/$10,500 $4,800/$9,600 $850/$1,700 $0/$0



Tier 1: $25Tier 2: $35Tier 3: $100

Tier 4: 30 percent

Tier 1: $25Tier 2: $30Tier 3: $100

Tier 4: 30 percent

Tier 1: $10Tier 2: $30Tier 3: $100

Tier 4: 30 percent

Tier 1: $10Tier 2: $30Tier 3: $100

Tier 4: 10 percent

SILVER 9

Copay (PCP/Specialist/Blue CareOnDemand) $30/$60/$20 $0 on first four visits then $20/$25/$10

$0 on first four visits then $20/$20/$10

$0 on first four visits then $20/$20/$10





Tier 1: $20Tier 2: $50Tier 3: $100

Tier 4: 30 percent

Tier 1: $5Tier 2: $30Tier 3: $100

Tier 4: 30 percent

Tier 1: $5Tier 2: $10Tier 3:$100

Tier 4: 30 percent

Tier 1: $5Tier 2: $10Tier 3:$100

Tier 4: 30 percent

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COST-SHARING PLANS




SILVER 10

Copay (PCP/Specialist/Blue CareOnDemand)$0 on first four visits

then deductible/ deductible/deductible

$0 on first four visits then deductible/

deductible/deductible









Tier 1: $5Tier 2: $50Tier 3: $100

Tier 4: 30 percent

Tier 1: $5Tier 2: $50Tier 3: $100

Tier 4: 30 percent

Tier 1: $5Tier 2: $50Tier 3: $100

Tier 4: 30 percent

Tier 1: $5Tier 2: $50Tier 3: $100

Tier 4: 30 percent

SILVER 11

Copay (PCP/Specialist/Blue CareOnDemand)$15/$15, then

deductible and coinsurance/$5

$5/$5, then deductible and coinsurance/$5







Tier 1: $5Tier 2: $50Tier 3: $100

Tier 4: 30 percent

Tier 1: $5Tier 2: $25Tier 3: $50

Tier 4: 30 percent

Tier 1: $5Tier 2: $25Tier 3: $50

Tier 4: 30 percent

Tier 1: $5Tier 2: $25Tier 3: $50

Tier 4: 30 percent

SILVER 12

Copay (PCP/Specialist/Blue CareOnDemand)$15/$15, then

deductible and coinsurance/$5








Tier 1: $10Tier 2: $50Tier 3: $100

Tier 4: 30 percent

Tier 1: $10Tier 2: $40Tier 3: $100

Tier 4: 30 percent

Tier 1: $5Tier 2: $30Tier 3: $100

Tier 4: 30 percent

Tier 1: $5Tier 2: $30Tier 3: $80

Tier 4: 30 percent

HD SILVER 13***







Out-of-pocket limit (Single/Family) $4,550/$9,100 $3,650/$7,300 $1,300/$2,600 $450/$900



coinsurance


coinsurance


coinsurance


coinsurance

SILVER 14 NOT available in the following counties: Berkeley, Dorchester, Charleston and Colleton.






