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Focus on life. Focus on health. Stay focused.
Blue Option
2022 Individual and Family Coverage
lease note: There should be a white line on top and bottom of this pattern
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Contents
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trip You
the same width as the white
Blue Option Has You Covered............................................................1
Get More With Blue Option.........................................................2
lines in the graphic when used on a color
Decide What You Need.......................................................................9
Plans.....................................................................................................10
ackground
Key Benefits andor photo. They are presentGlossary...............................................................................................16
Services....................................................................3 in this vector image.
Access Your Health Information Anytime...........................................6 Statement of Confidentiality..............................................................17
Choose Your 2022 Health Coverage...................................................7
Blue Option Has You Covered
Blue Option is here for you with these great benefits:
•O
ur all-inclusive, comprehensive copayment that covers all services at a participating provider’s office, such as labs, X-rays, surgical procedures and more
• $0 prescription tier on all plans
• Routine adult and pediatric vision coverage
• Dental allowance for exams and cleanings
• More rewards with the FOCUSfwd® Wellness Incentive Program
• Access to a board-certified physician anytime, anywhere with Blue CareOnDemandSM
• $0 primary care visits on select plans VISIT TYPE FOR A SILVER 5550 MEMBER EXAMPLE OF OUT-OF-POCKET COSTS*
• Doctors Care visits for the same cost as primary care visits, saving Doctors Care, Primary Care Physician or
$35
members money when an ER visit is unnecessary Blue CareOnDemand
Emergency Room $500 copayment, then 35% after deductible
Blue Option Gives You the Value You Deserve
• Large
network of doctors, hospitals, specialists, pharmacies and other health care providers
• No claim forms or referrals needed for in-network specialists
• Preventive screenings at NO cost to you
• $0 cost on immunizations, such as flu vaccines
• Health management programs to help keep you and your family healthy
• 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 free-standing imaging centers and ambulatory surgical centers that allow us to pass significant savings on to you
EXAMPLE FACILITY FEE*
You use a free-standing 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.
1
You Get More With Blue Option
We have more than 30 years of experience serving our members throughout Vision Coverage
South Carolina. We offer affordable plan options that provide more value, In-network vision providers include your favorite retailers, including Walmart
more benefits and more options. Not only do we have first-class customer Vision Center, Target Optical, LensCrafters, and more. There is an annual $150
service when you have questions, we have negotiated discounts with providers materials allowance for glasses and contacts, with a $0 copayment for adults
throughout the state to save you money. With Blue Option, you get more! and only a $25 copay for dependent children through the age of 18. Better yet,
Comprehensive Provider Network there are no limits on frame or lens selection. Most providers offer additional
discounts on any amounts spent over the material allowance.
With 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 Coverage for Essentials
choose your own health care providers within our statewide network, which We also cover essential health benefits:
includes all South Carolina hospitals. Plus, you have access to urgent and • Preventive and wellness services • Pediatric care
emergency care nationwide through our BlueCard program.
®
• Outpatient care • Mental health and substance abuse
Coverage for Preventive Services • Emergency care disorder services
• Hospitalization • Lab services
With Blue Option, you get coverage for preventive care, such as mammograms,
• Maternity and newborn care
vaccinations, colonoscopies and prostate cancer screenings, at no cost to you.
Coverage for Prescription Drugs More Value
With all-inclusive office visit copayments, dental coverage and online visits with
Blue 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 2018 Icons - Cumulative
a doctor, you get more value with Blue Option. Check out pages 3 – 5 for
more information.
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 Visit www.BlueOptionSC.com for more details.
find a pharmacy, visit www.BlueOptionSC.com.
2
QuickBill Bases Physician’s News
Office Manual
- Cumulative
Key Benefits and Services 2018
ForIcons
You - Cumulative
All-Inclusive Office Visit Copayments Vision Care
All-inclusive office visit copayments cover all diagnostic and treatment All Blue Option plans include routine adult and pediatric vision
services provided at the medical office of a participating
QuickBill Laboratory
Bases
provider.
Physician’s News
coverage through an independent company, Physicians
QuickBill Eyecare
Bases Physician’s
Biometric Learning Management Education Benefits Mgmt Office Manual Office Manual
Screening System Center
This includes preventive services, diagnostic procedures, surgical procedures, Network (PEN). PEN provides vision services through the Physicians Eyecare Plan
medical supplies and more. (PEP) network on behalf of BlueChoice HealthPlan. In-network providers include
Walmart Vision Center, Target Optical, LensCrafters and more. You can also use
Blue CareOnDemand
your material allowance online at www.PEPOptical.com to purchase glasses
All you need is your computer, tablet or smartphone to see a doctor
anytime, anywhere, even when you are outside of South Carolina. 2018 Icons - Cumulative
and/or contact lenses and have them shipped free directly to your door. Be sure
Great Hearing Aids Tobacco
Biometric Learning Management
Employee
Education to use coupon code BLUEOPTION5 to receive 5 percent offBiometric
Laboratory
Benefits Mgmt
your purchase. *
Learning Management Education
Screening Center
ectations During your video
Cessation visit, the doctor will
Storefront ask questions,
Producers
Guide Added Values answer
Screening
Discounts and
questions,
System
Assistance
Program
diagnose
Center System
your symptoms and, if appropriate, call in a prescription to your local pharmacy. Dental Care
Doctors can treat most common, non-emergency medical issues: All plans include a dental allowance for exams and cleanings. This
• Cold and flu symptoms 2018
• Allergies Icons - Cumulative benefit covers an allowed amount per benefit period for exams and
QuickBill Bases
• Bronchitis and other respiratory • Migraines cleanings by any South Carolina-licensed dentist. Please see page 10 for more details.
