Page 15 - The Final W book
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Medical Carrier: BlueCross BlueShield of South Carolina
PPO $3000 with HIA
In Network Benefit Level
Group #70-87357
Deductible $3,000/$6,000
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
$250, 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
$6,850/$13,700
Weekly Deductions (52)
Deduction
Employee $12.49
Employee + Spouse $155.78
Employee + Child(ren) $155.78
Family $217.19
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