Blue Pee Dee Bronze 1 - 26065SC0730004 Health Insurance Plan
Blue Cross and Blue Shield of South Carolina health insurance plan with the Plan ID 26065SC0730004. The plan is called Blue Pee Dee Bronze 1.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 0.00% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 26065SC0730004 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | South Carolina | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross and Blue Shield of South Carolina | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 26065SC0730004-02 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Sep 2025 15:17 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 26065SC0730004-00 Standard On Exchange Plan - 26065SC0730004-01 |
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| Last Plan Update Date | Wed, 19 Feb 2025 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 16 Sep 2025 15:17 GMT |
Benefits of Blue Pee Dee Bronze 1 Health Insurance Plan, 26065SC0730004-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: nan nan |
NO | ||
| Accidental Dental
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Acupuncture
Exclusions: nan nan |
NO | ||
| Allergy Testing
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Bariatric Surgery
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Child
Exclusions: nan nan |
NO | ||
| Chemotherapy
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Chiropractic Care
Limit: 500.0 Dollars per Benefit Period Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Cosmetic Surgery
Exclusions: nan nan |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Exclusions: nan No Preauthorization is required for the mother's hospitalization related to the delivery of a newborn child when the mother's hospital stay is 48 hours or less for a vaginal birth or 96 hours or less for a cesarean section. Confinements exceeding these limits require Preauthorization. |
YES | $0.00, 0.00% |
100.00% |
| Dental Check-Up for Children
Exclusions: nan nan |
NO | ||
| Diabetes Education
Exclusions: nan Diabetes self-management training and education will be provided on an outpatient basis when done by a registered or licensed health care professional that is certified in diabetes. |
YES | $0.00, 0.00% |
100.00% |
| Dialysis
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Durable Medical Equipment
Exclusions: nan A replacement DME is covered when due to a change in medical condition. |
YES | $0.00, 0.00% |
100.00% |
| Emergency Room Services
Exclusions: nan An out-of-Network Provider may Balance-Bill you for the difference between the Allowed Amount we pay and their billed charge. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Transportation/Ambulance
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: nan Frames and lenses are limited to 1 set per year. |
YES | $0.00, 0.00% |
100.00% |
| Gender Affirming Care
Exclusions: nan nan |
NO | ||
| Generic Drugs
Exclusions: nan Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits or prior authorization are required for some covered drugs. See Covered Drugs List for details. |
YES | $0.00, 0.00% |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period Exclusions: nan Habilitation services are health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Habilitative therapies are combined for a maximum 30 visits per Benefit Period. |
YES | $0.00, 0.00% |
100.00% |
| Hearing Aids
Exclusions: nan nan |
NO | ||
| Home Health Care Services
Limit: 60.0 Visit(s) per Benefit Period Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Hospice Services
Limit: 6.0 Months per Episode Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Infertility Treatment
Exclusions: nan nan |
NO | ||
| Infusion Therapy
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Inpatient Physician and Surgical Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Laboratory Outpatient and Professional Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Long-Term/Custodial Nursing Home Care
Exclusions: nan nan |
NO | ||
| Major Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Major Dental Care - Child
Exclusions: nan nan |
NO | ||
| Mental/Behavioral Health Inpatient Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
Exclusions: nan The cost sharing that displays applies to outpatient office visits only. All other outpatient services (e.g., intensive outpatient and partial hospitalization programs) may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
YES | $0.00, 0.00% |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: nan Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits or prior authorization are required for some covered drugs. See Covered Drugs List for details. |
YES | $0.00, 0.00% |
100.00% |
| Nutritional Counseling
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Orthodontia - Adult
Exclusions: nan nan |
NO | ||
| Orthodontia - Child
Exclusions: nan nan |
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Benefit Period Exclusions: nan Physical, speech and occupational rehabilitative therapy are combined for a maximum 30 visits per Benefit Period, other than inpatient therapy. |
YES | $0.00, 0.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Preferred Brand Drugs
Exclusions: nan Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits or prior authorization are required for some covered drugs. See Covered Drugs List for details. |
YES | $0.00, 0.00% |
100.00% |
| Prenatal and Postnatal Care
Exclusions: nan Prenatal and postnatal care will be covered after artificial insemination or in-vitro fertilization, but the actual insemination/fertilization is not covered. |
YES | $0.00, 0.00% |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: nan As required by USPSTF, CDC and HRSA, and including OBGYN exams (limit 2 per year), mammography services, pap smear services, prostate services, and routine colorectal cancer screening/testing. |
