BusinessADVANTAGESM€¦ · BlueChoice routinely reviews our benefit plans. This year we are...

Focus on life. Focus on health. Stay focused.

BusinessADVANTAGESM

2021 Employer Group Coverage (2 – 50)

The Power of Blue®

We have more than 30 years of experience serving our members throughout South Carolina. We offer affordable

plan options that provide more value, more benefits and more options. Not only do we have best-in-class

customer service when you have questions, we have negotiated discounts with providers throughout the state to

save your employees money. With BlueChoice® HealthPlan, you get more!

Our PlansBusinessADVANTAGE is an affordable and comprehensive series of health plans with options to suit employers

with 2 − 50 employees. We can work with you to determine which features and benefits best fit your company and

your employees. Our plans include a variety of programs for medical, health and disease management. We have

your employees covered regardless of their needs.

BlueChoice routinely reviews our benefit plans. This year we are offering 28 plans from which to choose. You can

choose from several levels of products with multiple plan designs:

• 10 Gold plans

• 12 Silver plans

• Six Bronze plans

• Six of these are qualified high-deductible health plans (HDHPs)

You can offer dual options in any combination from any of these plans down to two lives. All plans are health

reimbursement arrangement-compatible and six plans are health savings account-qualified.

Whole-Health SolutionsWhen you choose the plan design that’s best for your company, you can count on BlueChoice to deliver:

• Deductible and copayment amounts that help you manage your health care costs.

• Comprehensive mail-order and retail pharmacy benefits.

• Chiropractic care.

• Value-added services like routine vision, preventive dental, an employee assistance program, a discount

program and 24-hour video access to a certified physician.

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The Benefits of BusinessADVANTAGEAll BusinessADVANTAGE plans are comprehensive, open-access plans. In addition to the great benefits listed here,

your employees get the comfort and convenience of seeing any doctor they choose within the network without

getting a referral. This also includes full access to our in-network providers worldwide.

Through our BlueCard® program, BusinessADVANTAGE members living or traveling outside of South Carolina

can locate participating doctors and hospitals nationwide. When members use a doctor or hospital through

BlueCard, they receive the highest level of benefits. Plus, they always have access to a doctor by video or phone

with Blue CareOnDemandSM.

All-inclusive, comprehensive office visit copayment — One low copay per in-network office visit covers ALL related

diagnostic and treatment services, including labs and X-rays.

Comprehensive hospital, medical and Rx coverage PLUS routine vision care — All at no additional cost!

Preventive dental included — All of our BusinessADVANTAGE plans automatically cover an allowed amount per

benefit period for preventive exams and cleanings at any licensed dentist.

Adult and pediatric vision care included — All plans cover one eye exam each year and one pair of glasses or

contact lenses every two years from a designated selection through the Physicians Eyecare Network. Physicians

Eyecare Network is an independent company that administers a vision provider network on behalf of BlueChoice.

FOCUSfwd® Wellness Incentive Program — Offers members the chance to win cash rewards for participating in

various programs and healthy activities.

Employee Assistance Program — Available for family counseling, life management, training and more, included at no

additional cost through First Sun EAP. Because First Sun EAP is a separate company from BlueChoice HealthPlan, First

Sun will be responsible for all services related to this program. Includes three free face-to-face sessions per person for

individual, couples and family counseling; three free life-management services per person about topics like financial

counseling and planning, child and adult care resources; and employer assistance with training and on-site support.

Freestanding ambulatory surgical centers — Our network of freestanding ambulatory surgical centers can save

your employees money when they need surgery or a procedure that doesn’t require an overnight stay.

Specialist Visits — No referral necessary! Members can stay within our national network or seek medical care

outside the network. If they use professionals within our network, they’ll typically receive higher benefits.

Lab Choices — More lab choices, generating savings and less out-of-pocket costs for our members.

Doctors Care visits for the same cost as primary care visits — Saving your employees money when an ER visit is unnecessary.

Please refer to the plan grids on pages 16 – 25 for benefit details.

EXAMPLE FACILITY FEE*You use a freestanding ambulatory surgical center. $200

You use the hospital or an outpatient facility affiliated with a hospital.$400 copayment, then deductible, then 50%

* Benefits vary. Groups should check their Schedule of Benefits.

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Tiered Prescription Drug BenefitsBlueChoice offers pharmacy benefits programs that provide the highest level of clinical effectiveness and safety

for the lowest net spending. Our goal is to help our members get the appropriate drugs they need at the best

price. One way we do this is by developing and maintaining a covered drug list.

We continually evaluate our prescription drug formularies and drug management programs to ensure that quality and

costs are managed effectively. We work with a group of independent doctors and pharmacists to evaluate our pharmacy

programs and get their recommendations. This group also approves decisions about our covered drug list, specialty

drug list and drug management programs. They base their decisions on a drug’s effectiveness, safety and value.

To view the covered drug list, visit www.BlueChoiceSC.com, go to the Member Center and select BusinessADVANTAGE.

Six-Tier Drug ProgramBlueChoice has a six-tier prescription drug plan. This program offers flexibility in drug treatments. The chart shows

the drugs that are typically in each tier.

MEMBER COST

DRUG TIER USUALLY INCLUDES

Not Applicable

Tier 0These drugs are considered preventive medications under the Affordable Care Act (ACA) and we cover them at no cost to you.

$ Tier 1Drugs on this tier are usually preferred generic drugs. They will typically cost the least amount of money out of your pocket.

$$ Tier 2Drugs on this tier are usually generic drugs. They will typically cost less than brand-name drugs.

$$$ Tier 3Drugs on this tier are usually preferred brand-name drugs. They typically cost less than other brand-name drugs.

$$$$ Tier 4Drugs on this tier are usually non-preferred brand-name drugs. They typically cost more than other brand drugs and may have generic equivalents.

$$$$$ Tier 5Drugs on this tier are usually preferred specialty drugs that are used to treat complex conditions. They are typically expensive.

$$$$$$ Tier 6Drugs on this tier are usually specialty drugs that are used to treat complex medical conditions. They are typically the most expensive drugs available.

