Page 8 - Allegacy 2017 booklet 8.5x11
P. 8
Allegacy Benefit Solutions Page 8
Medical Benefits Group #070449
Provided by BlueCross BlueShield of NC
Member Responsibility
Benefit Feature Core Plan (In-Network) Buy Up Plan (In-Network)
Physician Office Visit;
Primary care physician
100% covered after deductible 100% covered after deductible
Specialist
Prescription Drugs:
Generic*
Preferred Brand
100% covered after deductible 100% covered after deductible
Non-preferred Brand
Annual Deductible:
$6,550 Individual $2,700 Individual
(see HSA on page 9) $13,100 Family $5,450 Family
Annual Out-Of-Pocket Max:
$6,550 Individual $2,700 Individual
$13,100 Family $5,450 Family
(includes Annual Deductible)
Emergency Room Visit 100% covered after deductible 100% covered after deductible
Urgent Care Facility 100% covered after deductible 100% covered after deductible
Chiropractic Care
(30 visits per year) 100% covered after deductible 100% covered after deductible
Lifetime Maximum Unlimited Unlimited
Inpatient Hospital Stay, Outpatient Sur-
gery, Professional Services, for Hospital & 100% covered after deductible 100% covered after deductible
Surgical, Maternity
Diagnostics & Testing: Lab,
X-ray, ultrasounds, EEG, EKG, CT scans, PET, 100% covered after deductible 100% covered after deductible
MRI, MRA, colonoscopy
