In-network
Inpatient hospital
Medicare-defined coinsurance cost sharing applies (in-network, tier 1).
Out-of-network
Verify in plan documents
Point of service
Not separately reported
● CMS 2027 plan record
BlueCross MA Only Non-calendar Year Group (PPO)
Choose and order benefitsSelections are saved only on this device.
Emergency transport
Ambulance
Ground · in-network20% coinsurance
Air · in-network20% coinsurance
Emergency services
Emergency room
20% coinsurance
Waived if admitted within 3 days
Medical maximum
Maximum out-of-pocket
In-network$9,850
Combined in + out$14,800
Skilled care at home
Home health
In-network0% coinsurance
Out-of-network0% coinsurance
Monthly cost
Premium & giveback
Part C premiumNot reported
Consolidated C + DNot reported
CMS reports no Part B premium reduction for this plan.
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Primary care physician
In: Primary Care Physician Services: 20% coinsurance · Out: 7a: 20% coinsurance
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Specialist
In: Physician Specialist Services: 20% coinsurance · Out: 7d: 20% coinsurance
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Preventive care
In: Annual Physical Exam: Not applicable; Kidney Disease Education Services: 20% coinsurance; Glaucoma Screening: 20% coinsurance; Diabetes Self-Management Training: 20% coinsurance; Digital Rectal Exams: 20% coinsurance; EKG following Welcome Visit: 20% coinsurance · Out: 14d: 20% coinsurance; 14e1: 20% coinsurance; 14e2: 20% coinsurance; 14e4: 20% coinsurance; 14e5: 20% coinsurance; 14a: 0% coinsurance
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Diagnostic procedures & tests
In: Diagnostic Procedures/Tests: 20% coinsurance · Out: 8a1: 20% coinsurance
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Laboratory services
In: Lab Services: 0% coinsurance · Out: 8a2: 20% coinsurance
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X-rays & standard imaging
In: Outpatient X-Ray Services: 20% coinsurance · Out: 8b3: 20% coinsurance
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MRI, CT & PET imaging
In: Diagnostic Radiological Services: 20% coinsurance · Out: 8b1: 20% coinsurance
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Urgent care
In: Urgently Needed Services: 20% coinsurance · Out: Not separately reported
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Emergency room
In: 20% coinsurance · Out: Not separately reported
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Ground ambulance
In: 20% coinsurance · Out: 20% coinsurance
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Air ambulance
In: 20% coinsurance · Out: 20% coinsurance
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Outpatient hospital
In: Outpatient Hospital Services: 20% coinsurance; Observation Services: 20% coinsurance · Out: 9a1: 20% coinsurance; 9a2: 20% coinsurance
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Outpatient surgery / ASC
In: Ambulatory Surgical Center (ASC) Services: 20% coinsurance · Out: 9b: 20% coinsurance
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Home health
In: 0% coinsurance · Out: 0% coinsurance
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Skilled nursing facility
In: Skilled nursing facility: Tier 1: Medicare-defined coinsurance cost sharing applies (in-network, tier 1). · Out: Skilled nursing facility: Verify in plan documents
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Cardiac & pulmonary rehabilitation
In: Cardiac Rehabilitation Services: 20% coinsurance; Intensive Cardiac Rehabilitation Services: 20% coinsurance; Pulmonary Rehabilitation Services: 20% coinsurance; SET for PAD Services: 20% coinsurance; 3-1(NMC): Not applicable; 3-2(NMC): Not applicable; 3-3(NMC): Not applicable; 3-4(NMC): Not applicable · Out: 3-1: 20% coinsurance; 3-2: 20% coinsurance; 3-3: 20% coinsurance; 3-4: 20% coinsurance
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Occupational therapy
In: Occupational Therapy Services: 20% coinsurance · Out: 7c: 20% coinsurance
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Physical & speech therapy
In: Physical Therapy and Speech-Language Pathology Services: 20% coinsurance · Out: 7i: 20% coinsurance
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Mental health services
