BlueCross Total (PPO)

Medicare Advantage Plan for South Carolina

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PARTCRX

Plan Summary

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderBlueCross BlueShield of South Carolina
Plan IDH8003-3-0
CMS RatingNot Rated1
Plan TypePPO
Annual Deductible$200.00

What To Know About This Plan

  • This plan has health and drug coverage

Why We Like This Plan

  • has both Health and Drug Coverage

Plan Details

Costs and Other Important Information

Plan Year:
2018
Optional Supplemental Benefits
No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$10,000 In and Out-of-network $6,700 In-network
Other health plan deductibles?
No
Health Plan Deductible
$300 annual deductible
Monthly Drug Plan Premium
$25.80
Monthly Health Plan Premium
$29.20

Benefits

Service
Cost
Inpatient hospital coverage
In-Network:
$350 for days 1 through 5
$0 for days 6 through 90
Out-of-Network:
20% per stay
Outpatient hospital coverage
In-Network:
$325 per visit. Out-of-Network:
20% per visit
Doctor visits
Primary:In-Network:
$10 per visit. Out-of-Network:
$30 per visit
Specialist:In-Network:
$40 per visit. Out-of-Network:
$55 per visit
Preventive care
In-Network:
$0 copay. Out-of-Network:
$0 copay
Emergency care/Urgent care
Emergency:$80 per visit (always covered)
Urgent care:$45 per visit (always covered)
Diagnostic procedures/lab services/imaging
Diagnostic tests and procedures:In-Network:
20%Out-of-Network:
20%
Lab services:In-Network:
$15Out-of-Network:
$15
Diagnostic radiology services (e.g., MRI):In-Network:
$150Out-of-Network:
$150
Outpatient x-rays:In-Network:
$15Out-of-Network:
$15
Mental health services
In-Network:
$405 for days 1 through 4
$0 for days 5 through 90
Out-of-Network:
20% per stay
Outpatient group therapy visit with a psychiatrist:In-Network:
$40Out-of-Network:
$55
Outpatient individual therapy visit with a psychiatrist:In-Network:
$40Out-of-Network:
$55
Outpatient group therapy visit:In-Network:
$40Out-of-Network:
$55
Outpatient individual therapy visit:In-Network:
$40Out-of-Network:
$55
Skilled Nursing Facility
In-Network:
$0 for days 1 through 20
$167.50 for days 21 through 100
Out-of-Network:
20% per stay
Rehabilitation services
Occupational therapy visit:In-Network:
$40Out-of-Network:
$55
Physical therapy and speech and language therapy visit:In-Network:
$40Out-of-Network:
$55
Ambulance
In-Network:
$275Out-of-Network:
$275
Transportation
Not covered
Foot care (podiatry services)
Foot exams and treatment:In-Network:
$50Out-of-Network:
$55
Routine foot care:Not covered
Medical equipment/supplies
Durable medical equipment (e.g., wheelchairs, oxygen):In-Network:
20% per item. Out-of-Network:
30% per item
Prosthetics (e.g., braces, artificial limbs):In-Network:
20% per item. Out-of-Network:
30% per item
Diabetes supplies:In-Network:
0-20% per item. Out-of-Network:
20% per item
Wellness programs (e.g., fitness, nursing hotline)
Covered
Medicare Part B drugs
Chemotherapy:In-Network:
20%Out-of-Network:
20%
Other Part B drugs:In-Network:
20%Out-of-Network:
20%

Coverage Area for BlueCross Total (PPO)

StateSouth Carolina
CountyRichland

Cost Sharing Information

All cost-sharing assumes in-network healthcare providers.

Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit

30 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$3 copay$8 copay$3 copay
Tier 2: Non-Preferred Generic$15 copay$20 copay$15 copay
Tier 3: Preferred Brand Name$37 copay$47 copay$37 copay
Tier 4: Non-Preferred Brand Name45% coinsurance50% coinsurance45% coinsurance
Tier 5: Specialty Tier29% coinsurance29% coinsurance29% coinsurance
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$6 copay$24 copay$0 copay
Tier 2: Non-Preferred Generic$45 copay$60 copay$37.5 copay
Tier 3: Preferred Brand Name$111 copay$141 copay$92.5 copay
Tier 4: Non-Preferred Brand Name45% coinsurance50% coinsurance45% coinsurance
Tier 5: Specialty Tier29% coinsurance29% coinsurance29% coinsurance

Physician Finder

Physicians that accept BlueCross Total (PPO) for South Carolina

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MOHIUDDIN, AZIZ
125 ALPINE CIRCLE
COLUMBIA, SC 29223
BUSNARDO, MARC
8231 PARKLANE RD
COLUMBIA, SC 29223
ROBINSON, WILLIAM
3000 NE MEDICAL PARK
COLUMBIA, SC 29223
SULLIVAN, WILLIAM
115 ATRIUM WAY
COLUMBIA, SC 29223
WILE, CHARLES
1021 PINNACLE POINT DR., SUITE 200
COLUMBIA, SC 29223
WALKUP, WILLIAM
125 ALPINE CIRCLE
COLUMBIA, SC 29223
LLOYD, SHANNON
731 POLO RD
COLUMBIA, SC 29223
BYRD, MIRIAM
1001 WILDEWOOD DOWNS CIR
COLUMBIA, SC 29223
RICHARDSON, IRENE
200 SPRINGTREE DR
COLUMBIA, SC 29223
ADAMS, ELIZABETH
731 POLO RD
COLUMBIA, SC 29223
BANGALORE-PUTTAIAH, MOHAN
10040 TWO NOTCH RD
COLUMBIA, SC 29223
ELMORE, JAMES
3000 NE MEDICAL PARK
COLUMBIA, SC 29223
BOULWARE, RALEIGH
7 MEDICAL PARK
COLUMBIA, SC 29223
DAVIES, BRYAN
122 BEAVER DAM RD
COLUMBIA, SC 29223
MUNN, MALA
9600 TWO NOTCH RD.
COLUMBIA, SC 29223
MAGEE, MICHAEL
7620 TRENHOLM ROAD EXT
COLUMBIA, SC 29223
GROSS, JEFFREY
7620 TRENHOLM ROAD EXT
COLUMBIA, SC 29223
FISHBURNE, BARRON
7620 TRENHOLM ROAD EXT
COLUMBIA, SC 29223
CHESONI, SOLOMON
200 SPRINGTREE DR
COLUMBIA, SC 29223
CALDWELL, JACQUETTE
6439 GARNERS FERRY RD
COLUMBIA, SC 29209
CRISP, JEREMY
76 POLO RD
COLUMBIA, SC 29223
NUNNERY, MICHAEL
76 POLO RD
COLUMBIA, SC 29223
CLINE, BRIAN
76 POLO RD
COLUMBIA, SC 29223
BOYLAN, MELISSA
3000 NE MEDICAL PARK
COLUMBIA, SC 29223
MARION, HENRY
76 POLO RD
COLUMBIA, SC 29223
Details
AZIZ MOHIUDDIN, MD
Phone Number
(803) 779-3548
Office Locations
125 ALPINE CIRCLE
COLUMBIA, SC 29223
125 ALPINE CIRCLE COLUMBIA SC, 29223

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