Blue Advantage Saver from Blue Cross Blue Shield of North Carolina

Blue Advantage Saver sm

Our Blue Advantage Saver is a PPO plan that allows you to make
certain decisions about what benefits you really need. If you want lower
monthly premiums, you can choose a higher deductible. If there are
prescriptions, you can choose a plan without that benefit and lower
your premiums even more. Traditional copayments for primary care
visits 1 also help you manage your expected health care expenses.

Lower premiums
Fewer benefits at a copayment
Higher deductible options

A plan featuring more cost saving options

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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.

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Blue Cross Blue Shield of North Carolina Health Insurance Quotes

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David Goebelt
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800-918-1158

1 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.

2 For Blue Advantage and Blue Advantage Saver: All services are limited to the allowed amount. 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 Blue Advantage and Blue Advantage Saver 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.

Benefit type	Benefit description	BlueAdvantageSaver sm
Benefit type	Benefit description	Saver 1 In-network coverage 2	Saver 2 In-network coverage 2	Saver 3 In-network coverage 2
Office visits	Primary doctors and specialists, including surgery, lab work, therapy and radiology when performed by the same doctor on the same day in office.	You pay 2 $25 copayment for primary physicians; 3 coinsurance after deductible for specialists	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	You pay $0 after deductible
Prescription drugs	No annual limit for generic drugs. For Plan 1 only: Copayment for brand-name drugs up to $2,000, then you pay 50% coinsurance	After $500 deductible per member, you pay $10 copayment for generics, $45 or $65 for brand-name drugs, 25% coinsurance for specialty brands	You pay $10 copayment for generics; members receive discounted rate for brand-name drugs
Deductible	The amount you pay during the benefit period for some services before BCBSNC pays its portion	Deductible options: $1,000, $2,500, $3,500 or $5,000	Deductible options: $1,000, $2,500, $3,500, $5,000, $10,000 or $20,000	Deductible options: $10,000 or $20,000
Coinsurance	The percentage of covered medical expenses that you pay after you’ve paid your deductible.	After deductible, you pay 30%	After $1,000 - $5,000 deductible, you pay 40% After $10,000 or $20,000 deductible, you pay 0%	After deductible, you pay 0%**
Coinsurance maximum	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.	Individual: $3,000 Family: $6,000	Individual: $4,000; Family: $8,000; For $10,000 or $20,000 deductible options, you pay $0 after deductible	For Individual and Family, you pay $0 after deductible
Vision	Routine eye exam.	You pay $25 copayment		After deductible, you pay $0
		All three Blue Advantage Saver plans have these benefits
Preventive care	Routine physical exams, including gynecological exam; well-child and well-baby care, including periodic assessments and immunizations. Visit bcbsnc.com/preventive for details.	You pay $0; preventive services are covered at 100%
Lifetime maximum	The maximum amount BCBSNC will pay per member for covered services. BCBSNC plans offer unlimited coverage for the lifetime of the policy	Unlimited
Hospital	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).	For inpatient, you pay coinsurance after benefit period deductible
Hospital	Outpatient laboratory tests and mammograms performed alone. May require prior review (prior plan approval).	For outpatient, you pay 0% with no deductible
Urgent care centers	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.	Saver plans 1 and 2 have coinsurance; $0 after deductible for Saver plan 3
Emergency room services	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.	After deductible, you pay coinsurance
Ambulatory surgery centers	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.	Saver plans 1 and 2 have coinsurance; $0 after deductible for Saver plan 3
Mental health and substance abuse	Inpatient and outpatient professionals. Includes 10 office (or) outpatient visits and five inpatient day limits.	After deductible, you pay 50%
Out-of-pocket expenses	The total amount of money you pay out of pocket in a benefit period.	You pay deductible(s), coinsurance (up to the maximum) and copayment(s)
Other Services*	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.	Saver plans 1 and 2 have coinsurance; $0 after deductible for Saver plan 3
Maternity rider	Pre- and post-natal coverage.	Maternity rider available: Cost depends on the deductible and coinsurance you select
Child-only coverage	Coverage for children 18 years of age and younger	Available

* 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.
** For mental health and substance abuse professionals, you pay 50% after deductible.