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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