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Focus on life. Focus on health. Stay focused.
Blue Option2020 Sales Booklet
New in 2020:
Enhanced Vision Coverage
ContentsWhy Blue Option is Your Best Option ...............................................1
Get More With Blue Option ...............................................................2
Benefits and Services Your Way ..........................................................3
Access Your Health Information Anytime ..........................................5
Choose Your 2020 Health Coverage ..................................................6
Decide What You Need ......................................................................7
Plans ......................................................................................................8
Glossary ..............................................................................................25
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1
• 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!
• Enhanced adult and pediatric vision coverage
• Dental coverage
• More rewards with 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
Why Blue Option is Your Best Option
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Blue Option Saves You Time and Money• Large network of doctors, hospitals, specialists, pharmacies and other health care providers
• No claim forms or referrals needed for 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
• Discounts on fitness memberships, wellness products, cosmetic services and more
• Discounts at chiropractors, massage therapists, dietitians and acupuncturists through our Natural BlueSM program
• 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!
More Providers in Our 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
emergent care nationwide through our BlueCard® program.
More 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.
More 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.
New in 2020: More Vision CoverageWe’ve greatly improved our vision coverage in 2020. In-network vision
providers now include your favorite retailers, including Walmart Vision Center,
Target Optical, LensCrafters, and more! There will be 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 will be
no limits on frame or lens selection! Additional discounts are available on any
amounts spent over the material allowance at most providers.
More 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 enhanced vision and dental coverage and online visits with
a doctor, you get more value with Blue Option. Check out pages 3-4 for
more information.
Get More With Blue Option
Visit www.BlueOptionSC.com for more details.
QuickEnroll
QuickBill
FOCUSfwd GreatExpectations
Hearing Aids
Biometric Screening
Learning Management System
TobaccoCessationBlueChoice
HealthPlan WireMy Health
ToolkitRewards
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Education Center
Laboratory Benefits Mgmt
Physician’s Office Manual
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Discounts andAdded Values
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Video Carolina ADVAdvantage Plus MyChoice ADV Primary Choice Medical PoliciesFlexible Savings
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3
Benefits and Services Your WayAll-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!
Vision 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.
FOCUSfwd ® Wellness Incentive ProgramThe FOCUSfwd Wellness Incentive Program is being redesigned to
showcase its four unique programs, plus a few new perks!
More Rewards — Members are now rewarded for completing
activities that are an important start to their overall health!
Sweepstakes — Members can still win $1,000 quarterly and annual cash
rewards of $5,000 for completing activities in all areas of FOCUSfwd!
GET FIT — Members receive exclusive FOCUSfwd prizes and
rewards for stepping up to the challenge.
Nutrition — We are giving members the knowledge and tools to
take control of their health. Members can search recipes, create
meal plans, obtain nutritional overviews of their meals for the entire
day, search by vitamin and mineral needs and much more!
Blue CareOnDemandSM
All 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.
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.
QuickEnroll
QuickBill
FOCUSfwd GreatExpectations
Hearing Aids
Biometric Screening
Learning Management System
TobaccoCessationBlueChoice
HealthPlan WireMy Health
ToolkitRewards
2018 Icons - Cumulative
Bases
Storefront
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Education Center
Laboratory Benefits Mgmt
Physician’s Office Manual
News
BlueOption
Blues Flash
ProducersGuide
Discounts andAdded Values
Business ADV Core ServicesCore ServicesHealth Care Reform
Video Carolina ADVAdvantage Plus MyChoice ADV Primary Choice Medical PoliciesFlexible Savings
AccountHealth
Reimbursement Account
EmployeeAssistanceProgram
Mobile App
QuickEnroll
QuickBill
FOCUSfwd GreatExpectations
Hearing Aids
Biometric Screening
Learning Management System
TobaccoCessationBlueChoice
HealthPlan WireMy Health
ToolkitRewards
2018 Icons - Cumulative
Bases
Storefront
REV: 11/27/2018
Education Center
Laboratory Benefits Mgmt
Physician’s Office Manual
News
BlueOption
Blues Flash
ProducersGuide
Discounts andAdded Values
Business ADV Core ServicesCore ServicesHealth Care Reform
Video Carolina ADVAdvantage Plus MyChoice ADV Primary Choice Medical PoliciesFlexible Savings
AccountHealth
Reimbursement Account
EmployeeAssistanceProgram
Mobile App
QuickEnroll
QuickBill
FOCUSfwd GreatExpectations
Hearing Aids
Biometric Screening
Learning Management System
TobaccoCessationBlueChoice
HealthPlan WireMy Health
ToolkitRewards
2018 Icons - Cumulative
Bases
Storefront
REV: 11/27/2018
Education Center
Laboratory Benefits Mgmt
Physician’s Office Manual
News
BlueOption
Blues Flash
ProducersGuide
Discounts andAdded Values
Business ADV Core ServicesCore ServicesHealth Care Reform
Video Carolina ADVAdvantage Plus MyChoice ADV Primary Choice Medical PoliciesFlexible Savings
AccountHealth
Reimbursement Account
EmployeeAssistanceProgram
Mobile App
QuickEnroll
QuickBill
FOCUSfwd GreatExpectations
Hearing Aids
Biometric Screening
Learning Management System
TobaccoCessationBlueChoice
HealthPlan WireMy Health
ToolkitRewards
2018 Icons - Cumulative
Bases
Storefront
REV: 11/27/2018
Education Center
Laboratory Benefits Mgmt
Physician’s Office Manual
News
BlueOption
Blues Flash
ProducersGuide
Discounts andAdded Values
Business ADV Core ServicesCore ServicesHealth Care Reform
Video Carolina ADVAdvantage Plus MyChoice ADV Primary Choice Medical PoliciesFlexible Savings
AccountHealth
Reimbursement Account
EmployeeAssistanceProgram
Mobile App
QuickEnroll
QuickBill
FOCUSfwd GreatExpectations
Hearing Aids
Biometric Screening
Learning Management System
TobaccoCessationBlueChoice
HealthPlan WireMy Health
ToolkitRewards
2018 Icons - Cumulative
Bases
Storefront
REV: 11/27/2018
Education Center
Laboratory Benefits Mgmt
Physician’s Office Manual
News
BlueOption
Blues Flash
ProducersGuide
Discounts andAdded Values
Business ADV Core ServicesCore ServicesHealth Care Reform
Video Carolina ADVAdvantage Plus MyChoice ADV Primary Choice Medical PoliciesFlexible Savings
AccountHealth
Reimbursement Account
EmployeeAssistanceProgram
Mobile App
4
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 prize drawings!
