| Company/Plan Name |
 BlueCross BlueShield of South Carolina - Short-Term Major Medical |
| Deductible |
|
| In-Network |
$250 Per Person, Per Term |
| Out-Network |
$250 Per Person, Per Term |
| Maximum Family Deductible |
No family maximum applies |
| Coinsurance |
|
| In-Network |
80/20% to $7,500 |
| Out-Network |
|
| Maximum Out-Of-Pocket Coinsurance |
|
| In-Network |
$1,500, excluding Deductible |
| Out-Network |
$1,500, excluding Deductible |
| Maximum Benefit |
$1,000,000 lifetime maximum per person |
| Physician Office Visit |
|
| In-Network |
Non-routine office visits subject to Deductible and CoInsurance
|
| Out-Network |
Non-routine office visits subject to Deductible and CoInsurance
|
| Outpatient Lab & X-Ray |
|
| In-Network |
Subject to Deductible and CoInsurance |
| Out-Network |
Subject to Deductible and CoInsurance |
| Outpatient Preventive Care |
Subject to Deductible and CoInsurance |
| In-Network |
Subject to Deductible and CoInsurance |
| Out-Network |
Subject to Deductible and CoInsurance |
| Prescription Drugs |
Subject to Deductible and CoInsurance |
| Generic |
Subject to Deductible and CoInsurance |
| Brand Name(formulary) |
Subject to Deductible and CoInsurance |
| Brand Name(Non-formulary) |
Subject to Deductible and CoInsurance |
| Outpatient Surgery |
|
| In-Network |
Subject to Deductible and CoInsurance |
| Out-Network |
Subject to Deductible and CoInsurance |
| Emergency Room |
Subject to Deductible and CoInsurance with a $200 maximum ambulatory benefit |
| In-Network |
Subject to Deductible and CoInsurance with a $200 maximum ambulatory benefit |
| Out-Network |
Subject to Deductible and CoInsurance with a $200 maximum ambulatory benefit |
| Maternity Prenatal/Post Natal |
|
| In-Network |
Not covered |
| Out-Network |
Not covered |
| Inpatient Benefits |
|
| Hospitalization |
|
| In-Network |
Subject to Deductible and CoInsurance |
| Out-Network |
Subject to Deductible and CoInsurance |
| Surgical |
|
| In-Network |
Subject to Deductible and CoInsurance |
| Out-Network |
Subject to Deductible and CoInsurance |
| Maternity |
|
| In-Network |
Not covered |
| Out-Network |
Not covered |
| Rate Guarantee |
N/A |
| Optional Benefits |
|
| Supplemental Accident |
Not available |
| 24 Hour Coverage |
Not available |
| Other |
Not available |