Blue Option · Blue Option Saves You Time and Money • Large network of doctors, hospitals, specialists, pharmacies and other health care providers • No claim forms or referrals

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Focus on life. Focus on health. Stay focused.

Blue Option2020 Sales Booklet

New in 2020:

Enhanced Vision Coverage

ContentsWhy Blue Option is Your Best Option ...............................................1

Get More With Blue Option ...............................................................2

Benefits and Services Your Way ..........................................................3

Access Your Health Information Anytime ..........................................5

Choose Your 2020 Health Coverage ..................................................6

Decide What You Need ......................................................................7

Plans ......................................................................................................8

Glossary ..............................................................................................25


1

• All-inclusive, comprehensive copayment on select plans that covers all services at a participating provider’s office, such as labs, X-rays, surgical procedures and more!

• Enhanced adult and pediatric vision coverage

• Dental coverage

• More rewards with FOCUSfwd® Wellness Incentive Program

• Access to a board-certified physician anytime, anywhere

• $0 primary care visits on select plans

• Doctors Care visits for the same cost as primary care visits,

saving members money when an ER visit is unnecessary

Why Blue Option is Your Best Option


Blue Option Saves You Time and Money• Large network of doctors, hospitals, specialists, pharmacies and other health care providers

• No claim forms or referrals needed for specialists

• Preventive screenings at NO cost to you

• $0 cost on immunizations such as flu shots

• Health management programs to help keep you and your family healthy

• Discounts on fitness memberships, wellness products, cosmetic services and more

• Discounts at chiropractors, massage therapists, dietitians and acupuncturists through our Natural BlueSM program

• More lab choices, generating savings and less out-of-pocket costs for our members

• Convenient online bill payment and online access to plan documents

• Help with services, including financial counseling, college consultation resources and legal services

• Partnerships with freestanding imaging centers and ambulatory surgical centers that allow us to pass significant savings on to you

VISIT TYPE FOR A SILVER 5550 MEMBER EXAMPLE OF OUT-OF-POCKET COSTS*Doctors Care, Primary Care Physician or Blue CareOnDemandSM $45

Emergency Room $500 Copayment, then 20% after deductible

EXAMPLE FACILITY FEE*You use a freestanding ambulatory surgical center. $200

You use the hospital or an outpatient facility affiliated with a hospital. Deductible, then 30%

*Benefits vary. Please check your Schedule of Benefits.

2

We have more than 30 years of experience serving our members throughout

South Carolina. We offer affordable plan options that provide more value,

more benefits and more options. Not only do we have first-class customer

service when you have questions, we have negotiated discounts with providers

throughout the state to save you money. With Blue Option, you get more!

More Providers in Our NetworkWith Blue Option, you have access to a large number of doctors, hospitals

and other health care providers in South Carolina. You have the freedom to

choose your own health care providers within our statewide network, which

includes all South Carolina hospitals. Plus, you have access to urgent and

emergent care nationwide through our BlueCard® program.

More Coverage for Preventive ServicesWith Blue Option, you get coverage for preventive care, such as mammograms,

vaccinations, colonoscopies and prostate cancer screenings, at no cost to you.

More Coverage for Prescription DrugsBlue Option plans include pharmacy services. You have coverage for a wide

variety of prescription drugs. Our goal is to give you a choice of safe and

effective drugs, while keeping your drug costs affordable. You can purchase

drugs at a retail pharmacy, or you can have them delivered to your doorstep

through our mail-order program. To see a complete list of covered drugs or to

find a pharmacy, visit www.BlueOptionSC.com.

New in 2020: More Vision CoverageWe’ve greatly improved our vision coverage in 2020. In-network vision

providers now include your favorite retailers, including Walmart Vision Center,

Target Optical, LensCrafters, and more! There will be a $150 materials

allowance for glasses and contacts, with a $0 copay for adults and only a $25

copay for dependent children through the age of 18. Better yet, there will be

no limits on frame or lens selection! Additional discounts are available on any

amounts spent over the material allowance at most providers.

More Coverage for EssentialsWe also cover essential health benefits, such as:

• Preventive and wellness services

• Outpatient care

• Emergency care

• Hospitalization

• Maternity and newborn care

• Pediatric care

• Mental health and substance abuse

disorder services

• Lab services

More ValueWith enhanced vision and dental coverage and online visits with

a doctor, you get more value with Blue Option. Check out pages 3-4 for

more information.

Get More With Blue Option

Visit www.BlueOptionSC.com for more details.

QuickEnroll

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FOCUSfwd GreatExpectations

Hearing Aids

Biometric Screening

Learning Management System

TobaccoCessationBlueChoice

HealthPlan WireMy Health

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Discounts andAdded Values

Business ADV Core ServicesCore ServicesHealth Care Reform

Video Carolina ADVAdvantage Plus MyChoice ADV Primary Choice Medical PoliciesFlexible Savings

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Benefits and Services Your WayAll-Inclusive Office Visit CopaymentsAll-inclusive office visit copayments cover all diagnostic and

treatment services provided at the medical office of a participating

provider. This includes preventive services, diagnostic procedures,

surgical procedures, medical supplies and more!