QuickEnroll
QuickBill
FOCUSfwd GreatExpectations
Hearing Aids
Biometric Screening
Learning Management System
TobaccoCessationBlueChoice
HealthPlan WireMy Health
ToolkitRewards
2018 Icons - Cumulative
Bases
Storefront
REV: 11/27/2018
Education Center
Laboratory Benefits Mgmt
Physician’s Office Manual
News
BlueOption
Blues Flash
ProducersGuide
Discounts andAdded Values
Business ADV Core ServicesCore ServicesHealth Care Reform
Video Carolina ADVAdvantage Plus MyChoice ADV Primary Choice Medical PoliciesFlexible Savings
AccountHealth
Reimbursement Account
EmployeeAssistanceProgram
Mobile App
Life Management Services All members can 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 EAP. Because
First Sun EAP is a separate company from BlueChoice, First Sun is solely
responsible for all services related to individual assistance programs.
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 entries into the FOCUSfwd Wellness Incentive
Program! Visit www.BlueOptionSC.com, log in to My Health Toolkit, and select FOCUSfwd Incentive Program on the Health and Wellness tab.
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
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 prize drawings for participating in some of these programs.
QuickEnroll
QuickBill
FOCUSfwd GreatExpectations
Hearing Aids
Biometric Screening
Learning Management System
TobaccoCessationBlueChoice
HealthPlan WireMy Health
ToolkitRewards
2018 Icons - Cumulative
Bases
Storefront
REV: 11/27/2018
Education Center
Laboratory Benefits Mgmt
Physician’s Office Manual
News
BlueOption
Blues Flash
ProducersGuide
Discounts andAdded Values
Business ADV Core ServicesCore ServicesHealth Care Reform
Video Carolina ADVAdvantage Plus MyChoice ADV Primary Choice Medical PoliciesFlexible Savings
AccountHealth
Reimbursement Account
EmployeeAssistanceProgram
Mobile App
QuickEnroll
QuickBill
FOCUSfwd GreatExpectations
Hearing Aids
Biometric Screening
Learning Management System
TobaccoCessationBlueChoice
HealthPlan WireMy Health
ToolkitRewards
2018 Icons - Cumulative
Bases
Storefront
REV: 11/27/2018
Education Center
Laboratory Benefits Mgmt
Physician’s Office Manual
News
BlueOption
Blues Flash
ProducersGuide
Discounts andAdded Values
Business ADV Core ServicesCore ServicesHealth Care Reform
Video Carolina ADVAdvantage Plus MyChoice ADV Primary Choice Medical PoliciesFlexible Savings
AccountHealth
Reimbursement Account
EmployeeAssistanceProgram
Mobile App
QuickEnroll
QuickBill
FOCUSfwd GreatExpectations
Hearing Aids
Biometric Screening
Learning Management System
TobaccoCessationBlueChoice
HealthPlan WireMy Health
ToolkitRewards
2018 Icons - Cumulative
Bases
Storefront
REV: 11/27/2018
Education Center
Laboratory Benefits Mgmt
Physician’s Office Manual
News
BlueOption
Blues Flash
ProducersGuide
Discounts andAdded Values
Business ADV Core ServicesCore ServicesHealth Care Reform
Video Carolina ADVAdvantage Plus MyChoice ADV Primary Choice Medical PoliciesFlexible Savings
AccountHealth
Reimbursement Account
EmployeeAssistanceProgram
Mobile App
QuickEnroll
QuickBill
FOCUSfwd GreatExpectations
Hearing Aids
Biometric Screening
Learning Management System
TobaccoCessationBlueChoice
HealthPlan WireMy Health
ToolkitRewards
2018 Icons - Cumulative
Bases
Storefront
REV: 11/27/2018
Education Center
Laboratory Benefits Mgmt
Physician’s Office Manual
News
BlueOption
Blues Flash
ProducersGuide
Discounts andAdded Values
Business ADV Core ServicesCore ServicesHealth Care Reform
Video Carolina ADVAdvantage Plus MyChoice ADV Primary Choice Medical PoliciesFlexible Savings
AccountHealth
Reimbursement Account
EmployeeAssistanceProgram
Mobile App
5
My Health Toolkit®
BlueChoice 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.
