BCBSNC Online Blue Advantage table

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Benefit / Description

Plan A:
In-network coverage¹

Plan B:
In-network coverage¹

Plan C:
In-network coverage¹

Out-of-network coverage¹

Office visits Primary doctors and specialists, including surgery, lab work, therapy and radiology performed by the same doctor on the same office visit.

You pay:1 $15 copayment for primary physicians,² $30 copayment for specialists

You pay:1 $25 copayment for primary physicians,² $50 copayment for specialists

You pay:1 $30 copayment for primary physicians,² $60 copayment for specialists

You pay:¹ 30% after benefit period deductible

Preventive care Routine physical exams, including gynecological exam, well-child and well-baby care, including periodic assessments and immunizations.

You pay:^1,3 $15 copayment for primary physicians,2 $30 copayment for specialists

You pay:^1,3 $25 copayment for primary physicians,2 $50 copayment for specialists

You pay:^1,3 $30 copayment for primary physicians,2 $60 copayment for specialists

Not available

Prescription drugs No annual limit for generic drugs. A $2,000 maximum for brand-name drugs per person, per benefit period.

You pay:⁴ $10 copayment for generics, $35 or $50 for brand-name, 25% coinsurance for specialty brand

You pay:⁴ After $200 deductible per member, $10 copayment for generics, $35 or $50 for brand-name, 25% coinsurance for specialty brand

You pay:⁴ After $500 deductible per member, $10 copayment for generics, $35 or $50 for brand-name 25% coinsurance for specialty brand

Same as in network, plus the charges exceeding the allowed amount

Deductible The amount you pay during the benefit period for some services before BCBSNC pays its portion. Benefits vary depending on the deductible selected.

Deductible options: $250, $500, $1,000 or $2,500

Deductible options: $500, $1,000, $2,500, $3,500 or $5,000

Deductible options: $1,000, $2,500, $3,500 or $5,000

Same as in network

Coinsurance The percentage of covered medical expenses that you pay after you’ve paid your deductible.

You pay: After deductible, 20%, 0% (0% coinsurance is not available on the $2,500 deductible option)

You pay: After deductible, 30%

You pay: After deductible, 50%

You pay: After deductible, Plan A 30%, Plan B 40%, Plan C 60%

Coinsurance maximum The total amount of coinsurance you’re required to pay for covered services in a year. Once you reach the coinsurance maximum, you will not have to pay any more for coinsurance for covered medical expenses for the remainder of the year.

Individual: $0 for 0% coinsurance plans; $2,000 for 20% for coinsurance plans; Family: $0 for 0% coinsurance plans; $4,000 per family for 20% for coinsurance plans

Individual: $3,000;
Family: $6,000

Individual: $3,000;
Family: $6,000

When using out-of-network providers, your coinsurance maximum is higher than the in-network coinsurance maximum. Maximums vary based on plan selected.

Out-of-pocket expenses The total amount of money you pay out of pocket for covered services in a benefit period.

You pay: Deductible(s), coinsurance (up to the maximum) and copayment(s)

You pay: Deductible(s), coinsurance (up to the maximum), copayment(s), and amounts over the allowed amount.

Lifetime maximum The maximum amount BCBSNC will pay per member for covered services.

Unlimited

$5 million

Same as in network

Hospital Inpatient and outpatient facility services, drugs, blood, supplies, medical care, surgical care, therapy services, diagnostic tests, X-rays, lab work and well-baby care (including periodic assessments and immunizations).

Outpatient laboratory tests and mammograms performed alone. (May require pre-authorization.)

Inpatient & outpatient, you pay: Coinsurance after benefit period deductible

Outpatient labs & mammography, you pay: 0% with no deductible

Inpatient & outpatient, you pay: Coinsurance after benefit period deductible

Outpatient labs & mammography, you pay: 0% with no deductible

Inpatient & outpatient, you pay: Coinsurance after benefit period deductible

Outpatient labs & mammography, you pay: 0% with no deductible

Inpatient & outpatient, you pay: Coinsurance after benefit period deductible

Outpatient labs & mammography, you pay: 30% with no deductible

Urgent care centers PProvide services for a sudden or unexpected condition requiring prompt diagnosis or treatment to prevent chronic illness, prolonged impairment or a more hazardous treatment. Examples: sprains, some lacerations and dizziness.

You pay: $30 copayment

You pay: $50 copayment

You pay: $60 copayment

You pay: Same copayment as in network

Emergency room services Services for the sudden onset of a condition that a person could reasonably expect the absence of immediate medical attention to result in placing one’s health at risk.

You pay: $150 copayment⁵

Ambulatory surgery centers A licensed or certified non-hospital facility which has permanent facilities and equipment for the primary purpose of performing surgical procedures on an outpatient basis and does not provide inpatient accommodations.

You pay: Coinsurance after benefit period deductible

Mental health and substance abuse Inpatient and outpatient professionals. A $2,000 benefit period maximum and a $10,000 lifetime maximum per member⁷

You pay: 50% after deductible

You pay: 50% after benefit period deductible (Plans A and B);
60% after benefit period deductible (Plan C)

Vision Routine eye exam.