Vision CareAll Blue Option plans include routine adult and pediatric vision coverage

through an independent company, Physicians Eyecare Network (PEN).

PEN provides vision services through the Physicians Eyecare Plan (PEP)

network on behalf of BlueChoice HealthPlan. In-network providers

include Walmart Vision Center, Target Optical, LensCrafters and more!

Dental CareAll plans include a dental allowance for exams and cleanings. This

benefit covers an allowed amount per benefit period for exams

and cleanings by any South Carolina-licensed dentist. Please see

page 9 for more details.

FOCUSfwd ® Wellness Incentive ProgramThe FOCUSfwd Wellness Incentive Program is being redesigned to

showcase its four unique programs, plus a few new perks!

More Rewards — Members are now rewarded for completing

activities that are an important start to their overall health!

Sweepstakes — Members can still win $1,000 quarterly and annual cash

rewards of $5,000 for completing activities in all areas of FOCUSfwd!

GET FIT — Members receive exclusive FOCUSfwd prizes and

rewards for stepping up to the challenge.

Nutrition — We are giving members the knowledge and tools to

take control of their health. Members can search recipes, create

meal plans, obtain nutritional overviews of their meals for the entire

day, search by vitamin and mineral needs and much more!

Blue CareOnDemandSM

All you need is your computer or smartphone device to see a

doctor anytime, anywhere, even when you are outside of South

Carolina. During your video visit, the doctor will ask questions,

answer questions, diagnose your symptoms and, if appropriate,

call in a prescription to your local pharmacy.

Doctors can treat most common, non-emergency medical issues, such as:

• Cold and flu symptoms

• Bronchitis and other

respiratory infections

• Sinus infections

• Pinkeye

• Ear infections

• Allergies

• Migraines

• Rashes and other

skin irritations

• Urinary tract infections

And more!

Mental Health and Breastfeeding Support services are also

available through Blue CareOnDemand.

Doctors CareWhen your doctor is not available and Blue CareOnDemand is not

appropriate, choose this option for urgent and after-hours care.

You can visit any Doctors Care location across the state for the

same price as a primary care physician visit. This includes visits for

injuries and illnesses that may be considered as regular doctor’s

visits, after-hours visits and urgent care visits.

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Get Text Messages The BlueChoice HealthPlan WireSM is a free text message communication service we

offer. It will keep you current on your health insurance information wherever you are.

By signing up for this service, you get important news and updates sent directly to your

smartphone, including:

• How to make the most of your coverage

• New features or enhancements

• Health and wellness reminders

Signing up is quick and easy and you can control the frequency of the messages

and stop messages at any time. Enrolling also earns you entries in the FOCUSfwd

Wellness Incentive Program prize drawings!

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Life Management Services All members can have access to three free sessions of their choice

for services such as:

• Financial counseling

and planning

• Adult care resources

• College consultation resources

• Legal consultations and

documents

• Child care resources

• Parenting/adoption resources

Life management services are offered through First Sun EAP. Because

First Sun EAP is a separate company from BlueChoice, First Sun is solely

responsible for all services related to individual assistance programs.

Personal Health Assessment Take a smart step toward living healthier. By completing your confidential

assessment, you’ll receive personal guidance and insights on your risk

for developing certain chronic conditions, so you can take preventive

action. You’ll also receive entries into the FOCUSfwd Wellness Incentive

Program! Visit www.BlueOptionSC.com, log in to My Health Toolkit, and select FOCUSfwd Incentive Program on the Health and Wellness tab.

Discount Programs As a Blue Option member, you get discounts on many items:

• Blue365® — exclusive access to health and wellness information,

discounts and savings from industry-leading brands

• Jenny Craig®

• Bosley®

• Discounts at a variety of fitness centers

Great Expectations® for healthGreat Expectations for health includes more than 20 wellness, disease

management, and behavioral health programs that focus on the early

detection of illness and the prevention of disease. Members with chronic

conditions also receive more targeted educational information and

contact with our staff of highly trained health specialists. Those with

intensive needs receive care coordination and the support of our caring

team of nurses. You can earn entries in the FOCUSfwd Wellness Incentive

Program prize drawings for participating in some of these programs.

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My Health Toolkit®

BlueChoice wants to make it easy for you to find answers to your questions.

So we created My Health Toolkit. My Health Toolkit is a secure, online tool

that will help you better manage your benefits, treatment and wellness.

Simply create an account on www.BlueOptionSC.com after you receive

your member ID card.

Then you can:

• View your digital ID card.

• See if your claim has been paid.

• Ask Member Services a question.

• Access the FOCUSfwd Wellness Incentive Program.

• Find a doctor or hospital.

• Find out how much a prescription drug costs.

• Take a personal health assessment.

• Find out how much you have paid toward your deductible.

• View your Schedule of Benefits (SOB), which includes your copay and

coinsurance amounts.

• Request a new member ID card.

My Health Toolkit App Take My Health Toolkit with you when you’re on the go with our FREE

mobile app! You can:

• View and share your digital ID card.

