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Blue Cross and Blue Shield of North Carolina (BCBSNC) 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
Each offers unique benefits and multiple deductible options, so you can find a plan that works for you.1
Like most health care plans, Blue Advantage, Blue Advantage Saver and Blue Options HSA have some limitations and exclusions. You must qualify medically. If
your application is approved, you will receive a Member Guide. It will contain detailed information about your plan benefits, exclusions and limitations. This is a
partial list of benefits that are not payable to Blue Advantage, Blue Advantage Saver or Blue Options HSA:
Your coverage will automatically renew. Your coverage may be canceled by Blue Cross and Blue Shield of North Carolina (BCBSNC) for fraud or intentional
misrepresentation of information on your application. Coverage for dependent children ends at age 26. Members will be notified 30 days in advance of any change
in coverage. A waiting period for coverage of pre-existing conditions may apply to your coverage. 11
The policy form number for Blue Advantage, Blue Advantage Saver and Blue Options HSA is PPO-I, 6/11. This brochure contains a summary of the benefits only. It
is not your insurance policy. Your policy is your insurance contract. If there is any difference between this brochure and the policy, the provisions of the policy will
control.
1 Select preventive services are covered at 100%. Visit bcbsnc.com/preventive for more details. Please note: Blue Advantage and Blue Advantage Saver plans are
not a high-deductible health plans (HDHP) under the federal tax code, and therefore are not intended to be paired with a health savings account (HSA). For Blue
Options HSA: Federal guidelines and interpretations are subject to change.
2 For Blue Advantage and Blue Advantage Saver: All services are limited to the allowed amount. If you see an out-of-network provider, 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 health benefit
plan’s and member’s payment obligations. For Blue Options HSA: All services are limited to the allowed amount. BCBSNC allowed amount is the amount that
BCBSNC determines is reasonable for covered services provided to a member, which may be established in accordance with an agreement between the provider
and BCBSNC. If you use an in-network provider, you will only be responsible for your deductible and any coinsurance amounts.
3 For Blue Advantage and Blue Advantage Saver: 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 deductible and
coinsurance. Please see the BCBSNC provider listing at bcbsnc.com to identify these providers.
4 Blue Advantage and Blue Advantage Saver 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. For Blue Advantage Saver
plans 1 and 2 only: Diabetic supplies are covered at 75% under the prescription drug benefit. In addition, benefits are provided for over-thecounter drugs when listed
as covered in the formulary and a provider’s prescription for that drug is presented at the pharmacy. Specialty brand-name drugs require member coinsurance.
5 Blue Options HSA may combine with a high-deductible health plan and a health savings account (HSA). BCBSNC does not administer the HSA and is not
affiliated with your HSA custodian or administrator. Withdrawals are tax free only if used for qualified medical expenses. Specific regulations and a list of qualified
medical expenses can be found in IRS publication 502, available at www.irs.gov.
6 For Blue Options HSA plans: Deductible and out-of-pocket maximum amounts are subject to change year to year in order to comply with IRS requirements. For the
most up-to-date requirement information, see www.irs.gov. Consult with a tax advisor.
7 Preventive care services as defined by recent federal regulations are covered at 100% in-network. For Blue Advantage and Blue Advantage Saver plans, coverage
for certain preventive care services (such as routine physical exams, well-baby and well-child care, and immunizations) is limited to in-network benefits only.
However, state-mandated preventive services are available out-of-network, for which members will pay deductible and coinsurance, plus charges over the allowed
amount. Blue Options HSA in-network preventive care services are covered at 100%, and out-of-network preventive care services are covered at 70%. Visit bcbsnc.
com/preventive for more details.
8 Brand-name drugs do not apply towards deductible and coinsurance on Blue Advantage Saver 2 and 3.
9 For Blue Options HSA, members pay a discounted amount for all prescription drugs until they meet the deductible. Once the deductible is met, the member then
pays any required coinsurance.
10 Maternity coverage benefits are not included in the rates for Blue Advantage, Blue Advantage Saver or Blue Options HSA. For costs and further details about
maternity coverage, including exclusions and reductions or limitations and terms under which the policy may be continued in force, contact your agent or BCBSNC.