• Take a personal health assessment.
• 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 AnytimeQuickEnroll
QuickBill
FOCUSfwd GreatExpectations
Hearing Aids
Biometric Screening
Learning Management System
TobaccoCessationBlueChoice
HealthPlan WireMy Health
ToolkitRewards
2018 Icons - Cumulative
Bases
Storefront
REV: 11/27/2018
Education Center
Laboratory Benefits Mgmt
Physician’s Office Manual
News
BlueOption
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ProducersGuide
Discounts andAdded Values
Business ADV Core ServicesCore ServicesHealth Care Reform
Video Carolina ADVAdvantage Plus MyChoice ADV Primary Choice Medical PoliciesFlexible Savings
AccountHealth
Reimbursement Account
EmployeeAssistanceProgram
Mobile App
Open Enrollment Period You can sign up for health insurance during the open enrollment period from
October 15, 2019, to December 15, 2019. 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 877-252-0632 or
contact your local agent during the open enrollment period to select your 2020
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 2020 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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Covered Drug List
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Back Let’s Go Continue Change Family Information
Let’s Go!
Where AreYou?
How Many in Family?
Bronze Plans Silver Plans CatastrophicPlans
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Covered Drug List
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PlansPLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PAGEBenefits for all plans . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Blue Option Silver 2000 . . . . . . . . . . . . . . . . . . . . . . .10
Blue Option Silver 2400 . . . . . . . . . . . . . . . . . . . . . . .10
Blue Option Silver 3200 . . . . . . . . . . . . . . . . . . . . . . .10
Blue Option Silver 3500 . . . . . . . . . . . . . . . . . . . . . . .11
Blue Option Silver 4200 HD . . . . . . . . . . . . . . . . . . . .11
Blue Option Silver 4500 . . . . . . . . . . . . . . . . . . . . . . .11
Blue Option Silver 4600 HD . . . . . . . . . . . . . . . . . . . .12
Blue Option Silver 5001 . . . . . . . . . . . . . . . . . . . . . . .12
Blue Option Silver 5004 HD . . . . . . . . . . . . . . . . . . . .12
Blue Option Silver 5550 . . . . . . . . . . . . . . . . . . . . . . .12
Blue Option Silver 6002 . . . . . . . . . . . . . . . . . . . . . . .13
Blue Option Silver 6250 . . . . . . . . . . . . . . . . . . . . . . .13
Blue Option Silver 6850 . . . . . . . . . . . . . . . . . . . . . . .13
Blue Option Silver 7000 . . . . . . . . . . . . . . . . . . . . . . .13
Blue Option Silver 7350 . . . . . . . . . . . . . . . . . . . . . . .14
Blue Option Silver 8150 . . . . . . . . . . . . . . . . . . . . . . .14
Blue Option Bronze 5550 . . . . . . . . . . . . . . . . . . . . . .15
Blue Option Bronze 5800 . . . . . . . . . . . . . . . . . . . . . .15
Blue Option Bronze 6000 . . . . . . . . . . . . . . . . . . . . . .15
Blue Option Bronze 6500 . . . . . . . . . . . . . . . . . . . . . .15
Blue Option Bronze 6900 HD . . . . . . . . . . . . . . . . . .16
Blue Option Bronze 7300 . . . . . . . . . . . . . . . . . . . . . .16
Blue Option Bronze 7900 . . . . . . . . . . . . . . . . . . . . . .16
Blue Option Catastrophic . . . . . . . . . . . . . . . . . . . . .17
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 Care — Enhanced in 2020To 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** — Enhanced in 2020To 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: $50 allowance• One cleaning every six months: $50 allowance
Mental Health/Substance Abuse Covered the same as medical benefits.
Transplants A BlueChoice-participating facility must provide services.
* These copayments do not apply to Catastrophic Plan members.**Costs incurred from these services do not count toward MOOP expenses.
