bluecrossandblueshieldofnorthcarolina:blueselectsilver …blueselectsilver 5000 coverageperiod:...

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Questions: Call 1-877-258-3334 or visit us at www.bcbsnc.com/booklets.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.cciio.cms.gov/programs/consumer/summaryandglossary/index.html or call 1-877-258-3334 to request a copy.

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Blue Cross and Blue Shield of North Carolina: Blue Select Silver 5000 Coverage Period: 01/01/2016 - 12/31/2016Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: PPO

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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in thepolicy or plan document at www.bcbsnc.com/booklets or by calling 1-877-258-3334.

Important Questions Answers Why this Matters:

What is the overalldeductible?

In-Network $5,000Individual / $10,000Family. Out-of-Network $10,000 Individual / $20,000 Family. Doesn'tapply to In-Networkpreventive care.Coinsurance andcopayments do not applyto the deductible.

You must pay all the costs up to the deductible amount before this planbegins to pay for covered services you use. Check your policy or plandocument to see when the deductible starts over (usually, but not always,

covered services after you meet the deductible.January 1st). See the chart starting on page 3 for how much you pay for

Are there otherdeductibles for specificservices?

Yes. $300 for prescriptiondrugs. There are no otherspecific deductibles.

You must pay all of the costs for these services up to the specific deductibleamount before this plan begins to pay for these services.

Is there an out–of–pocket limit on myexpenses?

Yes. In-Network $6,850Individual / $13,700Family. Out-of-Network $13,700 Individual / $27,400 Family.

The out-of-pocket limit is the most you could pay during a coverage period(usually one year) for your share of the cost of covered services. This limithelps you plan for health care expenses.


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Important Questions Answers Why this Matters:

What is not included inthe out–of–pocket limit?

Premiums, balance-billedcharges, health care thisplan doesn’t cover andpenalties for failure toobtain pre-authorizationfor services.

Even though you pay these expenses, they don't count toward the out-of-pocket limit.

Is there an overallannual limit on whatthe plan pays?

No.for specific covered services, such as office visits.The chart starting on page 3 describes any limits on what the plan will pay

Does this plan use anetwork of providers?

Yes. For a list ofIn-Network providers, seewww.bcbsnc.com/content/providersearch/index.htmor call 1-800-446-8053.

If you use an in-network doctor or other health care provider, this plan willpay some or all of the costs of covered services. Be aware, your in-networkdoctor or hospital may use an out-of-network provider for some services.Plans use the term in-network, preferred, or participating for providers in

different kinds of providers.their network. See the chart starting on page 3 for how this plan pays

Do I need a referral tosee a specialist?

No. You don't need areferral to see a specialist.

You can see the specialist you choose without permission from this plan.

Are there services thisplan doesn't cover?

Yes.policy or plan document for additional information about excluded services.Some of the services this plan doesn't cover are listed on page 10. See your

http://www.bcbsnc.com/content/providersearch/index.htm

http://www.bcbsnc.com/content/providersearch/index.htm


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• Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive theservice.

• Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service.For example, if the plan's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% wouldbe $200. This may change if you haven't met your deductible.

• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges morethan the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 foran overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

• This plan may encourage you to use in-network providers by charging you lower deductibles, copayments, andcoinsurance amounts.

Common Medical Event

Services You May Need

Your Cost* If You Use an In-networkProvider

Your Cost IfYou Use an

Out-of-networkProvider

Limitations & Exceptions

If you visit a healthcare provider's officeor clinic

Primary care visit to treat aninjury or illness

$25 copayment/visit

60% afterdeductible/ visit

---none---

Specialist visit

$50 copayment/visit for Tier 1 ;$75 copayment/visit for Tier 2

60% afterdeductible/ visit

---none---

Other practitioner office visit

$50 copayment/Chiropractic visitfor Tier 1 ; $75copayment/Chiropractic visitfor Tier 2

60% afterdeductible/Chiropractic visit

Limits may apply.

Preventivecare/screening/immunization

No Charge Not Covered Limits may apply.


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CommonMedical Event


Your Cost* IfYou Use anIn-networkProvider




If you have a test

Diagnostic test (x-ray, bloodwork)

30% afterdeductible/ visitfor Tier 1 ; 50%after deductible/visit for Tier 2

60% afterdeductible

No coverage for tests not ordered by adoctor.

