Page 9 - 2016 Benefit Booklet AYN

Page 9

Medical Benefits Provided by BlueCross BlueShield of NC
Blue Options 1-2-3

Member Responsibility
Benefit In-Network Non-Network
Physician Office Visit;
Primary care physician $35 copay Deductible then 50%
Specialist Deductible then 50% Deductible then 50%

Prescription Drugs:
Generic $10 Copayment + charge over
Preferred Brand 100% to a maximum of in-network allowed
Non-preferred Brand $100 for a amount
Specialty Brand 30-day supply

Annual Deductible $3,500 Individual $7,000 Individual
$7,000 Family $14,000 Family

Annual Out-Of-Pocket $6,600 Individual $13,200 Individual
Maximum (includes $13,200 Family $26,400 Family
deductible)

Emergency Room Visit Deductible then 50% Deductible then 50%

Urgent Care Facility Deductible then 50% Deductible then 50%

Routine Eye Exam 0% (plan covers 100%) N/A
(1 covered every
year)

Inpatient Hospital Stay /
Outpatient Surgery, Deductible then 30%; and Deductible then 60%; and
Professional Services $250 copay per admission $500 copay per admission
for Hospital & Surgical, for inpatient only for inpatient only
Maternity

Diagnostics & Testing:
Lab, X-ray, ultrasounds, Deductible then 50% Deductible then 40%
EEG, EKG, CT scans,
PET, MRI, MRA,
colonoscopy