Most popular
plan

Plan A (1, 2)

Plan B (1, 2)

Plan C (1, 2)

Plans A, B, & C (1, 2)

Blue Options
HSA (SM)

In-network coverage

In-network coverage

In-network coverage

Out-of-network coverage

In-network coverage

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

Deductible options

$1,100, $2,000, $2,700 or $5,000

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80% or 100%

(100% coinsurance is not available on $2,500
deductible options)

70%

Plan A: 70%

Plan B: 60%

Plan C: 40%

100%, 80% & 50%

(80% & 50% are not available with $5,000 individual or $10,000 family
deductible plans)

100%

coinsurance plans: $0

80%

coinsurance plans:
$2,000 per individual

$4,000 per family

$3,000 per individual,

$6,000 per family

$3,000 per individual

$6,000 per family

When using
out-of-network
providers, your
coinsurance
maximum is twice
the in-network
coinsurance
maximum

$1,100, $2,000, $2,700, $5000 INDIVIDUAL
deductible OR $2,200, $4,000, $5,450, or $10,000 FAMILY -- Aggregate deductible

Unlimited

$5 million

$5 million

Same as in-network

Unlimited

100%

after a $15 copay for primary physicians (3) or a $30 copay for specialists (4)

100%

after $25 copay for primary physicians (3) or a $50 copay for specialists (4)

100%

after a $30 copay for primary
physicians (3) or a $60 copay for specialists (4)

70%

after benefit period deductible

No. Before your deductible is met you pay the total cost. After the deductible, you pay coinsurance until you reach your total out-of- pocket maximum amount.

100%

after $10 copay for generic, $35 copay for preferred brand, $50 copay for brand or 25% coinsurance for specialty brand (5)

100%

after $200 annual deductible per member, then $10 copay for generic, $35 copay for preferred brand, $50 for brand or 25% coinsurance for specialty brand (5)

100%

after $500 annual deductible per member, then $10 copay for generic, $35 copay for preferred brand, $50 for brand or 25% coinsurance for specialty brand (5)

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

Yes. After you meet your deductible, you pay your coinsurance amount. (Both medical and pharmacy claims apply to the same deductible.)

100%

after $15 copay

100%

after $25 copay

100%

after $30 copay

Coinsurance after benefit period deductible,

Outpatient Lab Tests & Mammograms performed alone - 100% with no deductible

Coinsurance after benefit period deductible

Outpatient Lab Tests & Mammograms performed alone - 100% with no deductible

Coinsurance after benefit period deductible

Outpatient Lab Tests & Mammograms performed alone - 100% with no deductible

Coinsurance after benefit period deductible

Coinsurance after benefit period deductible

100%

after a $15 copay for primary physicians (3) or a $30 copay for specialists (4)

100%

after a $25 copay for primary physicians (3) or a $50 copay for specialists (4)

100%

after a $30 copay for primary physicians (3) or a $60 copay for specialists (4)

Not Available (6)

100%

Yes. To ensure good health, a variety of services are covered at 100% BEFORE you reach your deductible, no copay

100%

after a $30 copay

100%

after a $50 copay

100%

after a $60 copay

0%

no copay, but coinsurance after benefit period deductible

100%

after a $150 copay(7) (copay waived if admitted)

100%

after a $150 copay(7) (copay waived if admitted)

100%

after a $150 copay(7) (copay waived if admitted)

100%

after same copay as in-network

0%

no copay,but coinsurance after benefit period deductible

Coinsurance after benefit period deductible

Coinsurance after benefit period deductible

Coinsurance after benefit period deductible

Coinsurance after benefit period deductible

Coinsurance after benefit period deductible

Mental health & substance abuse

50%

after benefit period deductible Limited to combined in- and out-of-network maximum of $2,000 per benefit period per member, provide in all places of service.  Maximum lifetime benefit $10,000.

50%

after benefit period deductible Limited to combined in- and out-of-network maximum of $2,000 per benefit period per member, provide in all places of service.  Maximum lifetime benefit $10,000.

50%

after benefit period deductible

40%

after benefit period deductible for Plan C

50%

after benefit period deductible Limited to combined in- and out-of-network maximum of $2,000 per benefit period per member, provide in all places of service.  Maximum lifetime benefit $10,000.

Limited to combined in- and out-of-network maximum of $2,000 per benefit period per member, provided in all places of service. Limited to combined in-and out-of-network lifetime maximum of $10,000 per member, provided in all places of service.

Coinsurance after benefit period deductible

Coinsurance after benefit period deductible

Coinsurance after benefit period deductible

Coinsurance after benefit period deductible

Coinsurance after benefit period deductible

Limitations & exclusions

Like most health care plans, Blue Advantage® has some limitations and exclusions. When your application is approved, you will receive a benefit booklet. It will contain detailed information about plan benefits, exclusions and limitations.

This is a partial list of benefits that are not payable:

Your coverage will automatically renew. Your coverage may be canceled by Blue Cross and Blue Shield of North Carolina® for failure to pay premiums and for false statements on your application, among other reasons. 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.

This chart contains a summary of benefits only. It is not your insurance policy. Your policy is your insurance contract. If there is any difference between this chart and the policy, the provisions of the policy will control.   Please note: 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.

Footnotes:

1 All services subject to the allowed amount.

2 NOTICE: Your 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 payment obligations for BCBSNC® and its members.

3 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.

4 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 provider listing to identify these providers.

5 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 over-the-counter drugs when listed as covered in the formulary and a provider’s prescription for that drug is presented at the pharmacy.

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

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.

This is a partial list of benefits that are not payable:

• 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
• Vision exams except for some diagnoses (Plan B and C only)
• 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
• Services for maternity or elective abortion, except as provided by the maternity 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 a 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
• 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 for failure to pay premiums and for false statements on your application,
among other reasons. 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.8

This chart contains a summary of benefits only. It is not your insurance policy. Your policy is your
insurance contract. If there is any difference between this chart and the policy, the provisions of
the policy will control.

Please note: 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.

Richard Day is an independent authorized producer/agency licensed to sell and promote products from Blue Cross and Blue Shield of North Carolina®. The content contained in this site is maintained by Richard Day. Blue Cross and Blue Shield of North Carolina® is an independent licensee of the Blue Cross and Blue Shield Association. (R) Registered mark of the Blue Cross and Blue Shield Association. (SM) Service mark of the Blue Cross and Blue Shield Association.