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Value-Added Benefits and ServicesAll BusinessADVANTAGE plans include value-added benefits. These benefits are non-essential and do not count

toward any maximum out-of-pocket (MOOP) expenses.

Adult Routine Vision CareAll plans include our routine adult vision coverage provided through Physicians Eyecare Network. The benefit

covers one eye exam each year and one pair of glasses from a designated selection or contact lenses every two

years. For members outside of the South Carolina service area, we allow $71 toward the routine eye exam and

$120 toward the purchase of eyewear. The member must file these claims.

Preventive Dental CareAll plans include a dental allowance for exams and cleanings for adults and children. This benefit covers these

amounts per benefit period for exams and cleanings by any South Carolina-licensed dentist:

• Preventive dental, one exam every six months: up to $50

• Preventive dental, one cleaning every six months: up to $50

Members can send a completed dental reimbursement form and the paid receipt to BlueChoice for

reimbursement of the allowed amount. If you would like to offer a comprehensive dental plan, you can choose

one of our Blue DentalSM plans. See page 12 for details.

Employee Assistance Program (EAP)First Sun EAP provides a broad array of services designed to help people and encourage success at all levels in an

organization so your employees are at their best. By offering your employees the employee assistance program, you

can help to reduce the number of days employees miss, help to increase productivity and bring out the best in your

employees. These services are free to members and those in their households.

EAP services include, but are not limited to:

• Financial counseling and planning

• Adult care resources

• College consultation resources

• Legal consultations and documents

• Child care resources

• Parenting/adoption resources

DiscountsAt BlueChoice, members can take advantage of great discount programs and special services. We offer these

services and discounts to our members in addition to, but not included in, the services and benefits covered

under a BlueChoice policy. Through our value-added services, members have access to special discounts or

benefits on services such as:

• Blue365®, a program offering nationwide discounts

• Weight-loss programs and centers

• Hearing aid discounts

• Fitness center discounts

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FOCUSfwd Wellness Incentive ProgramThe FOCUSfwd Wellness Incentive Program is designed to help you lead a healthier lifestyle. Complete

our FOCUS Points, GET FIT and Nutrition programs and receive $55 in rewards. Plus increase your

chances of winning one of the $1,000 quarterly and $5,000 annual cash rewards in our Sweepstakes!

FOCUS PointsGet a $25 cash reward and 25 entries into the Sweepstakes when you complete the following

activities that are important to improving your overall health: Personal Health Assessment, annual

wellness visit, and preventive screening or flu shot.

GET FITGet up to $20 in gift cards and 25 entries into the Sweepstakes for stepping up to the annual challenge.

NutritionGet $10 in gift cards and 25 entries into the Sweepstakes for completing the Nutrition program, which

helps you with basic cooking skills that allow you to explore new foods while reaching nutrient-driven

goals. You’ll also have opportunities to win an instant pot, blender or food processor.

SweepstakesEarn entries into the Sweepstakes for chances to win one of the $1,000 quarterly and annual $5,000 cash rewards by simply signing up for FOCUSfwd and completing any of its programs.

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Find CareHelping your employees find a participating provider is quick

and easy! You can view and print customized lists of health care

providers and facilities. Your list will show providers or facilities in

the ADVANTAGE network. You can find providers and facilities

located near you. You can even create directories based on the

types of doctors your employees may need.

To see if a doctor is in the network, have your employees visit www.BlueChoiceSC.com and select Find Care on

the homepage.

BLUECHOICE HEALTHPLAN

ZCL00000000

www.BlueChoiceSC.com

SUBSCRIBER’S FIRST NAMESUBSCRIBER’S LAST NAME

ZCL00000000Member ID

PLANPLAN CODERxBINRxGRP

PPO380.04021684CHC

Health BenefitsPediatric VisionComprehensive Dental


ZCJ00000000

www.BlueOptionSC.com


ZCJ00000000Member ID

PLAN CODERxBINRxGRP

380.04021684CHC

Health Benefits

Blue Option Network

Out of State Only

Jan 1, 2021 - Jan 1, 2022 Jan 1, 2021 - Jan 1, 2022


ZCJ00000000


FIRST NAME LAST NAME


PLANPLAN CODE

PPO380.04

Advantage Network

BusinessADVANTAGE

Jan 1, 2021 - Jan 1, 2022

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Doctor Visits Anytime, Anywhere With Blue CareOnDemand, your employees can visit with a doctor via smartphone,

tablet or computer, rather than visiting an office or urgent care facility. Each

Blue CareOnDemand visit costs the same amount as a trip to their primary care

doctor. Doctors will diagnose and write prescriptions, as appropriate.

What types of medical issues can these doctors treat?• Cold and flu symptoms

• Bronchitis and other respiratory infections

• Sinus infections

• Pinkeye

• Ear infections

• Allergies

• Migraines

• Rashes and other skin irritations

• Urinary tract infections

And more.

Mental health and breastfeeding support services are also available through Blue CareOnDemand.

When should members use video visits?• If they need to see a doctor, but can’t fit it into

their schedule

• If their doctor’s office is closed

• If they feel too sick to drive

• If they have children at home and don’t want to bring

them to a doctor’s office

• If they are on business travel and stuck in a hotel room

• If they feel uncomfortable going to a doctor’s office

Get started nowThere are two easy ways for your employees to use Blue CareOnDemand:

• From a mobile phone or tablet, download the Blue CareOnDemand app for an Apple or Android device.