infections • Rashes and other skin irritations
QuickEnroll
Advantage Plus
FOCUSfwd
Carolina ADV
Great
MyChoice ADV
Expectations
Hearing Aids
Primary Choice Blues
TobaccoFlash
BlueChoice Core Services
My Health
HealthPlan Wire Storefront
Cessation Toolkit
Medical Rewards
Policies
Producers Discounts and EmployeeQuickEnroll
Assistance
My Life ConsultSM
FOCUSfwd Great
Expectations
Hearing Aids Tobacco
Cessation Storefront Producers Discounts and
• Sinus infections • Urinary tract infections
Guide Added Values
Program
Guide Added Values
All members have access to three free sessions of their choice for
• Pinkeye And more!
services such as these: QuickBill Bases Physician’s News
• Ear infections Office Manual
REV: 11/27/2018
• Financial counseling and planning • Legal consultations and documents
Mental health and breastfeeding support services are also available through • Adult care resources • Child care resources
Biometric
Screening
Learning Managem
System
Blue CareOnDemand. • College consultation resources • Parenting/adoption resources
Blue Blues Flash Health Care
Core Services Video Policies Blue Business ADV Blues Flash Core Services
Doctors Care
Business ADV Advantage Plus Carolina ADV Medical Advantage Plus Carolina ADV MyChoice ADV Primary Choice
MyChoice ADV
Mobile Primary
Flexible Choice
Savings Health
Option Reform Option
App Account Reimbursement
Account My Life Consult is offered through First Sun. Because First Sun is a separate
When your doctor is not available and Blue CareOnDemand is not company from BlueChoice®, First Sun is solely responsible for all services
Laboratory
appropriate, choose this option for urgent and after-hours care. You can visit related to individual assistance programs.
REV: 11/27/2018
Biometric
Screening
Learning Management
System
Education
Center
Benefits Mgmt
any Doctors Care location across the state for the same price as a primary care *Discount code cannot be combined
QuickEnroll
with any otherGreat
FOCUSfwd
discount codes.
Hearing Aids
BlueChoice My Health Rewards Tobacco Producers
Expectations Cessation Storefront
HealthPlan Wire Toolkit Guide
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.
BlueChoice My Health Rewards QuickEnroll FOCUSfwd Great Hearing Aids Tobacco Producers Discounts and Employee
3
Expectations Storefront Assistance
QuickBill Bases Physician’s News
Office Manual
2018 Icons - Cumulative QuickBill Bases Physician’s
Office Manual
News
Personal Health Assessment Discount Programs
Take a smart step toward living healthier. By completing your confidential As a Blue Option member, you get discounts on many items:
assessment, you’ll receiveQuickBill
personal guidance
Bases
and insights onNews
Physician’s
your risk for • Blue365® —QuickBill
Laboratory
exclusive access
Bases to health
Physician’s and wellness
News information, discounts
Biometric
Office Manual Learning Management Education Benefits Mgmt Office Manual
Screening System Center
developing certain chronic conditions so you can take preventive action. You’ll and savings from industry-leading brands
Laboratory
Biometric Learning Management Education
also receive a $25 cash reward and 10 entries into the FOCUSfwd Wellness
Benefits Mgmt
• Jenny Craig Screening System Center
Incentive Program Sweepstakes! • Bosley
• Discounts at a variety of fitness centers
FOCUSfwd Wellness Incentive Program
The FOCUSfwd Wellness Incentive Program is designed to help you
Laboratory
Great Expectations® for health Laboratory
Biometric Learning Management Education Biometric Learning Management Education Benefits Mgmt
FOCUS Points,
Center GET FIT and Nutrition
uickEnroll FOCUSfwd Great Hearing
Tobacco Aids Benefits Mgmt Employee Screening Center
lead a healthier lifestyle. Complete
Expectations Screening our System
Cessation Storefront
Guide
Discounts and
Added Values
Producers
Assistance
Program
Great Expectations
System
for health includes more than 20 wellness,
programs and receive $80 in rewards.
BlueChoice
HealthPlan Wire
My Health Plus increase
Toolkit
Rewards your chances ofQuickEnroll
winning oneFOCUSfwd
of chronic
Great
condition
Expectations management
Hearing Aids Tobacco and behavioral health
Cessation Storefront Producers programs
Guide
Discountsthat
and
Added Values
focusAssistance
on the
Employee
Program
the $1,000 quarterly and $5,000 annual cash rewards in our Sweepstakes! early detection of illness and the prevention of disease. Members with chronic
FOCUS Points — Get a $25 cash reward and 10 entries into the Sweepstakes conditions also receive more targeted educational information and contact with
when you complete your Personal Health Assessment. Plus, get an additional $25 cash our staff of highly trained health specialists. Those with intensive needs receive
reward and 15 entries into the Sweepstakes when you complete an annual wellness
QuickEnroll FOCUSfwd Great
care coordination and the support of our caring team of nurses. You can earn
reatBlueChoice
BlueHearing Aids
MyBusiness Rewards Plus
HealthADVTobaccoAdvantage Core Hearing
Services Aids Blues
Employee Flash Tobacco
Medical Policies Producers Discounts and Employee
Carolina ADV Producers
MyChoice ADV Discounts
Primary
and Choice Expectations Storefront
Program Sweepstakes drawings for
Storefront Cessation Assistance
entries in the FOCUSfwd Wellness Incentive Program
ctations
HealthPlan Wire
Option Toolkit Cessation Assistance Guide Added Values
exam and preventive screening or flu vaccine, for a total of $50 in cash rewards
Guide Added Values
Program
Health Care Video Blue Business ADV Blues Flash Core Services Medical Policies
Advantage Plus Carolina ADV
and 25 entries!
