Dental
Includes surgery, lab work, therapy and radiology performed by the same doctor on the same day in office. Copayments do not apply to deductible.
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This rate quote is an estimate based on your age, gender and location. Final rates are determined after you complete an application.
The rates quoted on the following page are valid from January 1, 2013 through December 31, 2013.
Apply by for your coverage to start as soon as .
Rates quoted are valid between 01/01/2013 through 12/31/2013.
: Most popular plans
U6262, 09/10
| plan name/button | plan name/button | plan name/button | |
| Deductible | |||
| Coinsurance | |||
| Coinsurance Maximum | |||
| Preventive Care | |||
| Primary Physician
What would it cost if...? You see your primary care doctor for flu-like symptoms. Average billed amount: $106* *Figures are for illustrative purposes only. |
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| Specialist Physician
What would it cost if...? Your knee has been hurting a lot lately and you need to see an orthopedic specialist. Based on the average billed amount for a visit like this, you would pay $125 without insurance.* *Figures are for illustrative purposes only. |
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| Prescription Drugs | |||
| Urgent Care | |||
| Emergency Room
What would it cost if...? You injure your leg while exercising and have to go to the emergency room. Based on the average billed amount for a visit like this, you would pay $1,381 without insurance.* *Figures are for illustrative purposes only. |
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| Hospitals and Major Medical Procedures
What would it cost if...? You have a heart attack and need to be admitted to the hospital for a coronary artery bypass. Based on the average billed amount for a hospital stay like this, you would pay $68,563 without insurance.* *Figures are for illustrative purposes only. |
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| Vision | |||
| Mental Health & Substance Abuse | |||
| Other Services | |||
| Maternity Coverage |
| Dental Deductible |
$75 |
|---|---|
| Preventive Dental Services |
You pay nothing for 2 cleanings and checkups. (No deductible and no waiting period) |
| Basic Services |
You pay 40% after the deductible is met. 6 month waiting period |
| Major Services |
You pay 50% after the deductible is met. (12 month waiting period) |
| Annual Maximum |
$1,000 |
Notice: Your actual expenses for covered services may exceed the stated coinsurance percentage because actual provider charges may not be used to determine the health benefit plan's and member's payment obligations.
U6262 09/10
ψ Blue Value has a closed formulary. A closed formulary only covers the specific drugs and device listed in the formulary.
§ Once BCBSNC has paid $2,000 for all brand drugs, then the member pays 50% coinsurance and the copayment no longer applies.
β The first claim received by BCBSNC will be considered the first visit.
* If you choose a brand-name drug when a generic is available, you may pay the difference between the brand-name and generic in addition to any applicable copayment.
** All services are subject to the allowed charge amount. When using out-of-network providers, any amount charged over the allowed amount may be your responsibility. Out-of-network benefits have higher deductible and coinsurance amounts than in-network benefits.
® Mark of the Blue Cross and Blue Shield Association. SM Blue Value Mark of Blue Cross and Blue Shield of North Carolina.
All services are subject to the allowed charge amount. When using out-of-network providers, any amount charged over the allowed amount may be your responsibility. Out-of-network benefits have higher deductible and coinsurance amounts than in-network benefits.
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Your rate quote is an estimate based on your age, gender and where you live. When you apply for coverage, BCBSNC reviews your health status and medical history to determine your actual rate.
Prior to enrolling, if approved, you'll be presented your final rate. You can accept the coverage, make changes to your plan that may lower your rate, or you can cancel your application.
| % of People Who Receive This Rate | |
|---|---|
| Preferred Plus | 19% |
| Preferred Rate (quoted rate) |
39% |
| Standard | 18% |
| Basic | 6% |
| Basic 5 | 5% |
| Medically Ineligible | 13% |
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Maternity rate: Please note that your maternity rate is in addition to the rates shown above and will be the same for all rate tiers. |
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Dental rate: Please note that your dental rate is in addition to the rates shown above and will be the same for all rate tiers. |
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* These estimates are averaged from applications submitted in the past year.The Medically Ineligible category does not apply to applicants under the age of 19.