You pay: $15 copayment

You pay: $25 copayment

You pay: $30 copayment

Not available

Other Services * Durable medical equipment, home health care, home infusion therapy, hospice care, private duty nursing, ambulance services, skilled nursing facilities (to 60 days per year) and dental accident.

You pay: Coinsurance after benefit period deductible

Maternity rider Pre- and post-natal coverage.

Rider available. You pay coinsurance after benefit period deductible.

* High-tech diagnostic imaging scans, such as CT scans, MRIs, MRAs and PET scans, are subject to deductible and coinsurance
payments regardless of where service is provided.

Limitations & Exclusions

Like most health care plans, Blue Advantage has some limitations and exclusions. You must qualify medically. If your application is approved, you will receive a Member Guide. It will contain detailed information about plan benefits, exclusions and limitations.

T his is a partial list of benefits that are not payable to Blue Advantage:

Services for or related to conception by artificial means or for reversal of sterilization
Treatment of sexual dysfunction not related to organic disease
Treatment for transsexualism, sex changes or modifications including surgery
Services that are investigational in nature
Services for complications or side effects arising from excluded services, procedures or treatments
Services that are not medically necessary
Dental care except as provided in your benefit booklet
Services or expenses that are covered by any governmental unit except as required by Federal law
Services received from an employer-sponsored dental or medical department
Services received or hospital stays before the effective date of coverage

Custodial care, domiciliary care or rest cures
Eyeglasses or contact lenses or refractive eye surgery
Services to correct nearsightedness or refractive errors; hearing aids, supplies, tinnitus maskers, or exams for hearing aids
Services for cosmetic purposes
Services for routine foot care
Travel, except as specifically listed in the benefit booklet
Services for weight control or reduction, except for morbid obesity, or as specifically covered by your health benefit plan
Services for maternity or elective abortion except as provided by the maternity rider option, if purchased
Inpatient admissions that are primarily for physical therapy, diagnostic studies, or environmental change
Services that are rendered by or on the direction of those other than doctors, hospitals, facility and professional providers; services that are in excess of the customary charge for services usually provided by one doctor when done by multiple doctors

Services that are the result of war or while in military service
Services for which a charge is not normally made in the absence of insurance, or services provided by an immediate relative
Non-prescription drugs and prescription drugs or refills which exceed the maximum supply
Personal hygiene, comfort and/or convenience items
Telephone consultations; charges for failure to keep scheduled visits, for completion of any form, or for medical information required by the plan
Services primarily for educational purposes
Services for conditions related to developmental delay and/or learning differences
Long-term rehabilitative therapy
Services not specifically listed as covered services

Your coverage will automatically renew. Your coverage may be canceled by Blue Cross and Blue Shield of North Carolina (BCBSNC) for failure to pay premiums and for misstatements in or omissions of information from your application. Coverage for dependent children ends at age 26. Members will be notified 30 days in advance of any change in coverage. A waiting period for coverage of pre-existing conditions may apply to your coverage.6 This brochure contains a summary of benefits only. It is not your insurance policy. Your policy is your insurance contract (for Blue Advantage: M58, 7/09). If there is any difference between this brochure and the policy, the provisions of the policy will control.

Blue Advantage is not a high-deductible health plan (HDHP) under the Tax Code, and therefore is not intended to be paired with a Health Savings Account.

1 All services are limited to the allowed amount. If you go to an out-of-network provider, actual expenses for covered services may exceed the stated coinsurance percentage or copayment amount because actual provider charges may not be used to determine the health benefit plan’s and member’s payment obligations.
2 Primary physicians are in-network providers designated by BCBSNC as a primary care provider (PCP). Please check with BCBSNC to confirm your provider is in our network.
3 Preventive care is limited to in-network benefits and includes in-network annual routine physical exams, well-baby and well-child care and certain immunizations. Screenings or other covered services may be subject to copayment or deductible and coinsurance. Members who receive covered services out-of-network may be required to pay the difference between the provider’s actual charge and the BCBSNC allowed amount, in addition to the coinsurance amount.
4 Prescription drug benefits are divided into four drug-formulary tiers with varying copayment/coinsurance amounts based on the tier placement of a drug. Specific drug information can be found on the Prescription Drug Search tool at bcbsnc.com. Diabetic supplies are covered at 75% under the prescription drug benefit. In addition, benefits are provided for overthe- counter drugs when listed as covered in the formulary and a provider’s prescription for that drug is presented at the pharmacy. Specialty brand drugs require member coinsurance.
5 If admitted to the hospital from the emergency room, inpatient hospital benefits apply to all covered services provided. If held for observation, outpatient benefits apply to all covered services provided. If you are sent to the emergency room from an urgent care center, you may be responsible for both the emergency room copayment and the urgent care copayment.
6 Pre-existing conditions are those for which medical advice, diagnosis, care or treatment was received or recommended within the 12 months immediately preceding the date that your plan’s coverage begins. You may receive credit toward the 12-month waiting period if you have not had a break in coverage of more than 63 consecutive days between your prior health plan and this health plan, and if we receive proof of such prior coverage.
7 Services in excess of any benefit period maximum or lifetime maximum are not covered services, and members may be responsible for the entire amount of the provider’s billed charge.

An independent licensee of the Blue Cross and Blue Shield Association.
U2074, 9/09

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