Mobile
App
Flexible Savings
Account
Health
Reimbursement
Reform Option participating in some of theseMyChoice ADV
programs. Primary Choice
Account
GET FIT — Get up to $20 in gift cards and 25 entries into the Sweepstakes NEW! My Health Novel
REV: 11/27/2018
for completing the annual step challenge. With Great Expectations for Weight Management, you will have access toREV:My
11/27/2018
Nutrition — Get $10 in giftHealth
cards and 25 entries into the Sweepstakes for completing Health Novel, a personalized program that includes digital tools and support from
Care Video Blue Business ADV Blues Flash Core Services Medical Policies
Blues Flash Core Services Medical Policies Advantage Plus Carolina ADV MyChoice ADV Primary Choice
Advantage Plus Flexible
Mobile Savings Health
App
Carolina
Account
ADV MyChoice ADV
Reimbursement
Primary
Reform Choice
the Nutrition program, which helps you build and maintain healthy eating habits.
Account
Option
proven health solutions.
You’ll also have opportunities to win a multicooker, blender or food processor. You’ll be matched with helpful resources and tools based on your specific
health needs. Whether you’re interested in starting new healthy habits or
Sweepstakes — Earn entries into the Sweepstakes for chances to win one of
REV: 11/27/2018 REV: 11/27/2018
maintaining your weight, the Weight Management program gives you access
the $1,000 quarterly and the annual $5,000 cash rewards by simply signing up
to health coaching, nutrition guidance, digital tools, group support and more
for FOCUSfwd and completing any of its programs.
to keep you on track.
Get the FOCUSfwd App
Stay connected to your health and rewards with the FOCUSfwd app.
To get started, access FOCUSfwd from your mobile device. Then
select Learn More and follow the prompts to download the app and link your account.
4
NEW! My Diabetes Discount Program You will continue receiving your $0 copay by completing the following annually:
If you’re one of the millions of people who have insulin prescribed n Visit your primary care physician for a checkup that includes:
for your diabetes, you know two things: n A comprehensive metabolic panel lab test* OR a basic metabolic panel and
1. Taking insulin as your doctor prescribes is extremely important to feel better liver function panel.
and avoid diabetes complications — and, quite possibly, just to stay alive. n A diabetes risk factor assessment of your feet and eyes.
2. Insulin has gotten very expensive. n Complete two A1C tests (one every six months).
n Get a flu vaccine.
My Diabetes Discount Program can help. Over several months, you’ll complete
n Complete diabetes education.** You can meet this requirement by
some actions on a checklist. Then you’ll be able to receive your insulin with a
completing ONE of the following:
$0 copayment. Take a look at the program checklist and you’ll see there are
n Complete the Diabetes module in My Health Planner. If you have already
things you might be doing already…or you know that you should be.
completed the Diabetes module, you may complete the High Blood
Program Checklist Pressure, High Cholesterol or Weight Management module.
To begin receiving your $0 copay, please complete the following requirements: n Complete one call with your care manager OR view one online education
n Visit your primary care physician for a checkup that includes: material per quarter for four consecutive quarters.
n A comprehensive metabolic panel lab test* OR a basic metabolic panel and n Complete an approved diabetes education session at an approved
liver function panel. independent facility.
n An A1C test. Jenny Craig and Bosley are independent companies that offer discount programs to members of your health plan.
n A diabetes risk factor assessment of your feet and eyes. *Members under the age of 18 require a fasting glucose test instead of a comprehensive metabolic panel test.
**For members under the age of 18, the parent/guardian must meet the diabetes education requirement.
n Get a flu vaccine. ***The $0 copay will be available for one year from the start date of the benefit – for example, December 1, 2021,
through November 30, 2022.
n Complete diabetes education.** You can meet this requirement by
completing ONE of the following:
n Complete the Diabetes module in My Health PlannerSM.
n Complete one call with your care manager OR view one diabetes
education article/video per quarter for two consecutive quarters.
n Complete an approved diabetes education session at an approved
independent facility.
You must maintain these requirements, including two semiannual A1C tests, on
an annual basis to continually receive discounted benefits.***
5
Rewards QuickEnroll FOCUSfwd Great Hearing Ai
BlueChoice My Health Expectations
HealthPlan Wire Toolkit
Access Your Health Information Anytime
My Health Toolkit My Health Toolkit App SUBSCRIBER’S FIRST NAME
SUBSCRIBER’S LAST NAME
SUBSCRIBER’S FIRST NAME
SUBSCRIBER’S LAST NAME
Blue Option Network
Member ID Member ID
BlueChoice wants to make it easy for you to find answers to your questions, so Take My Health Toolkit with you when
ZCL00000000 ZCJ00000000
PLAN PPO Health Benefits PLAN CODE 380.04 Health Benefits
PLAN CODE 380.04 Pediatric Vision RxBIN 021684
RxBIN 021684 Comprehensive Dental RxGRP CHC
RxGRP CHC
we created My Health Toolkit. My Health Toolkit is a secure, online tool that will Mobile
you’re on the go
Flexible Savings Health
with our FREE
Health Care mobile
Video Blue Business ADV Advantage Plus Ca
www.BlueChoiceSC.com
Reform Option
www.BlueOptionSC.com Out of State Only
App Account Reimbursement
help you better manage your benefits, treatment and wellness. app! You can: Account
2018 Icons - Cumulative
Simply create an account on www.BlueOptionSC.com after you receive your • View and share your digital ID card.