• Access the FOCUSfwd Wellness Incentive Program.

• Confirm coverage.

• Find a doctor or hospital in network.

• Update contact information.

• Check the status of claims.

Current My Health Toolkit users can log in to the app with their existing username

and password. New My Health Toolkit users can register through the app.

Get the AppSearch for My Health Toolkit in the App Store

or Google Play to download the

My Health Toolkit app.

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Open Enrollment Period You can sign up for health insurance during the open enrollment period from

October 15, 2019, to December 15, 2019. Choosing your coverage is easy:

1. Decide what you need. Look at your current insurance plan. Are there any changes to your current

benefits? Does your plan fit your budget and your medical needs? This book will

help you find the best fit for you.

2. Choose your plan.We are here to help you choose a plan. You can call us at 877-252-0632 or

contact your local agent during the open enrollment period to select your 2020

health plan. Or you can visit www.BlueOptionSC.com.

Special Enrollment PeriodIf you do not sign up during this time, you will have to qualify for a special

enrollment period (SEP) to apply for coverage. Typically, you can qualify for

special enrollment for 60 days following a qualifying life event. Events that

qualify for an SEP include:

• Getting married or divorced

• Having or adopting a child

• Losing other qualified health coverage for other than non-payment of premium

• Becoming a U.S. citizen

• Moving to South Carolina

Choose Your 2020 Health Coverage

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First, you need to figure out what kind of plan you need. Blue Option is divided

into two categories: the metallic plans (Silver and Bronze) and the Catastrophic

Plan. Anyone is eligible to buy a metallic plan. There are additional qualifying

criteria, however, to purchase the Catastrophic Plan.

Here’s a simple breakdown to choosing a plan category:

• Silver Plans — Silver plans are our most popular metallic level. The

plans balance monthly premiums with out-of-pocket costs for care.

Silver plans are well rounded and provide the best value.

• Bronze Plans — Bronze plans typically offer the lowest monthly

premiums, but you will pay more out of pocket when you need care.

These plans are best for those who don’t go to the doctor often and

don’t take many prescription medications.

• Catastrophic Plan — Adults under age 30 are eligible for the Catastrophic

Plan. This plan has low monthly premiums and a high deductible. You

pay less each month but more when you actually receive care.

What is included in each plan?Each plan must cover the same set of minimum essential health benefits. We

cover your mandated, routine preventive care services — such as mammograms

and colonoscopies — at no cost to you. Plus, you get value-added services such

as Life Management Services, vision, dental and more!

All plans include emergency care, maternity and newborn care, pediatric care,

prescription drugs, laboratory services, and preventive and wellness services.

What is the difference?The difference between the Silver and Bronze categories is the amount you pay,

such as copayments, coinsurance percentage, deductibles and maximum out-of-

pocket expenses.

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PlansPLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PAGEBenefits for all plans . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Blue Option Silver 2000 . . . . . . . . . . . . . . . . . . . . . . .10




Blue Option Silver 4200 HD . . . . . . . . . . . . . . . . . . . .11












Blue Option Bronze 5550 . . . . . . . . . . . . . . . . . . . . . .15




Blue Option Bronze 6900 HD . . . . . . . . . . . . . . . . . .16



Blue Option Catastrophic . . . . . . . . . . . . . . . . . . . . .17

PricingGo to www.BlueOptionSC.com to begin

shopping for a plan and determine pricing.

9

These benefits are applicable to all plans:

BENEFIT ALL PLANSGynecological Exam (two per benefit year) $0 copayment

Routine Screening Mammogram $0 copayment

Routine Screening Colonoscopy $0 copayment

BlueCardBlue Option benefits are provided in network only. No benefits are provided for services received out of network, unless the service is due to an emergency medical condition and the services are provided in an urgent care center or hospital emergency room. Visit www.BlueOptionSC.com to find a list of urgent care providers.

Pediatric Vision Care — Enhanced in 2020To locate an in-network vision care provider, please visit

www.BlueOptionSC.com.

• $15 copay for one routine eye exam*

• One standard contact lens fitting with a $49 copay* or• 15% discount off the provider’s non-standard contact lens fitting fee.• $150 material allowance with a $25 copay every benefit period that can be spent on frames, lens, lens upgrades, and contacts.

Members are not limited by a frame, lens or contact lens selection.*

• Benefit can be used for prescription sunglasses.• Discounts of 20% on glasses and 15% on contacts on any amounts spent over the material allowance (at most providers).• Necessary contact lenses are covered in full for specific conditions for which contact lenses provide better visual correction. For

out-of-network providers, the member is reimbursed up to $40 for a routine eye exam and up to 65% of the material allowance that is used, less material copay.

Adult Vision** — Enhanced in 2020To locate an in-network vision care provider, please visit www.BlueOptionSC.com.

For adult vision care (ages 19 and over), this includes:• $0 copay for one routine eye exam• One standard contact lens fitting with a $49 copay, or• 15% discount off the provider’s non-standard contact lens fitting fee.• $150 material allowance with a $0 copay every benefit period that can be spent on frames, lens, lens upgrades, and contacts.

