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Benefit period— Benefit
payments are based on where the services are received and how the services
are billed. |
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Physician Office Services |
In-Network |
Out-of-Network** |
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**The out-of-network column applies when you go to an out-of-network
provider. 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 Plan's and member's payment obligations.
For out-of-network benefits, you may be required to pay for charges
over the allowed amount, in addition to any copayment or coinsurance
amount. |
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See Outpatient Services for
outpatient clinic or hospital-based services. Office visits for
the evaluation and treatment of obesity are limited to a combined in and out-of-network
maximum of four visits per benefit period. |
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Office Services |
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Primary Care Provider |
$15 copayment |
80% after deductible |
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Specialist |
$30 copayment |
80% after deductible |
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Includes office surgery, x-rays,
and lab tests. |
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Preventive Care |
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Primary Care Provider |
100% |
Benefits not available |
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Specialist |
100% |
Benefits
not available |
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Includes
routine physical exams, well baby, well-child care, and immunizations. The
following preventive care benefits are available out-of-network: gynecological exams, cervical cancer
screening, ovarian cancer screening, screening mammograms, colorectal
screening, and prostate specific antigen tests. See "Covered Services"
section of complete plan document. |
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Short-term Rehabilitative
Therapies |
$15 copayment |
80% after deductible |
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Chiropractic Services |
$15 copayment |
80% after deductible |
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Combined in and out-of-network benefit
period maximums apply to home, office and outpatient settings. 40
visits per benefit period for physical/occupational therapy. 20 visits
per benefit period for chiropractic services. 30 visits per benefit
period for speech therapy. |
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Other Therapies |
100% |
80% after deductible |
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Includes
chemotherapy, dialysis and cardiac rehabilitation provided in the office. See
Outpatient Services for other therapies provided in an outpatient
setting. |
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Infertility and Sexual
Dysfunction Services |
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Primary Care |
$15 copayment |
80% after deductible |
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Specialist |
$30 copayment |
80% after
deductible |
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Combined in and out-of-network lifetime
maximum of $5,000 per member, provided in all places of service. |
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Urgent Care Centers and Emergency Room |
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Urgent
Care Centers |
$15copayment |
$15 copayment |
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Emergency
Room Visit |
$150 copayment |
$150 copayment |
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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. |
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Ambulatory Surgical Center |
100% after deductible |
80% after deductible |
|
Outpatient Services |
In-Network |
Out-of-Network** |
|
**The out-of-network column applies when you go to an out-of-network
provider. 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 Plan's and member's payment obligations.
For out-of-network benefits, you may be required to pay for charges
over the allowed amount, in addition to any copayment or coinsurance
amount |
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Physician Services |
100% after deductible |
80% after deductible |
|
Hospital and Hospital based Services |
100% after deductible |
80% after deductible |
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Outpatient Clinic Services |
100% after deductible |
80% after deductible |
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Outpatient Diagnostic Services: |
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Outpatient lab tests and mammography, when
performed alone |
100% |
80% after deductible |
|
Outpatient lab tests and mammography, when
performed with another service |
100%
after deductible |
80% after deductible |
|
Outpatient x-rays, ultrasounds, and other
diagnostic tests, such as EEGs, EKGs and pulmonary function tests |
100% |
80% after deductible |
|
CT scans, MRIs, MRAs and PET scans
received in any location, including in a physician's office |
100% |
80% after deductible |
|
Therapy Services |
100% after deductible |
80% after deductible |
|
Includes short-term
rehabilitative therapies and other therapies; see Physician Office
Services for visit maximums. |
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Inpatient Hospital Services |
In-Network |
Out-of-Network* |
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Physician Services (Excluding
Maternity) |
100% after deductible |
80% after deductible |
|
Physician Services/Maternity
Services |
100% after a one-time $15 copayment |
80% after deductible |
|
Hospital and Hospital based Services |
100% after deductible |
80% after deductible |
|
Includes maternity delivery,
prenatal and post-delivery care. |
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Skilled Nursing Facility |
100% after deductible |
80% after deductible |
|
Combined in and out-of-network maximum
of 100 days per benefit period and 200 days per lifetime. Services applied to the deductible count
towards this day maximum. |
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Other Services |
100% after deductible |
80% after deductible |
|
Includes durable medical
equipment, hospice services, medical supplies, orthotic devices —
correction of positional plagiocephaly limited to a lifetime
maximum of $600, private duty nursing, prosthetic appliances, home
health care. |
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Ambulance Ambulance charges do not require a
deductible |
100% |
100% |
|
Hearing Exams Hearing hardware covered in-network
only with a $2,000 maximum per benefit period |
100% |
Benefits
not available |
|
Impacted Tooth Removal |
$30 copayment, then 100% |
$30 copayment, then 100% |
|
Orthotic Devices |
100% |
100% |
|
Smoking Cessation One
treatment per year, two treatments per lifetime |
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Lifetime Maximum, Deductible, and Coinsurance Maximum The following deductibles and
maximums apply to the services listed above in the "Summary Of
Benefits" unless otherwise noted. |
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Lifetime Maximum |
$5,000,000 |
$1,000,000 |
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Deductible |
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Individual, per benefit period |
$250 |
$500 |
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Family, per benefit period |
$500 |
$1,000 |
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Charges for the following do not
apply to the benefit period deductible: •
inpatient newborn care for well baby •
mental health and substance abuse services •
prescription drugs |
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Coinsurance Maximums |
In-Network |
Out-of-Network** |
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**The out-of-network column applies when you go to an out-of-network
provider. 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 Plan's and member's payment obligations.
