Blue Option...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

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Focus on life. Focus on health. Stay focused.

Blue Option2021 Sales Booklet

ContentsBlue Option Has You Covered ...........................................................1

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

Key Benefits and Services For You .....................................................3

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

Choose Your 2021 Health Coverage ..................................................6

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

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

Glossary ..............................................................................................15


1

Blue Option is here for you with:

• Our 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

• $0 Rx tier on all plans

• Routine adult and pediatric vision coverage

• Dental allowance for exams and cleanings

• More rewards with the 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

Blue Option Has You Covered


Blue Option Gives You the Value You Deserve• Large network of doctors, hospitals, specialists, pharmacies and other health care providers

• No claim forms or referrals needed for in-network 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

• 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!

Comprehensive Provider 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

emergency care nationwide through our BlueCard® program.

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.

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.

Vision CoverageIn-network vision providers include your favorite retailers, including Walmart

Vision Center, Target Optical, LensCrafters, and more. There is 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 are no

limits on frame or lens selection. Most providers offer additional discounts on

any amounts spent over the material allowance.

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 all-inclusive office visit copayments, dental coverage and online visits with

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

more information.

You Get More With Blue Option

Visit www.BlueOptionSC.com for more details.

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3

Key Benefits and Services For YouVision 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.

Blue CareOnDemandAll 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.

All-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.

FOCUSfwd Wellness Incentive ProgramThe FOCUSfwd Wellness Incentive Program is designed to help you

lead a healthier lifestyle. Complete our FOCUS Points, GET FIT, and

Nutrition programs and receive $80 in rewards. Plus increase your

chances of winning one of the $1,000 quarterly and $5,000 annual cash rewards in our Sweepstakes!

FOCUS Points — Get a $25 cash reward and 10 entries into the Sweepstakes when you complete your Personal Health Assessment. Plus,

get an additional $25 cash reward and 15 entries into the Sweepstakes

when you complete an annual wellness visit and preventive screening or

flu shot, for a total of $50 in cash rewards and 25 entries!

GET FIT — Get up to $20 in gift cards and 25 entries into the Sweepstakes for stepping up to the annual challenge.

Nutrition — Get $10 in gift cards and 25 entries into the Sweepstakes

for completing the Nutrition program, which helps you with basic

cooking skills that allow you to explore new foods while reaching

nutrient-driven goals. You’ll also have opportunities to win an

Instant Pot®, blender or food processor.

Sweepstakes — Earn entries into the Sweepstakes for chances to win

one of the $1,000 quarterly and the annual $5,000 cash rewards by

simply signing up for FOCUSfwd and completing any of its programs.

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4

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.

Life Management Services All members 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. Because

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

responsible for all services related to individual assistance programs.

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

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 a $25 cash reward and 10 entries into the

FOCUSfwd Wellness Incentive Program Sweepstakes drawings! You

can complete your assessment at www.BlueOptionSC.com. Access

My Health Toolkit® and follow these steps:

1. Select the Health and Wellness tab.

2. Select the FOCUSfwd Incentive Program link.

3. Select the PHA tab.

4. Select the Complete Now button on the Complete Your Personal Health Assessment (PHA) tile.

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 Sweepstakes drawings for participating in

some of these programs.

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5

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 Sweepstakes drawings.

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My Health ToolkitBlueChoice 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.

• 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.

Access Your Health Information Anytime

BLUECHOICE HEALTHPLAN

ZCL00000000

www.BlueChoiceSC.com

SUBSCRIBER’S FIRST NAMESUBSCRIBER’S LAST NAME

ZCL00000000Member ID

PLANPLAN CODERxBINRxGRP

PPO380.04021684CHC

Health BenefitsPediatric VisionComprehensive Dental


ZCJ00000000

www.BlueOptionSC.com

SUBSCRIBER’S FIRST NAMESUBSCRIBER’S LAST NAME

ZCJ00000000Member ID

PLAN CODERxBINRxGRP

380.04021684CHC

Health Benefits

Blue Option Network

Out of State Only

Jan 1, 2021 - Jan 1, 2022 Jan 1, 2021 - Jan 1, 2022


ZCJ00000000

www.BlueChoiceSC.com

FIRST NAME LAST NAME

ZCL00000000Member ID

PLANPLAN CODE

PPO380.04

Advantage Network

BusinessADVANTAGE

Jan 1, 2021 - Jan 1, 2022

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

October 15, 2020, to December 15, 2020. 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 855-433-2132 or

contact your local agent during the open enrollment period to select your 2021

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 2021 Health Coverage

6

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 Bronze 5550 . . . . . . . . . . . . . . . . . . . . . .13




Blue Option Silver 4300 HD . . . . . . . . . . . . . . . . . . . .14

Blue Option Silver 6100 HD . . . . . . . . . . . . . . . . . . . .14

Blue Option Bronze 6900 HD . . . . . . . . . . . . . . . . . .14

Blue Option Catastrophic . . . . . . . . . . . . . . . . . . . . .14

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 CareTo 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*

To 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: up to a $50 allowance• One cleaning every six months: up to a $50 allowance

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

Transplants A BlueChoice-participating facility must provide services.

