BlueCross Secure (HMO)

BlueCross BlueShield of South Carolina (BCBSSC)
BlueCross Secure (HMO) H7165-001 Plan Details
Plan too new to be measured

BlueCross Secure (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by BlueCross BlueShield of South Carolina (BCBSSC).
Plan ID: H7165-001.

$0.00
Monthly Premium

BlueCross Secure (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by BlueCross BlueShield of South Carolina (BCBSSC).
Plan ID: H7165-001.

BlueCross BlueShield of South Carolina (BCBSSC)
BlueCross Secure (HMO) H7165-001 Plan Details
Plan too new to be measured

BlueCross Secure (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by BlueCross BlueShield of South Carolina (BCBSSC).
Plan ID: H7165-001.

$0.00
Monthly Premium

South Carolina Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $70
Out of Pocket Max In-Network: $6500
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $5.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $40.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$425.00 per day for days 1 to 4
$0.00 per day for days 5 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Urgent Care
Copayment for Urgent Care $40.00
Emergency Room Visit
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Coinsurance for Worldwide Emergency Coverage 20%
Maximum Plan Benefit of $25,000
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $275.00

Air Ambulance:
Copayment for Air Ambulance Services $275.00

Health Care Services and Medical Supplies

BlueCross Secure (HMO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $20.00
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Coinsurance for Medicare-covered Diabetic Supplies 0% to 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
This Plan has preferred Vendors/Manufacturers - Please see Evidence of Coverage
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $275.00
Copayment for Medicare-covered Lab Services $10.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $150.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $10.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$415.00 per day for days 1 to 4
$0.00 per day for days 5 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $325.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $325.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00 to $325.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $40.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $50.00
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$188.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Comprehensive Dental:
Copayment for Medicare-covered Benefits $50.00

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00 to $50.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00
  • Maximum 1 Pair every two years
Copayment for Eyeglasses (lenses and frames) $0.00
  • Maximum 1 Pair every two years
Copayment for Eyeglass Lenses $0.00
  • Maximum 1 Pair every two years
Copayment for Eyeglass Frames $0.00
  • Maximum 1 Pair every two years

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $45.00
Copayment for Routine Hearing Exams $45.00
  • Maximum 1 visit every year

Hearing Aids:
Copayment for Hearing Aids $699.00 to $999.00
  • Maximum 2 Hearing Aids every year
Copayment Structure Up to two TruHearing-branded hearing aids every year (one ear per year). Benefit is limited to TruHearing's Advanced and premium hearing aids, which come in various styles and colors. You must see a TruHearing provider to use this benefit. The co-payment range is based on different types and styles of hearing aids. The lower range is for the Advanced hearing aid type and the higher range is for the Premium hearing aid type. Hearing aid purchase includes: - Provider visits within the first year of hearing aid purchase - 60-day trial period - 3-year extended warranty - 80 batteries per aid Benefit does not includ or cover any of the following: - Ear molds - Haring aid accessories - additional provider visits - Extra batteries for the non-rechargeable models - Hearing aids that are not TruHearing-branded hearing aids - Costs assoicated with loss & damage warranty claims Costs associated with exlcuded items are the responsibility of the memb

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit

    Prescription Drug Costs and Coverage

    The BlueCross Secure (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $70 (excludes Tiers 1 and 2) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $70 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $5.00
    • Standard retail $10.00
    • Preferred mail order $5.00
    • Standard mail order $10.00
    Generic
    • Preferred retail $15.00
    • Standard retail $20.00
    • Preferred mail order $15.00
    • Standard mail order $20.00
    Annual Drug Deductible $70 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $10.00
    • Standard retail $20.00
    • Preferred mail order $10.00
    • Standard mail order $20.00
    Generic
    • Preferred retail $30.00
    • Standard retail $40.00
    • Preferred mail order $30.00
    • Standard mail order $40.00
    Annual Drug Deductible $70 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $0.00
    • Standard retail $30.00
    • Preferred mail order $0.00
    • Standard mail order $25.00
    Generic
    • Preferred retail $45.00
    • Standard retail $60.00
    • Preferred mail order $37.50
    • Standard mail order $50.00