In: Partial Hospitalization Program: 20% coinsurance; Individual Sessions for Mental Health Specialty Services: 20% coinsurance; Group Sessions for Mental Health Specialty Services: 20% coinsurance; Individual Sessions for Psychiatric Services: 20% coinsurance; Group Sessions for Psychiatric Services: 20% coinsurance; Inpatient psychiatric hospital: Tier 1: Medicare-defined coinsurance cost sharing applies (in-network, tier 1). · Out: 5a: 20% coinsurance; 7e1: 20% coinsurance; 7e2: 20% coinsurance; 7h1: 20% coinsurance; 7h2: 20% coinsurance; Inpatient psychiatric hospital: Verify in plan documents
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Substance use treatment
In: Intensive Outpatient Program Services: 20% coinsurance; Individual Sessions for Outpatient Substance Abuse: 20% coinsurance; Group Sessions for Outpatient Substance Abuse: 20% coinsurance · Out: 5b: 20% coinsurance; 9c1: 20% coinsurance; 9c2: 20% coinsurance
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Podiatry
In: Podiatry Services: 20% coinsurance; 7f(NMC): Not applicable · Out: 7f: 20% coinsurance
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Chiropractic
In: Chiropractic Services: 20% coinsurance · Out: 7b: 20% coinsurance
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Dental
In: Medicare Dental Services: 20% coinsurance · Out: 16a: 20% coinsurance
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Vision
In: Eye Exams: 20% coinsurance; Routine Eye Exams: Not applicable; Other Eye Exam Services: Not applicable; Eyewear: 20% coinsurance; Contact Lenses: Not applicable; Eyeglasses (lenses and frames): Not applicable; Eyeglass lenses: Not applicable; Eyeglass frames: Not applicable; Upgrades: Not applicable · Out: 17a: 20% coinsurance; 17b: 20% coinsurance
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Hearing
In: Hearing Exams: 20% coinsurance; Routine Hearing Exams: Not applicable; Fitting/Evaluation for Hearing Aid: Not applicable; Prescription Hearing Aids (all types): Not applicable; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable · Out: 18a: 20% coinsurance
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Transportation
In: 10b(NMC): Not applicable · Out: Not separately reported
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Fitness & wellness
In: Fitness Benefit: Not applicable · Out: Not separately reported
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Over-the-counter allowance
In: Over-the-Counter (OTC) Items: Not applicable · Out: Not separately reported
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Meals
In: Meal Benefit: Not applicable · Out: Not separately reported
Plan details
All plan benefits
No benefits match that search.
Medical care3 benefits
Primary care physician
In-networkPrimary Care Physician Services: 20% coinsurance
Out-of-network7a: 20% coinsurance
Specialist
In-networkPhysician Specialist Services: 20% coinsurance
Out-of-network7d: 20% coinsurance
Preventive care
In-networkAnnual Physical Exam: Not applicable; Kidney Disease Education Services: 20% coinsurance; Glaucoma Screening: 20% coinsurance; Diabetes Self-Management Training: 20% coinsurance; Digital Rectal Exams: 20% coinsurance; EKG following Welcome Visit: 20% coinsurance
Out-of-network14d: 20% coinsurance; 14e1: 20% coinsurance; 14e2: 20% coinsurance; 14e4: 20% coinsurance; 14e5: 20% coinsurance; 14a: 0% coinsurance
Diagnostics & imaging4 benefits
Diagnostic procedures & tests
In-networkDiagnostic Procedures/Tests: 20% coinsurance
Out-of-network8a1: 20% coinsurance
Laboratory services
In-networkLab Services: 0% coinsurance
Out-of-network8a2: 20% coinsurance
X-rays & standard imaging
In-networkOutpatient X-Ray Services: 20% coinsurance
Out-of-network8b3: 20% coinsurance
MRI, CT & PET imaging
In-networkDiagnostic Radiological Services: 20% coinsurance
Out-of-network8b1: 20% coinsurance
Urgent & hospital care6 benefits
Urgent care
In-networkUrgently Needed Services: 20% coinsurance
Out-of-networkNot separately reported
Emergency room
In-network20% coinsurance
Out-of-networkNot separately reported
Ground ambulance
In-network20% coinsurance
Out-of-network20% coinsurance
Air ambulance
In-network20% coinsurance
Out-of-network20% coinsurance
Outpatient hospital
In-networkOutpatient Hospital Services: 20% coinsurance; Observation Services: 20% coinsurance
Out-of-network9a1: 20% coinsurance; 9a2: 20% coinsurance
Outpatient surgery / ASC
In-networkAmbulatory Surgical Center (ASC) Services: 20% coinsurance
Out-of-network9b: 20% coinsurance
Recovery & therapy5 benefits
Home health
In-network0% coinsurance
Out-of-network0% coinsurance
Skilled nursing facility
In-networkSkilled nursing facility: Tier 1: Medicare-defined coinsurance cost sharing applies (in-network, tier 1).