• From a computer, go to www.BlueCareOnDemandSC.com.

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Great Expectations for health Coaching ProgramsComprehensive health management is an integral part of the services we offer our members. We use a 360-degree

approach in managing the health of our members. There are programs for all members that focus on the early detection

of illness and the prevention of disease. Members with chronic conditions also receive more targeted educational

information and contact with our staff of highly trained health specialists. Those with intensive needs receive care

coordination and the support of our caring team of nurses. Members can self-enroll by calling 855-838-5897 and selecting

option 2.

CONDITION NAME DESCRIPTION

Adult ADHD

The Great Expectations Adult Attention Deficit Hyperactivity Disorder (ADHD) program is a coaching program that educates members on steps to take to better manage their ADHD. The program helps members understand ADHD and empowers them with tools to manage medications and appointments. Members are able to set their own goals and may also receive educational mailings and access to online resources, as appropriate.

Asthma (adult and pediatric)

The Great Expectations Asthma program helps members learn how to manage their asthma and improve their quality of life. Through ongoing partnership, collaboration and telephone coaching calls, our experienced respiratory therapists provide education about asthma and support for complying with each member’s doctor’s plan of care. Members can request a free peak flow meter.

Back Care

The Great Expectations Back Care program helps members learn to be active members of their health care team. Participants receive information on how to effectively partner with their health care provider(s), questions to ask their doctor and options for pain management, including physical and behavioral therapies, self-care and building an action plan to prevent future problems. Members with severe, chronic back pain will be considered for case management.

Bipolar Support

The Great Expectations Bipolar Support program is a coaching program that helps members better manage their bipolar disorder. Coaches work with members in developing strategies to deal with mood shifts. The program educates and empowers members, allowing them to identify and self-monitor their symptoms. Members are able to set their own goals and may also receive educational mailings and access to online resources, as appropriate.

Case Management

Great Expectations Case Management is a health care advocacy program that uses a proactive, member-centered strategy focused on intensive education, care coordination and member empowerment across the care delivery system and throughout the life cycle of the disease or medical condition.

Chronic Kidney Disease

Great Expectations Chronic Kidney Disease is an individualized program for members with stages 1 – 3 kidney disease. The program helps members learn how to manage their condition and reduce the risk of developing complications. Members have access to individualized telephone coaching and educational materials. We automatically enroll eligible members at no charge. The program emphasizes the importance of having a personal physician to guide your kidney health management. This doctor can help you identify the best medications and dosing to enhance kidney function and improve quality of life.

Chronic Obstructive Pulmonary Disease (COPD)

Great Expectations COPD is a program that helps members with chronic obstructive pulmonary disease learn how to manage their disease. Our goal is to support members in practicing recommended self-care behaviors and following their physicians’ plan of care. Members may receive access to a personal health coach, educational materials and case management services, when needed.

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Depression

The Great Expectations Depression program is a coaching program that assists members in developing a personalized plan for strategies to better manage their depression. The program educates and empowers members using evidence-based interventions for symptom monitoring. Members are able to set their own goals and may also receive educational mailings and access to online resources, as appropriate.

Diabetes

The Great Expectations Diabetes program helps members learn how to manage their diabetes and reduce the risk of developing complications from their disease. Members may receive access to a personal health coach, educational materials, free preferred glucose monitors and a free yearly diabetes office visit. We also help members take advantage of their benefits for eye exams and diabetes education, both at no additional charge to the member.

Emergency Room Diversion Program

The Great Expectations Emergency Room Diversion program uses a proactive strategy to decrease ER overutilization. Members with two or more visits to the ER within three months are automatically enrolled in the program and receive outbound calls from an ER Care Guardian advocate. The ER Care Guardian aims to shape the habits of high utilizers and reduce ER visits.

Healthy and Active Kids and Teens

The Great Expectations Healthy and Active Kids and Teens program identifies children who are overweight or obese and offers their families education and interactive tools for adopting healthy habits.

Heart Disease

Great Expectations Heart Disease is a program for members with coronary artery or ischemic heart disease. The program educates members about lifestyle modifications and evidence-based guidelines for the monitoring and control of cardiac risk factors, such as hyperlipidemia and hypertension. Members may receive access to a personal health coach, educational materials and case management services, as appropriate.

Heart Failure

The Great Expectations Heart Failure program educates members with heart failure about appropriate self-care strategies to minimize exacerbation of their condition. Members receive access to a personal health coach, educational materials and case management services, as appropriate.

High Blood Pressure

Great Expectations High Blood Pressure is an educational program for members who want to learn more about managing their blood pressure. The program educates members about lifestyle modifications and evidence-based guidelines for the monitoring and control of cardiac risk factors, such as hypertension. Members may receive access to a personal health coach, and access to online resources, as appropriate.

High Cholesterol

The Great Expectations High Cholesterol program is an educational program for members who want to learn more about managing their cholesterol. The program educates members about lifestyle modifications and evidence-based guidelines for the monitoring and control of cardiac risk factors, such as high cholesterol. Members may receive access to a personal health coach, educational mailings and access to online resources.

MaternityThe Great Expectations Maternity program educates members about taking steps toward having a healthy baby. We provide educational materials, support and monitoring throughout a member’s pregnancy and postpartum period. The program is open to all eligible, expectant mothers.

Metabolic Health

The Great Expectations Metabolic Health program helps members learn how to manage prediabetes and/or metabolic syndrome, reducing the risk of developing complications such as Type 2 diabetes and heart disease. Metabolic syndrome is the name of a group of conditions linked to being overweight or obese. Members may receive access to a personal health coach, educational materials to encourage lifestyle changes, free preferred glucose monitors for members with prediabetes, and information to help members take advantage of their benefits for free diabetes education.

