BlueEssentials Silver 11

Coverage Period: 01/01/2017 - 12/31/2017

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: FAMILY | Plan Type: PPO

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy
or plan document at www.SouthCarolinaBlues.com or by calling 1-855-404-6752.
Important Questions Answers Why this Matters:
What is the overall $0 See the chart starting on page 2 for your costs for services this plan covers.
deductible?

Are there other Yes, $0 person/family for tier 4 drugs. There You must pay all of the costs for these services up to the specificdeductible
deductibles for specific are no other specific deductibles. amount before this plan begins to pay for these services.
services?
Is there an Yes. $2,250/person and $4,500/family. The out-of-pocket limit is the most you could pay during a coverage period
outofpocket limit on (usually one year) for your share of the cost of covered services. This limit helps
my expenses? you plan for health care expenses.
What is not included in Premiums; Balance-billed charges or health Not applicable because there's no out-of-pocket limit on your expenses.
the out-of-pocket limit? care that is not covered.

Does this plan use a Yes. For a list of in-network providers, see If you use an in-network doctor or other health care provider, this plan will pay
network of providers? https://www.southcarolinablues.com/links/ some or all of the costs of covered services. Be aware, your in-network doctor or
metallic/providers/EPO or call hospital may use an out-of-network provider for some services. Plans use the
1-800-810-2583 term in-network, preferred, or participating for providers in their network. See
the chart starting on page 2 for how this plan pays different kinds of providers.
Do I need a referral to No. You don't need a referral to see a You can see the specialist you choose without permission from this plan.
see a specialist? specialist.

Are there services this Yes. Some of the services this plan doesnt cover are listed in the Excluded Services
plan doesnt cover? and Other Covered Services section. See your policy or plan document for
additional information about excluded services.

Questions: Call 1-855-404-6752 or visit us at www.SouthCarolinaBlues.com. If you arent clear about any of the bolded terms used in this form, see the Glossary.
You can view the Glossary at www.dol.gov/ebsa/healthreform or www.cciio.cms.gov or call 1-855-404-6752 to request a copy.
FFECESAR20161122033115970360 Page 1 of 12
 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example,
if the plans allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if
you havent met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the
allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts.

Common Your cost if you use an

Medical Event Services You May Need In-Network Out-Of-Network Limitations & Exceptions
Provider Provider
If you visit a health Primary care visit to treat an injury or illness $0 copay/visit Not covered Copay doesn't include surgery,
care providers office outpatient lab & X-ray services
or clinic (except for standard plain film
X-rays), second surgical opinion,
dialysis, chemotherapy, radiation
therapy, administration of specialty
drugs, endoscopies and imaging.
Specialist visit 10% coinsurance Not covered NONE

Other practitioner office visit $0 copay/visit Not covered Covers only physician's assistant and
nurse practitioners. Copay doesn't
include surgery, outpatient lab &
x-ray services (except for standard
plain film X-rays), second surgical
opinion, dialysis, chemotherapy,
radiation therapy, administration of
specialty drugs, endoscopies and
imaging.

Page 2 of 12
Common Your cost if you use an
Medical Event Services You May Need In-Network Out-Of-Network Limitations & Exceptions
Provider Provider
Preventive care/screening/immunization No charge Not covered NONE

If you have a test Diagnostic test (x-ray, blood work) 10% coinsurance Not covered NONE

Imaging (CT/PET scans, MRIs) 10% coinsurance Not covered No benefits if not preapproved.
If you need drugs to Tier 1 $0 Not covered Quantity limits may apply. Some
treat your illness or copay/prescription drugs may require prior approval. No
condition (retail) $0 benefits if not approved. Drugs that
copay/prescription are considered specialty drugs must
(mail-order) be purchased from our Specialty
Pharmacy.
Tier 2 $25 Not covered Quantity limits may apply. Some
copay/prescription drugs may require prior approval. No
(retail) $68 benefits if not approved. Drugs that
copay/prescription are considered specialty drugs must
(mail-order) be purchased from our Specialty
Pharmacy.
Tier 3 $50 Not covered Quantity limits may apply. Some
copay/prescription drugs may require prior approval. No
(retail) $135 benefits if not approved. Drugs that
copay/prescription are considered specialty drugs must
(mail-order) be purchased from our Specialty
Pharmacy.

