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1 All services are limited to the allowed amount. If you go to 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.
2 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.
3 Preventive care services as defined by recent federal regulations are covered at 100% in-network. 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. Visit bcbsnc.com/ preventive for more details.
4 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 75% 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. Specialty brand-name drugs require member coinsurance.
5 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.
6 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. U2074, 11/11
percentage or copayment amount because actual provider charges may not be used to determine the health benefit plan’s and member’s payment obligations.
2 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.
3 Preventive care services as defined by recent federal regulations are covered at 100% in-network. 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. Visit bcbsnc.com/ preventive for more details.
4 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 75% 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. Specialty brand-name drugs require member coinsurance.
5 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.
6 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. U2074, 11/11
Like most health care plans, Blue Advantage has 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 plan benefits, exclusions and limitations.
This is a partial list of benefits that are not payable to Blue Advantage:
•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.6 (Pre-existing conditions apply only to adults age
19 and older and do not apply to children age 18 or younger.) The policy form number for Blue Advantage 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.
Blue Advantage is not a high-deductible health plan (HDHP) under the federal tax code, and therefore is not intended to be paired with a health savings
account (HSA). Benefits and premiums vary depending on plan selected.
Member Guide. It will contain detailed information about plan benefits, exclusions and limitations.
This is a partial list of benefits that are not payable to Blue Advantage:
•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.6 (Pre-existing conditions apply only to adults age
19 and older and do not apply to children age 18 or younger.) The policy form number for Blue Advantage 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.
Blue Advantage is not a high-deductible health plan (HDHP) under the federal tax code, and therefore is not intended to be paired with a health savings
account (HSA). Benefits and premiums vary depending on plan selected.
| Choose from three Blue Advantage® copay plans and four deductible options |
* High-tech diagnostic imaging scans, such as CT scans, MRIs, MRAs and PET scans, are subject to deductible and coinsurance payments
regardless of where service is provided.
** Excludes child dependents.
regardless of where service is provided.
** Excludes child dependents.
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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
Authorized Agency
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.
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.