 Download the BlueAdvantage® Plan Comparison in PDF
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| Benefit type/description |
Plan A:
Our most popular plan
In-network coverage1,2
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Plan B:
For the budget minded
In-network coverage1,2
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| Benefit period deductible The benefit period deductible is the amount you pay for some services before Blue Advantage pays its portion |
Deductible options: $250, $500, $1,000 or $2,500 |
Deductible options $500, $1,000, $2,500, $3,500 or $5,000 |
| Coinsurance Coinsurance is the percentage of the allowed amounts for covered services that BCBSNC will pay |
80 or 100%
(100% coinsurance is not available on the $2,500 deductible option) |
70% |
| Coinsurance maximum Once your coinsurance maximum is met, Blue Advantage covers 100% of all covered services for the rest of the benefit period |
100%
coinsurance plans: $0
80% coinsurance plans: $2,000 per individual, $4,000 per family |
$3,000 per individual,
$6,000 per family |
Lifetime benefits A maximum amount paid for covered services which is the extent of the Plan’s lifetime liability per
member |
Unlimited |
$5 million |
Physician office visits Primary doctors and specialists (including surgery, lab work, therapy and radiology performed by
the same doctor on the same day in office) |
100%
after a $15 copayment for primary physicians3 or a $30 copayment for specialists4 |
100%
after a $25 copayment for primary physicians3 or a $50 copayment for specialists4 |
| Prescription drugs No annual limit for generic drugs ($2,000 maximum for brand-name drugs per person per benefit) |
100%
after $10 copayment for generic, $35 or $50 for brand- name, or 25% member coinsurance for specialty brand5 |
100%
after $200 deductible per member, then $10 copayment for generic, $35 or $50 for brand-name, or 25% member coinsurance for specialty brand5 |
| Vision care Routine eye exam |
100%
after a $15 copayment |
Not available |
| Hospital care Inpatient facility, outpatient facility, drugs, blood, supplies, medical care, surgical care, therapy services, diagnostic tests, X-rays and lab work |
Coinsurance after benefit
period deductible |
Coinsurance after benefit
period deductible |
| Hospital care Outpatient laboratory tests and mammograms performed alone |
100%
with no deductible |
100%
with no deductible |
| Preventive care Routine physical exam, including gynecological exam; well-child and well-baby care (including periodic assessments and immunizations) |
100%
after a $15 copayment for primary physicians3 or a $30 copayment for specialists4 |
100%
after a $25 copayment for primary physicians3 or a $50 copayment for specialists4 |
Urgent care centers Services provided for a sudden or unexpected condition requiring prompt diagnosis or treatment to
prevent chronic illness, prolonged impairment or a more hazardous treatment |
100%
after a $30 copayment |
100%
after a $50 copayment |
Emergency room services Health care items and services furnished or required to screen for or treat an emergency medical
condition until the condition is stabilized |
100%
after a $150 copayment6(copayment waived if admitted) |
100%
after a $150 copayment6
(copayment waived if admitted) |
| Ambulatory surgery centers A licensed or certified nonhospital facility which has permanent facilities and equipment for the primary purpose of performing surgical procedures on an outpatient basis and does not provide inpatient accomodations |
Coinsurance after benefit
period deductible |
Coinsurance after benefit
period deductible |
| Mental health and substance abuse $2,000 maximum per person per benefit period, $10,000 lifetime per person; includes inpatient facility, inpatient professional and outpatient professional |
50%
after benefit period
deductible |
50%
after benefit period
deductible |
| Other services Durable medical equipment, home health care, and home infusion therapy, hospice care, private duty nursing, ambulance services, skilled nursing facilities (to 60 days per year) and dental accident |
Coinsurance after benefit
period deductible |
Coinsurance after benefit
period deductible |
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| Benefit type/description |
Plan C:
Our newest plan
In-network coverage1,2
|
Plan A, B & C:
Alternative options
Out-of-network coverage1,2
|
| Benefit period deductible The benefit period deductible is the amount you pay for some services before Blue Advantage pays its portion |
Deductible options: $1,000, $2,500, $3,500 or $5,000 |
Same as in-network |
| Coinsurance Coinsurance is the percentage of the allowed amounts for covered services that BCBSNC will pay |
50% |
Plan A: 70%, Plan B: 60%, Plan C: 40% |
| Coinsurance maximum Once your coinsurance maximum is met, Blue Advantage covers 100% of all covered services for the rest of the benefit period |
$3,000 per individual,
$6,000 per family |
When using out-of-network providers, your coinsurance maximum is twice the in network coinsurance maximum |
| Lifetime benefits A maximum amount paid for covered services which is the extent of the Plan’s lifetime liability per member |
$5 million |
Same as in-network |
Physician office visits Primary doctors and specialists (including surgery, lab work, therapy and radiology performed by
the same doctor on the same day in office) |
100%
after a $30 copayment for primary physicians3 or a $60 copayment for specialists4 |
70%
after benefit period deductible |
| Prescription drugs No annual limit for generic drugs ($2,000 maximum for brand-name drugs per person per benefit) |
100%
after $500 deductible per member, then $10 copayment for generic, $35 or $50 for brand-name, or 25% member coinsurance for specialty brand5 |
Same as in-network, plus the charges exceeding the allowed amount |
| Vision care Routine eye exam |
Not available |
Not available |
| Hospital care Inpatient facility, outpatient facility, drugs, blood, supplies, medical care, surgical care, therapy services, diagnostic tests, X-rays and lab work |
Coinsurance after benefit
period deductible |
Coinsurance after benefit period deductible |
| Hospital care Outpatient laboratory tests and mammograms performed alone |
100%
with no deductible |
Coinsurance after benefit
period deductible |
| Preventive care Routine physical exam, including gynecological exam; well-child and well-baby care (including periodic assessments and immunizations) |