Imaging (CT/PET scans,MRIs)


60% afterdeductible

Precertification may be required.


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CommonMedical Event






If you need drugs totreat your illness orcondition

More informationabout prescription drug coverage isavailable atwww.bcbsnc.com/content/services/formulary/presdrugben.htm

Tier 1 Drugs$10 copaymentafter prescriptiondrug deductible

$10 copaymentafter prescriptiondrug deductible

No coverage for drugs in excess ofquantity limits, or therapeuticallyequivalent to an over the counterdrug. For Infertility, dosage limitsapply.



Same as above.



Same as above.



Same as above.

Tier 5 Drugs25% afterprescription drugdeductible

25% afterprescription drugdeductible

Coverage is limited to a 30 daysupply.

If you haveoutpatient surgery

Facility fee (e.g., ambulatorysurgery center)

30% afterdeductible

60% afterdeductible

---none---

Physician/surgeon fees30% afterdeductible

60% afterdeductible

---none---

http://www.bcbsnc.com/content/services/formulary/presdrugben.htm




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CommonMedical Event






If you needimmediate medicalattention

Emergency room services$500 copayment/visit

$500 copayment/visit

---none---

Emergency medicaltransportation

30% afterdeductible

30% afterdeductible

---none---

Urgent care$50 copayment/visit

$50 copayment/visit

---none---

If you have ahospital stay

Facility fee (e.g., hospitalroom)

30% afterdeductible

60% afterdeductible


Physician/surgeon fee


60% afterdeductible

---none---


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CommonMedical Event






If you have mentalhealth, behavioralhealth, or substanceabuse needs

Mental/Behavioral healthoutpatient services

$50 copayment/office visit ; 30% afterdeductible/outpatient for Tier 1 /$75 copayment/office visit ; 50% afterdeductible/outpatient for Tier 2

60% afterdeductible


Mental/Behavioral healthinpatient services


60% afterdeductible


Substance use disorderoutpatient services

$50 copayment/office visit ; 30% afterdeductible/outpatient for Tier 1 /$75 copayment/office visit ; 50% afterdeductible/outpatient for Tier 2

60% afterdeductible


Substance use disorderinpatient services


60% afterdeductible



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CommonMedical Event






If you are pregnant

Prenatal and postnatal care

30% afterdeductible/ forTier 1 ; 50% afterdeductible/ forTier 2

60% afterdeductible

---none---

Delivery and all inpatientservices


60% afterdeductible



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CommonMedical Event






If you need helprecovering or haveother special healthneeds

Home health care30% afterdeductible

60% afterdeductible

Prior authorization may be requiredfor benefits to be provided.

Rehabilitation services $50 copayment60% afterdeductible

Coverage is limited to 30 visits perbenefit period for Rehabilitation andHabilitation services combined, forOccupational Therapy/PhysicalTherapy/Chiropractic and 30 visits perbenefit period for Speech Therapy.

Habilitation services $50 copayment60% afterdeductible

Coverage is limited to 30 visits perbenefit period for Rehabilitation andHabilitation services combined, forOccupational Therapy/PhysicalTherapy/Chiropractic and 30 visits perbenefit period for Speech Therapy.

Skilled nursing care30% afterdeductible

60% afterdeductible

Coverage is limited to 60 days perbenefit period. Precertificationrequired.

Durable medical equipment30% afterdeductible

60% afterdeductible

Prior authorization may be requiredfor benefits to be provided. Limitsmay apply.

Hospice service30% afterdeductible

60% afterdeductible

Precertification required for inpatientservices.


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CommonMedical Event






If your child needsdental or eye care

Eye exam $25 copayment60% afterdeductible

Limits may apply.

Glasses50% nodeductible

50% nodeductible

Limited to one pair of glasses orcontacts per benefit period.

Dental check-up No Charge30% afterdeductible

Limited to twice per benefit period.

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.)

• Acupuncture• Cosmetic Surgery and Services• Dental Care (Adult)• Routine Eye Care (Adult)

• Long Term Care, Respite Care, Rest Cures • Routine Foot Care• Weight Loss Programs• Abortion (Except in cases of rape, incest,

or when the life of the mother isendangered)

Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and yourcosts for these services.)