Page 3 of 12
Common Your cost if you use an
Medical Event Services You May Need In-Network Out-Of-Network Limitations & Exceptions
Provider Provider
More information about Tier 4 30% after the Not covered $0 Prescription drug deductible
prescription drug Prescription Drug applies. Quantity limits may apply.
coverage is available at Deductible Some drugs may require prior
www.SouthCarolinaBl approval. No benefits if not
ues.com/links/metalli approved. Drugs that are considered
c/pharmacy/BlueEsse specialty drugs must be purchased
ntials from our Specialty Pharmacy.
If you have outpatient Facility fee (e.g., ambulatory surgery center) 10% coinsurance Not covered Hysterectomy or septoplasty must be
surgery preapproved or no benefits.
Cosmetic surgery is not covered.
Physician/surgeon fees 10% coinsurance Not covered Hysterectomy or septoplasty must be
preapproved or no benefits.
Cosmetic surgery is not covered.
If you need immediate Emergency room services 10% coinsurance Facility charges only NONE
medical attention - 10% coinsurance.
All other charges -
Not covered
Emergency medical transportation 10% coinsurance Not covered NONE

Urgent care 10% coinsurance Not covered NONE

If you have a Facility fee (e.g., hospital room) 10% coinsurance Not covered No benefits if not preapproved. No
hospital stay benefits for human organ/tissue
transplant if not preapproved and at
designated provider.

Page 4 of 12
Common Your cost if you use an
Medical Event Services You May Need In-Network Out-Of-Network Limitations & Exceptions
Provider Provider
Physician/surgeon fee 10% coinsurance Not covered No benefits for human organ/tissue
transplant if not preapproved and at
designated provider.
If you have mental Mental/Behavioral health outpatient services 10% coinsurance Not covered $0 copay/visit for in-network office
health, behavioral visit. No benefits for psychological
health, or substance testing, repetitive Transcranial
abuse needs Magnetic Stimulation, intensive
outpatient services, partial
hospitalization and electroconvulsive
therapy if not preapproved.
Mental/Behavioral health inpatient services 10% coinsurance Not covered No benefits if not preapproved.

Substance use disorder outpatient services 10% coinsurance Not covered $0 copay/visit for in-network office
visit. No benefits for psychological
testing, repetitive Transcranial
Magnetic Stimulation, intensive
outpatient services, partial
hospitalization and electroconvulsive
therapy if not preapproved.
Substance use disorder inpatient services 10% coinsurance Not covered No benefits if not preapproved.

If you are pregnant Prenatal and postnatal care 10% coinsurance Not covered NONE

Delivery and all inpatient services 10% coinsurance Not covered No benefits for termination of
pregnancy, except in limited
circumstances.

Page 5 of 12
Common Your cost if you use an
Medical Event Services You May Need In-Network Out-Of-Network Limitations & Exceptions
Provider Provider
If you need help Home health care 10% coinsurance Not covered Limited to 60 visits/year. No benefits
recovering or have if not preapproved.
other special health
needs
Rehabilitation services 10% coinsurance Not covered Outpatient physical, occupational and
speech therapy limited to 15
visits/year combined. No inpatient
benefits if not preapproved.
Habilitation services 10% coinsurance Not covered Outpatient physical, occupational and
speech therapy limited to 15
visits/year combined. No inpatient
benefits if not preapproved.
Skilled nursing care 10% coinsurance Not covered Limited to 60 days/year. No benefits
if not approved.
Durable medical equipment 10% coinsurance Not covered Excludes repair of, replacement of
and duplicate. No benefits if not
preapproved when cost is $500 or
more.
Hospice service 10% coinsurance Not covered Limited to 6 months/episode. No
benefits if not preapproved.
If your child needs Eye exam $25 copay Not covered Limited to one exam per benefit
dental or eye care period.
Glasses $50 copay Not covered Limited to once per benefit period
for lenses and every two years for
frames. Contacts covered only when
medically necessary.

Page 6 of 12
Common Your cost if you use an
Medical Event Services You May Need In-Network Out-Of-Network Limitations & Exceptions
Provider Provider
Dental check-up Not covered Not covered NONE

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isnt a complete list. Check your policy or plan document for other excluded services)
Abortion Services Acupuncture Bariatric Surgery
Cosmetic Surgery Hearing aids Infertility treatment
Long-term care Private Duty Nursing Residential and custodial care
Routine foot care Varicose vein treatment Weight loss programs.

Other Covered Services. (This isnt a complete list. Check your policy or plan document for other covered services and your costs for these
services.)
Chiropractic care if purchased separately Dental Check-up (Child) Routine eye care (Adult)
Dental Care (Adult) Non-emergency care when traveling outside the
U.S. See
www.SouthCarolinaBlues.com/members/findap
rovider.aspx

Page 7 of 12
Your Rights to Continue Coverage:
Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are
exceptions, however, such as if:
You commit fraud

The insurer stops offering services in the State

You move outside the coverage area

For more information on your rights to continue coverage, contact the insurer at 1-855-404-6752. You may also contact your state insurance department at
South Carolina Department of Insurance, Post Office Box 100105, Columbia, SC 29202-3105, Telephone: 800-768-3467.

