Compare BCBCNC Blue Advantage Plans A, B and C

Compare Blue Advantage® Plans

Company

Plan Name

Plan A 100%^2,3

Plan A 80%^2,3

Plan B 70%^2,3

Plan C 50%^2,3

Our Newest Plan A

Our Most Popular Plan

Budget-Minded
Premiums 15%-35% Less

Save Even More
Premiums 28%-40% Less

Plan Type

PPO

Summary of Benefits

Network

Non-Network

Network

Non-Network

Network

Non-Network

Network

Non-Network

Office Visit/Copay
Primary doctors and specialists (including surgery, lab work, therapy and radiology performed by the same doctor on the same day in the office)

100% after a $15 copay with no deductible for primary physicians⁴ or a $30 copay for specialists¹

70% after calendar year deductible

100% after a $15 copay with no deductible for primary physicians or a $30 copay for specialists¹

70% after calendar year deductible

100% after a $25 copay with no deductible for primary physicians or a $50 copay for specialists¹

70% after calendar year deductible

100% after a $30 copay with no deductible for primary physicians or a $60 copay for specialists¹

70% after calendar year deductible

Benefit period deductible

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

Same as In-Network

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

Same as In-Network

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

Same as In-Network

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

Same as In-Network

Coinsurance (% Paid by Company) Includes Home Health Care, Skilled Nursing, and Inpatient Hospital Care.

100% after calendar year deductible. You pay nothing after deductible of covered charges.

70% after calendar year deductible

80% after calendar year deductible

70% after calendar year deductible

60% after calendar year deductible

50% after calendar year deductible

40% after calendar year deductible

Annual Out-of-Pocket Coinsurance Limit (% Paid by You)

After calendar year deductible you pay nothing.

You pay 20% after calendar year deductible until you have paid maximum $2000 per individual, $4000 per family

You pay 30% after calendar year deductible until you have paid maximum $3000 per individual, $6000 per family

You pay 50% after calendar year deductible until you have paid maximum $3000 per individual, $6000 per family

Lifetime Maximum

unlimited

$5 million

Prescription Drugs

Unlimited coverage for generic drugs (max for brand drugs is $2000 benefit per person per calendar year) Includes family planning
100% after copayment with no deductible $10 copay for generic $35 or $50 copay for brand.⁶ Tier 4/25% coinsurance

Unlimited coverage for generic drugs (max for brand drugs is $2000 benefit per person per calendar year) Includes family planning
100% after $200 annual deductible per member $10 copay for generic $35 or $50 for brand.⁶ Tier 4/25% coinsurance

Unlimited coverage for generic drugs (max for brand drugs is $2000 benefit per person per calendar year) Includes family planning
100% after $500 annual deductible per member $10 copay for generic $35 or $50 for brand.⁶ Tier 4/25% coinsurance

Urgent Care Centers

100% after $30 copay with no deductible

100% after $50 copay with no deductible

100% after $60 copay with no deductible

Emergency Room

100% after $150 copay⁷ (copay waived if admitted)

Preventive Care

Routine physical exam, including gynecological exam

100% after a $15 copay with no deductible for primary physicians⁴ or a $30 copay for specialists¹

Not available

100% after a $15 copay with no deductible for primary physicians⁴ or a $30 copay for specialists¹

Not available

100% after a $25 copay with no deductible for primary physicians⁴ or a $50 copay for specialists¹

Not available

100% after a $30 copay with no deductible for primary physicians⁴ or a $60 copay for specialists¹

Not available

Well-child and baby care (including periodic assessments and immunizations)

100% after a $15 copay with no deductible for primary physicians⁴ or a $30 copay for specialists¹

Not available

100% after a $15 copay with no deductible for primary physicians⁴ or a $30 copay for specialists¹

Not available

100% after a $25 copay with no deductible for primary physicians⁴ or a $50 copay for specialists¹

Not available

100% after a $30 copay with no deductible for primary physicians⁴ or a $60 copay for specialists¹

Not available

Immunizations

100%

Not available

100%

Not available

100%

Not available

100%

Not available

MRI PET & CT Scans

Subject to the deductible and coinsurance regardless of where performed.

Physical Therapy

$15/$30 copay maximum combined therapy 30 visits

70% after calendar year deductible

$15/$30 copay maximum combined therapy 30 visits

70% after calendar year deductible

$25/$50 copay maximum combined therapy 30 visits

60% after calendar year deductible

$30/$60 copay maximum combined therapy 30 visits

40% after calendar year deductible

Routine Eye Exam

100% after $15 copay

Not Available

100% after $15 copay

Not Available

Covered In-Network w/copay of $25

Not Available

Covered In-Network w/copay of $30

Not Available

Mental Health

$2,000 benefit max per person per calendar year; $10,000 lifetime max per person Inpatient facility, Inpatient professional. Outpatient professional
50% after calendar year deductible

Maternity Benefits

Optional -- please call for rates.

Note

COVERAGE MAY BEGIN ON THE 1ST OR 15TH OF EACH MONTH BUT APPLICATION MUST BE SUBMITTED AT LEAST 7 DAYS PRIOR TO REQUESTED EFFECTIVE DATE.

IF YOU NEED ASSISTANCE, PLEASE CALL 888-765-5400 OR 252-726-5400.

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1 Some services and supplies received by members in an office setting or in connection with an office visit are in fact outpatient hospital-based services provided by hospital-owned or operated practices. These services and supplies may be subject to your deductible and coinsurance. Please see the BCBSNC provider listing to identify these providers.

2 All services subject to the allowed amount.

3 Your actual expenses for covered services may exceed the stated amount because actual provider charges may not be used to determine the payment obligations of BCBSNC or its members.

4 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.

5 Only gynecological exams, cervical cancer screening, screening mammograms, colorectal screening and prostate specific antigen (PSA) tests are covered out-of-network subject to benefit period deductible and coinsurance.

6 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 76% under the prescription drug benefit. In addition, benefits are provided for over-the-counter drugs when listed as covered in the formulary and a provider's prescription for that drug is presented at the pharmacy.

7 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.

8 Pre-existing conditions are those for which medical advice, diagnosis, care or treatment was received or recommended within 12 months of the date that your Blue Advantage® coverage begins. You may receive credit toward the 12 month waiting period if we receive your completed Blue Advantage® application within 63 days of the termination of your previous health coverage.

9 BCBSNC® Internal Enrollment figures as of 2006/2007.