Tier 1: $12Tier 2: $40

Tier 3: Deductible and coinsuranceTier 4: Deductible and coinsurance

Tier 1: $10Tier 2: $40


Tier 1: $5Tier 2: $40


Tier 1: $5Tier 2: $40


***For the HD Silver 13 plan, cost share variants 2 and 3 are not HD qualified.

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COST-SHARING PLANS




SILVER 29‡






Tier 1: $20Tier 2: $60

Tiers 3, 4: Deductible/ Coinsurance

Tier 1: $20Tier 2: $50

Tier 3: Deductible/ Coinsurance


Tier 1: $0Tier 2: $25



Tier 1: $0Tier 2: $25



SILVER 30‡






Tier 1: $20Tier 2: $60



Tier 1: $10Tier 2: $50



Tier 1: $0Tier 2: $25



Tier 1: $0Tier 2: $25



SILVER 33‡






Tier 1: $10Tier 2: $60Tier 3: $175


Tier 1: $7Tier 2: $30Tier 3: $100

Tier 4: Deductible/Coin-surance

Tier 1: $7Tier 2: $30Tier 3: $100


Tier 1: $7Tier 2: $30Tier 3: $100


SILVER 34‡






Tier 1: $10Tier 2: $40



Tier 1: $10Tier 2: $40

Tier 3: Deductible/Coinsurance


Tier 1: $5Tier 2: $40



Tier 1: $5Tier 2: $40



‡Plans ONLY available in the following counties: Berkeley, Dorchester, Charleston and Colleton.

BENEFITSThese plans are available if you receive or don’t receive financial assistance toward your plan.

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GOLD PLANSGOLD 1 GOLD 2 HD GOLD 3 GOLD 4

DeductibleIndividual: $2,000 Family: $4,000

Individual: $1,500 Family: $3,000



Coinsurance 20% 30% 0% 20%

Out-of-Pocket MaximumIndividual: $4,500 Family: $9,000




PCP$20 copay $20 copay 0% coinsurance after

deductible is met$10 for kids up to age 20; $30 for those 20 and over

Blue CareOnDemand$10 copay $10 copay 0% coinsurance after

deductible is met$10 copay

Specialist$40 copay $40 copay 0% coinsurance after


Urgent Care$50 copay $50 copay 0% coinsurance after


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


Inpatient Hospitalization20% after deductible is met

30% after deductible is met



Ambulatory Surgery CenterFacility Charge – $500 copay per visit

Facility Charge – $500 copay per visit


Facility Charge – $500 copay per visitt

PHARMACY BENEFITS

Prescription Drugs (up to 31-day supply)

Tier 0: $0Tier 1: $12Tier 2: $40Tier 3: $100Tier 4: 30%


Tier 0: $0 Tier 1: 0% coinsurance

after deductible is metTier 2: 0% coinsurance



after deductible is met


Mail Order (up to 90-day supply)

Tier 1: $17Tier 2: $108Tier 3: $270

Tier 1: $28Tier 2: $108Tier 3: $270

Tier 1: 0% coinsurance after deductible is met



Tier 1: $14Tier 2: $108Tier 3: $270

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SILVER PLANSSILVER 1 SILVER 2 SILVER 3 SILVER 4










PCP $30 copay $25 copay $30 copay $30 copay

Blue CareOnDemand $20 copay $15 copay $20 copay $20 copay

Specialist $60 copay $50 copay $60 copay $60 copay

Urgent Care $60 copay $50 copay $60 copay $60 copay





Inpatient Hospitalization50% coinsurance after deductible is met








PHARMACY BENEFITS



Tier 0: $0Tier 1: $10Tier 2: 40% coinsurance







Tier 1: $42Tier 2: $216Tier 3: $270

Tier 1: $14Tier 2: 40% coinsurance



Tier 1: $21Tier 2: $108Tier 3: $338

Tier 1: $42Tier 2: $135Tier 3: $270

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‡Not available in Berkeley, Dorchester, Charleston or

Colleton counties.

HD SILVER 5 HD SILVER 6 SILVER 7 SILVER 8










PCP20% coinsurance after deductible is met


$25 copay$10 for kids up to age 20; $25 for those 20 and over

Blue CareOnDemand20% coinsurance after deductible is met


$20 copay $10 copay

Specialist20% coinsurance after deductible is met


$60 copay $40 copay

Urgent Care20% coinsurance after deductible is met


$60 copay $50 copay

Emergency Room Services20% coinsurance after deductible is met








Ambulatory Surgery Center20% coinsurance after deductible is met




PHARMACY BENEFITS












Tier 0: $0Tier 1: $15Tier 2: $45Tier 3: $150Tier 4: 25% coinsurance










Tier 1: $21Tier 2: $122Tier 3: $405

Tier 1: $35Tier 2: $95Tier 3: $270

SILVER PLANS

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SILVER 9 SILVER 10 SILVER 11 SILVER 12