*Costs incurred from these services do not count toward MOOP expenses.

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BENEFIT FEATURE & DESCRIPTION BLUE OPTION SILVER 2000 BLUE OPTION SILVER 3200 BLUE OPTION SILVER 3500

Coinsurance 50% 50% 40%

Deductible (Single/Family) $2,000/$4,000 $3,200/$6,400 $3,500/$7,000

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

Primary Care Office Visit $35 $35 $40

Doctors Care/Blue CareOnDemand $35 $35 $40

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

Specialist Office Visit $75 $80 $80

Urgent Care $50 $50 $50

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 40% after deductible

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

Emergency Room $400 copayment, then 50% after deductible $400 copayment, then 50% after deductible $350 copayment, then 40% after deductible

Ambulance 50% after deductible 50% after deductible 40% after deductible

PRESCRIPTION DRUGS**

Retail

Tier 0: $0Tier 1: $20Tier 2: $20Tier 3: 50% after deductibleTier 4: 50% after deductibleTier 5: 50% after deductibleTier 6: 50% after deductible

Tier 0: $0Tier 1: $25Tier 2: $25Tier 3: $50Tier 4: $90Tier 5: $300Tier 6: $300


Mail Order

Tier 0: $0Tier 1: $40Tier 2: $40Tier 3: 50% after deductibleTier 4: 50% after deductibleTier 5: 50% after deductibleTier 6: 50% after deductible



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

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

50% after deductible 50% after deductible 40% after deductible

NOTES: • All plans include an embedded deductible and MOOP. If necessary, please see the glossary on page 15 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.** If a drug manufacturer provides any form of direct support (cash, reimbursement, coupon, voucher, debit card, etc.) for some or all of the cost sharing on the purchase of prescription and/or specialty drugs, this amount will not be

counted toward the member’s annual limitation on cost sharing. The drug will still be considered a covered prescription drug.***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 5550 BLUE OPTION SILVER 6250 BLUE OPTION SILVER 6850

Coinsurance 20% 25% 40%

Deductible (Single/Family) $5,550/$11,100 $6,250/$12,500 $6,850/$13,700

Maximum Out of Pocket (Single/Family) $7,350/$14,700 $7,800/$15,600 $7,800/$15,600

Primary Care Office Visit $45 $20 $25

Doctors Care/Blue CareOnDemand $45 $20 $25

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

Specialist Office Visit $100 $55 $60

Urgent Care $50 $50 $50

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

Inpatient Hospital Services $500 copayment, then 20% after deductible 25% after deductible 40% after deductible

Outpatient Hospital Services 20% after deductible 25% after deductible 40% after deductible

Emergency Room $500 copayment, then 20% after deductible 25% after deductible 40% after deductible

Ambulance 20% after deductible 25% after deductible 40% after deductible


Retail

Tier 0: $0Tier 1: $15Tier 2: $15Tier 3: $35Tier 4: 20% after deductibleTier 5: 20% after deductibleTier 6: 20% after deductible



Mail Order

Tier 0: $0Tier 1: $30Tier 2: $30Tier 3: $70Tier 4: 20% after deductibleTier 5: 20% after deductibleTier 6: 20% after deductible



Durable Medical Equipment 20% after deductible 25% after deductible 40% after deductible


20% after deductible 25% after deductible 40% after deductible



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BENEFIT FEATURE & DESCRIPTION BLUE OPTION SILVER 7000 BLUE OPTION SILVER 7350

Coinsurance 0% 0%

Deductible (Single/Family) $7,000/$14,000 $7,350/$14,700

Maximum Out of Pocket (Single/Family) $7,000/$14,000 $7,350/$14,700

Primary Care Office Visit $0 $40

Doctors Care/Blue CareOnDemand $0 $40

Maternity Care $50 first visit $80 first visit

Specialist Office Visit $50 $80

Urgent Care $50 $50

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

Inpatient Hospital Services $500 copayment, then deductible Deductible

Outpatient Hospital Services Deductible Deductible

Emergency Room $500 copayment, then deductible Deductible

Ambulance Deductible Deductible


Retail

Tier 0: $0Tier 1: $25Tier 2: $25Tier 3: $45Tier 4: DeductibleTier 5: DeductibleTier 6: Deductible


Mail Order

Tier 0: $0Tier 1: $50Tier 2: $50Tier 3: $90Tier 4: DeductibleTier 5: DeductibleTier 6: Deductible