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Migraine

The Great Expectations Migraine program is for adults who suffer from severe, recurrent headaches. We provide information about the importance of having a personal physician to guide headache management. Members may receive access to a personal health coach, educational materials about pertinent migraine-related topics and access to online resources, as appropriate.

Moms Support Program

The Great Expectations Moms Support program is a coaching program that helps moms across the child-bearing spectrum. Members develop strategies to better manage their depression and anxiety at any stage, pre- or post-pregnancy. The program empowers and educates members, which allows them to identify and self-monitor their symptoms. Members are able to set their own goals. They may also receive educational mailings and access to online resources, as appropriate.

NICU Case Management

We offer the Great Expectations NICU Case Management program for infants who have certain conditions. These conditions include, but aren’t limited to, complications associated with premature birth, congenital birth defects, hydrocephalus, seizures, cystic fibrosis and genetic disorders. Clinically experienced certified nurse case managers work closely with the caregiver and the member’s providers to ensure ongoing communication and coordination of care.

Recovery Support for Substance Use Disorder

The Great Expectations Recovery Support program helps members through recovery, one day at a time. Members set personal sobriety goals to stay off alcohol, opiates and other substances. Coaches help members develop a personalized action plan to help overcome the challenges of addiction and better manage their recovery. The program educates members about evidence-based coping strategies to deal with cravings and relapse triggers. Members may receive educational mailings and access to online resources, as appropriate.

Stress Management

The Great Expectations Stress Management program is a coaching program that helps members develop a personalized plan for strategies to better manage their stress. The program educates and empowers members, providing them with tools to improve functioning for an overall healthier life and lifestyle. Members are able to set their own goals and may also receive educational mailings and access to online resources, as appropriate.

Tobacco CessationThe Great Expectations Tobacco Cessation program provides support and resources to help members become tobacco free. This program guides members through deciding to quit, identifying triggers and overcoming the challenges of giving up tobacco.

Weight Management

The Great Expectations Weight Management program educates members about healthy eating and exercise, as well as behavior modification strategies to maximize weight loss and maintenance. Members who enroll in the program receive unlimited telephone access to a weight-loss coach and a wide variety of digital tools designed to help members learn more about the key principles of implementing a successful weight-loss plan.


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Blue DentalFor Groups With 2 – 50 Employees

If you would like to offer a comprehensive dental plan to your employees, you can purchase one of our Blue

Dental plans. Blue Dental can offer your employees a whole-health approach to their dental care. By choosing

BlueChoice for both your medical and dental coverage, your covered employees get an integrated approach that

provides a complete picture of their overall health. Proper dental care can help your employees spot issues early,

like diabetes, heart disease, osteoporosis, oral cancer and kidney disease.

Our comprehensive dental offerings allow you to choose a dental benefit design that fits the needs of you and

your employees. Plus, by offering your medical and dental through BlueChoice, administering your dental benefits

becomes easier.

Why Choose Blue Dental?Flexible plan designsChoose from our comprehensive dental plan options: Open Access or Select.

OrthodontiaFor employers with preferred pricing, orthodontia is available for children and adults up to age 19. Preferred

pricing is for employers that contribute at least 50 percent or more of the single premium and have a minimum

10 or more contracts or 50 percent participation, whichever is greater. Blue Dental 1 is not available for standard

pricing options.

Easy to administerSingle-source placement consolidates billing, eligibility and enrollment through a single account team.

Comprehensive dental networksBlue Dental gives your covered employees access to one of the industry’s largest national dental PPO networks.

Your covered employees can choose from more than 2,800 access points in South Carolina and more than 265,000

nationally. Referrals are not required before your covered employee sees a specialist. Visit www.BlueChoiceSC.com

for a comprehensive list of dental providers.

Let your BlueChoice representative help you find the best dental plan for your employees.

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Companion LifeCompanion Life offers a complete portfolio of innovative and competitive employee benefit plans. Because

Companion Life is a separate company from BlueChoice, Companion Life will be responsible for all services

related to these products. Companion Life specializes in comprehensive and affordable group life and disability

income programs with a variety of features and flexible plan design options. Products can be offered on a

voluntary or group basis.

LifeGroup term life insurance can be offered as a flat amount or multiple of salaries up to $500,000, with accidental

death and dismemberment included. Guaranteed issue amounts are available.

Short- and Long-Term DisabilityShort-term disability protection offers a wide selection of benefit percentages, waiting periods, benefit maximums

and payment durations up to one year. Partial disability is also available. Companion Life offers small group short-term

disability benefits down to two lives, with no pre-existing limitations on employer-paid plans.

Long-term disability protection provides choices for benefit payment maximums, elimination periods and benefit

duration periods. New enhancements include a less restrictive definition of a disability and a less restrictive

definition of own occupation.

Voluntary VisionYour BusinessADVANTAGE plan includes a routine vision program. If you prefer, you can also offer your employees

vision through Companion Life. To offer this service, two participants are required. Your employees will have access to

a national network of providers. You have the choice of three plans: exam-only, materials-only or exam and materials.

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Options That Make Your Life Easier It’s the little extras that make a big difference. Time and money savings can add up with these optional services.

QuickBillSM

QuickBill is an electronic benefit service that allows you to view and pay your invoices online, 24 hours a day,

seven days a week.

Bill PresentationView your invoices directly via the internet, 24 hours a day, seven days a week. New invoice notifications are sent

to you via email. Simply log in to QuickBill to view, print, export or create detailed reports.

Bill PaymentPay invoices via a one-time electronic funds transfer (EFT), establish a recurring credit card payment, or establish a

recurring bank draft from one of your corporate bank accounts. QuickBill offers a quick, easy and secure online payment

experience. Reduce the number of lost checks and invoices and decrease postage and check production costs.