Out-of-networkSkilled nursing facility: Verify in plan documents
Cardiac & pulmonary rehabilitation
In-networkCardiac Rehabilitation Services: 20% coinsurance; Intensive Cardiac Rehabilitation Services: 20% coinsurance; Pulmonary Rehabilitation Services: 20% coinsurance; SET for PAD Services: 20% coinsurance; 3-1(NMC): Not applicable; 3-2(NMC): Not applicable; 3-3(NMC): Not applicable; 3-4(NMC): Not applicable
Out-of-network3-1: 20% coinsurance; 3-2: 20% coinsurance; 3-3: 20% coinsurance; 3-4: 20% coinsurance
Occupational therapy
In-networkOccupational Therapy Services: 20% coinsurance
Out-of-network7c: 20% coinsurance
Physical & speech therapy
In-networkPhysical Therapy and Speech-Language Pathology Services: 20% coinsurance
Out-of-network7i: 20% coinsurance
Behavioral health2 benefits
Mental health services
In-networkPartial Hospitalization Program: 20% coinsurance; Individual Sessions for Mental Health Specialty Services: 20% coinsurance; Group Sessions for Mental Health Specialty Services: 20% coinsurance; Individual Sessions for Psychiatric Services: 20% coinsurance; Group Sessions for Psychiatric Services: 20% coinsurance; Inpatient psychiatric hospital: Tier 1: Medicare-defined coinsurance cost sharing applies (in-network, tier 1).
Out-of-network5a: 20% coinsurance; 7e1: 20% coinsurance; 7e2: 20% coinsurance; 7h1: 20% coinsurance; 7h2: 20% coinsurance; Inpatient psychiatric hospital: Verify in plan documents
Substance use treatment
In-networkIntensive Outpatient Program Services: 20% coinsurance; Individual Sessions for Outpatient Substance Abuse: 20% coinsurance; Group Sessions for Outpatient Substance Abuse: 20% coinsurance
Out-of-network5b: 20% coinsurance; 9c1: 20% coinsurance; 9c2: 20% coinsurance
Specialty care2 benefits
Podiatry
In-networkPodiatry Services: 20% coinsurance; 7f(NMC): Not applicable
Out-of-network7f: 20% coinsurance
Chiropractic
In-networkChiropractic Services: 20% coinsurance
Out-of-network7b: 20% coinsurance
Supplemental benefits7 benefits
Dental
In-networkMedicare Dental Services: 20% coinsurance
Out-of-network16a: 20% coinsurance
Vision
In-networkEye Exams: 20% coinsurance; Routine Eye Exams: Not applicable; Other Eye Exam Services: Not applicable; Eyewear: 20% coinsurance; Contact Lenses: Not applicable; Eyeglasses (lenses and frames): Not applicable; Eyeglass lenses: Not applicable; Eyeglass frames: Not applicable; Upgrades: Not applicable
Out-of-network17a: 20% coinsurance; 17b: 20% coinsurance
Hearing
In-networkHearing Exams: 20% coinsurance; Routine Hearing Exams: Not applicable; Fitting/Evaluation for Hearing Aid: Not applicable; Prescription Hearing Aids (all types): Not applicable; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable
Out-of-network18a: 20% coinsurance
Transportation
Not applicableIn-network10b(NMC): Not applicable
Out-of-networkNot separately reported
Fitness & wellness
Not applicableIn-networkFitness Benefit: Not applicable
Out-of-networkNot separately reported
Over-the-counter allowance
Not applicableIn-networkOver-the-Counter (OTC) Items: Not applicable
Out-of-networkNot separately reported
Meals
Not applicableIn-networkMeal Benefit: Not applicable
Out-of-networkNot separately reported
Plan costs & rulesCoverage overview
Premium & Part B giveback
Part C premium not reported · CMS reports no Part B premium reduction for this plan.
