Benefit type
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Benefit description
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BlueAdvantageSaver sm
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Saver 1 In-network coverage 2
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Saver 2 In-network coverage 2
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Saver 3 In-network coverage 2
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Office visits
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Primary doctors and specialists, including surgery, lab work, therapy and radiology when performed by the same doctor on the same day in office.
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You pay 2 $25 copayment for primary physicians; 3 coinsurance after deductible for specialists
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You pay 2 $25 copayment for up to four primary care provider visits, 3 then covered by deductible and coinsurance; for specialists, you pay coinsurance after deductible
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You pay $0 after deductible
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Prescription drugs
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No annual limit for generic drugs. For Plan 1 only: Copayment for brand-name drugs up to $2,000, then you pay 50% coinsurance
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After $500 deductible per member, you pay $10 copayment for generics, $45 or $65 for brand-name drugs, 25% coinsurance for specialty brands
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You pay $10 copayment for generics; members receive discounted rate for brand-name drugs
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Deductible
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The amount you pay during the benefit period for some services before BCBSNC pays its portion
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Deductible options: $1,000, $2,500, $3,500 or $5,000
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Deductible options: $1,000, $2,500, $3,500, $5,000, $10,000 or $20,000
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Deductible options: $10,000 or $20,000
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Coinsurance
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The percentage of covered medical expenses that you pay after you’ve paid your deductible.
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After deductible, you pay 30%
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After $1,000 - $5,000 deductible, you pay 40% After $10,000 or $20,000 deductible, you pay 0%
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After deductible, you pay 0%**
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Coinsurance maximum
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The total amount of coinsurance you’re required to pay for covered services in a year. Once you reach the coinsurance maximum, you will not have to pay any more for coinsurance for covered medical expenses for the remainder of the year.
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Individual: $3,000 Family: $6,000
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Individual: $4,000; Family: $8,000; For $10,000 or $20,000 deductible options, you pay $0 after deductible
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For Individual and Family, you pay $0 after deductible
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Vision
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Routine eye exam.
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You pay $25 copayment
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After deductible, you pay $0
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All three Blue Advantage Saver plans have these benefits
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Preventive care
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Routine physical exams, including gynecological exam; well-child and well-baby care, including periodic assessments and immunizations. Visit bcbsnc.com/preventive for details.
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You pay $0; preventive services are covered at 100%
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Lifetime maximum
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The maximum amount BCBSNC will pay per member for covered services. BCBSNC plans offer unlimited coverage for the lifetime of the policy
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Unlimited
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Hospital
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Inpatient and outpatient facility services, drugs, blood, supplies, medical care, surgical care, therapy services, diagnostic tests, X-rays, lab work and well-baby care (including periodic assessments and immunizations).
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For inpatient, you pay coinsurance after benefit period deductible
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Outpatient laboratory tests and mammograms performed alone. May require prior review (prior plan approval).
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For outpatient, you pay 0% with no deductible
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Urgent care centers
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Provide services for a sudden or unexpected condition requiring prompt diagnosis or treatment to prevent chronic illness, prolonged impairment or a more hazardous treatment. Examples: sprains, some lacerations and dizziness.
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Saver plans 1 and 2 have coinsurance; $0 after deductible for Saver plan 3
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Emergency room services
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Services for the sudden onset of a condition that a person could reasonably expect the absence of immediate medical attention to result in placing one’s health at risk.
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After deductible, you pay coinsurance
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Ambulatory surgery centers
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A licensed or certified non-hospital facility that has permanent facilities and equipment for the primary purpose of performing surgical procedures on an outpatient basis and does not provide inpatient accommodations.
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Saver plans 1 and 2 have coinsurance; $0 after deductible for Saver plan 3
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Mental health and substance abuse
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Inpatient and outpatient professionals. Includes 10 office (or) outpatient visits and five inpatient day limits.
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After deductible, you pay 50%
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Out-of-pocket expenses
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The total amount of money you pay out of pocket in a benefit period.
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You pay deductible(s), coinsurance (up to the maximum) and copayment(s)
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Other Services*
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Durable medical equipment, home health care, home infusion therapy, hospice care, private duty nursing, ambulance services, skilled nursing facilities (to 60 days per year) and dental accident-related services.
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Saver plans 1 and 2 have coinsurance; $0 after deductible for Saver plan 3
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Maternity rider
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Pre- and post-natal coverage.
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Maternity rider available: Cost depends on the deductible and coinsurance you select
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Child-only coverage
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Coverage for children 18 years of age and younger
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Available
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