Online Eligibility Systems – QuickEnroll and ChoiceEnroll

QuickEnroll is the group online enrollment and benefits administration platform, while ChoiceEnroll is the

platform agents use to manage all their BlueChoice small groups.

QuickEnroll replaces time-consuming, expensive and paper-based benefit enrollment with a comprehensive

electronic benefit administration and enrollment solution. It’s secure, online and paper free! Call your agent or

marketing representative to get started.

ChoiceEnroll eliminates paper by allowing enrollments, changes and terminations to be processed securely

online. There’s no software to download and best of all, this service is FREE. Agents can manage transactions and

requests, such as annual enrollments, terminations, qualifying life events, and more. All transactions are processed

in five minutes or less per event.

HRA/HSA/FSA/COBRAWe have health reimbursement accounts (HRAs), health savings accounts (HSAs), flexible spending accounts

(FSAs) and COBRA administration solutions. With BlueChoice, you have the flexibility of choosing the vendor to

meet your needs. We can discuss which of our partners can help you accomplish your goals.


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Access to Health Information AnytimeMy Health Toolkit

To get answers specific to their plan, your employees can create a free account and log in to My Health Toolkit.

My Health Toolkit is a protected, secure and convenient way for members to access their personal information.

With My Health Toolkit, your employees can:

• View their digital ID card.

• See if their claim has been paid.

• Ask Member Services a question.

• Access the FOCUSfwd Wellness Incentive Program.

• Find a doctor or hospital.

• Find out how much a prescription drug costs.

• Find out how much they have paid toward their deductible.

• View their Schedule of Benefits, which includes their copay and coinsurance amounts.

• Request a new member ID card.

• Confirm coverage.

• Update their contact information.

My Health Toolkit AppYour employees can take My Health Toolkit with them when they’re on the go with our FREE mobile app. They can:

• View and share their digital ID card.

• Access the FOCUSfwd Wellness Incentive Program.

• Confirm coverage.

• Find a doctor or hospital in network.

• Update their contact information.

• Check the status of their claims.

Get the AppSearch for My Health Toolkit in the App Store or Google Play

to download the My Health Toolkit app.


ZCL00000000




PLANPLAN CODERxBINRxGRP

PPO380.04021684CHC

Health BenefitsPediatric VisionComprehensive Dental


ZCJ00000000

www.BlueOptionSC.com


ZCJ00000000Member ID

PLAN CODERxBINRxGRP

380.04021684CHC

Health Benefits

Blue Option Network

Out of State Only

Jan 1, 2021 - Jan 1, 2022 Jan 1, 2021 - Jan 1, 2022


ZCJ00000000


FIRST NAME LAST NAME


PLANPLAN CODE

PPO380.04

Advantage Network

BusinessADVANTAGE

Jan 1, 2021 - Jan 1, 2022

16

2021 Gold Level Plans

Important Notes for 2021: • These products provide out-of-network coverage at 50 percent with no deductible or maximum out-of-pocket cost, except where noted otherwise. • Emergency room services received out of network are covered at the same level as in network if emergency room criteria are met. Non-contracting providers may

balance bill for services provided out of network.• Pharmacy benefits and preventive services are only covered at a participating provider. • All plans include: routine vision care, preventive dental, FOCUSfwd, EAP and Blue CareOnDemand. • The MOOP for out-of-network services is unlimited. • All plans include an embedded deductible and MOOP.• All plans include 30 visits for rehabilitative therapy and 30 visits for habilitative therapy per benefit year.

BENEFIT FEATURE & DESCRIPTION GOLD 1001 GOLD 1502 GOLD 1750 GOLD 2000 GOLD 2001 GOLD 2500 GOLD 2503 GOLD 5225Coinsurance 30% 30% 30% 50% 40% 0% 30% 0%

Deductible (Single/Family) $1,000/$2,000 $1,500/$3,000 $1,750/$3,500 $2,000/$4,000 $2,000/$4,000 $2,500/$5,000 $2,500/$5,000 $5,225/$10,450

Maximum Out of Pocket (MOOP) (Single/Family) $5,800/$11,600 $5,000/$10,000 $4,600/$9,200 $4,000/$8,000 $7,000/$14,000 $2,500/$5,000 $3,900/$7,800 $5,225/$10,450

Annual Dollar Limits Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited UnlimitedLifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited UnlimitedPrimary Care Physician (PCP) Office Visits $20 $15 $25 $20 $25 Deductible $25 $0Doctors Care Office Visits/Blue CareOnDemand $20 $15 $25 $20 $25 Deductible $25 $0Specialist Office Visits $45 $45 $50 $45 $50 Deductible $50 $50

Inpatient Physician and Surgical Services 30% after deductible 30% after deductible 30% after deductible 50% after deductible 40% after deductible Deductible 30% after deductible Deductible

Outpatient Surgery Physician and Surgical Services 30% after deductible 30% after deductible 30% after deductible 50% after deductible 40% after deductible Deductible 30% after deductible Deductible

Urgent Care $50 $50 $50 $50 $50 Deductible $50 $50

Freestanding Ambulatory Surgical Center* $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit

Emergency Room $250 copayment, then deductible,

then 30%30% after deductible

$250 copayment, then deductible,

then 30%

$250 copayment, then deductible, then 50%

40% after deductible Deductible$250 copayment, then 30% after deductible

Deductible

Chiropractic Care** 30% after deductible 30% after deductible 30% after deductible 50% after deductible 40% after deductible Deductible 30% after deductible Deductible

Preventive Care/Screenings/Immunizations, including lactation support*** $0 $0 $0 $0 $0 $0 $0 $0

Pediatric Vision One exam per benefit period. Eyeglass frames every two years. Eyeglass lenses once per benefit period. In network only.