10
BENEFIT FEATURE & DESCRIPTION NEW – BLUE OPTION SILVER 2000 BLUE OPTION SILVER 2400 BLUE OPTION SILVER 3200
Deductible (Single/Family) $2,000/$4,000 $2,400/$4,800 $3,200/$6,400
Maximum Out of Pocket (Single/Family) $7,500/$15,000 $8,150/$16,300 $7,900/$15,800
Primary Care Physician Services $35 $45 $35
Doctors Care/Blue CareOnDemand $35 $45 $35
Maternity Care $75 first visit $85 first visit $80 first visit
Specialist Visit $75 $85 $80
Urgent Care $75 $75 $75
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 50% after deductible
Outpatient Hospital Services 50% after deductible 50% after deductible 50% after deductible
Emergency Room $400 copayment, then 50% after deductible$450 copayment,
then 50% after deductible$400 copayment,
then 50% after deductible
Ambulance 50% after deductible 50% after deductible 50% after deductible
PRESCRIPTION DRUGS
Retail
Tier 1: $20Tier 2: $20Tier 3: 50% after deductibleTier 4: 50% after deductibleTier 5: 50% after deductibleTier 6: 50% after deductible
Tier 1: $25Tier 2: $25Tier 3: $55Tier 4: $85Tier 5: $300Tier 6: $300
Tier 1: $25Tier 2: $25Tier 3: $50Tier 4: $90Tier 5: $300Tier 6: $300
Mail Order
Tier 1: $40Tier 2: $40Tier 3: 50% after deductibleTier 4: 50% after deductibleTier 5: 50% after deductibleTier 6: 50% after deductible
Tier 1: $50Tier 2: $50Tier 3: $110Tier 4: $170Tier 5: $600Tier 6: $600
Tier 1: $50Tier 2: $50Tier 3: $100Tier 4: $180Tier 5: $600Tier 6: $600
Durable Medical Equipment 50% after deductible 50% after deductible 50% after deductible
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation**
50% after deductible 50% after deductible 50% after deductible
NOTES: • All plans include an embedded deductible and MOOP. If necessary, please see the glossary on page 25 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.**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 3500 BLUE OPTION SILVER 4200 HD BLUE OPTION SILVER 4500
Deductible (Single/Family) $3,500/$7,000 $4,200/$8,400 $4,500/$9,000
Maximum Out of Pocket (Single/Family) $8,000/$16,000 $4,200/$8,400 $8,150/$16,300
Primary Care Physician Services $40 Deductible $40
Doctors Care/Blue CareOnDemand $40 Deductible $40
Maternity Care $80 first visit Deductible $80 first visit
Specialist Visit $80 Deductible $80
Urgent Care $75 Deductible $75
Freestanding Ambulatory Surgical Center* $200 per visit Deductible $200 per visit
Inpatient Hospital Services 40% after deductible Deductible 50% after deductible
Outpatient Hospital Services 40% after deductible Deductible 50% after deductible
Emergency Room$350 copayment,
then 40% after deductibleDeductible 50% after deductible
Ambulance 40% after deductible Deductible 50% after deductible
PRESCRIPTION DRUGS
Retail
Tier 1: $25Tier 2: $25Tier 3: $70Tier 4: $95Tier 5: $300Tier 6: $300
All Tiers – Deductible
Tier 1: $15Tier 2: $15Tier 3: $60Tier 4: $90Tier 5: $300Tier 6: $300
Mail Order
Tier 1: $50Tier 2: $50Tier 3: $140Tier 4: $190Tier 5: $600Tier 6: $600
All Tiers – Deductible
Tier 1: $30Tier 2: $30 Tier 3: $120Tier 4: $180Tier 5: $600Tier 6: $600
Durable Medical Equipment 40% after deductible Deductible 50% after deductible
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation** 40% after deductible Deductible 50% after deductible
NOTES: • All plans include an embedded deductible and MOOP. If necessary, please see the glossary on page 25 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.**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 4600 HD BLUE OPTION SILVER 5001 BLUE OPTION
SILVER 5004 HDNEW – BLUE OPTION
SILVER 5550Deductible (Single/Family) $4,600/$9,200 $5,000/$10,000 $5,000/$10,000 $5,550/$11,100
Maximum Out of Pocket (Single/Family) $4,600/$9,200 $7,900/$15,800 $5,000/$10,000 $7,350/$14,700
Primary Care Physician Services Deductible $30 Deductible $45
Doctors Care/Blue CareOnDemand Deductible $30 Deductible $45
Maternity Care Deductible $60 first visit Deductible $100 first visit
Specialist Visit Deductible $60 Deductible $100
Urgent Care Deductible $75 Deductible $75
Freestanding Ambulatory Surgical Center* Deductible $200 per visit Deductible $200 per visit
Inpatient Hospital Services Deductible 30% after deductible Deductible$500 copayment,
then 20% after deductible
Outpatient Hospital Services Deductible 30% after deductible Deductible 20% after deductible
Emergency Room Deductible$400 copayment,
then 30% after deductibleDeductible
