Company   Plan Name Plan A 100%2,3 Plan A 80%2,3 Plan B 70%2,3 Plan C 50%2,3   BCBSNC®'s Newest Plan A BCBSNC®'s Most Popular Plan Budget-Minded Premiums 15%-35% Less Save Even More Premiums 28%-40% Less   Apply Apply Now Apply Now Apply Now Apply Now   Estimated Monthly Premium View Rates View Rates View Rates View Rates   Plan Type PPO PPO PPO PPO   Networks Search for Doctors and Hospitals Search for Doctors and Hospitals Search for Doctors and Hospitals Search for Doctors and Hospitals   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 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 unlimited $5 million $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 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 $30 copay with no deductible 100% after $30 copay with no deductible 100% after $30 copay with no deductible 100% after $50 copay with no deductible 100% after $50 copay with no deductible 100% after $60 copay with no deductible 100% after $60 copay with no deductible   Emergency Room 100% after $150 copay7 (copay waived if admitted) 100% after $150 copay7 (copay waived if admitted) 100% after $150 copay7 (copay waived if admitted) 100% after $150 copay7 (copay waived if admitted) 100% after $150 copay7 (copay waived if admitted) 100% after $150 copay7 (copay waived if admitted) 100% after $150 copay7 (copay waived if admitted) 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   Vision Services 100% after $15 copay Not Available 100% after $15 copay Not Available Not Available Not Available Not Available 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 $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 $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 $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. Optional -- please call for rates. Optional -- please call for rates. Optional -- please call for rates.   Note YOU MAY CHOOSE THE 1ST OR THE 15TH OF THE MONTH FOR YOUR COVERAGE TO BEGIN, BUT IT MUST BE AT LEAST 30 DAYS, BUT NO MORE THAN 60 DAYS, FROM SIGNATURE DATE ONE EXCEPTION: IF YOU APPLY ON-LINE YOUR EFFECTIVE DATE CAN BE AS EARLY AS 15 DAYS FROM SIGNATURE DATE. APPLYING ON LINE IS SIGNIFICANTLY FASTER AND EASIER THAN COMPLETING A PAPER APPLICATION AND REDUCES THE TIME IT TAKES TO GET YOUR POLICY ISSUED. TO REQUEST A LINK TO APPLY ON LINE, PLEASE CALL 877-359-9250 OR CLICK "APPLY NOW" AND COMPLETE THE REQUESTED INFORMATION. IF YOU NEED ASSISTANCE, PLEASE CALL TOLL FREE: 877-359-9250.   Apply

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 reference your provider directory for a complete list of these providers.
² All services subject to the allowed amount.
³ 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.
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.