Exam — $25 Eyeglasses — $50








Inpatient Hospital Services Including mental health and substance use disorder

30% after deductible 30% after deductible 30% after deductible 50% after deductible 40% after deductible Deductible 30% after deductible Deductible

Outpatient Facility Fee (e.g., ambulatory surgical center) Including mental health and substance use disorder


PRESCRIPTION DRUGS****

Pharmacy Retail Copays reflect a 31-day supply. Can purchase a 90-day supply for three times the cost.

Tier 0: $0Tier 1: $15Tier 2: $15Tier 3: $35Tier 4: $70Tier 5: $250Tier 6: $250

Tier 0: $0Tier 1: $15 Tier 2: $15 Tier 3: $35 Tier 4: $70 Tier 5: $250 Tier 6: $250




Tier 0: $0Tiers 1-6: Deductible



Mail Order 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.









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BENEFIT FEATURE & DESCRIPTION GOLD 1001 GOLD 1502 GOLD 1750 GOLD 2000 GOLD 2001 GOLD 2500 GOLD 2503 GOLD 5225Coinsurance 30% 30% 30% 50% 40% 0% 30% 0%

Deductible (Single/Family) $1,000/$2,000 $1,500/$3,000 $1,750/$3,500 $2,000/$4,000 $2,000/$4,000 $2,500/$5,000 $2,500/$5,000 $5,225/$10,450

Maximum Out of Pocket (MOOP) (Single/Family) $5,800/$11,600 $5,000/$10,000 $4,600/$9,200 $4,000/$8,000 $7,000/$14,000 $2,500/$5,000 $3,900/$7,800 $5,225/$10,450

Annual Dollar Limits Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited UnlimitedLifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited UnlimitedPrimary Care Physician (PCP) Office Visits $20 $15 $25 $20 $25 Deductible $25 $0Doctors Care Office Visits/Blue CareOnDemand $20 $15 $25 $20 $25 Deductible $25 $0Specialist Office Visits $45 $45 $50 $45 $50 Deductible $50 $50

Inpatient Physician and Surgical Services 30% after deductible 30% after deductible 30% after deductible 50% after deductible 40% after deductible Deductible 30% after deductible Deductible

Outpatient Surgery Physician and Surgical Services 30% after deductible 30% after deductible 30% after deductible 50% after deductible 40% after deductible Deductible 30% after deductible Deductible

Urgent Care $50 $50 $50 $50 $50 Deductible $50 $50

Freestanding Ambulatory Surgical Center* $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit

Emergency Room $250 copayment, then deductible,

then 30%30% after deductible

$250 copayment, then deductible,

then 30%


40% after deductible Deductible$250 copayment, then 30% after deductible

Deductible

Chiropractic Care** 30% after deductible 30% after deductible 30% after deductible 50% after deductible 40% after deductible Deductible 30% after deductible Deductible

Preventive Care/Screenings/Immunizations, including lactation support*** $0 $0 $0 $0 $0 $0 $0 $0

































* Facility charges only. Providers may bill separately for their services.**Limited to five visits per benefit period for subluxation under chiropractic care.*** Covered according to the United States Preventive Services Task Force (USPSTF), the Centers for Disease Control and Prevention (CDC) and the Health Resources

and Services Administration (HRSA). It includes prostate screening (PSA). These are independent organizations that offer health information you may find helpful.**** 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.

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2021 Silver Level PlansBENEFIT FEATURE & DESCRIPTION SILVER 2000 SILVER 2375 SILVER 2850 SILVER 3200 SILVER 4500 SILVER 5001

Coinsurance 50% 50% 45% 50% 50% 30%

Deductible (Single/Family) $2,000/$4,000 $2,375/$4,750 $2,850/$5,700 $3,200/$6,400 $4,500/$9,000 $5,000/$10,000

Maximum Out of Pocket (MOOP) (Single/Family) $7,500/$15,000 $8,150/$16,300 $8,000/$16,000 $7,500/$15,000 $8,150/$16,300 $7,900/$15,800

Annual Dollar Limits Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited

Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited

Primary Care Office (PCP) Visits $35 $40 $35 $35 $40 $30

Doctors Care Office Visits/Blue CareOnDemand $35 $40 $35 $35 $40 $30

Specialist Office Visits $75 $80 $65 $75 $80 $60

Inpatient Physician and Surgical Services 50% after deductible 50% after deductible 45% after deductible 50% after deductible 50% after deductible 30% after deductible

Outpatient Surgery Physician and Surgical Services 50% after deductible 50% after deductible 45% after deductible 50% after deductible 50% after deductible 30% after deductible

Urgent Care $50 $50 $50 $50 $50 $50

Freestanding Ambulatory Surgical Center* $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit

Emergency Room $400 copayment,

then deductible, then 50% $350 copayment,

then deductible, then 50%$250 copayment,


then deductible, then 50%50% after deductible


Chiropractic Care** 50% after deductible 50% after deductible 45% after deductible 50% after deductible 50% after deductible 30% after deductible

Preventive Care/Screenings/Immunizations, including lactation support*** $0 $0 $0 $0 $0 $0













50% after deductible 30% after deductible


50% after deductible 50% after deductible 45% after deductible 50% after deductible 50% after deductible 30% after deductible



Tier 0: $0Tier 1: $20Tier 2: $20Tier 3: 50% after deductibleTier 4: 50% after deductibleTier 5: 50% after deductibleTier 6: 50% after deductible















BENEFIT FEATURE & DESCRIPTION SILVER 2000 SILVER 2375 SILVER 2850 SILVER 3200 SILVER 4500 SILVER 5001Coinsurance 50% 50% 45% 50% 50% 30%