YES | $0.00, 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: nan When you use the Pee Dee telehealth service, there is no charge for your first 4 telehealth office visits. Starting with the 5th visit, a copay applies. |
YES | $0.00, 0.00% |
100.00% |
| Private-Duty Nursing
Exclusions: nan nan |
NO | ||
| Prosthetic Devices
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Radiation
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Reconstructive Surgery
Exclusions: nan Reconstructive Surgery that is considered a Covered Expense is limited to Surgery: To correct a functional defect that results from a birth defect, disease and anomaly; or Performed to correct a seriously disfiguring condition resulting from injury; or For breast reconstruction after a mastectomy. |
YES | $0.00, 0.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Benefit Period Exclusions: nan Physical, speech and occupational rehabilitative therapy are combined for a maximum 30 visits per Benefit Period, other than inpatient therapy. |
YES | $0.00, 0.00% |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Benefit Period Exclusions: nan Physical, speech and occupational rehabilitative therapy are combined for a maximum 30 visits per Benefit Period, other than inpatient therapy. |
YES | $0.00, 0.00% |
100.00% |
| Routine Dental Services (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Routine Foot Care
Exclusions: nan nan |
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period Exclusions: nan You must be admitted to a Skilled Nursing Facility within 14 days of discharge from an approved hospital admission. |
YES | $0.00, 0.00% |
100.00% |
| Specialist Visit
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Specialty Drugs
Exclusions: nan Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits or prior authorization are required for some covered drugs. See Covered Drugs List for details. |
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Transplant
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: nan nan |
NO | ||
| Urgent Care Centers or Facilities
Exclusions: nan An out-of-Network Provider may Balance-Bill you for the difference between the Allowed Amount we pay and their billed charge. |
YES | $0.00, 0.00% |
100.00% |
| Weight Loss Programs
Exclusions: nan nan |
NO | ||
| Well Baby Visits and Care
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
Blue Pee Dee Bronze 1 Health Insurance Plan Variant 26065SC0730004-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1.0 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Zero Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | SCF015 |
| Formulary URL | URL |
| HIOS Product ID | 26065SC073 |
| Import Date | 2025-02-19 01:01:54 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 26065 |
| Issuer Marketplace Marketing Name | BlueCross BlueShield of South Carolina |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | SCN006 |
| Out of Country Coverage | No |
| Out of Country Coverage Description | Benefits are available only for emergency medical conditions. Special pricing may be available through a Blue Cross Blue Shield Global Core provider. |
| Out of Service Area Coverage | No |
| Out of Service Area Coverage Description | Benefits are available only for emergency medical conditions when treated in an outpatient hospital emergency room or urgent treatment center, or for urgent conditions when treated in an urgent treatment center. Special pricing may be available through a BlueCard provider. |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 26065SC0730004-02 |
| Plan Marketing Name | Blue Pee Dee Bronze 1 |
| Plan Type | HMO |
| Plan Variant Marketing Name | Blue Pee Dee Bronze 1 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | SCS005 |
| Source Name | HIOS |
| Plan ID | 26065SC0730004 |
| State Code | SC |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $0 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Blue Pee Dee Bronze 1 Health Insurance Plan, 26065SC0730004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Blue Pee Dee Bronze 1, 26065SC0730004 Health Insurance Plan, 26065SC0730004
-
Does Blue Pee Dee Bronze 1 Health Insurance Plan, 26065SC0730004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (26065SC0730004) Health Insurance Plan, Variant (26065SC0730004-02) offer Disease Management Programs?
Does (26065SC0730004) Health Insurance Plan, Variant (26065SC0730004-02) have Out Of Country Coverage?
Does (26065SC0730004) Health Insurance Plan, Variant (26065SC0730004-02) have Out of Service Area Coverage?
Does (26065SC0730004) Health Insurance Plan, Variant (26065SC0730004-02) offer Disease Management Programs?
Does Blue Pee Dee Bronze 1 Health Insurance Plan, Variant (26065SC0730004-02) offer Disease Management Programs for Asthma?
Does Blue Pee Dee Bronze 1 Health Insurance Plan, Variant (26065SC0730004-02) offer Disease Management Programs for Heart disease?
Does Blue Pee Dee Bronze 1 Health Insurance Plan, Variant (26065SC0730004-02) offer Disease Management Programs for Depression?
Does Blue Pee Dee Bronze 1 Health Insurance Plan, Variant (26065SC0730004-02) offer Disease Management Programs for Diabetes?
Does Blue Pee Dee Bronze 1 Health Insurance Plan, Variant (26065SC0730004-02) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Blue Pee Dee Bronze 1 Health Insurance Plan, Variant (26065SC0730004-02) offer Disease Management Programs for Low back pain?
Does Blue Pee Dee Bronze 1 Health Insurance Plan, Variant (26065SC0730004-02) offer Disease Management Programs for Pregnancy?
Does Blue Pee Dee Bronze 1 Health Insurance Plan, Variant (26065SC0730004-02) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 16 Sep 2025 15:17 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API