Members are not limited by a frame, lens or contact lens selection.• Benefit can be used for prescription sunglasses.• Discounts of 20% on glasses and 15% on contacts on any amounts spent over the material allowance (at most providers). For

out-of-network providers, the member is reimbursed up to $40 for a routine eye exam and up to 65% of the material allowance that is used, less material copay.

Preventive Dental Care**

Members will be responsible for paying any additional balance above what we cover. They will need to submit a dental reimbursement form to BlueChoice for reimbursement.For example, if your dentist charges you $130 for an initial cleaning and exam, you will pay your dentist $130 at the time of service. We will reimburse you $100 once we receive your reimbursement form.

• One exam every six months: $50 allowance• One cleaning every six months: $50 allowance

Mental Health/Substance Abuse Covered the same as medical benefits.

Transplants A BlueChoice-participating facility must provide services.

* These copayments do not apply to Catastrophic Plan members.**Costs incurred from these services do not count toward MOOP expenses.

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BENEFIT FEATURE & DESCRIPTION NEW – BLUE OPTION SILVER 2000 BLUE OPTION SILVER 2400 BLUE OPTION SILVER 3200

Deductible (Single/Family) $2,000/$4,000 $2,400/$4,800 $3,200/$6,400

Maximum Out of Pocket (Single/Family) $7,500/$15,000 $8,150/$16,300 $7,900/$15,800

Primary Care Physician Services $35 $45 $35

Doctors Care/Blue CareOnDemand $35 $45 $35

Maternity Care $75 first visit $85 first visit $80 first visit

Specialist Visit $75 $85 $80

Urgent Care $75 $75 $75

Freestanding Ambulatory Surgical Center* $200 per visit $200 per visit $200 per visit

Inpatient Hospital Services $400 copayment, then 50% after deductible 50% after deductible 50% after deductible

Outpatient Hospital Services 50% after deductible 50% after deductible 50% after deductible

Emergency Room $400 copayment, then 50% after deductible$450 copayment,

then 50% after deductible$400 copayment,

then 50% after deductible

Ambulance 50% after deductible 50% after deductible 50% after deductible

PRESCRIPTION DRUGS

Retail

Tier 1: $20Tier 2: $20Tier 3: 50% after deductibleTier 4: 50% after deductibleTier 5: 50% after deductibleTier 6: 50% after deductible

Tier 1: $25Tier 2: $25Tier 3: $55Tier 4: $85Tier 5: $300Tier 6: $300


Mail Order




Durable Medical Equipment 50% after deductible 50% after deductible 50% after deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation**

50% after deductible 50% after deductible 50% after deductible

NOTES: • All plans include an embedded deductible and MOOP. If necessary, please see the glossary on page 25 for an explanation of embedded deductible. • Generic and brand drugs are available for a 90-day supply through the mail-order program. Specialty drugs are available for a 30-day supply through the mail-order program. *Facility charges only. Providers may bill separately for their services.**30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year. 30 visits for habilitation per benefit year.

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BENEFIT FEATURE & DESCRIPTION BLUE OPTION SILVER 3500 BLUE OPTION SILVER 4200 HD BLUE OPTION SILVER 4500



Primary Care Physician Services $40 Deductible $40

Doctors Care/Blue CareOnDemand $40 Deductible $40

Maternity Care $80 first visit Deductible $80 first visit

Specialist Visit $80 Deductible $80

Urgent Care $75 Deductible $75

Freestanding Ambulatory Surgical Center* $200 per visit Deductible $200 per visit

Inpatient Hospital Services 40% after deductible Deductible 50% after deductible

Outpatient Hospital Services 40% after deductible Deductible 50% after deductible

Emergency Room$350 copayment,

then 40% after deductibleDeductible 50% after deductible

Ambulance 40% after deductible Deductible 50% after deductible

PRESCRIPTION DRUGS

Retail


All Tiers – Deductible


Mail Order



Tier 1: $30Tier 2: $30 Tier 3: $120Tier 4: $180Tier 5: $600Tier 6: $600

Durable Medical Equipment 40% after deductible Deductible 50% after deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation** 40% after deductible Deductible 50% after deductible


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BENEFIT FEATURE & DESCRIPTION BLUE OPTION SILVER 4600 HD BLUE OPTION SILVER 5001 BLUE OPTION

SILVER 5004 HDNEW – BLUE OPTION

SILVER 5550Deductible (Single/Family) $4,600/$9,200 $5,000/$10,000 $5,000/$10,000 $5,550/$11,100

Maximum Out of Pocket (Single/Family) $4,600/$9,200 $7,900/$15,800 $5,000/$10,000 $7,350/$14,700

Primary Care Physician Services Deductible $30 Deductible $45

Doctors Care/Blue CareOnDemand Deductible $30 Deductible $45

Maternity Care Deductible $60 first visit Deductible $100 first visit

Specialist Visit Deductible $60 Deductible $100

Urgent Care Deductible $75 Deductible $75

Freestanding Ambulatory Surgical Center* Deductible $200 per visit Deductible $200 per visit