$500 copayment, then 20% after deductible
Ambulance Deductible 30% after deductible Deductible 20% after deductible
PRESCRIPTION DRUGS
Retail All Tiers – Deductible
Tier 1: $20Tier 2: $20Tier 3: $40Tier 4: $80Tier 5: $300Tier 6: $300
All Tiers – Deductible
Tier 1: $15Tier 2: $15Tier 3: $35Tier 4: 20% after deductibleTier 5: 20% after deductibleTier 6: 20% after deductible
Mail Order All Tiers – Deductible
Tier 1: $40Tier 2: $40Tier 3: $80Tier 4: $160Tier 5: $600Tier 6: $600
All Tiers – Deductible
Tier 1: $30Tier 2: $30Tier 3: $70Tier 4: 20% after deductibleTier 5: 20% after deductibleTier 6: 20% after deductible
Durable Medical Equipment Deductible 30% after deductible Deductible 20% after deductible
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation** Deductible 30% after deductible Deductible 20% after deductible
NOTES: • All plans include an embedded deductible and MOOP. If necessary, please see the glossary on page 25 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.**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 NEW – BLUE OPTION SILVER 6002
BLUE OPTION SILVER 6250
BLUE OPTION SILVER 6850
NEW – BLUE OPTION SILVER 7000
Deductible (Single/Family) $6,000/$12,000 $6,250/$12,500 $6,850/$13,700 $7,000/$14,000
Maximum Out of Pocket (Single/Family) $6,000/$12,000 $7,800/$15,600 $7,800/$15,600 $7,000/$14,000
Primary Care Physician Services $55 $20 $25 $0
Doctors Care/Blue CareOnDemand $55 $20 $25 $0
Maternity Care $100 first visit $55 first visit $60 first visit $50 first visit
Specialist Visit $100 $55 $60 $50
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 Deductible 25% after deductible 40% after deductible$500 copayment, then
deductible
Outpatient Hospital Services Deductible 25% after deductible 40% after deductible Deductible
Emergency Room$400 copayment, then deductible
25% after deductible 40% after deductible$500 copayment, then
deductible
Ambulance Deductible 25% after deductible 40% after deductible Deductible
PRESCRIPTION DRUGS
Retail
Tier 1: $30Tier 2: $30Tier 3: $55Tier 4: DeductibleTier 5: DeductibleTier 6: Deductible
Tier 1: $20Tier 2: $20Tier 3: $40Tier 4: $90Tier 5: $300Tier 6: $300
Tier 1: $25Tier 2: $25Tier 3: $45Tier 4: $80Tier 5: $300Tier 6: $300
Tier 1: $25Tier 2: $25Tier 3: $45Tier 4: DeductibleTier 5: DeductibleTier 6: Deductible
Mail Order
Tier 1: $60Tier 2: $60Tier 3: $110Tier 4: DeductibleTier 5: DeductibleTier 6: Deductible
Tier 1 – $40Tier 2 – $40Tier 3 – $80Tier 4 – $180Tier 5 – $600Tier 6 – $600
Tier 1: $50Tier 2: $50Tier 3: $90Tier 4: $160Tier 5: $600Tier 6: $600
Tier 1: $50Tier 2: $50Tier 3: $90Tier 4: DeductibleTier 5: DeductibleTier 6: Deductible
Durable Medical Equipment Deductible 25% after deductible 40% after deductible Deductible
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation** Deductible 25% after deductible 40% after deductible Deductible
NOTES: • All plans include an embedded deductible and MOOP. If necessary, please see the glossary on page 25 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.**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 7350 NEW – BLUE OPTION SILVER 8150
Deductible (Single/Family) $7,350/$14,700 $8,150/$16,300
Maximum Out of Pocket (Single/Family) $7,350/$14,700 $8,150/$16,300
Primary Care Physician Services $40 $0
Doctors Care/Blue CareOnDemand $40 $0
Maternity Care $80 first visit $50 first visit
Specialist Visit $80 $50
Urgent Care $75 $75
Freestanding Ambulatory Surgical Center* $200 per visit $200 per visit
Inpatient Hospital Services Deductible $500 copayment, then deductible
Outpatient Hospital Services Deductible Deductible
Emergency Room Deductible $500 copayment, then deductible
Ambulance Deductible Deductible
PRESCRIPTION DRUGS
Retail
Tier 1: $35Tier 2: $35Tier 3: $60Tier 4: $75Tier 5: $300Tier 6: $300
Tier 1: $15Tier 2: $15Tier 3: $35Tier 4: $75Tier 5: $300Tier 6: $300
Mail Order
Tier 1: $70Tier 2: $70Tier 3: $120Tier 4: $150Tier 5: $600Tier 6: $600
Tier 1: $30Tier 2: $30Tier 3: $70Tier 4: $150Tier 5: $600Tier 6: $600
Durable Medical Equipment Deductible Deductible
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation**
Deductible Deductible
NOTES: • All plans include an embedded deductible and MOOP. If necessary, please see the glossary on page 25 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.**30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year. 30 visits for habilitation per benefit year.
