Medical
Medical coverage offers healthcare protection for you and your family. You may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.
Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need care.
Words to Know:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums– the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
BCBSNC PPO
Plan Information
Plan Name: BCBSNC PPO
Policy Number: 14167203
Effective Date: 01/01/2025
Provider Network: Blue Cross Blue Shield of NC
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$0/$0
Preventive Care
$0
Primary Care Visit
$0
Specialist Visit
$0
Urgent Care
$0
Emergency Room
$0
Retail Rx (Up to 30-Day Supply)
Generic
$0
Preferred Brand
$0
Non-Preferred Brand
$0
Specialty
$0
Mail-Order Rx (Up to 90-Day Supply)
Generic
$0
Preferred Brand
$0
Non-Preferred Brand
$0
Specialty
$0
Out-of-Network
Deductible (Individual/Family)
$1,000/$2,000
Out-of-Pocket Max (Individual/Family)
$2,000/$4,000
Preventive Care
80% coinsurance after deductible
Primary Care Visit
80% coinsurance after deductible
Specialist Visit
80% coinsurance after deductible
Urgent Care
$0 after deductible
Emergency Room
$0 after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$0 after deductible + charge over in-network allowed amount
Preferred Brand
$0 after deductible + charge over in-network allowed amount
Non-Preferred Brand
$0 after deductible + charge over in-network allowed amount
Specialty
$0 after deductible + charge over in-network allowed amount
Mail-Order Rx (Up to 90-Day Supply)
Generic
$0 after deductible + charge over in-network allowed amount
Preferred Brand
$0 after deductible + charge over in-network allowed amount
Non-Preferred Brand
$0 after deductible + charge over in-network allowed amount
Specialty
$0 after deductible + charge over in-network allowed amount