Coverage for all regular full time employees (scheduled to work 30 hours or more per week) who purchase Health insurance will begin on the first day of the month following your date of hire. If you start on the first day of the month, your coverage is effective immediately.
What is covered
| BENEFITS | BLUECROSS BLUESHIELD PPO 2026 | BLUECROSS BLUESHIELD HDHP 2026 | ||
| SERVICES | IN-NETWORK | OUT-OF-NETWORK | IN-NETWORK | OUT-OF-NETWORK |
| Medical & Surgical Benefits | ||||
| Deductible (Embedded*) | $0 Individual / $0 Family | $0 Individual / $0 Family | $3,400 Individual / $6,800 Family | $6,600 Individual / $13,200 Family |
| Co-Insurance Shown as percentages below |
$3,000 Individual / $6,000 Family | $6,000 Individual / $12,000 Family | $0 Individual / $0 Family | $6,600 Individual / $13,200 Family |
| Standard Out-of-Pocket Includes deductible and Coinsurance | $3,000 Individual / $6,000 Family | $6,000 Individual / $12,000 Family | $3,400 Individual / $6,800 Family | $13,200 Individual / $26,400 Family |
| Standard Out-Of-Pocket: Allowable charges for Coinsurance are paid at 100% after the Out-Of-Pocket is met | ||||
| In-Network Maximum Out-of-Pocket Includes deductible and Coinsurance |
$3,000 Individual / $6,000 Family |
$6,000 Individual / $12,000 Family |
$3,400 Individual / $6,600 Family |
|
| Physician Services in Office |
70% | 50% | Deductible, 100% | Deductible, 50% |
| Blue Care On Demand | 70% | Not Covered | Deductible, 100% | Not Covered |
| Other Physician Services Inpatient/Outpatient hospital, allergy injections, anesthesia services, radiology, chemotherapy, dialysis, pathology, obstetrical delivery, initial newborn pediatric exam and all other outpatient/office services |
70% | 50% | Deductible, 100% | Deductible, 50% |
| Wellness Benefits – Based on the Health Care Reform Guidelines refer to www.healthcare.gov |
100% | Not Covered | 100% | Not Covered |
| Sustained Health Services ($300 annual maximum) |
100% | Not Covered | 100% | Not Covered |
| Preventive Care and Sustained Health Services are only covered at a Primary Care Provider | ||||
| Inpatient Facility Charges | 70% | 50% | Deductible, 100% | Deductible, 50% |
| Skilled Nursing Facility Charges (60 days per year) |
70% | 50% | Deductible, 100% | Deductible, 50% |
| Outpatient Facility Charges | 70% | 50% | Deductible, 100% | Deductible, 50% |
| Other Services Physical/Occupational Therapy (30 combined visits), Home Healthcare, Hospice |
70% | 50% | Deductible, 100% | Deductible, 50% |
| Chiropractic Benefits ($700 annual maximum) |
70% | 50% | Deductible, 100% | Deductible, 50% |
| Ambulance | 70% | 70% | Deductible, 100% | In-Network Deductible, 100% |
| Urgent Care | 70% | 50% | Deductible, 100% | Deductible, 50% |
| Emergency Room Facility Charges ** | 70% | 70% | Deductible, 100% | Deductible, 100% |
| Emergency Room Professional Charges ** | 70% | 70% | Deductible, 100% | Deductible, 100% |
| ** Non-Participating Provider at a Participating Provider Facility (generally includes Ambulance Services, Emergency Services and non-Emergency Services) are subject to In-Network Deductible, Coinsurance and Out-of-Pocket Level. | ||||
| Mental Health and Substance Abuse Benefits | ||||
| Inpatient Facility Charges | 70% | 50% | Deductible, 100% | Deductible, 50% |
| Inpatient Professional Charges | 70% | 50% | Deductible, 100% | Deductible, 50% |
| Outpatient Facility Charges | 70% | 50% | Deductible, 100% | Deductible, 50% |
| Outpatient Professional Charges | 70% | 50% | Deductible, 100% | Deductible, 50% |
| Emergency Room Facility Charges | 70% | 70% | Deductible, 100% | In-Network Deductible, 100% |
| Emergency Room Professional Charges | 70% | 70% | Deductible, 100% | In-Network Deductible, 100% |
| Physician Services in the Office | 70% | 50% | Deductible, 100% | Deductible, 50% |
| Pharmacy Benefits | ||||
| Prescriptions (Includes diabetic supplies and oral contraceptives) | 70% | 50% | Deductible, 100% | Deductible, 50% |
| Integrated Retail Pharmacy Benefit (31 or 90 day supply) | 70% | Not Covered | Not Covered | Not Covered |
| Specialty Drug – Optum Specialty Pharmacy Only | 70% | Not Covered | Deductible, 100% | Not Covered |
| BENEFIT MAXIMUMS | ||||
| Annual / Lifetime Maximum | Unlimited | |||
*Embedded Deductible: An individual deductible “embedded” within the family deductible. Before insurance benefits begin the individual must meet the embedded individual deductible amount, which is equal to the single coverage deductible.