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact the South Carolina Department of Insurance, Consumer Services Division, Post
Office Box 100105, Columbia, SC 29202-3105, Telephone: 803-737-6180, Email: [email protected].

Does this Coverage Provide Minimum Essential Coverage?

The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage."This plan or policy does
provide minimum essential coverage.

Spanish: Para obtener asistencia en espaol, llame al nmero de atencin al cliente que aparece en la primera pgina de esta notificacin.

To see examples of how this plan might cover costs for a sample medical situation, see the next page.

Page 8 of 12
 Having a baby Managing type 2 diabetes
About these Coverage (normal delivery) (routine maintenance of
Examples: a well-controlled condition)
Amount owed to providers: $7,540 Amount owed to providers: $5,400
These examples show how this plan might
cover medical care in given situations. Use
Plan pays $6,660 Plan pays $5,180
these examples to see, in general, how much Patient pays $880 Patient pays $220
financial protection a sample patient might Sample care costs:
get if they are covered under different plans. Sample care costs:
Hospital charges (mother) $2,700
Routine obstetric care $2,100 Prescriptions $2,900
Hospital charges (baby) $900 Medical Equipment and Supplies $1,300
This is Office Visits and Procedures $700
not a cost Anesthesia $900
Laboratory tests $500 Education $300
estimator. Laboratory tests $100
Prescriptions $200
Dont use these examples to Radiology $200 Vaccines, other preventive $100
estimate your actual costs under Vaccines, other preventive $40 Total $5,400
this plan. The actual care you
Total $7,540 Patient pays:
receive will be different from
these examples, and the cost of Deductibles $0
Patient pays:
that care will also be different. Co-pays $0
Deductibles $0
Co-pays $0 Co-insurance $140
See the next page for important
information about these examples. Co-insurance $730 Limits or exclusions $80
Limits or exclusions $150 Total $220
Total $880

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 Questions and answers about the Coverage Examples:

What are some of the assumptions What does a Coverage Example Can I use Coverage Examples to
behind the Coverage Examples? show? compare plans?


Costs don't include premiums.
Sample care costs are based on national
For each treatment situation, the Coverage
Example helps you see how deductibles, PYes . When you look at the Summary of
Benefits and Coverage for other plans, youll
averages supplied by the U.S. Department copayments, and coinsurance can add up. It find the same Coverage Examples. When you
of Health and Human Services, and arent also helps you see what expenses might be left up compare plans, check the Patient Pays box
specific to a particular geographic area or to you to pay because the service or treatment in each example. The smaller that number, the
health plan. isnt covered or payment is limited. more coverage the plan provides.
The patients condition was not an
excluded or preexisting condition. Does the Coverage Example predict
All services and treatments started and Are there other costs I should
ended in the same coverage period. my own care needs? consider when comparing
There are no other medical expenses for
OThe care you would receive for this condition
No. Treatments shown are just examples. plans?

any member covered under this plan.
Out-of-pocket expenses are based only on could be different based on your doctors
Ppay. Generally, the lower your premium, the
Yes. An important cost is the premium you
treating the condition in the example. advice, your age, how serious your condition more youll pay in out-of-pocket costs, such
The patient received all care from is, and many other factors as copayments, deductibles, and
in-network providers. If the patient had coinsurance. You should also consider
received care from out-of-network contributions to accounts such as health
providers, costs would have been higher.
Does the Coverage Example predict
savings accounts (HSAs), flexible spending
my future expenses? arrangements (FSAs) or health reimbursement
Oestimators. You cant use the examples to
No. Coverage Examples are not cost accounts (HRAs) that help you pay
out-of-pocket expenses.
estimate costs for an actual condition. They
are for comparative purposes only. Your own
costs will be different depending on the care
you receive, the prices your providers charge,
and the reimbursement your health plan
allows.

Questions: Call 1-855-404-6752 or visit us at www.SouthCarolinaBlues.com. If you arent clear about any of the bolded terms used in this form, see the
Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or www.cciio.cms.gov or call 1-855-404-6752 to request a copy.
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
FFECESAR20161122033115970360 Page 10 of 12
 Non-Discrimination Statement and Foreign Language Access
We do not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in our health plans,
when we enroll members or provide benefits.
If you or someone youre assisting is disabled and needs interpretation assistance, help is available at the contact number posted on our website or listed in
the materials included with this notice.
Free language interpretation support is available for those who cannot read or speak English by calling one of the appropriate numbers listed below.
If you think we have not provided these services or have discriminated in any way, you can file a grievance online at [email protected] or by calling
our Compliance area at 1-800-832-9686 or the U.S. Department of Health and Human Services, Office for Civil Rights at 1-800-368-1019 or
1-800-537-7697(TDD).

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