Page 7 - RS&A Benefits Enrollments Guide

Medical & Prescription Drug Plan

Blue Cross Blue Shield of NC
Group# 068677

Blue Options HSA Compatible
Transitional Plan
Benefit Highlights

In-Network Member Pays

Primary Care Physician Copay Deductible then 50%
Specialist Office Visit Copay Deductible then 50%

Preventive Care Visits 100% Covered
Emergency Room Services (waived if admitted) Deductible then 50%

Urgent Care Center Copay Deductible then 50%
Inpatient Hospital & Professional Charges Deductible then 50%
Outpatient Facility & Physician Charges Deductible then 50%

Prescription Drugs Deductible then 50%

Individual Annual Deductible $ 3,000

Individual Annual Coinsurance Maximum $ 2,000
Individual Annual Out-of-Pocket Maximum $ 5,000
Family Annual Deductible $ 7,000

Family Annual Coinsurance Maximum $ 1,000
Family Annual Out-of-Pocket Maximum $ 8,000

*On HSA plans, those with any coverage other than Employee Only, must meet the total family
deductible before any benefits are payable.

st
Deductibles and out-of-pocket maximums are accumulated on a plan year basis running from April 1
st
through March 31 of each year.

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