Inpatient Hospital Services Deductible 30% after deductible Deductible$500 copayment,


Outpatient Hospital Services Deductible 30% after deductible Deductible 20% after deductible

Emergency Room Deductible$400 copayment,

then 30% after deductibleDeductible

$500 copayment, then 20% after deductible

Ambulance Deductible 30% after deductible Deductible 20% after deductible

PRESCRIPTION DRUGS

Retail All Tiers – Deductible



Tier 1: $15Tier 2: $15Tier 3: $35Tier 4: 20% after deductibleTier 5: 20% after deductibleTier 6: 20% after deductible

Mail Order All Tiers – Deductible



Tier 1: $30Tier 2: $30Tier 3: $70Tier 4: 20% after deductibleTier 5: 20% after deductibleTier 6: 20% after deductible

Durable Medical Equipment Deductible 30% after deductible Deductible 20% after deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation** Deductible 30% after deductible Deductible 20% after deductible

NOTES: • All plans include an embedded deductible and MOOP. If necessary, please see the glossary on page 25 for an explanation of embedded deductible. • Generic and brand drugs are available for a 90-day supply through the mail-order program. Specialty drugs are available for a 30-day supply through the mail-order program.*Facility charges only. Providers may bill separately for their services.**30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year. 30 visits for habilitation per benefit year.

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BENEFIT FEATURE & DESCRIPTION NEW – BLUE OPTION SILVER 6002

BLUE OPTION SILVER 6250

BLUE OPTION SILVER 6850

NEW – BLUE OPTION SILVER 7000

Deductible (Single/Family) $6,000/$12,000 $6,250/$12,500 $6,850/$13,700 $7,000/$14,000


Primary Care Physician Services $55 $20 $25 $0

Doctors Care/Blue CareOnDemand $55 $20 $25 $0

Maternity Care $100 first visit $55 first visit $60 first visit $50 first visit

Specialist Visit $100 $55 $60 $50

Urgent Care $75 $75 $75 $75

Freestanding Ambulatory Surgical Center* $200 per visit $200 per visit $200 per visit $200 per visit

Inpatient Hospital Services Deductible 25% after deductible 40% after deductible$500 copayment, then

deductible

Outpatient Hospital Services Deductible 25% after deductible 40% after deductible Deductible

Emergency Room$400 copayment, then deductible

25% after deductible 40% after deductible$500 copayment, then

deductible

Ambulance Deductible 25% after deductible 40% after deductible Deductible

PRESCRIPTION DRUGS

Retail

Tier 1: $30Tier 2: $30Tier 3: $55Tier 4: DeductibleTier 5: DeductibleTier 6: Deductible




Mail Order


Tier 1 – $40Tier 2 – $40Tier 3 – $80Tier 4 – $180Tier 5 – $600Tier 6 – $600



Durable Medical Equipment Deductible 25% after deductible 40% after deductible Deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation** Deductible 25% after deductible 40% after deductible Deductible


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BENEFIT FEATURE & DESCRIPTION BLUE OPTION SILVER 7350 NEW – BLUE OPTION SILVER 8150

Deductible (Single/Family) $7,350/$14,700 $8,150/$16,300

Maximum Out of Pocket (Single/Family) $7,350/$14,700 $8,150/$16,300

Primary Care Physician Services $40 $0

Doctors Care/Blue CareOnDemand $40 $0

Maternity Care $80 first visit $50 first visit

Specialist Visit $80 $50

Urgent Care $75 $75

Freestanding Ambulatory Surgical Center* $200 per visit $200 per visit

Inpatient Hospital Services Deductible $500 copayment, then deductible

Outpatient Hospital Services Deductible Deductible

Emergency Room Deductible $500 copayment, then deductible

Ambulance Deductible Deductible

PRESCRIPTION DRUGS

Retail



Mail Order



Durable Medical Equipment Deductible Deductible


Deductible Deductible


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BENEFIT FEATURE & DESCRIPTION BLUE OPTION BRONZE 5550

NEW – BLUE OPTION BRONZE 5800

NEW – BLUE OPTIONBRONZE 6000

BLUE OPTION BRONZE 6500

Deductible (Single/Family) $5,550/$11,100 $5,800/$11,600 $6,000/$12,000 $6,500/$13,000


Primary Care Physician Services 20% after deductible $45 20% after deductible $40

Doctors Care/Blue CareOnDemand 20% after deductible $45 20% after deductible $40

Maternity Care 20% after deductible $90 first visit 20% after deductible $90 first visit

Specialist Visit 20% after deductible $90 20% after deductible $90

Urgent Care 20% after deductible $75 20% after deductible $75

Freestanding Ambulatory Surgical Center* $200 per visit $200 per visit $200 per visit $200 per visit

Inpatient Hospital Services $500 copayment,





Outpatient Hospital Services 20% after deductible 20% after deductible 20% after deductible 20% after deductible

Emergency Room$500 copayment,





Ambulance 20% after deductible 20% after deductible 20% after deductible 20% after deductible