100%
after a $30 copayment for primary physicians10 or a $60 copayment for specialists2 |
Not available7 |
Urgent care centers Services provided for a sudden or unexpected condition requiring prompt diagnosis or treatment to
prevent chronic illness, prolonged impairment or a more hazardous treatment |
100%
after a $60 copayment |
100%
after same copayment as in-network |
Emergency room services Health care items and services furnished or required to screen for or treat an emergency medical
condition until the condition is stabilized |
100%
after a $150 copayment (copayment waived if admitted) |
100%
after a $150 copayment6
(copayment waived if admitted) |
| Ambulatory surgery centers A licensed or certified nonhospital facility which has permanent facilities and equipment for the primary purpose of performing surgical procedures on an outpatient basis and does not provide inpatient accomodations |
Coinsurance after benefit
period deductible |
Coinsurance after benefit
period deductible |
| Mental health and substance abuse $2,000 maximum per person per benefit period, $10,000 lifetime per person; includes inpatient facility, inpatient professional and outpatient professional |
50%
after benefit period deductible |
50%
after benefit period deductible (Plans A & B)
40% after benefit period
deductible (Plan C) |
| Other services Durable medical equipment, home health care, and home infusion therapy, hospice care, private duty nursing, ambulance services, skilled nursing facilities (to 60 days per year) and dental accident |
Coinsurance after benefit
period deductible |
Coinsurance after benefit
period deductible |
|
| Limitations & exclusions |
 |
Like most health care plans, Blue Advantage has some limitations and exclusions. When your application is approved, you will receive a benefit booklet. It will contain detailed information about plan benefits, exclusions and limitations.
This is a partial list of benefits that are not payable:
• Services for or related to conception by artificial means or for reversal of sterilization
• Treatment of sexual dysfunction not related to organic disease
• Treatment for transsexualism, sex changes or modifications including surgery
• Services that are investigational in nature
• Services for complications or side effects arising from excluded services, procedures or treatments
• Services that are not medically necessary
• Dental care except as provided in your benefit booklet
• 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 the effective date of coverage
• Custodial care, domicilary care or rest cures
• Eyeglasses or contact lenses or refractive eye surgery
• Vision exams except for some diagnoses (covered by Plan A only)
• Services to correct nearsightedness or refractive errors; hearing aids,
supplies, tinnitus maskers, or exams for hearing aids
• 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
• Service for maternity or elective abortion, except as provided by the maternity 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
• Services that are the result of war or while in military service
• Services for which a charge is not normally made in the absence ofinsurance, 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
• Telephone consultations; charges for failure to keep scheduled visits, for completion of any form, or for medical information required by the plan
• 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 automatically renews. Your coverage may be canceled by BCBSNC for failure to pay premiums and for false statements on your application, among other reasons. Coverage for dependent children ends at age 26. Members will be notified 30 days in advance of any change in coverage. Any change in your rate will be preceded by a 30-day notice and is guaranteed for 12 months. A waiting period for coverage of pre-existing conditions may apply to your coverage.13 This brochure contains a summary of benefits only. It is not your insurance policy. Your M58, 7/07 policy is your insurance contract. If there is any difference between this brochure and the policy, the provisions of the policy will control.
Please note: Blue Advantage is not a High Deductible Health Plan (HDHP) under the Tax Code, and therefore is not intended to be paired with a Health Savings Account.
1 All services subject to the allowed amount.
2 Your 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.
3 Primary physicians are in-network providers designated by BCBSNC as a primary care provider (PCP). Please check with BCBSNC to confirm your provider is in our network.
4 Some services and supplies received by members in an office setting or in connection with an office visit are in fact outpatient hospital-based services provided by hospital-owned or operated practices. These services and supplies may be subject to your deductible and coinsurance. Please see the BCBSNC provider listing to identify these providers.
5 Prescription drug benefits are divided into four drug-formulary tiers with varying copayment/coinsurance amounts based on the tier placement of a drug. Specific drug information can be found on the Prescription Drug Search tool at bcbsnc.com. Diabetic supplies are covered at 75% under the prescription drug benefit. In addition, benefits are provided for overthe- counter drugs when listed as covered in the formulary and a provider’s prescription for that drug is presented at the pharmacy. Specialty brand drugs require member coinsurance.
6 If admitted to the hospital from the emergency room, inpatient hospital benefits apply to all covered services provided. If held for observation, outpatient benefits apply to all covered services provided. If you are sent to the emergency room from an urgent care center, you may be responsible for both the emergency room copayment and the urgent care copayment.
7 Only gynecological exams, cervical cancer screening, ovarian cancer screening, screening mammograms, colorectal screening and prostate specific antigen (PSA) tests are covered out-of-network subject to benefit period deductible and coinsurance.
An independent licensee of the Blue Cross and Blue Shield Association. ‰, SM Marks of the Blue Cross
and Blue Shield Association. SM1 Mark of Blue Cross and Blue Shield of North Carolina. U2074, 11/07
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