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MEDICAL PLANS
City of Raleigh offers a choice of medical plan options so you can choose the plan that best meets your needs – and those of your family. Each plan includes comprehensive health care benefits, including free preventive care services.
Medical benefits are administered by Blue Cross Blue Shield of North Carolina.
PLAN PROVISION
Annual Deductible (Individual / Family)
Out-of-Pocket Maximum
(Individual / Family) includes deductible
Lifetime Maximum
Preventive Care
Primary Physician Office Visit
Specialist Office Visit
X-Ray and Lab
Rehabilitative & Habilitative Therapies –
visit limits apply
Chiropractic Services – visit limits apply
Inpatient Hospital Services
Outpatient Hospital Services
Chiropractic Services
visit limits apply
Inpatient Hospital Services
Outpatient Hospital Services
Urgent Care
Emergency Room Care
Mental Health & Substance Abuse – Office Visit
Mental Health & Substance Abuse – Inpatient or Outpatient Services
Vision - Routine Eye Exam
Vision - Hardware Limit
Transgender Services
precertification and limits apply
Nutrition Counseling
visit limits apply
IN-NETWORK
$500 / $1,000
$2,500 / $5,000
100%
$20 copay
$40 copay
80% *
$40 copay
$20 copay
80% *
80% *
$20 copay
80% *
80% *
$20 copay
80% *
100%
PLAN A
Unlimited
$40 copay
$200 copay
$130 allowance, then 10%
80% *
100%
OUT-OF-NETWORK
$1,000 / $2,000
$4,000 / $8,000
70% *
70%*
70% *
70% *
70%*
70%*
70% *
70% *
70%*
70% *
70% *
70% *
70% *
Not Covered
70% *
70% *
IN-NETWORK
$1,000 / $2,000
$3,500 / $7,000
100%
$25 copay
$45 copay
80% *
$45 copay
$25 copay
80% *
80% *
$25 copay
80% *
80% *
$25 copay
80% *
100%
PLAN B
Unlimited
$45 copay
$250 copay
$130 allowance, then 10%
80% *
100%
OUT-OF-NETWORK
$2,000 / $4,000
$5,500 / $11,000
50% *
50% *
50% *
50%*
50% *
50%*
50% *
50%*
50%*
50% *
50%*
50%*
50%*
Not Covered
50%*
50%*
*After deductible is met.
Note: This is a summary only of your coverage. Please refer to your summary plan description for the full scope of services. In-network services are based on negotiated charges; out-of-network services are based on reasonable and customary (R&C) charges.
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