PRESCRIPTION DRUGS

Retail All Tiers –20% after deductible


Tier 1: 20% after deductibleTier 2: 20% after deductibleTier 3: 20% after deductibleTier 4: 20% after deductibleTier 5: 20% after deductibleTier 6: 20% after deductible

Tier 1: $35Tier 2: $35Tier 3: 20% after deductible Tier 4: 20% after deductible Tier 5: 20% after deductible Tier 6: 20% after deductible

Mail OrderAll Tiers –20% after deductible


Tier 1: 20% after deductibleTier 2: 20% after deductibleTier 3: 20% after deductibleTier 4: 20% after deductibleTier 5: 20% after deductibleTier 6: 20% after deductible

Tier 1: $70Tier 2: $70Tier 3: 20% after deductible Tier 4: 20% after deductible Tier 5: 20% after deductibleTier 6: 20% after deductible

Durable Medical Equipment 20% after deductible 20% after deductible 20% after deductible 20% after deductible


20% after deductible 20% after deductible 20% after deductible 20% after deductible


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BENEFIT FEATURE & DESCRIPTION BLUE OPTION BRONZE 6900 HD BLUE OPTION BRONZE 7300 BLUE OPTION BRONZE 7900



Primary Care Physician Services Deductible $40 $45

Doctors Care/Blue CareOnDemand Deductible $40 $45

Maternity Care Deductible $90 first visit $90 first visit

Specialist Visit Deductible $90 $90

Urgent Care Deductible $75 $75

Freestanding Ambulatory Surgical Center* Deductible $200 per visit $200 per visit

Inpatient Hospital Services Deductible $500 copayment, then 50% after deductible $500 copayment, then deductible

Outpatient Hospital Services Deductible 50% after deductible Deductible

Emergency Room Deductible $500 copayment, then 50% after deductible $500 copayment, then deductible

Ambulance Deductible 50% after deductible Deductible

PRESCRIPTION DRUGS

Retail All Tiers – Deductible


Tier 1: $35Tier 2: $35Tier 3: Deductible Tier 4: Deductible Tier 5: DeductibleTier 6: Deductible



Tier 1: $70Tier 2: $70Tier 3: Deductible Tier 4: Deductible Tier 5: Deductible Tier 6: Deductible

Durable Medical Equipment Deductible 50% after deductible Deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation** Deductible 50% after deductible Deductible

NOTES: • All plans include an embedded deductible and MOOP. If necessary, please see the glossary on page 25 for an explanation of embedded deductible. • Generic and brand drugs are available for a 90-day supply through the mail-order program. Specialty drugs are available for a 30-day supply through the mail-order program.*Facility charges only. Providers may bill separately for their services.**30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year. 30 visits for habilitation per benefit year.

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NotesBENEFIT FEATURE & DESCRIPTION BLUE OPTION CATASTROPHIC

Deductible (Single/Family) $8,150/$16,300

Maximum Out of Pocket (Single/Family) $8,150/$16,300

Primary Care Physician Services $25 for first 3 visits, then deductible

Doctors Care/Blue CareOnDemand $25 for first 3 visits, then deductible

Maternity Care Deductible

Specialist Visit Deductible

Urgent Care Deductible

Freestanding Ambulatory Surgical Center* Deductible

Inpatient Hospital Services Deductible

Outpatient Hospital Services Deductible

Emergency Room Deductible

Ambulance Deductible

PRESCRIPTION DRUGSRetail All Tiers – Deductible


Durable Medical Equipment Deductible

Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation** Deductible

NOTES: • All plans include an embedded deductible and MOOP. If necessary, please see the glossary on page 25 for an

explanation of embedded deductible. • Generic and brand drugs are available for a 90-day supply through the mail-order program. Specialty drugs are available

for a 30-day supply through the mail-order program. *Facility charges only. Providers may bill separately for their services.**30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year. 30 visits for habilitation per benefit year.

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2020 Blue OptionSM Plan ChangesThis grid illustrates benefit changes that will become effective Jan. 1, 2020, for existing Blue Option plans that were offered during 2019. Please refer to your Schedule

of Benefits for complete details of your 2020 plan benefits.

SILVER PLANS2019 SILVER 1500 2019 - Silver 1500 2020 - Silver 2000

Plan is no longer available. Members will move to new Silver 2000.Individual Deductible $1,500 $2,000Family Deductible $3,000 $4,000Individual MOOP $7,100 $7,500Family MOOP $14,200 $15,000Primary Care Visit $15 $35Specialist Office Visit $15, then 50% after deductible $75

2019 SILVER 1501 2019 - Silver 1501 2020 - Silver 2000Plan is no longer available. Members will move to new Silver 2000.Individual Deductible $1,500 $2,000Family Deductible $3,000 $4,000Primary Care Visit $40 $35Specialist Office Visit $80 $75

2019 SILVER 2000 2019 - Silver 2000 2020 - Silver 2400Members who were in Silver 2000 in 2019 will move to Silver 2400 in 2020.Individual Deductible $2,000 $2,400Family Deductible $4,000 $4,800Individual MOOP $7,350 $8,150Family MOOP $14,700 $16,300Primary Care Visit $0 $45Specialist Office Visit 50% after deductible $85

