Review the Plan Benefits for
Blue Advantage SaverSM
Take a look at the benefits of plans A, B and C.

Benefit Saver 1
In-network coverage17		 Saver 2
In-network coverage17		 Saver 3
In-network coverage17
Office visits - in network
Primary doctors and specialists, including surgery, lab work, therapy and radiology when performed by the same doctor on the same day in office. 		You pay $25 copayment for primary care physicians; coinsurance after deductible for specialists You pay17 $25 copayment for up to four primary care provider visits,18 then covered by deductible and coinsurance; for specialists, you pay coinsurance after deductible You pay $0 after deductible
Prescription drugs
No annual limit for generic drugs. Copayment for brand-name drugs up to $2,000, then you pay 50% coinsurance.		 After $500 deductible per member, you pay $10 copayment for generics, $45 or $65 for brand-name drugs, 25% coinsurance for specialty brands You pay $10 copayment for generics; members receive discounted rate for brand-name drugs7
Deductible
The amount you pay during the benefit period for some services before BCBSNC pays its portion.		 Deductible options: $1,000, $2,500, $3,500 or $5,000 Deductible options: $1,000, $2,500, $3,500, $5,000, $10,000 or $20,000 Deductible options: $10,000 or $20,000
Coinsurance
The percentage of covered medical expenses that you pay after you've paid your deductible.		 After deductible, you pay 30% After $1,000 - $5,000 deductible, you pay 40% After $10,000 or $20,000 deductible, you pay 0% After deductible, you pay 0%**
Coinsurance Maximum
The total amount of coinsurance you're required to pay for covered services in a year. Once you reach the coinsurance maximum, you will not have to pay any more for coinsurance for covered medical expenses for the remainder of the year.		 Individual: $3,000
Family: $6,000		 Individual: $4,000; Family: $8,000; For $10,000 or $20,000 deductible options, you pay $0 after deductible For Individual and Family, you pay $0 after deductible
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Provide services for a sudden or unexpected condition requiring prompt diagnosis or treatment to prevent chronic illness, prolonged impairment or a more hazardous treatment. Examples: sprains, some lacerations and dizziness.		 After deductible, you pay coinsurance
Vision
Routine eye exam.		 You pay $25 copayment After deductible, you pay $0
All three Blue Advantage SaverSM plans have these benefits
Preventive care
Routine physical exams, including gynecological exam; well-child and well-baby care, including periodic assessments and immunizations. Visit bcbsnc.com/preventive for details. 		You pay $0; preventive services are covered at 100%6
Out-of-pocket expenses
The total amount of money you pay out of pocket in a benefit period.		 You pay deductible(s), coinsurance (up to the maximum) and copayment(s)
Lifetime maximum
The maximum amount BCBSNC will pay per member for covered services. BCBSNC plans offer unlimited coverage for the lifetime of the policy.		 Unlimited
Hospital
Inpatient and outpatient facility services, drugs, blood, supplies, medical care, surgical care, therapy services, diagnostic tests, X-rays, lab work.		 For inpatient, you pay coinsurance after benefit period deductible
Emergency room services
Services for the sudden onset of a condition that a person could reasonably expect the absence of immediate medical attention to result in placing one’s health at risk.		 After deductible, you pay coinsurance
Ambulatory surgery centers
A licensed or certified non-hospital facility that has permanent facilities and equipment for the primary purpose of performing surgical procedures on an outpatient basis and does not provide inpatient accommodations.		 For Saver plans 1 and 2, you pay coinsurance after deductible; for Saver plan 3, you pay $0 after deductible
Mental health and substance abuse
Inpatient and outpatient professionals. Includes 10 office (or) outpatient visits and five inpatient day limits.		 After deductible, you pay: 50%
Other services*
Durable medical equipment, home health care, home infusion therapy, hospice care, private duty nursing, ambulance services, skilled nursing facilities (to 60 days per year) and dental accident-related services.		 For Saver plans 1 and 2, you pay coinsurance after deductible; for Saver plan 3, you pay $0 after deductible
Maternity rider
Pre- and post-natal coverage.		 Maternity rider available: Cost depends on the deductible and coinsurance you select
Child-only coverage
Coverage for children 18 years of age and younger.		 Available

* High-tech diagnostic imaging scans, such as CT scans, MRIs, MRAs and PET scans, are subject to deductible and coinsurance payments regardless of where service is provided. Prior review (prior plan approval) is required for these services.

Limitations & Exclusions

Like most health care plans, Blue Advantage, Blue Advantage Saver and Blue Options HSA have some limitations and exclusions. You must qualify medically. If your application is approved, you will receive a Member Guide. It will contain detailed information about your plan benefits, exclusions and limitations.