• Access the FOCUSfwd Wellness Incentive Program.
BLUECHOICE HEALTHPLAN BLUECHOICE HEALTHPLAN
member ID card.
ZCL00000000 ZCJ00000000
• Confirm coverage.
Then you can: Jan 1, 2022 - Jan 1, 2023 Jan 1, 2022 - Jan 1, 2023
• Find a doctor or hospital in network.
• View your digital ID card.
• Update contact information.
• See if your claim has been paid.
• Check the status ofQuickBill
claims. Bases Physician’s News
• Ask Member Services a question. Office Manual
• Access the FOCUSfwd Wellness Incentive Program. Current My Health Toolkit users can log in to the app
• Find a doctor or hospital. with their existing username and password. New My Health Toolkit users can
• Find out how much a prescription drug costs. register through the app.
• Find out how much you have paid toward your deductible.
Get the App
• View your Schedule of Benefits (SOB), which includes your copayment and
Search for My Health Biometric
Toolkit in the App StoreEducation
Learning Management
Laboratory
Benefits Mgmt
coinsurance amounts. Screening System Center
or Google Play to download the My Health Toolkit app.
• Request a new member ID card.
Get Text Messages
Get important information delivered to your smartphone when you sign up for our text messages.
BlueChoice
HealthPlan Wire
Messages
My Health
Toolkit
include:
Rewards QuickEnroll FOCUSfwd Great
Expectations
Hearing Aids Tobacco
Cessation Storefront Producers
Guide
Discounts and
Added Values
Employee
Assistance
Program
• Keys to using your coverage • Ways you can save
• Health and wellness reminders ... and more!
To get started, simply call 844-206-0622. You’ll need to have your member ID card ready.
Enrolling also earns you entries in the FOCUSfwd Wellness Incentive Program Sweepstakes.
Health Care Video Blue Business ADV Blues Flash Core Services Medical Policies
Mobile Flexible Savings Health Advantage Plus Carolina ADV MyChoice ADV Primary Choice
Reform Option
App Account Reimbursement
Account
6Choose Your 2022 Health Coverage
Open Enrollment Period Special Enrollment Period
You can sign up for health insurance during the open enrollment period from If you do not sign up during this time, you will have to qualify for a special
October 15, 2021, to January 15, 2022. If you enroll in a plan between October enrollment period (SEP) to apply for coverage. Typically, you can qualify for
15, 2021, and December 31, 2021, your coverage will start January 1, 2022. special enrollment for 60 days following a qualifying life event. Events that
If you enroll in a plan between January 1, 2022 and January 15, 2022, your qualify for an SEP include:
coverage will start February 1, 2022. Choosing your coverage is easy:
• Getting married or divorced.
1. Decide what you need. • Having or adopting a child.
Look at your current insurance plan. Are there any changes to your current • Losing other qualified health coverage for other than nonpayment of premium.
benefits? Does your plan fit your budget and your medical needs? This book will • Becoming a U.S. citizen.
help you find the best fit for you. • Moving to South Carolina.
2. Choose your plan.
We are here to help you choose a plan. You can call us at 855-433-2132 or
contact your local agent during the open enrollment period to select your 2022
health plan. Or you can visit www.BlueOptionSC.com.
78
Decide What You Need Let’s Plans
018 Icons for Blue Option Website - Sales
Go!
PLAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PAGE
Benefits for all plans. . . . . . . . . . . . . . . . . . . . . . . . . . 10
First, you need to figure out what kind of plan you need. Blue Option is divided into two categories:
Let’s Blue Option Silver 2000. . . . . . . . . . . . . . . . . . . . . . . 11
the metallic plans (Silver and Bronze) and the Catastrophic
? Plan. Anyone isGo!
eligible to buy a metallic
2018 Icons for Blue Option Website - Sales
plan. There are additional qualifying criteria, however, to purchase the Catastrophic Plan.
Blue Option Silver 3200. . . . . . . . . . . . . . . . . . . . . . . 11
Blue Option Silver 3500. . . . . . . . . . . . . . . . . . . . . . . 11
Back Let’s Go Continue Change Family Where Are How Many
Information You? in Family?
Here’s a simple breakdown to choosing a plan category: Blue Option Silver 5550. . . . . . . . . . . . . . . . . . . . . . . 12
Let’s
• Silver Plans — Silver plans are our most ? level. The plans balance Blue Option Silver 6250. . . . . . . . . . . . . . . . . . . . . . . 12
ns for Blue Option Website - Sales
Go! popular metallic
Blue Option Silver 6850. . . . . . . . . . . . . . . . . . . . . . . 12
Back Let’s Go Continue Change Family
?
monthly premiums with out-of-pocket costs for care. Silver plans are well rounded and
Where Are How Many
Information You? in Family? Blue Option Silver 7350. . . . . . . . . . . . . . . . . . . . . . . 13
provide the best value.
nze Plans Silver Plans Catastrophic Change Plan Tell Us Who Else Are Blue Option Silver 7500. . . . . . . . . . . . . . . . . . . . . . . 13
•B
ronze
Plans
Plans — Bronze plans? typically Youoffer
About Yourself
the lowest monthly premiums, but you will
Adding?