• Bariatric surgery• Chiropractic care

• Hearing aids up to age 22• Infertility Treatment• Non-emergency care when traveling

outside the U.S.Coverage provided outside the United States.See www.bcbsnc.com

• Private duty nursing


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Your Rights to Continue Coverage:Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if:

• You commit fraud

• The insurer stops offering services in the State

• You move outside the coverage area

For more information on your rights to continue coverage, contact BCBSNC at 1-800-446-8053. You may also contact your state insurance department at 1201 Mail Service Center, Raleigh, NC 27699-1201, or toll free 855-408-1212.

Your Grievance and Appeals Rights:If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: North Carolina Department of Insurance at 1201 Mail Service Center, Raleigh, NC 27699-1201, or toll free 855-408-1212.

Additionally, a consumer assistance program can help you file your appeal. Services provided by Health Insurance Smart NC are available through the North Carolina Department of Insurance. Contact Health Insurance Smart NC, North Carolina Department of Insurance, 1201 Mail Service Center, Raleigh, NC 27699-1201, Toll free: (855) 408-1212.

Does this Coverage Provide Minimum Essential Coverage?The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage.

Language Access Services:


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To see examples of how this plan might cover costs for a sample medical situation, see the next page.

About these CoverageExamples:

These examples show how this plan mightcover medical care in given situations. Usethese examples to see, in general, howmuch financial protection a sample patientmight get if they are covered underdifferent plans.

This isnot a costestimator.

Don't use these examples toestimate your actual costsunder this plan. The actualcare you receive will bedifferent from theseexamples, and the cost ofthat care will also bedifferent.

See the next page forimportant information aboutthese examples.


Having a baby(normal delivery)

Managing type 2 diabetes(routine maintenance of

a well-controlled condition)

Amount owed to providers: $7,540 Amount owed to providers: $5,400 Plan pays $1,840 Plan pays $2,800 Patient pays $5,700 Patient pays $2,600

Sample care costs: Sample care costs:Hospital charges (mother) $2,700 Prescriptions $2,900Routine obstetric care $2,100 Medical Equipment and Supplies $1,300Hospital charges (baby) $900 Office Visits and Procedures $700Anesthesia $900 Education $300Laboratory tests $500 Laboratory tests $100Prescriptions $200 Vaccines, other preventive $100Radiology $200 Total $5,400Vaccines, other preventive $40Total $7,540 Patient pays:

Deductibles $1,900Patient pays: Copays $600Deductibles $5,000 Coinsurance $0Copays $40 Limits or exclusions $80Coinsurance $500 Total $2,600Limits or exclusions $200Total $5,700

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Questions and answers about the Coverage Examples:

What are some of theassumptions behind theCoverage Examples?

• Costs don't include premiums.• Sample care costs are based on

national averages supplied by theU.S. Department of Health andHuman Services, and aren'tspecific to a particular geographicarea or health plan.

• The patient's condition was notan excluded or preexistingcondition.

• All services and treatments startedand ended in the same coverageperiod.

• There are no other medicalexpenses for any membercovered under this plan.

• Out-of-pocket expenses are basedonly on treating the condition inthe example.

• The patient received all care fromin-network providers. If thepatient had received care fromout-of-network providers, costswould have been higher.

What does a Coverage Exampleshow?For each treatment situation, the CoverageExample helps you see how deductibles, copayments, and coinsurance can add up. Italso helps you see what expenses might beleft up to you to pay because the service ortreatment isn't covered or payment is limited.

Does the Coverage Examplepredict my own care needs?

No. Treatments shown are just examples.The care you would receive for thiscondition could be different based onyour doctor's advice, your age, howserious your condition is, and many otherfactors.

Does the Coverage Examplepredict my future expenses?

No. Coverage Examples are not costestimators. You can't use the examples toestimate costs for an actual condition.They are for comparative purposes only.Your own costs will be differentdepending on the care you receive, theprices your providers charge, and thereimbursement your health plan allows.

Can I use Coverage Examples tocompare plans?

Yes. When you look at the Summaryof Benefits and Coverage for otherplans, you'll find the same CoverageExamples. When you compare plans,check the “Patient Pays” box in eachexample. The smaller that number, themore coverage the plan provides.

Are there other costs I shouldconsider when comparingplans?

Yes. An important cost is the premium you pay. Generally, thelower your premium, the more you'llpay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should alsoconsider contributions to accountssuch as health savings accounts(HSAs), flexible spendingarrangements (FSAs) or healthreimbursement accounts (HRAs) thathelp you pay out-of-pocket expenses.


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