15
BENEFIT FEATURE & DESCRIPTION BLUE OPTION BRONZE 5550
NEW – BLUE OPTION BRONZE 5800
NEW – BLUE OPTIONBRONZE 6000
BLUE OPTION BRONZE 6500
Deductible (Single/Family) $5,550/$11,100 $5,800/$11,600 $6,000/$12,000 $6,500/$13,000
Maximum Out of Pocket (Single/Family) $7,900/$15,800 $8,150/$16,300 $7,900/$15,800 $8,150/$16,300
Primary Care Physician Services 20% after deductible $45 20% after deductible $40
Doctors Care/Blue CareOnDemand 20% after deductible $45 20% after deductible $40
Maternity Care 20% after deductible $90 first visit 20% after deductible $90 first visit
Specialist Visit 20% after deductible $90 20% after deductible $90
Urgent Care 20% after deductible $75 20% after deductible $75
Freestanding Ambulatory Surgical Center* $200 per visit $200 per visit $200 per visit $200 per visit
Inpatient Hospital Services $500 copayment,
then 20% after deductible$500 copayment,
then 20% after deductible$500 copayment,
then 20% after deductible$500 copayment,
then 20% after deductible
Outpatient Hospital Services 20% after deductible 20% after deductible 20% after deductible 20% after deductible
Emergency Room$500 copayment,
then 20% after deductible$500 copayment,
then 20% after deductible$500 copayment,
then 20% after deductible$500 copayment,
then 20% after deductible
Ambulance 20% after deductible 20% after deductible 20% after deductible 20% after deductible
PRESCRIPTION DRUGS
Retail All Tiers –20% after deductible
Tier 1: $40Tier 2: $40Tier 3: 20% after deductibleTier 4: 20% after deductibleTier 5: 20% after deductibleTier 6: 20% after deductible
Tier 1: 20% after deductibleTier 2: 20% after deductibleTier 3: 20% after deductibleTier 4: 20% after deductibleTier 5: 20% after deductibleTier 6: 20% after deductible
Tier 1: $35Tier 2: $35Tier 3: 20% after deductible Tier 4: 20% after deductible Tier 5: 20% after deductible Tier 6: 20% after deductible
Mail OrderAll Tiers –20% after deductible
Tier 1: $80Tier 2: $80Tier 3: 20% after deductibleTier 4: 20% after deductibleTier 5: 20% after deductibleTier 6: 20% after deductible
Tier 1: 20% after deductibleTier 2: 20% after deductibleTier 3: 20% after deductibleTier 4: 20% after deductibleTier 5: 20% after deductibleTier 6: 20% after deductible
Tier 1: $70Tier 2: $70Tier 3: 20% after deductible Tier 4: 20% after deductible Tier 5: 20% after deductibleTier 6: 20% after deductible
Durable Medical Equipment 20% after deductible 20% after deductible 20% after deductible 20% after deductible
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation**
20% after deductible 20% after deductible 20% after deductible 20% after deductible
NOTES: • All plans include an embedded deductible and MOOP. If necessary, please see the glossary on page 25 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.**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 BRONZE 6900 HD BLUE OPTION BRONZE 7300 BLUE OPTION BRONZE 7900
Deductible (Single/Family) $6,900/$13,800 $7,300/$14,600 $7,900/$15,800
Maximum Out of Pocket (Single/Family) $6,900/$13,800 $8,150/$16,300 $7,900/$15,800
Primary Care Physician Services Deductible $40 $45
Doctors Care/Blue CareOnDemand Deductible $40 $45
Maternity Care Deductible $90 first visit $90 first visit
Specialist Visit Deductible $90 $90
Urgent Care Deductible $75 $75
Freestanding Ambulatory Surgical Center* Deductible $200 per visit $200 per visit
Inpatient Hospital Services Deductible $500 copayment, then 50% after deductible $500 copayment, then deductible
Outpatient Hospital Services Deductible 50% after deductible Deductible
Emergency Room Deductible $500 copayment, then 50% after deductible $500 copayment, then deductible
Ambulance Deductible 50% after deductible Deductible
PRESCRIPTION DRUGS
Retail All Tiers – Deductible
Tier 1: $25Tier 2: $25Tier 3: 50% after deductibleTier 4: 50% after deductibleTier 5: 50% after deductibleTier 6: 50% after deductible
Tier 1: $35Tier 2: $35Tier 3: Deductible Tier 4: Deductible Tier 5: DeductibleTier 6: Deductible
Mail Order All Tiers – Deductible
Tier 1: $50Tier 2: $50Tier 3: 50% after deductibleTier 4: 50% after deductibleTier 5: 50% after deductibleTier 6: 50% after deductible
Tier 1: $70Tier 2: $70Tier 3: Deductible Tier 4: Deductible Tier 5: Deductible Tier 6: Deductible
Durable Medical Equipment Deductible 50% after deductible Deductible
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation** Deductible 50% after deductible Deductible
NOTES: • All plans include an embedded deductible and MOOP. If necessary, please see the glossary on page 25 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.**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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NotesBENEFIT FEATURE & DESCRIPTION BLUE OPTION CATASTROPHIC
Deductible (Single/Family) $8,150/$16,300
Maximum Out of Pocket (Single/Family) $8,150/$16,300
Primary Care Physician Services $25 for first 3 visits, then deductible
Doctors Care/Blue CareOnDemand $25 for first 3 visits, then deductible
Maternity Care Deductible
Specialist Visit Deductible
Urgent Care Deductible
Freestanding Ambulatory Surgical Center* Deductible
Inpatient Hospital Services Deductible
Outpatient Hospital Services Deductible
Emergency Room Deductible
Ambulance Deductible
PRESCRIPTION DRUGSRetail All Tiers – Deductible
Mail Order All Tiers – Deductible
Durable Medical Equipment Deductible
Physical Therapy, Speech Therapy, Occupational Therapy and Habilitation** Deductible
NOTES: • All plans include an embedded deductible and MOOP. If necessary, please see the glossary on page 25 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.**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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2020 Blue OptionSM Plan ChangesThis grid illustrates benefit changes that will become effective Jan. 1, 2020, for existing Blue Option plans that were offered during 2019. Please refer to your Schedule
of Benefits for complete details of your 2020 plan benefits.
