Page 16 - The Final W book

Medical Carrier: BlueCross BlueShield of South Carolina

HDHP with HIA
In Network Benefit Level
Group #70-87357
Deductible $2,000/$4,000
Coinsurance
Paid by Carrier/Paid by You 80%/20%

Preventive Care Plan pays 100%

Physician’s Office Visit
Deductible + 80%

Specialist
Deductible + 80%

Urgent Care
Deductible + 80%

Emergency Room
Deductible + 80%

Telemedicine/Virtual Visit
Deductible + 80%

Outpatient Surgery
Freestanding Facility/Hospital Deductible + 80%

Inpatient Hospitalization
Deductible + 80%

Independent Labs
Contracted Lab or Freestanding Facility Deductible + 80%
Hospital

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

Annual Out of Pocket Maximum
$4,500/$9,000

Weekly Deductions (52)
Deduction

Employee $0.00
Employee + Spouse $125.81

Employee + Child(ren) $125.81
Family $179.73

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