Maximum out-of-pocket (MOOP)
In-network$9,850
Combined in + out$14,800
Medical deductibles
In-networkNot reported
Out-of-networkNot reported
Annual health deductible
Not separately reported
Combined network deductible
Not separately reported
Part D premium
Not reported
Network & referrals
Local PPO · Referrals: Not required · Out-of-network coverage: Yes
Prescription drugs0 tiers
Part D deductible
Not reported
Using this plan
Understand H8003-804-000
Plain-language context built from this plan’s 2027 CMS record. It is a guide to the reported benefits, not a personalized cost estimate.
Plan at a glance
A quick read on this plan
BlueCross MA Only Non-calendar Year Group (PPO) is a 2027 Local PPO offered by Blue Cross Blue Shield of South Carolina in Nationwide. The CMS record indicates out-of-network coverage, although member costs may differ from in-network care. The plan record does not require referrals.
Common benefit costs
What you may pay
These are individual in-network benefit amounts. A real visit may involve more than one separately billed service.
Routine care
- Primary care physician
- Primary Care Physician Services: 20% coinsurance
- Specialist
- Physician Specialist Services: 20% coinsurance
- Laboratory services
- Lab Services: 0% coinsurance
Separate visits or services; costs are not added together.
Tests & outpatient care
- Diagnostic procedures & tests
- Diagnostic Procedures/Tests: 20% coinsurance
- MRI, CT & PET imaging
- Diagnostic Radiological Services: 20% coinsurance
- Outpatient hospital
- Outpatient Hospital Services: 20% coinsurance; Observation Services: 20% coinsurance
The service setting and billing details can change what you pay.
Emergency & hospital care
- Emergency room
- 20% coinsurance
Actual costs depend on the care received and plan rules.
Helpful context
Terms worth knowing
Maximum out-of-pocket (MOOP)
This is the most you generally pay during the plan year for covered Part A and Part B medical services under the applicable network limit. Premiums and prescription drug costs generally do not count toward it.
Part B premium reduction (“giveback”)
A giveback may reduce the amount you pay toward Medicare Part B; it is not usually paid to you as cash. The CMS record notes: CMS reports no Part B premium reduction for this plan.
Availability
Who can enroll
- Service area
- Nationwide (AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY)
- Plan type
- Local PPO
- Contract / plan
- H8003-804
- Coverage year
- 2027
Enrollment is limited to people eligible through the sponsoring employer or group. Confirm eligibility and the exact service area with the plan before enrolling.
Supplemental coverage
Extra benefits reported
Availability is summarized here; allowances, frequency limits, networks, and prior-authorization rules may apply.
DentalMedicare Dental Services: 20% coinsurance
VisionEye Exams: 20% coinsurance; Routine Eye Exams: Not applicable; Other Eye Exam Services: Not applicable; Eyewear: 20% coinsurance; Contact Lenses: Not applicable; Eyeglasses (lenses and frames): Not applicable; Eyeglass lenses: Not applicable; Eyeglass frames: Not applicable; Upgrades: Not applicable
HearingHearing Exams: 20% coinsurance; Routine Hearing Exams: Not applicable; Fitting/Evaluation for Hearing Aid: Not applicable; Prescription Hearing Aids (all types): Not applicable; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable
Plan-specific answers
Frequently asked questions
Where is H8003-804-000 available?
