Goebelt
Insurance
Services, Inc.
Where Integrity Matters
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Authorized Agency
  Traditional copayment plan
Access to our largest network of
doctors with the freedom to see the
doctor you want and access to
specialists without referral (1)
 High-deductible health plan paired
with a health savings account (2)
A deductible and coinsurance plan
that can cut your premium costs and
offer significant tax advantages
Minimum Deductible
 $250 deductible per person
 $1,200 for an individual plan
$2,400 for a family plan (3)
Copayment for office visits
 Yes. Just present your BCBSNC ID card
and pay a convenient copayment when in
network. (4)
 No. Before your deductible is met, you
pay the total cost of your care. After your
deductible is met, you pay coinsurance
until you reach your total out-ofpocket
maximum amount.
Prescription drug coverage
 Yes. At a network pharmacy, you pay
only a convenient copayment. (5) (A
separate pharmacy deductible may apply.)
 Yes. After you meet your deductible, you
pay your coinsurance amount. (Both
medical and pharmacy claims apply to
the same deductible.)
Tax advantages
 No
 Yes. HSA contributions are tax
deductible. HSA withdrawals and interest
are tax free.(6)
Largest provider network in the
state
 Yes. Plus the freedom to go outside the
network. Includes coverage across the
nation and worldwide. (7)
 Yes. Plus the freedom to go outside the
network. Includes coverage across the
nation and worldwide. (7)
Preventive care coverage
 Yes. Includes a variety of services
important to your good health.
 Yes. To ensure your good health, a variety
of services are covered at 100% before
you reach your deductible. (8)
Eligible for an HSA
 No
 Yes. Your HSA is automatically included
when you enroll in the plan.
Blue Cross Blue Shield NC offers two primary health care plans for individuals and families.  Each offers unique benefits
and multiple deductible options, so you can find a plan that works for you.
1 Some behavioral health services may require a referral.
2 BCBSNC does not administer the HSA and is not affiliated with the HSA custodian or administrator. Your HSA custodian is Mellon Trust of New England, N.A.
3 These amounts will be updated annually for inflation. For the most up-to-date information visit www.irs.gov.
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.
5 Prescription drug benefits are divided into four drug-formulary tiers with varying copayments/coinsurance amounts based on the tier placement of a drug.
6 Withdrawals are tax-free only if used for qualified medical expenses. See irs.gov for specific regulations.
7 Source: www.bcbs.com/news/press/facts/bluecard.html.
8 Includes in-network annual routine physical exam, well-baby and well-child care and certain immunizations and screenings. Other covered services may be
subject to deductible and coinsurance.
Goebelt Insurance Services, Inc. and David Goebelt are an independent authorized agency/producer licensed to sell and promote products
from Blue Cross and Blue Shield of North Carolina (BCBSNC). The content contained in this site is maintained by Goebelt Insurance
Services, Inc. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
David Goebelt
Authorized NC Agent
704-402-2277