Blue Option Bronze 6000. . . . . . . . . . . . . . . . . . . . . . 14
pay more out of pocket when you need care. These ?
plans are best for those who don’t go Blue Option Bronze 6500. . . . . . . . . . . . . . . . . . . . . . 14
t’s Go Continue Change Family Where Are How Many
toInformation You?
the doctor often in Family?
and don’t take many prescription medications. Blue Option Bronze 8000. . . . . . . . . . . . . . . . . . . . . . 14
Bronze Plans Silver Plans Catastrophic Change Plan Tell Us Who Else Are
•C
atastrophic Plan — Adults under age 30 are eligible for the Catastrophic Plan. This plan has
Plans About Yourself You Adding?
Blue Option Bronze 8700. . . . . . . . . . . . . . . . . . . . . . 14
red Drug Find a Doctor Print Enroll Now More Details Less Details
List
low monthly premiums and a?high deductible. You pay less each month but more when you Blue Option Silver 4300 HD. . . . . . . . . . . . . . . . . . . . 15
actually receive care. Blue Option Silver 6100 HD. . . . . . . . . . . . . . . . . . . . 15
er Plans Catastrophic Change Plan Tell Us Who Else Are
Plans About Yourself You Adding? Blue Option Bronze 7000 HD . . . . . . . . . . . . . . . . . . 15
What is included in each plan?
Covered Drug
List
Find a Doctor Print Enroll Now More Details Less Details Blue Option Catastrophic . . . . . . . . . . . . . . . . . . . . . 15
here do
Each plan mustApplication
Cancel
cover the Payment
same set of Payment
Method
minimum Method
essential health
Payment Method
benefits. We cover your mandated,
General Plan Icon for
u live? Confirmation Bank Draft Credit Card Paper Billing Email Confirmation
routine preventive care services, such as mammograms and colonoscopies, at no cost to you. Plus,
Pricing
ONLY
a Doctor you Print
get value-added
Enroll Now services, such as life
More Details management services, vision, dental and more!
Less Details
Go to www.BlueOptionSC.com to begin
AllWhere
plans do
you live?
includeCancel
emergency care, maternity
Application
Confirmation
Payment Method
Bank Draft
and newborn
Payment Method care,
Credit Card
pediatric
Payment Method
Paper Billing
care,
General Planprescription
Icon for
Email Confirmation
drugs,
ONLY shopping for a plan and determine pricing.
laboratory services, and preventive and wellness services.
ancel
What is the difference?
Application Payment Method Payment Method Payment Method General Plan Icon for
Confirmation
The difference Bank Draft
between theCredit Card
Silver Paper Billing
and Bronze Email Confirmation
categories
ONLY is the amount you pay, such as copayments,
coinsurance percentage, deductibles and maximum out-of-pocket expenses.
9These benefits are applicable to all plans:
BENEFIT ALL PLANS
Gynecological Exam (two per benefit year) $0 copayment
Routine Screening Mammogram $0 copayment
Routine Screening Colonoscopy $0 copayment
Blue Option benefits are provided in network only. No benefits are provided for services received out of network unless the
BlueCard 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.
Benefits include:
• $15 copayment for one routine eye exam.
• One standard contact lens fitting with a $49 copayment, or 15% discount off the provider’s non-standard contact lens fitting fee.
•$ 150 material allowance with a $25 copayment every benefit period that can be spent on frames, lenses, lens upgrades and
Pediatric Vision Care
contacts. Members are not limited by a frame, lens or contact lens selection.
To locate an in-network vision care provider, please visit
• Benefit for prescription sunglasses.
www.BlueOptionSC.com.
•D iscounts of 20% on glasses and 15% on contacts on any amounts spent over the material allowance (at most providers).
•N ecessary 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 minus material copay.
For adult vision care (ages 19 and over), this includes:
• $0 copayment for one routine eye exam.
• One standard contact lens fitting with a $49 copayment, or 15% discount off the provider’s non-standard contact lens fitting fee.
Adult Vision* •$ 150 material allowance with a $0 copayment every benefit period that can be spent on frames, lenses, lens upgrades and contacts.
To locate an in-network vision care provider, please visit Members are not limited by a frame, lens or contact lens selection.
www.BlueOptionSC.com. • Benefit for prescription sunglasses.
•D iscounts 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 minus material copayment.
Preventive Dental Care*
Members will be responsible for paying any additional
balance above what we cover. They will need to submit a Dental
• One exam every six months, up to a $50 allowance
Reimbursement form to BlueChoice for reimbursement.
For example, if your dentist charges you $130 for an initial cleaning
• One cleaning every six months, up to a $50 allowance
and exam, you will pay your dentist $130 at the time of service. We
will reimburse you $100 once we receive your reimbursement form.
Mental Health/Substance Abuse Covered the same as medical benefits
Transplants A BlueChoice-participating facility must provide services.
Costs incurred from these services do not count toward MOOP expenses.