SILVER PLANS2019 SILVER 1500 2019 - Silver 1500 2020 - Silver 2000
Plan is no longer available. Members will move to new Silver 2000.Individual Deductible $1,500 $2,000Family Deductible $3,000 $4,000Individual MOOP $7,100 $7,500Family MOOP $14,200 $15,000Primary Care Visit $15 $35Specialist Office Visit $15, then 50% after deductible $75
2019 SILVER 1501 2019 - Silver 1501 2020 - Silver 2000Plan is no longer available. Members will move to new Silver 2000.Individual Deductible $1,500 $2,000Family Deductible $3,000 $4,000Primary Care Visit $40 $35Specialist Office Visit $80 $75
2019 SILVER 2000 2019 - Silver 2000 2020 - Silver 2400Members who were in Silver 2000 in 2019 will move to Silver 2400 in 2020.Individual Deductible $2,000 $2,400Family Deductible $4,000 $4,800Individual MOOP $7,350 $8,150Family MOOP $14,700 $16,300Primary Care Visit $0 $45Specialist Office Visit 50% after deductible $85
SILVER 2502 2019 - Silver 2502 2020 - Silver 2000Plan is no longer available. Members will move to new Silver 2000.Coinsurance 30% 50%Individual Deductible $2,500 $2,000Family Deductible $5,000 $4,000Individual MOOP $7,000 $7,500Family MOOP $14,000 $15,000Primary Care Visit $25 $35Specialist Office Visit $50 $75
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SILVER PLANS (continued) SILVER 2503 2019 - Silver 2503 2020 - Silver 2000
Plan is no longer available. Members will move to new Silver 2000.Individual Deductible $2,500 $2,000
Family Deductible $5,000 $4,000
Individual MOOP $7,350 $7,500
Family MOOP $14,700 $15,000
Primary Care Visit $0 for the first two visits, then 50% after deductible $35
Specialist Office Visit 50% after deductible $75
SILVER 3000 2019 - Silver 3000 2020 - Silver 3200Plan is no longer available. Name changes to Silver 3200.Individual Deductible $3,000 $3,200
Family Deductible $6,000 $6,400
Individual MOOP $7,350 $7,900
Family MOOP $14,700 $15,800
Primary Care Visit $20 $35
Specialist Office Visit $50 $80
SILVER 3001 2019 - Silver 3001 2020 - Silver 3200Plan is no longer available. Members will move to Silver 3200.Coinsurance 35% 50%
Individual Deductible $3,000 $3,200
Family Deductible $6,000 $6,400
Individual MOOP $7,350 $7,900
Family MOOP $14,700 $15,800
Primary Care Visit $30 $35
SILVER 3500 2019 - Silver 3500 2020 - Silver 3500Coinsurance 30% 40%
Individual MOOP $7,350 $8,000
Family MOOP $14,700 $16,000
Primary Care Visit $0 $40
Specialist Office Visit $60 $80
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SILVER PLANS (continued) SILVER 3501 2019 - Silver 3501 2020 - Silver 3500
Plan is no longer available. Members will move to Silver 3500.Individual MOOP $7,500 $8,000
Family MOOP $15,000 $16,000
Primary Care Visit $0 $40
Specialist Office Visit $60 $80
Silver 4000 2019 - Silver 4000 2020 - Silver 4500Plan is no longer available. Name changes to Silver 4500.Coinsurance 30% 50%
Individual Deductible $4,000 $4,500
Family Deductible $8,000 $9,000
Individual MOOP $6,600 $8,150
Family MOOP $13,200 $16,300
Primary Care Visit $15 $40
Specialist Office Visit $40 $80
Silver 4500 HD 2019 - Silver 4500 HD 2020 - Silver 4600 HDPlan is no longer available. Name changes to Silver 4600 HD.Individual Deductible $4,500 $4,600
Family Deductible $9,000 $9,200
Individual MOOP $4,500 $4,600
Family MOOP $9,000 $9,200
Silver 5001 2019 - Silver 5001 2020 - Silver 5001Individual MOOP $7,350 $7,900
Family MOOP $14,700 $15,800
Primary Care Visit $35 $30
Specialist Office Visit $75 $60
Silver 6002 2019 - Silver 6002 2020 - Silver 6250Members who were in Silver 6002 in 2019 will move to Silver 6250 in 2020.Coinsurance 20% 25%
Individual Deductible $6,000 $6,250
Family Deductible $12,000 $12,500
Individual MOOP $7,350 $7,800
Family MOOP $14,700 $15,600
Primary Care Visit $0 $20
Specialist Office Visit $35 $55
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SILVER PLANS (continued)Silver 6250 2019 - Silver 6250 2020 - Silver 6250
Individual MOOP $7,350 $7,800
Family MOOP $14,700 $15,600
Primary Care Visit $0 $20
Specialist Office Visit $50 $55
Silver 6251 2019 - Silver 6251 2020 - Silver 6250Plan is no longer available. Members will move to Silver 6250.Individual MOOP $7,750 $7,800
Family MOOP $15,500 $15,600
Primary Care Visit $0 $20
Specialist Office Visit $35 $55
Silver 6900 2019 - Silver 6900 2020 - Silver 6850Plan is no longer available. Name changes to Silver 6850.Individual Deductible $6,900 $6,850
Family Deductible $13,800 $13,700
Individual MOOP $7,350 $7,800
Family MOOP $14,700 $15,600
Primary Care Visit $0 $25
Specialist Office Visit $35 $60