SILVER 2502 2019 - Silver 2502 2020 - Silver 2000Plan is no longer available. Members will move to new Silver 2000.Coinsurance 30% 50%Individual Deductible $2,500 $2,000Family Deductible $5,000 $4,000Individual MOOP $7,000 $7,500Family MOOP $14,000 $15,000Primary Care Visit $25 $35Specialist Office Visit $50 $75

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SILVER PLANS (continued) SILVER 2503 2019 - Silver 2503 2020 - Silver 2000

Plan is no longer available. Members will move to new Silver 2000.Individual Deductible $2,500 $2,000

Family Deductible $5,000 $4,000

Individual MOOP $7,350 $7,500

Family MOOP $14,700 $15,000

Primary Care Visit $0 for the first two visits, then 50% after deductible $35

Specialist Office Visit 50% after deductible $75

SILVER 3000 2019 - Silver 3000 2020 - Silver 3200Plan is no longer available. Name changes to Silver 3200.Individual Deductible $3,000 $3,200



Family MOOP $14,700 $15,800

Primary Care Visit $20 $35

Specialist Office Visit $50 $80

SILVER 3001 2019 - Silver 3001 2020 - Silver 3200Plan is no longer available. Members will move to Silver 3200.Coinsurance 35% 50%

Individual Deductible $3,000 $3,200



Family MOOP $14,700 $15,800


SILVER 3500 2019 - Silver 3500 2020 - Silver 3500Coinsurance 30% 40%


Family MOOP $14,700 $16,000



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SILVER PLANS (continued) SILVER 3501 2019 - Silver 3501 2020 - Silver 3500

Plan is no longer available. Members will move to Silver 3500.Individual MOOP $7,500 $8,000

Family MOOP $15,000 $16,000



Silver 4000 2019 - Silver 4000 2020 - Silver 4500Plan is no longer available. Name changes to Silver 4500.Coinsurance 30% 50%




Family MOOP $13,200 $16,300



Silver 4500 HD 2019 - Silver 4500 HD 2020 - Silver 4600 HDPlan is no longer available. Name changes to Silver 4600 HD.Individual Deductible $4,500 $4,600



Family MOOP $9,000 $9,200

Silver 5001 2019 - Silver 5001 2020 - Silver 5001Individual MOOP $7,350 $7,900

Family MOOP $14,700 $15,800



Silver 6002 2019 - Silver 6002 2020 - Silver 6250Members who were in Silver 6002 in 2019 will move to Silver 6250 in 2020.Coinsurance 20% 25%




Family MOOP $14,700 $15,600



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SILVER PLANS (continued)Silver 6250 2019 - Silver 6250 2020 - Silver 6250


Family MOOP $14,700 $15,600



Silver 6251 2019 - Silver 6251 2020 - Silver 6250Plan is no longer available. Members will move to Silver 6250.Individual MOOP $7,750 $7,800

Family MOOP $15,500 $15,600



Silver 6900 2019 - Silver 6900 2020 - Silver 6850Plan is no longer available. Name changes to Silver 6850.Individual Deductible $6,900 $6,850



Family MOOP $14,700 $15,600



Silver 7350 2019 - Silver 7350 2020 - Silver 7350Primary Care Visit $25 $40


Silver 7750 2019 - Silver 7750 2020 - Bronze 7900Plan is no longer available. Members will move to Bronze 7900.Individual Deductible $7,750 $7,900



Family MOOP $15,500 $15,800



22

BRONZE PLANSBRONZE 5500 2019 - Bronze 5500 2020 - Bronze 5550

Plan is no longer available. Members will move to Bronze 5550.Coinsurance 50% 20%




Family MOOP $13,200 $15,800

Primary Care Visit 50% after deductible 20% after deductible

Specialist Office Visit 50% after deductible 20% after deductible

BRONZE 5501 2019 - Bronze 5501 2020 - Bronze 5550Plan is no longer available. Name changes to Bronze 5550.Coinsurance 50% 20%



Primary Care Visit 50% after deductible 20% after deductible

Specialist Office Visit 50% after deductible 20% after deductible

BRONZE 6000 HD 2019 - Bronze 6000 HD 2020 - Bronze 6900 HDPlan is no longer available. Members will move to Bronze 6900 HD.Individual Deductible $6,000 $6,900


Primary Care Visit $6,000 $6,900

Specialist Office Visit $12,000 $13,800

BRONZE 6350 HD 2019 - Bronze 6350 HD 2020 - Bronze 6900 HDPlan is no longer available. Name changes to Bronze 6900 HD.Individual Deductible $6,350 $6,900


Primary Care Visit $6,350 $6,900

Specialist Office Visit $12,700 $13,800

BRONZE 6500 2019 - Bronze 6500 2020 - Bronze 6500Coinsurance 50% 20%


Family MOOP $13,700 $16,300

Primary Care Visit 50% after deductible $40

Specialist Office Visit 50% after deductible $90

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BRONZE PLANS (continued)BRONZE 7150 2019 - Bronze 7150 2020 - Bronze 7300