*
10BENEFIT FEATURE & DESCRIPTION BLUE OPTION SILVER 2000 BLUE OPTION SILVER 3200 BLUE OPTION SILVER 3500
Coinsurance 50% 50% 40%
Deductible (Single/Family) $2,000/$4,000 $3,200/$6,400 $3,500/$7,000
Maximum Out of Pocket (Single/Family) $7,500/$15,000 $7,900/$15,800 $8,200/$16,400
Primary Care Office Visit $35 $35 $30
Doctors Care/Blue CareOnDemand $35 $35 $30
Maternity Care $75 first visit $80 first visit $75 first visit
Specialist Office Visit $75 $80 $75
Urgent Care $50 $50 $50
Free-Standing Ambulatory Surgical Center *
$200 per visit $200 per visit $200 per visit
Inpatient Hospital Services $400 copayment, then 50% after deductible 50% after deductible 40% after deductible
Outpatient Hospital Services 50% after deductible 50% after deductible 40% after deductible
Emergency Room $400 copayment, then 50% after deductible $400 copayment, then 50% after deductible $350 copayment, then 40% after deductible
Ambulance 50% after deductible 50% after deductible 40% after deductible
PRESCRIPTION DRUGS**
Tier 0: $0 Tier 0: $0 Tier 0: $0
Tier 1: $20 Tier 1: $25 Tier 1: $20
Tier 2: $20 Tier 2: $25 Tier 2: $20
Retail Tier 3: 50% after deductible Tier 3: $50 Tier 3: $60
Tier 4: 50% after deductible Tier 4: $90 Tier 4: $80
Tier 5: 50% after deductible Tier 5: $300 Tier 5: $300
Tier 6: 50% after deductible Tier 6: $300 Tier 6: $300
Tier 0: $0 Tier 0: $0 Tier 0: $0
Tier 1: $40 Tier 1: $50 Tier 1: $40
Tier 2: $40 Tier 2: $50 Tier 2: $40
Mail Order Tier 3: 50% after deductible Tier 3: $100 Tier 3: $120
Tier 4: 50% after deductible Tier 4: $180 Tier 4: $160
Tier 5: 50% after deductible Tier 5: $600 Tier 5: $600
Tier 6: 50% after deductible Tier 6: $600 Tier 6: $600
Durable Medical Equipment 50% after deductible 50% after deductible 40% after deductible
Physical Therapy, Speech Therapy,
50% after deductible 50% after deductible 40% after deductible
Occupational Therapy and Habilitation***
NOTES:
• All plans include an embedded deductible and MOOP. If necessary, please see the glossary on page 16 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.
**If a drug manufacturer provides any form of direct support (cash, reimbursement, coupon, voucher, debit card, etc.) for some or all of the cost sharing on the purchase of prescription and/or specialty drugs, this amount will not be
counted toward the member’s annual limitation on cost sharing. The drug will still be considered a covered prescription drug.
***30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year; 30 visits for habilitation per benefit year.
11BENEFIT FEATURE & DESCRIPTION BLUE OPTION SILVER 5550 BLUE OPTION SILVER 6250 BLUE OPTION SILVER 6850
Coinsurance 35% 25% 40%
Deductible (Single/Family) $5,550/$11,100 $6,250/$12,500 $6,850/$13,700
Maximum Out of Pocket (Single/Family) $7,400/$14,800 $7,800/$15,600 $8,500/$17,000
Primary Care Office Visit $35 $20 $25
Doctors Care/Blue CareOnDemand $35 $20 $25
Maternity Care $85 first visit $55 first visit $60 first visit
Specialist Office Visit $85 $55 $60
Urgent Care $50 $50 $50
Free-Standing Ambulatory Surgical Center *
$200 per visit $200 per visit $200 per visit
Inpatient Hospital Services 35% after deductible 25% after deductible 40% after deductible
Outpatient Hospital Services 35% after deductible 25% after deductible 40% after deductible
Emergency Room $500 copayment, then 35% after deductible 25% after deductible 40% after deductible
Ambulance 35% after deductible 25% after deductible 40% after deductible
PRESCRIPTION DRUGS**
Tier 0: $0 Tier 0: $0 Tier 0: $0
Tier 1: $35 Tier 1: $20 Tier 1: $25
Tier 2: $35 Tier 2: $20 Tier 2: $25
Retail Tier 3: 35% after deductible Tier 3: $40 Tier 3: $45
Tier 4: 35% after deductible Tier 4: $90 Tier 4: $80
Tier 5: 35% after deductible Tier 5: $300 Tier 5: $300
Tier 6: 35% after deductible Tier 6: $300 Tier 6: $300
Tier 0: $0 Tier 0: $0 Tier 0: $0
Tier 1: $70 Tier 1: $40 Tier 1: $50
Tier 2: $70 Tier 2: $40 Tier 2: $50
Mail Order Tier 3: 35% after deductible Tier 3: $80 Tier 3: $90
Tier 4: 35% after deductible Tier 4: $180 Tier 4: $160
Tier 5: 35% after deductible Tier 5: $600 Tier 5: $600
Tier 6: 35% after deductible Tier 6: $600 Tier 6: $600
Durable Medical Equipment 35% after deductible 25% after deductible 40% after deductible
Physical Therapy, Speech Therapy,
35% after deductible 25% after deductible 40% after deductible
Occupational Therapy and Habilitation***
NOTES:
• All plans include an embedded deductible and MOOP. If necessary, please see the glossary on page 16 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.
**If a drug manufacturer provides any form of direct support (cash, reimbursement, coupon, voucher, debit card, etc.) for some or all of the cost sharing on the purchase of prescription and/or specialty drugs, this amount will not be
counted toward the member’s annual limitation on cost sharing. The drug will still be considered a covered prescription drug.
