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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