2023 Benefits Guide

MEDICAL PLAN For this Plan Year, we will offer two medical plans with Blue Cross Blue Shield. You have a choice of a HDHP and PPO. You may locate a provider for medical in network services at www.bcbsnc.com.

BlueCross BlueShield of North Carolina

Blue Options HDHP - HSA

Blue Options PPO

In-Network

Out-of-Network

In-Network

Out-of-Network

$20 Copay (Waived for the 1 st 3 visits)

Primary

Deductible, then 0% Deductible, then 30%

Deductible, then 30%

Specialist

Deductible, then 0% Deductible, then 30%

$40

Deductible, then 30%

Virtual Visits

Deductible then 0%

N/A

$10 Copay

Deductible, then 30%

Common Services

In-Patient Facility

Deductible, then 0% Deductible, then 30% Deductible, then 20% Deductible, then 30%

Out-Patient Facility

Deductible, then 0% Deductible, then 30% Deductible, then 20% Deductible, then 30%

Urgent Care

Deductible, then 0% Deductible, then 30% $40 Copay

$80 Copay

Emergency Room

Deductible, then 0%

$300 Copay

Pharmacy

Tier 1

$10 Copay

Tier 2

$35 Copay

Please see Benefit Summary for OON Benefits

Please see Benefit Summary for OON Benefits

Tier 3

$60 Copay

Deductible, then 0%

Tier 4

25% up to $100

Tier 5

25% up to $100

Mail Order

3x Copay

Annual Deductible

Individual

$3,000

$6,000

$1,000

$2,000

Family

$6,000

$12,000

$2,000

$6,000

Annual Out of Pocket

Includes Deductible, Coinsurance and Copays

Individual

$3,000

$7,250

$3,000

$8,000

Family

$6,000

$15,750

$6,000

$24,000

The benefit plan information shown in this guide is illustrative only. To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the underlying insurance documents will govern in all cases .

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