***30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year; 30 visits for habilitation per benefit year.
12BENEFIT FEATURE & DESCRIPTION BLUE OPTION SILVER 7350 BLUE OPTION SILVER 7500
Coinsurance 50% 0%
Deductible (Single/Family) $7,350/$14,700 $7,500/$15,000
Maximum Out of Pocket (Single/Family) $8,500/$17,000 $7,500/$15,000
Primary Care Office Visit $35 $0
Doctors Care/Blue CareOnDemand $35 $0
Maternity Care $80 first visit $50 first visit
Specialist Office Visit $80 $50
Urgent Care $50 $50
Free-Standing Ambulatory Surgical Center* $200 per visit $200 per visit
Inpatient Hospital Services 50% after deductible Deductible
Outpatient Hospital Services 50% after deductible Deductible
Emergency Room 50% after deductible $500 copayment, then deductible
Ambulance 50% after deductible Deductible
PRESCRIPTION DRUGS**
Tier 0: $0 Tier 0: $0
Tier 1: $30 Tier 1: $25
Tier 2: $30 Tier 2: $25
Retail Tier 3: $60 Tier 3: $45
Tier 4: $75 Tier 4: Deductible
Tier 5: $300 Tier 5: Deductible
Tier 6: $300 Tier 6: Deductible
Tier 0: $0 Tier 0: $0
Tier 1: $60 Tier 1: $50
Tier 2: $60 Tier 2: $50
Mail Order Tier 3: $120 Tier 3: $90
Tier 4: $150 Tier 4: Deductible
Tier 5: $600 Tier 5: Deductible
Tier 6: $600 Tier 6: Deductible
Durable Medical Equipment 50% after deductible Deductible
Physical Therapy, Speech Therapy,
50% after deductible Deductible
Occupational Therapy and Habilitation***
NOTES:
• All plans include an embedded deductible and MOOP. If necessary, please see the glossary on page 16 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.
**If a drug manufacturer provides any form of direct support (cash, reimbursement, coupon, voucher, debit card, etc.) for some or all of the cost sharing on the purchase of prescription and/or specialty drugs, this amount will not be
counted toward the member’s annual limitation on cost sharing. The drug will still be considered a covered prescription drug.
***30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year; 30 visits for habilitation per benefit year.
13BLUE OPTION BLUE OPTION BLUE OPTION NEW — BLUE OPTION
BENEFIT FEATURE & DESCRIPTION
BRONZE 6000 BRONZE 6500 BRONZE 8000 BRONZE 8700
Coinsurance 40% 30% 50% 0%
Deductible (Single/Family) $6,000/$12,000 $6,500/$13,000 $8,000/$16,000 $8,700/$17,400
Maximum Out of Pocket (Single/Family) $8,700/$17,400 $8,700/$17,400 $8,700/$17,400 $8,700/$17,400
Primary Care Office Visit $60 $50 $60 $70
Doctors Care/Blue CareOnDemand $60 $50 $60 $70
Maternity Care $110 first visit $100 first visit $100 first visit $120 first visit
Specialist Office Visit $110 $100 $100 $120
Urgent Care $75 $75 $75 $75
Free-Standing Ambulatory Surgical Center *
$200 per visit $200 per visit $200 per visit $200 per visit
$300 copayment,
Inpatient Hospital Services 40% after deductible 50% after deductible Deductible
then 30% after deductible
$300 copayment,
Outpatient Hospital Services 40% after deductible 50% after deductible Deductible
then 30% after deductible
$500 copayment, $300 copayment,
Emergency Room 50% after deductible Deductible
then 40% after deductible then 30% after deductible
Ambulance 40% after deductible 30% after deductible 50% after deductible Deductible
PRESCRIPTION DRUGS **
Tier 0: $0
Tier 1: $30
Tier 0: $0 Tier 0: $0 Tier 0: $0
Tier 2: $30
Tier 1: $30 Tier 1: $30 Tier 1: $30
Retail Tier 3: $135
Tier 2: $30 Tier 2: $30 Tier 2: $30
Tier 4: $215
Tiers 3–6: 40% after deductible Tiers 3–6: 30% after deductible Tiers 3–6: 50% after deductible
Tier 5: $350
Tier 6: $350
Tier 0: $0
Tier 1: $60
Tier 0: $0 Tier 0: $0 Tier 0: $0
Tier 2: $60
Tier 1: $60 Tier 1: $60 Tier 1: $60
Mail Order Tier 3: $270
Tier 2: $60 Tier 2: $60 Tier 2: $60
Tier 4: $430
Tiers 3–6: 40% after deductible Tiers 3–6: 30% after deductible Tiers 3–6: 50% after deductible
Tier 5: $700
Tier 6: $700
Durable Medical Equipment 40% after deductible 30% after deductible 50% after deductible Deductible
Physical Therapy, Speech Therapy,
40% after deductible 30% after deductible 50% after deductible Deductible
Occupational Therapy and Habilitation***
NOTES:
• All plans include an embedded deductible and MOOP. If necessary, please see the glossary on page 16 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.
**If a drug manufacturer provides any form of direct support (cash, reimbursement, coupon, voucher, debit card, etc.) for some or all of the cost sharing on the purchase of prescription and/or specialty drugs, this amount will not
be counted toward the member’s annual limitation on cost sharing. The drug will still be considered a covered prescription drug.