Machine Readable Files (MRF’s)
Recent transparency laws require us to make “machine-readable files” (MRFs) publicly available to help you make informed health care decisions. The MRFs contain negotiated rates with in-network providers for all covered items and services as well as historical payments to, and billed charges from, out-of-network providers.
To access this information please click on the link below.
*** Please contact Camelia Stepanov for instructions on how to access the documents.
Important Numbers
Customer Service: 800-922-1185(Medical) / 855-811-2218 (Prescription Drugs)
Pre-authorization: 800-327-3238
Pre-authorization for MRI, MRA, PET, CT & CAT scans: 866-500-7664
Pre-authorization for Mental Health and Substance Abuse: 800-868-1032
This is a convenient summary. The actual contract provisions prevail. Please read your booklet carefully.
Cost of Benefit
| Benefit Tier 1 | Employee | Employee+ 1 | Employee+Family |
| BCBS PPO Plan under $125,000 | |||
| Employee Pays (Bi-Weekly) | $54.64 | $318.96 | $370.29 |
| BCBS HDHP Plan under $125,000 | |||
| Employee Pays (Bi-Weekly) | $28.55 | $230.74 | $270.74 |
| Benefit Tier 2 | Employee | Employee+ 1 | Employee+Family |
| BCBS PPO Plan at or above $125,000 | |||
| Employee Pays (Bi-Weekly) | $68.30 | $359.45 | $415.17 |
| BCBS HDHP Plan at or above $125,000 | |||
| Employee Pays (Bi-Weekly) | $36.71 | $262.42 | $310.85 |
These are current costs and are subject to change from time to time.
The Flexible Spending Plan may save you tax dollars. These amounts will be deducted from your base pay before tax, saving you tax dollars. You may elect, however, to have the amount deducted after tax. A Health Savings Account may save you tax dollars if you select the HDHP plan. These amounts will be deducted from your base pay before tax or from your bonus, saving you tax dollars, or you have a one time option to fund your account from an IRA. You may elect, however, to have the amount deducted after tax.
Additional Benefits of BCBS membership
If you register for My Health Toolkit at www.southcarolinablues.com, it will allow you to view your digital ID card, check the status of your claims, find a local provider and see what’s covered by your health plan. My Health Toolkit also gives you access to additional member offerings from BCBS listed below. For even easier access to your information, download the My Health Toolkit App
- Getting Started with Shopping for Care
- Blue 365 – member discounts
- Blue 365 FAQs
- Blue CareOnDemand Video Visits
- Happify – science based activities and games to reduce stress and anxiety, build optimism and mindfulness, gain self-confidence and self-esteem, and stop negative thoughts.
- Health Coaching
- Natural Blue for Holistic Health Choices
- Rally – digital health platform that rewards you to become healthier, using the Rally Mobile App for Rally Missions, Rally Challenges and Rally Rewards
- Quit For Life – coaching for tobacco cessation
Preferred providers
For employees outside of South Carolina, Blue Cares gives provider information. You may access information at http://web.southcarolinablues.com/members.aspx.
Employees in South Carolina may access provider information through Blue Cross Blue Shield of South Carolina at www.southcarolinablues.com.
Checking status of my claim
Blue Cross Blue Shield offers a feature called My Health Toolkit where you can access your account for things such as: claims status, My Pharmacy Manager, explanation of benefits (EOB), eligibility and benefits, authorization status, or to request an ID card. To find out more, log on at: http://web.southcarolinablues.com/members.aspx.