11 Availability of The ACS/Mellon HSA Solution investment alternative is subject to HSA account balance minimums. SaveDaily is made available by Mellon.
BCBSNC is not affiliated with your investment fund. Blue Options HSA contribution amounts are limited to the amount established by the IRS for each year for single
or family coverage. Anyone age 55 or older can contribute an additional $1,000 to their HSA in 2012. For the most up-to-date requirement information, see www.irs.
gov.
12 Pre-existing conditions apply only to adults age 19 and older and do not apply to children age 18 or younger. Pre-existing conditions are those for which medical
advice, diagnosis, care or treatment was received or recommended within the 12 months immediately preceding the date that your plan’s coverage begins. You
may receive credit toward the 12-month waiting period if you have not had a break in coverage of more than 63 consecutive days between your prior health plan
and this health plan, and if we receive proof of such prior coverage.
®, SM Marks of the Blue Cross and Blue Shield Association. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue
Shield Association. U4182, 10/11
your application is approved, you will receive a Member Guide. It will contain detailed information about your plan benefits, exclusions and limitations. This is a
partial list of benefits that are not payable to Blue Advantage, Blue Advantage Saver or Blue Options HSA:
- Services for or related to conception by artificial means or for reversal of sterilization
- Treatment of sexual dysfunction not related to organic disease
- Treatment or studies leading to or in connection with sex changes or modifications and related care
- Services that are investigational in nature or obsolete, including any service, drugs, procedure or treatment directly related to an investigational treatment
- Side effects and complications of noncovered services, except for emergency services in the case of an emergency
- Services that are not medically necessary
- Dental services provided in a hospital, except as specifically covered by your health benefit plan
- Services or expenses that are covered by any governmental unit except as required by Federal law
- Services received from an employer-sponsored dental or medical department
- Services received or hospital stays before (or after) the effective dates of coverage
- Custodial care, domiciliary care or rest cures
- Eyeglasses or contact lenses or refractive eye surgery
- Services to correct nearsightedness or refractive errors
- Services for cosmetic purposes
- Services for routine foot care
- Travel, except as specifically listed in the benefit booklet
- Services for weight control or reduction, except for morbid obesity, or as specifically covered by your health benefit plan
- Services for maternity or elective abortion except as provided by the maternity rider option, if purchased
- Inpatient admissions that are primarily for physical therapy, diagnostic studies, or environmental change
- Services that are rendered by or on the direction of those other than doctors, hospitals, facility and professional providers; services that are in excess of the
customary charge for services usually provided by one doctor when done by multiple doctors - For any condition suffered as a result of any act of war or while on active or reserve military duty
- Services for which a charge is not normally made in the absence of insurance, or services provided by an immediate relative
- Non-prescription drugs and prescription drugs or refills which exceed the maximum supply
- Personal hygiene, comfort and/or convenience items
- For telephone consultations, charges for failure to keep a scheduled visit, charges for completion of a claim form, charges for obtaining medical records,
and late payment charges - Services primarily for educational purposes
- Services for conditions related to developmental delay and/or learning differences
- Long-term rehabilitative therapy
- Services not specifically listed as covered services
Your coverage will automatically renew. Your coverage may be canceled by Blue Cross and Blue Shield of North Carolina (BCBSNC) for fraud or intentional
misrepresentation of information on your application. Coverage for dependent children ends at age 26. Members will be notified 30 days in advance of any change
in coverage. A waiting period for coverage of pre-existing conditions may apply to your coverage. 11
The policy form number for Blue Advantage, Blue Advantage Saver and Blue Options HSA is PPO-I, 6/11. This brochure contains a summary of the benefits only. It
is not your insurance policy. Your policy is your insurance contract. If there is any difference between this brochure and the policy, the provisions of the policy will
control.
1 Select preventive services are covered at 100%. Visit bcbsnc.com/preventive for more details. Please note: Blue Advantage and Blue Advantage Saver plans are
not a high-deductible health plans (HDHP) under the federal tax code, and therefore are not intended to be paired with a health savings account (HSA). For Blue
Options HSA: Federal guidelines and interpretations are subject to change.