This is a partial list of benefits that are not payable to Blue Advantage, Blue Advantage Saver or Blue Options HSA:

  • Services for or related to conception by artificial means or for reversal of sterilization
  • Treatment of sexual dysfunction not related to organic disease
  • Treatment or studies leading to or in connection with sex changes or modifications and related care
  • Services that are investigational in nature or obsolete, including any service, drugs, procedure or treatment directly related to an investigational treatment
  • Side effects and complications of noncovered services, except for emergency services in the case of an emergency
  • Services that are not medically necessary
  • Dental services provided in a hospital, except as specifically covered by your health benefit plan
  • Services or expenses that are covered by any governmental unit except as required by Federal law
  • Services received from an employer-sponsored dental or medical department
  • Services received or hospital stays before (or after) the effective dates of coverage
  • Custodial care, domiciliary care or rest cures
  • Eyeglasses or contact lenses or refractive eye surgery
  • Services to correct nearsightedness or refractive errors
  • Services for cosmetic purposes
  • Services for routine foot care
  • Travel, except as specifically listed in the benefit booklet
  • Services for weight control or reduction, except for morbid obesity, or as specifically covered by your health benefit plan
  • Services for maternity or elective abortion except as provided by the maternity rider option, if purchased
  • Inpatient admissions that are primarily for physical therapy, diagnostic studies, or environmental change
  • Services that are rendered by or on the direction of those other than doctors, hospitals, facility and professional providers; services that are in excess of the customary charge for services usually provided by one doctor when done by multiple doctors
  • For any condition suffered as a result of any act of war or while on active or reserve military duty
  • Services for which a charge is not normally made in the absence of insurance, or services provided by an immediate relative
  • Non-prescription drugs and prescription drugs or refills which exceed the maximum supply
  • Personal hygiene, comfort and/or convenience items
  • For telephone consultations, charges for failure to keep a scheduled visit, charges for completion of a claim form, charges for obtaining medical records, and late payment charges
  • Services primarily for educational purposes
  • Services for conditions related to developmental delay and/or learning differences
  • Long-term rehabilitative therapy
  • Services not specifically listed as covered services

Your coverage will automatically renew. Your coverage may be canceled by Blue Cross and Blue Shield of North Carolina (BCBSNC) for fraud or intentional misrepresentation of information on your application. Coverage for dependent children ends at age 26. Members will be notified 30 days in advance of any change in coverage. A waiting period for coverage of pre-existing conditions may apply to your coverage.21 (Pre-existing conditions apply only to adults age 19 and older and do not apply to children age 18 or younger.) The policy form number for Blue Advantage is PPO-I, 6/11. This brochure contains a summary of the benefits only. It is not your insurance policy. Your policy is your insurance contract. If there is any difference between this brochure and the policy, the provisions of the policy will control.

Blue Advantage is not a high-deductible health plan (HDHP) under the federal tax code, and therefore is not intended to be paired with a health savings account (HSA). Benefits and premiums vary depending on plan selected.

6 Preventive care services as defined by recent federal regulations are covered at 100% in-network. For Blue Advantage and Blue Advantage Saver plans, coverage for certain preventive care services (such as routine physical exams, well-baby and well-child care, and immunizations) is limited to in-network benefits only. However, state-mandated preventive services are available out-of network, for which members will pay deductible and coinsurance, plus charges over the allowed amount. Blue Options HSA in-network preventive care services are covered at 100%, and out-of-network preventive care services are covered at 70%. Visit bcbsnc.com/preventive for more details.
7 Brand-name drugs do not apply towards deductible and coinsurance on Blue Advantage Saver 2 and 3.
17 For Blue Advantage and Blue Advantage Saver: All services are limited to the allowed amount. If you see an out-of-network provider, actual expenses for covered services may exceed the stated coinsurance percentage or copayment amount because actual provider charges may not be used to determine the health benefit plan’s and member’s payment obligations. For Blue Options HSA: All services are limited to the allowed amount. BCBSNC allowed amount is the amount that BCBSNC determines is reasonable for covered services provided to a member, which may be established in accordance with an agreement between the provider and BCBSNC. If you use an in-network provider, you will only be responsible for your deductible and any coinsurance amounts.
18 Blue Advantage and Blue Advantage Saver primary physicians are in-network providers designated by BCBSNC as a primary care provider (PCP). Please check with BCBSNC to confirm that your provider is in our network.
21 Pre-existing conditions apply only to adults age 19 and older and do not apply to children age 18 or younger. Pre-existing conditions are those for which medical advice, diagnosis, care or treatment was received or recommended within the 12 months immediately preceding the date that your plan’s coverage begins. You may receive credit toward the 12-month waiting period if you have not had a break in coverage of more than 63 consecutive days between your prior health plan and this health plan, and if we receive proof of such prior coverage.

U5079b, 11/11