BlueEssentials HD Bronze 5 Plan Details for 2021- HealthPocket

BlueEssentials HD Bronze 5

$333.71/mo

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Zip Code29223
Applicant9/18/1986 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameBlueEssentials HD Bronze 5
Plan IDhhs-26065SC0380014
Plan Year2021
Insurance ProviderBlueCross BlueShield of South Carolina
Metal LevelExpanded Bronze
Plan TypeEPO
Deductible$6,850
Out-of-Pocket Maximum$6,850
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or IllnessNo Charge after deductible
Specialist VisitNo Charge after deductible
Laboratory Outpatient and Professional ServicesNo Charge after deductible
X-rays and Diagnostic ImagingNo Charge after deductible
Diagnostic Imaging such as MRIs, CT, and PET scansNo Charge after deductible
Deductible - Family$13700 per group
Out-of-Pocket Maximum - Family$13700 per group

Prescription drug coverage

Generic DrugsNo Charge after deductible
Preferred Brand DrugsNo Charge after deductible
Non-Preferred Brand DrugsNo Charge after deductible
Specialty DrugsNo Charge after deductible

Access to doctors and hospitals

Provider directory URLhttps://www.southcarolinablues.com/links/providers/EPO
Does this plan have access to a national provider network?No
Is a referral required to see a Specialist?Not Covered
Does this plan cover services outside plan service area?No - 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.
Does this plan cover services outside the country?No - Benefits are available only for emergency medical conditions. Special pricing may be available through a Blue Cross Blue Shield Global Core provider.

Hospital services

Emergency Room ServicesNo Charge after deductible
Inpatient Hospital Services (e.g., Hospital Stay)No Charge after deductible
Inpatient Physician and Surgical ServicesNo Charge after deductible
Emergency Transportation or Ambulance ServiceNo Charge after deductible

Maternity

Prenatal and Postnatal CareNo Charge after deductible
Delivery and all inpatient services for maternity careNo Charge after deductible

Mental Health

Mental/Behavioral Health Outpatient ServicesNo Charge after deductible
Mental/Behavioral Health Inpatient ServicesNo Charge after deductible
Substance use disorder outpatient servicesNo Charge after deductible
Substance use disorder inpatient servicesNo Charge after deductible

Medical Management Programs

Does this plan offer a wellness program?Not Covered

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsNot Covered

Child Dental Coverage

Child Dental Coverage - Routine Dental CareNot Covered
Child Dental Coverage - Basic Dental CareNot Covered
Child Dental Coverage - OrthodontiaNot Covered
Child Dental Coverage - Major Dental CareNot Covered

Adult Dental Coverage

Adult Dental Coverage - Routine Dental CareNot Covered
Adult Dental Coverage - Basic Dental CareNot Covered
Adult Dental Coverage - OrthodontiaNot Covered
Adult Dental Coverage - Major Dental CareNot Covered

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
Preventive Care/Screening/Immunization
Imaging (CT/PET Scans, MRIs)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Durable Medical Equipment
Non-Emergency Care When Traveling Outside the U.S.
Diabetes Care Management
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
Prosthetic Devices
Radiation
Reconstructive Surgery
Transplant
Well Baby Visits and Care
Breast Reconstructive Surgery
Congenital Anomaly, including Cleft Lip/Palate
Off Label Prescription Drugs
Eye Glasses for Adults
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
More Limited BenefitsSkilled Nursing Facility
Home Health Care Services
Outpatient Rehabilitation Services
Habilitation Services
Hospice Services
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
More Excluded BenefitsAcupuncture
Bariatric Surgery
Cosmetic Surgery
Hearing Aids
Infertility Treatment
Long Term Care
Private-Duty Nursing
Weight Loss Programs
Dental Check-Up for Children
Chiropractic Care
Routine Foot Care
Dental Care - Adult
Abortion for Which Public Funding is Prohibited
Treatment for Temporomandibular Joint Disorders
Long-Term/Custodial Nursing Home Care
PremiumPlan NameDeductible
from $317Ambetter Essential Care 2 HSA (2021) + Vision + Adult Dental$6,900.00Select
from $319BlueEssentials Bronze 1$7,000.00Select
from $364BlueEssentials Silver 28$7,000.00Select
from $367BlueEssentials Silver 21$7,000.00Select
from $487BlueEssentials Silver 14$7,000.00Select
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  • Phone Number
    (803) 736-5540
  • Office Locations
    9600 Two Notch Rd
    Columbia, SC 29223
9600 Two Notch Rd Columbia SC, 29223

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HealthPocket.com is a free information source. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. While on our site, if you click on a plan or link, you may be directed to one of our partners who offers health insurance products. HealthPocket, Inc. is part of the Benefytt Technologies, Inc. family of companies.