PCP $30 copay

$0 copay per visit on first four visits, then 0% coinsurance after deductible is met

$15 copay $15 copay

Blue CareOnDemand $20 copay0% coinsurance after deductible is met

$5 copay $5 copay

Specialist $60 copay0% coinsurance after deductible is met

$15, then coinsurance after deductible is met

$15, then coinsurance after deductible is met

Urgent Care $60 copay0% coinsurance after deductible is met















PHARMACY BENEFITS







Tier 1: $28Tier 2: $135Tier 3: $270

Tier 1: $7Tier 2: $135Tier 3: $270

Tier 1: $7Tier 2: $135Tier 3: $270

Tier 1: $14Tier 2: $135Tier 3: $270

SILVER PLANS

17


Colleton counties.

HD SILVER 13 SILVER 14



Coinsurance 0% 25%




$25 copay


$15 copay


$50 copay


$50 copay







PHARMACY BENEFITS







Tier 0: $0Tier 1: $12Tier 2: $40Tier 3: 25% coinsurance









SILVER PLANS

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SILVER PLANS

SILVER 29* SILVER 30* SILVER 33* SILVER 34*
















$300 copay per visit. Meet deductible, then 25% coinsurance










PHARMACY BENEFITS


















Tier 1: $14Tier 2: $162Tier 3: $473



*Plans ONLY available in the following counties: Berkeley, Dorchester, Charleston and Colleton.

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BRONZE PLANSBRONZE 1 HD BRONZE 2 HD BRONZE 3




Coinsurance 50% 50% 30%

























PHARMACY BENEFITS


Tier 0: $0Tier 1: $30Tier 2: 50% coinsurance after

deductible is metTier 3: 50% coinsurance after


deductible is met

Tier 0: $0Tier 1: 50% coinsurance after




deductible is met





deductible is met




deductible is met







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BRONZE PLANSBRONZE 4 HD BRONZE 5



Coinsurance 50% 0%



PCP $30 copay0% coinsurance after deductible is met

Blue CareOnDemand $20 copay0% coinsurance after deductible is met

Specialist $60 copay0% coinsurance after deductible is met

Urgent Care $60 copay0% coinsurance after deductible is met



Inpatient Hospitalization50% coinsurance after deductible is met.




PHARMACY BENEFITS


Tier 0: $0Tier 1: $17Tier 2: 50% coinsurance after



deductible is met





deductible is met




deductible is met




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CATASTROPHIC PLANCATASTROPHIC 1


Coinsurance 0%


PCP$25 copay per visit on first three visits then 0% coinsurance after deductible is met







PHARMACY BENEFITS






deductible is met





PRIVATE MARKETPLACE PLANSThese plans are only available for those not receiving financial assistance.

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SILVEROFF-EXCHANGE OFF-EXCHANGE OFF-EXCHANGE OFF-EXCHANGE















Emergency Room Services









Ambulatory Surgery Center





PHARMACY BENEFITS










Tier 1: $42Tier 2: $216Tier 3: $270




Tier 1: $21Tier 2: $108Tier 3: $338

Tier 1: $42Tier 2: $135Tier 3: $270

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Colleton counties.

