BlueEssentials Bronze 4 - 26065SC0380013 Health Insurance Plan
Blue Cross and Blue Shield of South Carolina health insurance plan with the Plan ID 26065SC0380013. The plan is called BlueEssentials Bronze 4.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.89% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.11% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 26065SC0380013 | ||||||||||||||||||
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| Health Insurance Plan Year | 2022 | ||||||||||||||||||
| State | South Carolina | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross and Blue Shield of South Carolina | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 26065SC0380013-00 | ||||||||||||||||||
| Provider Network(s) | ['SCN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Apr 2024 06:19 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 26065SC0380013-00 Standard On Exchange Plan - 26065SC0380013-01 |
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| Last Plan Update Date | Thu, 02 Dec 2021 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 16 Apr 2024 06:19 GMT |
BlueEssentials Bronze 4 Health Insurance Plan Variant 26065SC0380013-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.648948585 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2022 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Bronze Off Exchange Plan |
| Dental Only Plan | No |
| EHB Percent of Total Premium | 1 |
| First Tier Utilization | 100% |
| Formulary ID | SCF011 |
| Formulary URL | URL |
| HIOS Product ID | 26065SC038 |
| Import Date | 12/2/2021 1:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 26065 |
| Issuer Marketplace Marketing Name | BlueCross BlueShield of South Carolina |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | SCN001 |
| Out of Country Coverage | No |
| Out of Country Coverage Description | Benefits are available only for emergency medical conditions. Special pricing may be available through a Blue Cross Blue Shield Global Core provider. |
| Out of Service Area Coverage | No |
| Out of Service Area Coverage Description | Benefits are available only for emergency medical conditions when treated in an outpatient hospital emergency room or urgent treatment center, or for urgent conditions when treated in an urgent treatment center. Special pricing may be available through a BlueCard provider. |
| Plan Effective Date | 1/1/2022 |
| Plan Expiration Date | 12/31/2022 |
| Plan ID (Standard Component ID with Variant) | 26065SC0380013-00 |
| Plan Marketing Name | BlueEssentials Bronze 4 |
| Plan Type | EPO |
| Plan Variant Marketing Name | BlueEssentials Bronze 4 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,500 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $7,200 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $600 |
| SBC Scenario, Having Diabetes, Deductible | $4,000 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | SCS001 |
| Source Name | HIOS |
| Plan ID | 26065SC0380013 |
| State Code | SC |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $14400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $7200 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $7,200 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $17400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of BlueEssentials Bronze 4 Health Insurance Plan, 26065SC0380013
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about BlueEssentials Bronze 4, 26065SC0380013 Health Insurance Plan, 26065SC0380013
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Does BlueEssentials Bronze 4 Health Insurance Plan, 26065SC0380013 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (26065SC0380013) Health Insurance Plan, Variant (26065SC0380013-00) have Out Of Country Coverage?
No, unfortunately there
is no Out Of Country Coverage for this Health Insurance Plan
(variant of plan). Details: Benefits are available only for emergency medical conditions. Special pricing may be available through a Blue Cross Blue Shield Global Core provider.
Does (26065SC0380013) Health Insurance Plan, Variant (26065SC0380013-00) have Out of Service Area Coverage?
No, unfortunately there
is no Out of Service Area Coverage for this Health Insurance
Plan (variant of plan). Details: Benefits are available only for emergency medical conditions when treated in an outpatient hospital emergency room or urgent treatment center, or for urgent conditions when treated in an urgent treatment center. Special pricing may be available through a BlueCard provider.
Disclaimer: This is based on the import(Date: Tue, 16 Apr 2024 06:19 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API