Durable Medical Equipment Deductible Deductible


Deductible Deductible



13

BENEFIT FEATURE & DESCRIPTION BLUE OPTION BRONZE 5550

BLUE OPTION BRONZE 6500

BLUE OPTION BRONZE 7300

NEW — BLUE OPTION BRONZE 8550

Coinsurance 35% 20% 50% 0%

Deductible (Single/Family) $5,550/$11,100 $6,500/$13,000 $7,300/$14,600 $8,550/$17,100

Maximum Out of Pocket (Single/Family) $8,550/$17,100 $8,550/$17,100 $8,550/$17,100 $8,550/$17,100

Primary Care Office Visit $60 $60 $65 $70

Doctors Care/Blue CareOnDemand $60 $60 $65 $70

Maternity Care 35% after deductible $100 first visit $100 first visit $100 first visit

Specialist Office Visit 35% after deductible $100 $100 $100

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 $500 copayment,

then 35% after deductible$500 copayment,

then 20% after deductible $500 copayment,

then 50% after deductible Deductible

Outpatient Hospital Services 35% after deductible$500 copayment,


then 50% after deductibleDeductible

Emergency Room$500 copayment,


then 20% after deductible $500 copayment,

then 50% after deductible Deductible

Ambulance 35% after deductible 20% after deductible 50% after deductible Deductible


Retail Tier 0: $0Tiers 1-6: 35% after deductible

Tier 0: $0Tier 1: $40Tier 2: $40Tiers 3-6: 20% after deductible


Tier 0: $0Tier 1: $40Tier 2: $40Tiers 3-6: Deductible

Mail OrderTier 0: $0Tiers 1-6: 35% after deductible



Tier 0: $0Tier 1: $80Tier 2: $80Tiers 3-6: Deductible

Durable Medical Equipment 35% after deductible 20% after deductible 50% after deductible Deductible


35% after deductible 20% after deductible 50% after deductible Deductible

NOTES: • All plans include an embedded deductible and MOOP. If necessary, please see the glossary on page 15 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.** If a drug manufacturer provides any form of direct support (cash, reimbursement, coupon, voucher, debit card, etc.) for some or all of the cost sharing on the purchase of prescription and/or specialty drugs, this

amount will not be counted toward the member’s annual limitation on cost sharing. The drug will still be considered a covered prescription drug.***30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year; 30 visits for habilitation per benefit year.

14

BENEFIT FEATURE & DESCRIPTION BLUE OPTION SILVER 4300 HD

NEW — BLUE OPTION SILVER 6100 HD

BLUE OPTION BRONZE 6900 HD

BLUE OPTION CATASTROPHIC

Coinsurance 0% 0% 0% 0%

Deductible (Single/Family) $4,300/$8,600 $6,100/$12,200 $6,900/$13,800 $8,550/$17,100

Maximum Out of Pocket (Single/Family) $4,300/$8,600 $6,100/$12,200 $6,900/$13,800 $8,550/$17,100

Primary Care Office Visit Deductible Deductible Deductible $25 for first 3 visits, then deductible

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

Maternity Care Deductible Deductible Deductible Deductible

Specialist Office Visit Deductible Deductible Deductible Deductible

Urgent Care Deductible Deductible Deductible Deductible

Freestanding Ambulatory Surgical Center* Deductible Deductible Deductible Deductible

Inpatient Hospital Services Deductible Deductible Deductible Deductible

Outpatient Hospital Services Deductible Deductible Deductible Deductible

Emergency Room Deductible Deductible Deductible Deductible

Ambulance Deductible Deductible Deductible Deductible


Retail Tier 0: $0Tiers 1-6: Deductible

Tier 0: $0Tiers 1-6: Deductible



Mail OrderTier 0: $0Tiers 1-6: Deductible




Durable Medical Equipment Deductible Deductible Deductible Deductible


Deductible Deductible Deductible Deductible



15

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, say 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.

Essential Health BenefitsA set of 10 categories of services health insurance plans must cover, including:• Ambulatory patient services• Emergency services• Hospitalization• Maternity and newborn care• Mental health and substance use

disorder services, including behavioral health treatment

• Prescription drugs

• Rehabilitative and habilitative services and devices

• Laboratory services• Preventive and wellness services and

chronic disease management• Pediatric services, including oral and

vision care.

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 2021 runs from October 15, 2020, to

December 15, 2020.

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

16

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.

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.

Statement of Confidentiality

17

Notes



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

212468-BC-3022-10-2020

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Education Center



News

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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 855-433-2132 Monday – Friday, 9 a.m. to 5 p.m.

3: Visit www.BlueOptionSC.com.

Documents

Blue Option...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