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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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