Page 7 - Walter Robbs 2018 Benefit Guide
P. 7
Medical & Prescription Drug Plan
Group # 14151058
Blue Cross Blue Shield of NC
Blue Options Silver 2500 CX
Benefit Highlights
In-Network Member Pays
Primary Care Physician Copay $25
Specialist Office Visit Copay $75
Preventive Care Visits 0% (Plan covers 100%)
Emergency Room Services (waived if admitted) $1,000
Urgent Care Center Copay $75
Inpatient Hospital & Professional Charges Deductible then 40%
Outpatient Facility & Physician Charges Deductible then 40%
Prescription Medication Copay:
Tier 1 $20
Tier 2 $35
Tier 3 $45
Tier 4 $90
25% (min $50 – max $200 per 30 day
Tier 5
supply)
50% (min $50 – max $300 per 30 day
Tier 6
supply)
Individual Annual Deductible $2,500
Individual Annual Coinsurance Maximum $4,850
Individual Annual Out-of-Pocket Maximum $7,350
Family Annual Deductible $5,000
Family Annual Coinsurance Maximum $9,700
Family Annual Out-of-Pocket Maximum $14,700
Your annual Out-of-Pocket Maximum includes deductible, coninsurance and copayments.
How do I avoid extra cost?
Sometimes you go to the doctor for preventive care and end up with a charge on your bill. You can avoid costs when you go to
your appointment by following these steps:
1. When you schedule your appointment, say that you want preventive care screenings and tests that are 100% covered
by your plan.
2. Ask if any tests or treatments done during your appointment might not be considered preventive care.
3. Ask if talking about other health problems that are not considered preventive care during your appointment will lead
to extra costs.
4. Ask if lab work can be sent to a Blue Cross NC in-network lab to lower your costs.
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