Silver 7350 2019 - Silver 7350 2020 - Silver 7350Primary Care Visit $25 $40
Specialist Office Visit $60 $80
Silver 7750 2019 - Silver 7750 2020 - Bronze 7900Plan is no longer available. Members will move to Bronze 7900.Individual Deductible $7,750 $7,900
Family Deductible $15,500 $15,800
Individual MOOP $7,750 $7,900
Family MOOP $15,500 $15,800
Primary Care Visit $25 $45
Specialist Office Visit $60 $90
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BRONZE PLANSBRONZE 5500 2019 - Bronze 5500 2020 - Bronze 5550
Plan is no longer available. Members will move to Bronze 5550.Coinsurance 50% 20%
Individual Deductible $5,500 $5,550
Family Deductible $11,000 $11,100
Individual MOOP $6,600 $7,900
Family MOOP $13,200 $15,800
Primary Care Visit 50% after deductible 20% after deductible
Specialist Office Visit 50% after deductible 20% after deductible
BRONZE 5501 2019 - Bronze 5501 2020 - Bronze 5550Plan is no longer available. Name changes to Bronze 5550.Coinsurance 50% 20%
Individual Deductible $5,500 $5,550
Family Deductible $11,000 $11,100
Primary Care Visit 50% after deductible 20% after deductible
Specialist Office Visit 50% after deductible 20% after deductible
BRONZE 6000 HD 2019 - Bronze 6000 HD 2020 - Bronze 6900 HDPlan is no longer available. Members will move to Bronze 6900 HD.Individual Deductible $6,000 $6,900
Family Deductible $12,000 $13,800
Primary Care Visit $6,000 $6,900
Specialist Office Visit $12,000 $13,800
BRONZE 6350 HD 2019 - Bronze 6350 HD 2020 - Bronze 6900 HDPlan is no longer available. Name changes to Bronze 6900 HD.Individual Deductible $6,350 $6,900
Family Deductible $12,700 $13,800
Primary Care Visit $6,350 $6,900
Specialist Office Visit $12,700 $13,800
BRONZE 6500 2019 - Bronze 6500 2020 - Bronze 6500Coinsurance 50% 20%
Individual MOOP $6,850 $8,150
Family MOOP $13,700 $16,300
Primary Care Visit 50% after deductible $40
Specialist Office Visit 50% after deductible $90
23
BRONZE PLANS (continued)BRONZE 7150 2019 - Bronze 7150 2020 - Bronze 7300
Plan is no longer available. Members will move to Bronze 7300.Coinsurance Deductible 50%
Individual Deductible $7,150 $7,300
Family Deductible $14,300 $14,600
Individual MOOP $7,150 $8,150
Family MOOP $14,300 $16,300
Primary Care Visit $45 $40
BRONZE 7350 2019 - Bronze 7350 2020 - Bronze 7300Plan is no longer available. Name changes to Bronze 7300.Coinsurance Deductible 50%
Individual Deductible $7,350 $7,300
Family Deductible $14,700 $14,600
Individual MOOP $7,350 $8,150
Family MOOP $14,700 $16,300
Primary Care Visit $45 $40
BRONZE 7900 2019 - Bronze 7900 2020 - Bronze 7900Primary Care Visit Deductible $45
Specialist Office Visit Deductible $90
BRONZE 7901 2019 - Bronze 7901 2020 - Bronze 7900Plan is no longer available. Members will move to Bronze 7900.Primary Care Visit $50 $45
Specialist Office Visit $100 $90
CATASTROPHIC PLANCATASTROPHIC 2019 - Catastrophic 2020 - Catastrophic
Individual Deductible $7,900 $8,150
Family Deductible $15,800 $16,300
Individual MOOP $7,900 $8,150
Family MOOP $15,800 $16,300
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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.
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.
Statement of Confidentiality
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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, 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.
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 2020 runs from October 15, 2019,
to December 15, 2019.
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
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Focus on life. Focus on health. Stay focused.
BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association.
210864-BC-3015-9-2019
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QuickEnroll
QuickBill
FOCUSfwd GreatExpectations
Hearing Aids
Biometric Screening
Learning Management System
TobaccoCessationBlueChoice
HealthPlan WireMy Health
ToolkitRewards
2018 Icons - Cumulative
Bases
Storefront
REV: 11/27/2018
Education Center
Laboratory Benefits Mgmt
Physician’s Office Manual
News
BlueOption
Blues Flash
ProducersGuide
Discounts andAdded Values
Business ADV Core ServicesCore ServicesHealth Care Reform
Video Carolina ADVAdvantage Plus MyChoice ADV Primary Choice Medical PoliciesFlexible Savings
AccountHealth
Reimbursement Account
EmployeeAssistanceProgram
Mobile App
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 877-252-0632 Monday – Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m.
3: Visit www.BlueOptionSC.com.