Deductible (Single/Family) $2,000/$4,000 $2,375/$4,750 $2,850/$5,700 $3,200/$6,400 $4,500/$9,000 $5,000/$10,000

Maximum Out of Pocket (MOOP) (Single/Family) $7,500/$15,000 $8,150/$16,300 $8,000/$16,000 $7,500/$15,000 $8,150/$16,300 $7,900/$15,800

Annual Dollar Limits Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited

Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited

Primary Care Office (PCP) Visits $35 $40 $35 $35 $40 $30

Doctors Care Office Visits/Blue CareOnDemand $35 $40 $35 $35 $40 $30

Specialist Office Visits $75 $80 $65 $75 $80 $60

Inpatient Physician and Surgical Services 50% after deductible 50% after deductible 45% after deductible 50% after deductible 50% after deductible 30% after deductible

Outpatient Surgery Physician and Surgical Services 50% after deductible 50% after deductible 45% after deductible 50% after deductible 50% after deductible 30% after deductible

Urgent Care $50 $50 $50 $50 $50 $50

Freestanding Ambulatory Surgical Center* $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit

Emergency Room $400 copayment,

then deductible, then 50% $350 copayment,



then deductible, then 50%50% after deductible


Chiropractic Care** 50% after deductible 50% after deductible 45% after deductible 50% after deductible 50% after deductible 30% after deductible

Preventive Care/Screenings/Immunizations, including lactation support*** $0 $0 $0 $0 $0 $0













50% after deductible 30% after deductible


50% after deductible 50% after deductible 45% after deductible 50% after deductible 50% after deductible 30% after deductible
















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20

2021 Silver Level PlansBENEFIT FEATURE & DESCRIPTION SILVER 6900 SILVER 7100 NEW – SILVER 8550

Coinsurance 0% 20% 0%

Deductible (Single/Family) $6,900/$13,800 $7,100/$14,200 $8,550/$17,100

Maximum Out of Pocket (MOOP) (Single/Family) $6,900/$13,800 $8,150/$16,300 $8,550/$17,100

Annual Dollar Limits Unlimited Unlimited Unlimited

Lifetime Maximum Unlimited Unlimited Unlimited

Primary Care Office (PCP) Visits $0 $15 $30

Doctors Care Office Visits/Blue CareOnDemand $0 $15 $30

Specialist Office Visits $60 $50 $60

Inpatient Physician and Surgical Services Deductible 20% after deductible Deductible

Outpatient Surgery Physician and Surgical Services Deductible 20% after deductible Deductible

Urgent Care $50 $50 $50

Freestanding Ambulatory Surgical Center* $200 per visit $200 per visit $200 per visit

Emergency Room $200 copayment, then deductible $500 copayment, then deductible, then 20% Deductible

Chiropractic Care** Deductible 20% after deductible Deductible

Preventive Care/Screenings/Immunizations, including lactation support*** $0 $0 $0






$200 copayment, then deductible $500 copayment, then deductible, then 20% Deductible


Deductible 20% after deductible Deductible




Tier 0: $0Tier 1: $15Tier 2: $15Tier 3: $35Tier 4: 20% after deductibleTier 5: 20% after deductibleTier 6: 20% after deductible








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BENEFIT FEATURE & DESCRIPTION SILVER 6900 SILVER 7100 NEW – SILVER 8550Coinsurance 0% 20% 0%

Deductible (Single/Family) $6,900/$13,800 $7,100/$14,200 $8,550/$17,100

Maximum Out of Pocket (MOOP) (Single/Family) $6,900/$13,800 $8,150/$16,300 $8,550/$17,100

Annual Dollar Limits Unlimited Unlimited Unlimited

Lifetime Maximum Unlimited Unlimited Unlimited

Primary Care Office (PCP) Visits $0 $15 $30

Doctors Care Office Visits/Blue CareOnDemand $0 $15 $30

Specialist Office Visits $60 $50 $60

Inpatient Physician and Surgical Services Deductible 20% after deductible Deductible

Outpatient Surgery Physician and Surgical Services Deductible 20% after deductible Deductible

Urgent Care $50 $50 $50

Freestanding Ambulatory Surgical Center* $200 per visit $200 per visit $200 per visit

Emergency Room $200 copayment, then deductible $500 copayment, then deductible, then 20% Deductible

Chiropractic Care** Deductible 20% after deductible Deductible

Preventive Care/Screenings/Immunizations, including lactation support*** $0 $0 $0






$200 copayment, then deductible $500 copayment, then deductible, then 20% Deductible


Deductible 20% after deductible Deductible













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2021 Bronze Level PlansBENEFIT FEATURE & DESCRIPTION BRONZE 5550 NEW – BRONZE 6400 BRONZE 6500 BRONZE 7500 BRONZE 8300

Coinsurance 35% 50% 30% 50% 0%

Deductible (Single/Family) $5,550/$11,100 $6,400/$12,800 $6,500/$13,000 $7,500/$15,000 $8,300/$16,600

Maximum Out of Pocket (MOOP) (Single/Family) $8,550/$17,100 $8,550/$17,100 $8,550/$17,100 $8,550/$17,100 $8,300/$16,600

Annual Dollar Limits Unlimited Unlimited Unlimited Unlimited Unlimited

Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited

Primary Care Office Visits $35 50% after deductible $60 $60 $55

Doctors Care Office Visits/Blue CareOnDemand $35 50% after deductible $60 $60 $55

Specialist Office Visits 35% after deductible 50% after deductible $100 $100 Deductible

Inpatient Physician and Surgical Services 35% after deductible 50% after deductible 30% after deductible 50% after deductible Deductible

Outpatient Surgery Physician and Surgical Services $500 copayment, then deductible, then 35%

