Page 13 - The Final W book

Medical Carrier: BlueCross BlueShield of South Carolina

PPO $1000 with HIA
In Network Benefit Level
Group #70-87357
Deductible $1,000/$2,000

Coinsurance
Paid by Carrier/Paid by You 80%/20%

Preventive Care Plan pays 100%

Physician’s Office Visit
$30

Specialist
$50

Urgent Care
$50

Emergency Room
$150, then Deductible, 80%

Telemedicine/Virtual Visit
$30

Outpatient Surgery
Freestanding Facility/Hospital Deductible + 80%

Inpatient Hospitalization
Deductible + 80%

Independent Labs
Contracted Lab or Freestanding Facility 100%
Hospital

Complex Imaging (CT/MRI/PET SCAN)
Deductible + 80%

Annual Out of Pocket Maximum
$6,350/$12,700

Weekly Deductions (52)
Deduction

Employee $27.53
Employee + Spouse $191.88

Employee + Child(ren) $191.88
Family $262.31

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