***30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year; 30 visits for habilitation per benefit year.
14BLUE OPTION BLUE OPTION BLUE OPTION BLUE OPTION
BENEFIT FEATURE & DESCRIPTION
SILVER 4300 HD SILVER 6100 HD BRONZE 7000 HD CATASTROPHIC
Coinsurance 0% 0% 0% 0%
Deductible (Single/Family) $4,300/$8,600 $6,100/$12,200 $7,000/$14,000 $8,700/$17,400
Maximum Out of Pocket (Single/Family) $4,300/$8,600 $6,100/$12,200 $7,000/$14,000 $8,700/$17,400
Primary Care Office Visit Deductible Deductible Deductible $25 for first 3 visits, then deductible
Doctors Care/Blue CareOnDemand Deductible Deductible Deductible $25 for first 3 visits, then deductible
Maternity Care Deductible Deductible Deductible Deductible
Specialist Office Visit Deductible Deductible Deductible Deductible
Urgent Care Deductible Deductible Deductible Deductible
Free-Standing Ambulatory Surgical Center* Deductible Deductible Deductible Deductible
Inpatient Hospital Services Deductible Deductible Deductible Deductible
Outpatient Hospital Services Deductible Deductible Deductible Deductible
Emergency Room Deductible Deductible Deductible Deductible
Ambulance Deductible Deductible Deductible Deductible
PRESCRIPTION DRUGS**
Tier 0: $0 Tier 0: $0 Tier 0: $0 Tier 0: $0
Retail
Tiers 1–6: Deductible Tiers 1–6: Deductible Tiers 1–6: Deductible Tiers 1–6: Deductible
Tier 0: $0 Tier 0: $0 Tier 0: $0 Tier 0: $0
Mail Order
Tiers 1–6: Deductible Tiers 1–6: Deductible Tiers 1–6: Deductible Tiers 1–6: Deductible
Durable Medical Equipment Deductible Deductible Deductible Deductible
Physical Therapy, Speech Therapy,
Deductible Deductible Deductible Deductible
Occupational Therapy and Habilitation***
NOTES:
• All plans include an embedded deductible and MOOP. If necessary, please see the glossary on page 16 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.
**If a drug manufacturer provides any form of direct support (cash, reimbursement, coupon, voucher, debit card, etc.) for some or all of the cost sharing on the purchase of prescription and/or specialty drugs, this amount will not be
counted toward the member’s annual limitation on cost sharing. The drug will still be considered a covered prescription drug.
***30 combined visits for physical therapy, speech therapy and occupational therapy per benefit year; 30 visits for habilitation per benefit year.
15Glossary
Coinsurance Essential Health Benefits
The dollar amount or percentage you pay for your covered health care services. There is a set of 10 categories of services health insurance plans must cover:
For example, if you have an “80/20” plan, your health plan would pay 80 percent • Ambulatory patient services • Rehabilitative and habilitative
• Emergency services services and devices
of the allowed amount, and you would pay 20 percent. The 20 percent you pay is
• Hospitalization • Laboratory services
your coinsurance amount. • Maternity and newborn care • Preventive and wellness services and
Copayment • Mental health and substance use chronic condition management
disorder services, including • Pediatric services, including oral and
A set dollar amount you pay each time you receive a health care service. For behavioral health treatment vision care
example, your health plan may have a $20 copayment for a doctor’s office visit. • Prescription drugs
You will pay this amount each time you go to the in-network doctor.
Maximum Out of Pocket (MOOP)
Deductible The most you pay for covered services in a year before this plan begins to pay
The amount you must pay for covered services before your health plan starts 100 percent of the allowed amount. This limit never includes your premium,
to pay. For example, say your plan has a $500 deductible. You must pay the balance-billed charges, health care your plan doesn’t cover or coupons for
first $500 of allowable charges for covered services before your plan starts to medical and/or prescription coverage.
pay benefits. Your health plan may pay some benefits before you meet your
Network Provider
deductible. For example, your plan may pay some preventive services at
Network providers are doctors, hospitals and other health care providers that we
100 percent, even if you have not met your deductible.
have contracted with to provide health care services to our members. Network
Embedded Deductible providers are also called “in-network” providers or “participating” providers.
Your plan contains two components: an individual deductible and a family
Open Enrollment Period
deductible. Once a family member meets his or her individual deductible, the
The yearly period when you can enroll in or make changes to your health
plan will cover that family member’s covered medical expenses. Once family
insurance coverage. Open enrollment for 2022 runs from October 15, 2021, to
members have reached the family deductible, the plan will pay for covered
January 15, 2022.
expenses for all family members. The individual deductible is embedded in
the family deductible. 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.
16Statement of Confidentiality
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.
Protection of Privacy
BlueChoice 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 Information
BlueChoice 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.
17Focus on life. Focus on health. Stay focused.
BlueChoice HealthPlan’s goal is to help keep you healthy. We look forward to helping you decide
which BlueIcons
2018 Option plan is best for you and your family.
- Cumulative
For more information on Blue Option plans, you can:
1: Contact a 2018 Icons - Cumulative
local insurance agent.
2: Call us at 855-433-2132 Monday through Friday, 9 a.m. to 5 p.m.
QuickBill Bases Physician’s News
Office Manual
3: Visit www.BlueOptionSC.com.
QuickBill Bases Physician’s News
Office Manual
Laboratory
Biometric Learning Management Education Benefits Mgmt
Screening System Center
Please note: There should be a white line on top and bottom of this pattern Biometric
Screening
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background or photo. They are present in this vector image.
Rewards QuickEnroll FOCUSfwd Great Hearing Aids Tobacco Employee
ueChoice My Health Expectations Storefront Producers Discounts and
thPlan Wire Toolkit Cessation Guide Added Values Assistance
Program
BlueChoice HealthPlan is an independent licensee
of the Blue Cross Blue Shield Association.
Rewards QuickEnroll FOCUSfwd Great Hearing Aids Tobacco Employee
BlueChoice My Health Expectations Storefront Producers Discounts and
HealthPlan Wire Toolkit Cessation Guide Added Values Assistance
Program
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