2 For Blue Advantage and Blue Advantage Saver: All services are limited to the allowed amount. If you see an out-of-network provider, 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 health benefit
plan’s and member’s payment obligations. For Blue Options HSA: All services are limited to the allowed amount. BCBSNC allowed amount is the amount that
BCBSNC determines is reasonable for covered services provided to a member, which may be established in accordance with an agreement between the provider
and BCBSNC. If you use an in-network provider, you will only be responsible for your deductible and any coinsurance amounts.
3 For Blue Advantage and Blue Advantage Saver: 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 deductible and
coinsurance. Please see the BCBSNC provider listing at bcbsnc.com to identify these providers.
4 Blue Advantage and Blue Advantage Saver 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. For Blue Advantage Saver
plans 1 and 2 only: Diabetic supplies are covered at 75% under the prescription drug benefit. In addition, benefits are provided for over-thecounter drugs when listed
as covered in the formulary and a provider’s prescription for that drug is presented at the pharmacy. Specialty brand-name drugs require member coinsurance.
5 Blue Options HSA may combine with a high-deductible health plan and a health savings account (HSA). BCBSNC does not administer the HSA and is not
affiliated with your HSA custodian or administrator. Withdrawals are tax free only if used for qualified medical expenses. Specific regulations and a list of qualified
medical expenses can be found in IRS publication 502, available at www.irs.gov.
6 For Blue Options HSA plans: Deductible and out-of-pocket maximum amounts are subject to change year to year in order to comply with IRS requirements. For the
most up-to-date requirement information, see www.irs.gov. Consult with a tax advisor.
7 Preventive care services as defined by recent federal regulations are covered at 100% in-network. For Blue Advantage and Blue Advantage Saver plans, coverage
for certain preventive care services (such as routine physical exams, well-baby and well-child care, and immunizations) is limited to in-network benefits only.
However, state-mandated preventive services are available out-of-network, for which members will pay deductible and coinsurance, plus charges over the allowed
amount. Blue Options HSA in-network preventive care services are covered at 100%, and out-of-network preventive care services are covered at 70%. Visit bcbsnc.
com/preventive for more details.
8 Brand-name drugs do not apply towards deductible and coinsurance on Blue Advantage Saver 2 and 3.
9 For Blue Options HSA, members pay a discounted amount for all prescription drugs until they meet the deductible. Once the deductible is met, the member then
pays any required coinsurance.
10 Maternity coverage benefits are not included in the rates for Blue Advantage, Blue Advantage Saver or Blue Options HSA. For costs and further details about
maternity coverage, including exclusions and reductions or limitations and terms under which the policy may be continued in force, contact your agent or BCBSNC.
11 Availability of The ACS/Mellon HSA Solution investment alternative is subject to HSA account balance minimums. SaveDaily is made available by Mellon.
BCBSNC is not affiliated with your investment fund. Blue Options HSA contribution amounts are limited to the amount established by the IRS for each year for single
or family coverage. Anyone age 55 or older can contribute an additional $1,000 to their HSA in 2012. For the most up-to-date requirement information, see www.irs.
gov.
12 Pre-existing conditions apply only to adults age 19 and older and do not apply to children age 18 or younger. Pre-existing conditions are those for which medical
advice, diagnosis, care or treatment was received or recommended within the 12 months immediately preceding the date that your plan’s coverage begins. You
may receive credit toward the 12-month waiting period if you have not had a break in coverage of more than 63 consecutive days between your prior health plan
and this health plan, and if we receive proof of such prior coverage.
®, SM Marks of the Blue Cross and Blue Shield Association. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue
Shield Association. U4182, 10/11
* Fifth visit and up covered by deductible and coinsurance.
** Blue Advantage Plans B and C and Saver 1 have a prescription deductible before copayments apply.
** Blue Advantage Plans B and C and Saver 1 have a prescription deductible before copayments apply.
Goebelt
Insurance
Services, Inc.
Services, Inc.
Where Integrity Matters
| David Goebelt Authorized NC Agent 800-918-1158 |
Blue Cross Blue Shield of North Carolina Health Insurance Quotes
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Inc. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
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.
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