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Goebelt
Insurance
Services, Inc.
Services, Inc.
Where Integrity Matters
 | |  | |  | |  | |  | |  |
Authorized Agency
(U2074, 11/07)
1 All services subject to the allowed amount.
2 Your 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.
3 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.
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. Please see the BCBSNC provider listing
to identify these providers.
5 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 drugs require member coinsurance.
6 Only gynecological exams, cervical cancer screening, ovarian cancer screening, screening mammograms, colorectal screening and prostate specific antigen
(PSA) tests are covered out-of-network subject to benefit period deductible and coinsurance.
7 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.
1 All services subject to the allowed amount.
2 Your 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.
3 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.
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. Please see the BCBSNC provider listing
to identify these providers.
5 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 drugs require member coinsurance.
6 Only gynecological exams, cervical cancer screening, ovarian cancer screening, screening mammograms, colorectal screening and prostate specific antigen
(PSA) tests are covered out-of-network subject to benefit period deductible and coinsurance.
7 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.
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.
| Choose from three Blue Advantage® copay plans and six deductible options |
| David Goebelt Authorized NC Agent 800-918-1158 |