Continuing coverage
2026 COBRA Cost
You may continue coverage for you and your legal dependents at your own expense. Certain conditions may apply. You will be provided with the proper forms, information, and costs upon leaving your employment with EDENS.
| Benefit | Employee | Employee+ 1 | Employee+Family |
| COBRA PPO Costs (monthly) | $1,006.25 | $2237.73 | $2479.81 |
| COBRA HDHP Costs (monthly) | $901.45 | $1999.82 | $2216.04 |
Other resources
Contract No. PPO 70-27212-00
Contract No. HDHP 70-27212-11
Blue Cross and Blue Shield Association
ww.southcarolinablues.com
Consumer Reports “Best Buy Drugs” Guide
http://www.crbestbuydrugs.org/
American Medical Association
www.ama-assn.org
US Department of Health
www.healthfinder.gov
Insurance Information Institute
www.insurance.info
Medicare
www.medicare.com
Cobra Continuation Information
www.dol.gov
Online forms
You may obtain the following forms simply by clicking on the description. Since these files are in a special format (PDF) you will need to download the Adobe Acrobat Reader
Online resources
- New Health Insurance Marketplace Coverage
- Wrap Summary Plan Description
- PPO Booklet
- 2026 PPO Plan Benefit Summary
- HDHP Booklet
- 2026 HDHP Plan Benefits Summary
- Understanding a Health Savings Account
- HSA Banking Authorization Form
- Health & Welfare Summary Annual Report – Plan Year 2024
- PPO Summary of Benefits & Coverage 2026
- HDHP Summary of Benefits & Coverage 2026
- Glossary of Health Coverage and Medical Terms
- Preventive Services Guide
- Wellness and your Insurance Premiums
- Children’s Health Insurance Program (CHIP)
- Medicare Part D Creditable Coverage Notice
SPECIAL NOTICES
Health Insurance Portability and Accountability Act (HIPAA) of 1996 Notice
Special Enrollment Information
This information is being provided to you pursuant to the Health Insurance Portability and Accountability Act (HIPAA) of 1996. It contains some special information regarding your rights to enroll for coverage under the medical plan in the future. This information is very important if you are currently declining coverage under the medical plan for yourself or for any of your dependents. We are required to provide you with this notice in order to comply with HIPAA.
If You are Declining Coverage Now
If you have decided to decline coverage for yourself or for any of your dependents (including your spouse), you may be able to enroll yourself and/or your dependents in this plan later, under some circumstances, without waiting for an open enrollment period.
Special Enrollment Allowed
You can enroll yourself and your dependents in this plan without waiting for an open enrollment period if:
- You decline coverage under this plan because you have other health care coverage, then you lose the other coverage because you are no longer eligible or because the employer failed to pay the required premium. In such cases, you must enroll in this plan within 30 days after losing the other coverage.
- You decline coverage under this plan and then a new dependent is added to your family due to marriage, birth, adoption, or placement or adoption. In such cases, you must enroll in this plan (or add your new dependent) within 30 days after the marriage, birth, adoption, or placement for adoption.
Any request must be consistent with the change in family status. For example, the birth or adoption of a child would permit enrollment in or change to family coverage.
Other Late Entrants
If you decide not to enroll in this plan now and then want to enroll later, you must qualify for special enrollment as described above. If you do not qualify for special enrollment, you will have to wait until an open enrollment period.
For more information, please contact your human resources administrator.
Women’s Health and Cancer Rights Act (WHCRA) Notice
Health Plan Coverage for Reconstructive Breast Surgery under The Women’s Health and Cancer Rights Act of 1998
Since 1998, Congress has required that all health plans cover reconstructive surgery following a mastectomy. When a covered individual receives benefits for a mastectomy and decides to have breast reconstruction based on consultation between the attending physician and the patient, the health plan must cover:
- reconstruction of the breast on which the mastectomy was performed;
- surgery and reconstruction of the other breast to produce symmetrical appearance; and
- prostheses and physical complications of all stages of mastectomy, including lymphedema.
Our plan complies with the Federal mandate. This coverage will be subject to all other Plan provisions.
Note: The simplified benefit summaries contained herein are designed to be concise, simplified highlights of each benefit plan. As such, they are not comprehensive or authoritative. For complete details, please refer to the applicable benefit plan booklet provided by the insurer or your employer. In matters of tax or legal interpretation, seek the services of a qualified professional.