OFF-EXCHANGE OFF-EXCHANGE OFF-EXCHANGE OFF-EXCHANGE

HD SILVER 19 HD SILVER 20 SILVER 21‡ SILVER 22












$25 copay $10 for kids up to age 20; $25 for those 20 and over



$20 copay $10 copay



$60 copay $40 copay



$60 copay $50 copay














PHARMACY BENEFITS






















Tier 1: $21Tier 2: $122Tier 3: $405

Tier 1: $35Tier 2: $95Tier 3: $270

SILVER

25












PCP$30 copay $0 copay on first four vis-

its, then 0% coinsurance after deductible is met

$15 copay $15 copay

Blue CareOnDemand$20 copay 0% coinsurance after

deductible is met$5 copay $5 copay

Specialist$60 copay 0% coinsurance after

deductible is met$15 copay, then 20% coinsurance after deductible is met

$15 copay, then 30% coinsurance after deductible is met

Urgent Care$60 copay 0% coinsurance after

deductible is met20% coinsurance after deductible is met















PHARMACY BENEFITS







Tier 1: $28Tier 2: $135Tier 3: $270

Tier 1: $7Tier 2: $135Tier 3: $270

Tier 1: $7Tier 2: $135Tier 3: $270

Tier 1: $14Tier 2: $135Tier 3: $270

SILVER

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SILVEROFF-EXCHANGE OFF-EXCHANGE

HD SILVER 27 SILVER 28‡



Coinsurance 0% 25%




$25 copay


$15 copay


$50 copay


$50 copay







PHARMACY BENEFITS

















Colleton counties.

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SILVER


SILVER 31* SILVER 32* SILVER 35* SILVER 36*



























PHARMACY BENEFITS














Tier 1: $28Tier 2: $162Tier 3: 0% coinsurance after deductible is met


Tier 1: $14Tier 2: $162Tier 3: $473


*Plans ONLY available in the following counties: Berkeley, Dorchester, Charleston and Colleton.

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SERVICES, FEES AND CHARGES YOU PAY, ALONG WITH EXCLUDED SERVICES

You Must Pay For

n Non-emergency services when received at or from an out-of-network provider or hospital, including outside of the United States.

n Hospital or skilled nursing facility charges when the patient did not receive preauthorization.

n Services and supplies not medically necessary, investigational or experimental in nature, not needed for the diagnosis or treatment of an illness or injury or not specifically listed in Covered Services.

n Any service or supply provided by a member of the patient’s family or by the patient, including the dispensing of drugs. This means the spouse, parent, grandparent, brother, sister, child or spouse’s parent.

n Charges for a missed appointment or for filling out claim forms.

n Services or supplies related to chewing or biting problems, pain in the face, jaw or neck resulting from problems of the jaw joint(s), also known as temporomandibular joint disorders (TMJ).

This is a partial list of some of our exclusions. For a full list of excluded services and supplies, or for all limitations, please refer to your policy in My Health Toolkit.

Benefits We Do Not Cover

n Any services or benefits not specifically covered under the terms of the policy, services received before the policy went into effect or after it terminates, or claims submitted after the time limit for filing claims has been exceeded.

n Services or charges for which the member is entitled to payment or benefits from other sources (i.e., worker’s compensation), for which the provider does not charge or for which the member is not legally obliged to pay, including treatment provided in a government hospital or benefits provided under Medicare or other government programs (except Medicaid).

n Cosmetic surgery, surgery or treatment for the purpose of weight reduction, including any complications from or reversal of these procedures, or reconstructive procedures made necessary by weight loss.

n Illness contracted or injury sustained as the result of war or act of war (whether declared or undeclared), or participation in a felony, riot or insurrection.

n Refractive care, such as radial keratotomy, laser eye surgery or Lasik.

n Services for the detection and correction of structural imbalance, distortion or subluxation (spinal subluxation) to remove nerve interference, unless the optional coverage is purchased.

n Treatment, services or supplies received because of suicide, attempted suicide or intentionally self-inflicted injuries, unless it results from a medical (physical or mental) condition, even if the condition is not diagnosed prior to the injury.

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NOTES

210804-11-19 BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.

WORK WITH YOUR AGENT OR BROKER FOR A FREE QUOTE.

BCBSSC

BCBSSC

www.SouthCarolinaBlues.com

HAVE QUESTIONS?Contact your agent or broker today.

Documents

2020 INDIVIDUAL AND FAMILY PLANS - BlueCross BlueShield …...4 $0 cost preventive services. All BlueEssentialsSM plans from BlueCross BlueShield of South Carolina provide preventive