BlueCross MA Only Non-calendar Year Group (PPO) is listed for Nationwide (AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY). Enrollment is limited to people eligible through the sponsoring employer or group.
What is the in-network maximum out-of-pocket limit for H8003-804-000?
The 2027 CMS record lists an in-network medical maximum out-of-pocket limit of $9,850. Prescription drug spending generally does not count toward this medical limit.
What does an emergency room visit cost on H8003-804-000?
The plan record lists 20% coinsurance, waived when an admission meets the plan's stated timing rule.
Does H8003-804-000 report extra benefits?
Yes. CMS reports dental, vision, hearing. See the detailed benefit rows and official plan documents for limits and conditions.
Source trail
Official CMS, Contract Year 2027
Plan identity and benefits come from CMS PBP data. Benefits and drug cost sharing come from the approved annual PBP tabular extract and its CMS dictionary. Premiums and drug deductibles are cross-checked with the annual Landscape. Geography comes from annual PlanArea and PlanRegionArea records, including exact segments and partial-county or employer/group qualifiers. Quick-reference values should be confirmed in current official plan documents.
Plan context
Where H8003-804-000 fits
- Full CMS plan ID
H8003-804-000- Contract
H8003- Base plan code
H8003-804- Segment
000- Carrier
- Blue Cross Blue Shield of South Carolina
- Plan type
- Local PPO
- Service area
- Nationwide (AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY)
43 additional service-area states listed in the CMS record.
County/service-area foundation
CMS service-area entries
Service areas come from the annual CMS PlanArea and PlanRegionArea tables for this exact contract, plan, and segment. Partial-county and employer/group qualifiers remain part of the coverage area. Regional PPO county entries use the matching annual Landscape expansion of the CMS region.
- Aleutians East, AK · employer/group only
- Aleutians West, AK · employer/group only
- Anchorage, AK · employer/group only
- Bethel, AK · employer/group only
- Bristol Bay, AK · employer/group only
- Chugach, AK · employer/group only
- Copper River, AK · employer/group only
- Denali, AK · employer/group only
- Dillingham, AK · employer/group only
- Fairbanks North Star, AK · employer/group only
- Haines, AK · employer/group only
- Hoonah-Angoon, AK · employer/group only
3132 additional service-area entries are retained in the data record.
Exact county navigation
Counties with exact segment geography
These links are limited to named counties tied to this exact medical plan segment. Partial-county entries remain labeled for verification.
Show 29 county links
South Carolina
- Aiken County, South Carolina
- Beaufort County, South Carolina
- Berkeley County, South Carolina
- Charleston County, South Carolina
- Cherokee County, South Carolina
- Chesterfield County, South Carolina
- Colleton County, South Carolina
- Dillon County, South Carolina
- Dorchester County, South Carolina
- Fairfield County, South Carolina
- Florence County, South Carolina
- Georgetown County, South Carolina
- Greenville County, South Carolina
- Horry County, South Carolina
- Jasper County, South Carolina
- Kershaw County, South Carolina
- Lancaster County, South Carolina
- Lexington County, South Carolina
- Marion County, South Carolina
- Marlboro County, South Carolina
- Newberry County, South Carolina
- Oconee County, South Carolina
- Orangeburg County, South Carolina
- Pickens County, South Carolina
- Richland County, South Carolina
- Saluda County, South Carolina
- Spartanburg County, South Carolina
- Sumter County, South Carolina
- York County, South Carolina
About this code
What H8003-804-000 identifies
H8003-804-000 is a Contract Year 2027 Medicare plan segment code. Searches written as H8003-804, H8003 804, or the compact full CMS ID H8003804000 refer to this plan or its base plan code.
Medicare Plan Lookup uses official CMS data as a quick reference. Benefit details, eligibility, service-area rules, and cost sharing should be confirmed in the current Summary of Benefits or Evidence of Coverage.