Page 6 - NH NC Guide
P. 6
Medical and Pharmacy Insurance
For many of us, nothing is more important than our health and the health
Your medical plan contributions are
based on completion of the Health Risk of our family members. The importance of having health insurance should
Assessment (HRA). Employees need to not be dismissed or underestimated. Medical and pharmacy insurance can
complete the HRA in order to receive help you avoid or limit some of these costs and it can also help you develop
the discounted HRA medical plan and maintain a healthier lifestyle.
premiums. Please complete the HRA
through HealthStat.
Blue Cross Blue Shield (BCBS) of North Carolina
Blue Cross Blue Shield of North Carolina administers our comprehensive
medical plan. BCBS of North Carolina’s network offers exceptional access to in-network providers and deep
discounts on services. This results in lower costs to you and our plan. It is highly recommended you verify all
associated providers are participating in the BCBS of North Carolina network. This helps you avoid incurring
any unexpected out-of-network charges and ensures the most cost effective use of your health plan. The
medical plan deductible and out-of-pocket maximum will run through December 31, 2016 and will restart again
on January 1, 2017.
In-Network Out-of-Network
Plan Year Deductible
Individual deductible * $2,000 $4,000
Family deductible * $5,000 $10,000
Plan Year Out-of-Pocket Maximum
Individual out-of-pocket maximum ** $5,000 $9,000
Family out-of-pocket maximum $9,000 $16,500
Wellness Care
Preventive care w100% 70% after deductible
Ofice Visits
Primary care visits 80% after deductible 50% after deductible
Specialist visits 80% after deductible 50% after deductible
Hospital
Inpatient services 80% after deductible 50% after deductible
Outpatient services 80% after deductible 50% after deductible
Emergency room 80% after deductible 80% after deductible
Urgent care 80% after deductible 80% after deductible
Pharmacy
Retail supply limit 30 days
Tier 1 $10 copay $10 copay
Tier 2 $40 copay $40 copay
Tier 3 $55 copay $55 copay
Specialty 25% coinsurance with a minimum of $50 Not covered
and maximum of $100
Mail order supply limit 90 days
Tier 1 $25 copay Not covered
Tier 2 $100 copay Not covered
Tier 3 $137.50 copay Not covered
Specialty Not covered—limited to 30 days Not covered
* Employees will be responsible for paying the irst $500 for individual coverage and $1,000 for family coverage before the HRA
pays. MG + BW will continue to fund the HRA at the same level and will pay $1,000 in claims which apply toward the deductible
for individual coverage and $2,500 for family coverage, regardless of whether the claims are in-network or out-of-network.
** Prescription copays apply to the out-of-pocket maximum.
6
New Hire Guide
For many of us, nothing is more important than our health and the health
Your medical plan contributions are
based on completion of the Health Risk of our family members. The importance of having health insurance should
Assessment (HRA). Employees need to not be dismissed or underestimated. Medical and pharmacy insurance can
complete the HRA in order to receive help you avoid or limit some of these costs and it can also help you develop
the discounted HRA medical plan and maintain a healthier lifestyle.
premiums. Please complete the HRA
through HealthStat.
Blue Cross Blue Shield (BCBS) of North Carolina
Blue Cross Blue Shield of North Carolina administers our comprehensive
medical plan. BCBS of North Carolina’s network offers exceptional access to in-network providers and deep
discounts on services. This results in lower costs to you and our plan. It is highly recommended you verify all
associated providers are participating in the BCBS of North Carolina network. This helps you avoid incurring
any unexpected out-of-network charges and ensures the most cost effective use of your health plan. The
medical plan deductible and out-of-pocket maximum will run through December 31, 2016 and will restart again
on January 1, 2017.
In-Network Out-of-Network
Plan Year Deductible
Individual deductible * $2,000 $4,000
Family deductible * $5,000 $10,000
Plan Year Out-of-Pocket Maximum
Individual out-of-pocket maximum ** $5,000 $9,000
Family out-of-pocket maximum $9,000 $16,500
Wellness Care
Preventive care w100% 70% after deductible
Ofice Visits
Primary care visits 80% after deductible 50% after deductible
Specialist visits 80% after deductible 50% after deductible
Hospital
Inpatient services 80% after deductible 50% after deductible
Outpatient services 80% after deductible 50% after deductible
Emergency room 80% after deductible 80% after deductible
Urgent care 80% after deductible 80% after deductible
Pharmacy
Retail supply limit 30 days
Tier 1 $10 copay $10 copay
Tier 2 $40 copay $40 copay
Tier 3 $55 copay $55 copay
Specialty 25% coinsurance with a minimum of $50 Not covered
and maximum of $100
Mail order supply limit 90 days
Tier 1 $25 copay Not covered
Tier 2 $100 copay Not covered
Tier 3 $137.50 copay Not covered
Specialty Not covered—limited to 30 days Not covered
* Employees will be responsible for paying the irst $500 for individual coverage and $1,000 for family coverage before the HRA
pays. MG + BW will continue to fund the HRA at the same level and will pay $1,000 in claims which apply toward the deductible
for individual coverage and $2,500 for family coverage, regardless of whether the claims are in-network or out-of-network.
** Prescription copays apply to the out-of-pocket maximum.
6
New Hire Guide