For out-of-network benefits, you may be required to pay for charges
over the allowed amount, in addition to any copayment or coinsurance
amount |
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|
Individual, per benefit period |
$0 |
$2,000 |
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Family, per benefit period |
$0 |
$4,000 |
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Charges for the following do not
apply to the benefit period coinsurance maximum: •
mental health and substance abuse services •
prescription drugs |
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Penalty For Failure To Obtain Certification |
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Certain services, regardless of
the location, require prior review and certification by BCBSNC
in order to receive benefits. If you go to an in-network provider in
North Carolina, your provider will request prior review when
necessary. If you go to an out-of-network provider in North Carolina
or to any provider outside of North Carolina, you are responsible for
requesting or ensuring that your provider requests prior review by
BCBSNC. Failure to request prior review and receive certification
may result in allowed charges being reduced by 25% or a full denial of
benefits. See "Covered
Services" and "Prospective Review/Prior Review" in
"Utilization Management" section of the complete plan
document. |
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Mental Health and Substance Abuse Services |
In-Network |
Out-of-Network** |
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|
**The out-of-network column applies when you go to an out-of-network
provider. 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 Plan's and member's payment obligations.
For out-of-network benefits, you may be required to pay for charges
over the allowed amount, in addition to any copayment or coinsurance
amount. |
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|
Prior review and certification by
Magellan Behavioral Health are required for all mental health and substance
abuse services, except office visits.
Please call 1-800-359-2422 |
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Mental Health Office Services |
$25 copayment |
80% |
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Combined in and out-of-network limit
of: 30 office visits per benefit period. Benefits for severe mental illness
are not subject to this limit. |
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Mental Health Inpatient
Services |
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Physician Services |
100%
coinsurance |
80%
coinsurance |
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Hospital and Hospital-based Services |
100%
coinsurance |
80%
coinsurance |
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Mental Health Outpatient
Services |
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|
Physician Services |
100%
coinsurance |
80%
coinsurance |
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Hospital and Hospital-based Services |
100%
coinsurance |
80%
coinsurance |
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|
Benefits for inpatient/outpatient mental illness are limited to a combined in and out-of-network limit of
30 days per benefit period. Benefits
for severe mental illness are not subject to this limit. |
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Substance Abuse Office Services |
$25 copayment |
80% |
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Substance Abuse Inpatient
Services |
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|
Physician Services |
100%
coinsurance |
80%
coinsurance |
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Hospital and Hospital-based Services |
100%
coinsurance |
80%
coinsurance |
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|
Substance Abuse Outpatient
Services |
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|
Physician Services |
100%
coinsurance |
80%
coinsurance |
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|
Hospital and Hospital-based Services |
100%
coinsurance |
80%
coinsurance |
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|
Substance Abuse Benefit Period Maximum |
$8,000 |
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|
Substance Abuse Lifetime Maximum |
$16,000 |
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Prescription Drugs |
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|
Generic Drugs Tier 1 |
$0
copayment |
Benefits not available |
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|
Preferred Brand Name Drugs Tier 2 |
$20
copayment |
Benefits not available |
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|
Brand Name Drugs Tier 3 |
$35
copayment |
Benefits not available |
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|
Diabetic Supplies |
100%** |
Benefits not available |
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|
Spacers and Peak Flow Meters |
100%** |
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