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1 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.
2 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.
3 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.
4 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.
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.
5 Primary physicians are in-network providers designated by BCBSNC as a primary care provider (PCP). Please check with BCBSNC to confirm that your provider is in
our network.
6 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. U2074b, 2/13
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.
2 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.
3 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.
4 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.
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.
5 Primary physicians are in-network providers designated by BCBSNC as a primary care provider (PCP). Please check with BCBSNC to confirm that your provider is in
our network.
6 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. U2074b, 2/13
Limitations & Exclusions
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 your plan benefits, exclusions and limitations.
This is a partial list of benefits that are not payable to Blue Advantage:
misrepresentation of material fact 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, 6/12. 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.
Please note: Blue Advantage plans are not high-deductible health plans (HDHP) under the federal tax code, and therefore are not intended to be paired with a
health savings account (HSA).
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 your 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
misrepresentation of material fact 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, 6/12. 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.
Please note: Blue Advantage plans are not high-deductible health plans (HDHP) under the federal tax code, and therefore are not intended to be paired with a
health savings account (HSA).
IN =In-network coverage4
OUT =Out-of-network coverage4
OUT =Out-of-network coverage4
Note: Child-only coverage – coverage for children 18 years of age and younger – is available on all plans.
*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. Prior review (prior plan approval) is required for these services.
** Once BCBSNC has paid $2,000 for all brand drugs then the member pays 50% coinsurance and the copayment no longer applies
*** The first claim received by BCBSNC will be considered the first visit.
*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. Prior review (prior plan approval) is required for these services.
** Once BCBSNC has paid $2,000 for all brand drugs then the member pays 50% coinsurance and the copayment no longer applies
*** The first claim received by BCBSNC will be considered the first visit.
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Goebelt
| David Goebelt Authorized NC Agent 800-918-1158 |
Blue Cross Blue Shield of North Carolina Health Insurance Quotes
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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.
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