50% after deductible$500 copayment, then deductible,

then 30%$500 copayment, then deductible,

then 50%$500 copayment, then deductible

Urgent Care $75 50% after deductible $75 $75 $75Freestanding Ambulatory Surgical Center* $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit

Emergency Room $500 copayment, then deductible, then 35%

50% after deductible$500 copayment,


then deductible, then 50%$500 copayment, then deductible

Chiropractic Care** 35% after deductible 50% after deductible 30% after deductible 50% after deductible Deductible

Preventive Care/Screenings/Immunizations, including lactation support*** $0 $0 $0 $0 $0













35% after deductible 50% after deductible 30% after deductible 50% after deductible Deductible



Tier 0: $0Tiers 1-6: 35% after deductible


Tier 0: $0Tier 1: $40Tier 2: $40Tiers 3-6: 30% after deductible


Tier 0: $0Tier 1: $45Tier 2: $45Tiers 3-6: Deductible









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BENEFIT FEATURE & DESCRIPTION BRONZE 5550 NEW – BRONZE 6400 BRONZE 6500 BRONZE 7500 BRONZE 8300Coinsurance 35% 50% 30% 50% 0%

Deductible (Single/Family) $5,550/$11,100 $6,400/$12,800 $6,500/$13,000 $7,500/$15,000 $8,300/$16,600

Maximum Out of Pocket (MOOP) (Single/Family) $8,550/$17,100 $8,550/$17,100 $8,550/$17,100 $8,550/$17,100 $8,300/$16,600

Annual Dollar Limits Unlimited Unlimited Unlimited Unlimited Unlimited

Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited

Primary Care Office Visits $35 50% after deductible $60 $60 $55

Doctors Care Office Visits/Blue CareOnDemand $35 50% after deductible $60 $60 $55

Specialist Office Visits 35% after deductible 50% after deductible $100 $100 Deductible

Inpatient Physician and Surgical Services 35% after deductible 50% after deductible 30% after deductible 50% after deductible Deductible

Outpatient Surgery Physician and Surgical Services $500 copayment, then deductible, then 35%

50% after deductible$500 copayment, then deductible,

then 30%$500 copayment, then deductible,

then 50%$500 copayment, then deductible

Urgent Care $75 50% after deductible $75 $75 $75Freestanding Ambulatory Surgical Center* $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit

Emergency Room $500 copayment, then deductible, then 35%




Chiropractic Care** 35% after deductible 50% after deductible 30% after deductible 50% after deductible Deductible

Preventive Care/Screenings/Immunizations, including lactation support*** $0 $0 $0 $0 $0













35% after deductible 50% after deductible 30% after deductible 50% after deductible Deductible

















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BENEFIT FEATURE & DESCRIPTION GOLD 2850 HD GOLD 3225 HDCoinsurance 0% 0%

Deductible (Single/Family) $2,850/$5,700 $3,225/$6,450

Maximum Out of Pocket (MOOP) (Single/Family) $2,850/$5,700 $3,225/$6,450

Annual Dollar Limits Unlimited Unlimited

Lifetime Maximum Unlimited Unlimited

Primary Care Physician (PCP) Office Visits Deductible Deductible

Doctors Care Office Visits/Blue CareOnDemand Deductible Deductible

Specialist Office Visits Deductible Deductible

Inpatient Physician and Surgical Services Deductible Deductible

Outpatient Surgery Physician and Surgical Services Deductible Deductible

Urgent Care Deductible Deductible

Freestanding Ambulatory Surgical Center* Deductible Deductible

Emergency Room Deductible Deductible

Chiropractic Care** Deductible Deductible

Preventive Care/Screenings/Immunizations, including lactation support*** $0 $0

Pediatric Vision One exam per benefit period. Eyeglass frames every two years. Eyeglass lenses once per benefit period.In network only.



Inpatient Hospital Services Including mental health and substance use disorder Deductible Deductible


Deductible Deductible








2021 HDHP Plans



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SILVER 4300 HD SILVER 5004 HD NEW – SILVER 6100 HD BRONZE 6900 HD0% 0% 0% 0%

$4,300/$8,600 $5,000/$10,000 $6,100/$12,200 $6,900/$13,800

$4,300/$8,600 $5,000/$10,000 $6,100/$12,200 $6,900/$13,800

Unlimited Unlimited Unlimited Unlimited

Unlimited Unlimited Unlimited Unlimited

Deductible Deductible Deductible Deductible







Deductible Deductible Deductible DeductibleDeductible Deductible Deductible Deductible

$0 $0 $0 $0


















27

Statement of ConfidentialityBlueChoice 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 PrivacyBlueChoice 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 InformationBlueChoice may use and disclose medical information about your employee 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.

BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association.

BlueChoiceSC.com


212466-BC-3016-10-2020

Our Commitment to Keeping Your Employees HealthyBlueChoice has a commitment to offer quality comprehensive health coverage. We participate in these

quality-focused programs:

• Health Employer Data and Information Set (HEDIS®) — a set of measures health plans use to uniformly collect

data and report on their performance.

• Consumer Assessment of Healthcare Providers and Systems (CAHPS) — standardized surveys of patients’ experiences.

• Touchpoints — a quality assurance program that measures performance of all Blue Plans on established criteria

the Blue Cross and Blue Shield Association sets.

In each of these programs, we consistently meet or exceed national averages on measures that most other

carriers don’t even track. From our 98 percent score on timeliness of prenatal care to an average claim processing

time of less than two days, BlueChoice is focused on providing exceptional quality and superior service.

Your representative can provide you with the most updated operational performance statistics.

BusinessADVANTAGESM€¦ · BlueChoice routinely reviews our benefit plans. This year we are...

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