Plan is no longer available. Members will move to Bronze 7300.Coinsurance Deductible 50%




Family MOOP $14,300 $16,300


BRONZE 7350 2019 - Bronze 7350 2020 - Bronze 7300Plan is no longer available. Name changes to Bronze 7300.Coinsurance Deductible 50%




Family MOOP $14,700 $16,300


BRONZE 7900 2019 - Bronze 7900 2020 - Bronze 7900Primary Care Visit Deductible $45

Specialist Office Visit Deductible $90

BRONZE 7901 2019 - Bronze 7901 2020 - Bronze 7900Plan is no longer available. Members will move to Bronze 7900.Primary Care Visit $50 $45


CATASTROPHIC PLANCATASTROPHIC 2019 - Catastrophic 2020 - Catastrophic




Family MOOP $15,800 $16,300

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Protection of PrivacyBlueChoice keeps all medical information about a member strictly confidential. BlueChoice has administrative, technical and physical safeguards in place to

protect the privacy of members’ personal health information. Our information systems have advanced security that limits access to personal health information

to authorized personnel only. We require all staff to keep confidential any personal health information they learn in performing their jobs. Additionally, staff is

required to limit requests to external entities for a member’s personal health information to the minimum necessary for their intended purpose.

BlueChoice requires all physicians and other health care professionals in our provider network to maintain the confidentiality of their patients’ health information,

and they must guard against unauthorized or inadvertent disclosure of this confidential information. Through on-site visits, BlueChoice reviews each provider’s

privacy policies and methods for storing and protecting patients’ medical records.

BlueChoice requires all business associates, consultants and other entities with whom we contract for clinical or administrative services to maintain such

confidentiality and to have a privacy policy in place that protects against unauthorized use or disclosure of confidential information. All such entities must sign an

agreement attesting to the fact that they are compliant with federal privacy regulations.

Collection, Use and Disclosure of Medical InformationBlueChoice may use and disclose medical information about you for the purposes of treatment, payment and health care operations. Examples of these routine

activities that involve the collection, use and disclosure of health information include getting information from health care providers to determine medical

necessity, processing claims, issuing Explanations of Benefits to policyholders and conducting quality improvement activities.

If there is a need to release member-identifiable information for purposes other than those approved by law for treatment, payment and health care operations,

BlueChoice must first get a written authorization form signed by the member. The authorization form allows the member to specify what information BlueChoice is

authorized to release, to whom it may be released and for what purpose.

BlueChoice knows how important it is to protect the privacy of each member’s confidential medical information. Here are the efforts we make to protect your privacy.

Statement of Confidentiality

25

CoinsuranceThe dollar amount or percentage you pay for your covered health care services.

For example, if you have an “80/20” plan, your health plan would pay 80 percent

of the allowed amount, and you would pay 20 percent. The 20 percent you pay is

your coinsurance amount.

Copayment A set dollar amount you pay each time you receive a health care service. For

example, your health plan may have a $20 copayment for a doctor’s office visit.

You will pay this amount each time you go to the in-network doctor.

DeductibleThe amount you must pay for covered services before your health plan starts

to pay. For example, your plan has a $500 deductible. You must pay the first

$500 of allowable charges for covered services before your plan starts to

pay benefits. Your health plan may pay some benefits before you meet your

deductible. For example, your plan may pay some preventive services at

100 percent, even if you have not met your deductible.

Embedded DeductibleYour plan contains two components — an individual deductible and a family

deductible. Once a family member meets his or her individual deductible, the

plan will cover that family member’s covered medical expenses. Once family

members have reached the family deductible, the plan will pay for covered

expenses for all family members. The individual deductible is embedded in

the family deductible.

Maximum Out of Pocket (MOOP)The most you pay for covered services in a year before this plan begins to pay

100 percent of the allowed amount. This limit never includes your premium,

balance-billed charges, health care your plan doesn’t cover or coupons for

medical and/or prescription coverage.

Network ProviderNetwork providers are doctors, hospitals and other health care providers that we

have contracted with to provide health care services to our members. Network

providers are also called “in-network” providers or “participating” providers.

Open Enrollment Period The yearly period when you can enroll in or make changes to your health

insurance coverage. Open enrollment for 2020 runs from October 15, 2019,

to December 15, 2019.

Special Enrollment Period (SEP) An SEP is a time outside of the yearly open enrollment period when you can

enroll in a health insurance plan. You qualify for an SEP if you’ve had certain life

events like losing health coverage, moving, getting married, having a baby or

adopting a child.

Glossary


Focus on life. Focus on health. Stay focused.

BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association.

210864-BC-3015-9-2019

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BlueChoice HealthPlan’s goal is to help keep you healthy. We look forward to helping you decide which Blue Option plan is best for you and your family.

For more information on Blue Option plans, you can:

1: Contact a local insurance agent.2: Call us at 877-252-0632 Monday – Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m.

3: Visit www.BlueOptionSC.com.

Documents

Blue Option · Blue Option Saves You Time and Money • Large network of doctors, hospitals, specialists, pharmacies and other health care providers • No claim forms or referrals