** In some circumstances dependents are not eligible for Preferred Plus rates.
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Includes primary doctors and specialists, including surgery, lab work, therapy and radiology performed by the same doctor on the same day in office. Copayments don't apply to deductible.
What you pay each year for covered medical expenses before your health insurance begins paying toward those expenses. A general rule of thumb: The higher your deductible, the lower your premium.
A fixed-dollar amount that's payable at the time a covered service is provided.
The amount you pay for covered services before your health insurance plan pays for all or part of the remaining covered services.
The percentage you pay for covered services after you meet your deductible.
The total amount of coinsurance you have to pay for covered services per benefit period. Deductibles, copayments and amounts exceeding the allowed amounts for covered services don't apply.
Routine physical exams, including gynecological exams, well-child and well-baby care, including periodic assessments and immunizations.
Routine eye exams
Includes surgery, lab work, therapy and radiology performed by the same doctor on the same day in office. Copayments do not apply to deductible.
Includes surgery, lab work, therapy and radiology performed by the same doctor on the same day in office. Copayments do not apply to deductible.
No annual limit for generic drugs. For brand name drugs, the following benefits apply:
Blue Advantage A, B, C, Blue Advantage Saver 1, Blue Value A and B - Once BCBSNC has paid $2,000 for all brand name drugs then the member pays 50% coinsurance and the copayment no longer applies.
Blue Advantage Saver 2 and 3 - No brand name drug coverage.
Blue Value C and D - No yearly benefit limits on covered brand name drugs.
Blue Options HSA - Prescription drug benefits are subject to the plan deductible and coinsurance.
No annual limit for generic drugs. Brand name drugs are covered at 50% after $2,000 in brand name drug coverage per person, per benefit period.
No annual limit for generic drugs. Brand name drugs are not covered.
Prescription drug benefits are subject to the plan deductible and coinsurance.
No annual limits for covered generic or brand name drugs.
Services provided for a sudden or unexpected condition requiring prompt diagnosis or treatment to prevent chronic illness, prolonged impairment or a more hazardous treatment.
Health care items and services furnished or required to screen for or treat an emergency medical condition until the condition is stabilized.
Inpatient and outpatient facility services, drugs, blood, supplies, medical care, surgical care, therapy services, diagnostic test, x-rays, lab work.
Five inpatient days and 10 outpatient visits per person, per benefit period.
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.
Your recommended plan.
Services covered under deductible and coinsurance, without office visit copayments or a separate deductible.
The family deductible is met using all eligible medical expenses from each family member. Each family member contributes to this single deductible amount.
The family deductible is met after three family members have each met their individual deductibles.
The family deductible is met after three family members have each met their individual deductibles.
The family deductible is met after three family members have each met their individual deductibles. For $10,000 and $20,000 deductible options, the deductible is satisfied after two family members have each met their individual deductible.
The family deductible is met after two family members have each met their individual deductibles.
| Dental Benefits | ||
| Dental Deductible: | $75 | |
| Preventive Dental Services: | You pay nothing for two checkups and cleanings per benefit period (with no deductible and no waiting period). | |
| Basic Services: | You pay 40% after dental deductible is met (6 month waiting period). | |
| Major Services: | You pay 50% after dental deductible is met (12 month waiting period). | |
| Annual Maximum (All services): | $1,000 | |
The maternity rider is available for females (subscriber or spouse), ages 18 or older, who aren't pregnant at the time of enrollment and aren't on a child-only policy. An extra monthly charge applies for this option.
The maternity rider can be added during the annual renewal period (November for a January 1 effective date), as long as the policy has been in effect for at least 6 months; within 30 days following marriage (requires copy of marriage certificate); or upon adding your spouse as a dependent for reasons other than marriage (requires supporting documentation).
Please note that the maternity rider covers maternity services under the core health plan's deductible and coinsurance. There are usually no office visit co-payments and no separate deductible for maternity coverage. Complications from pregnancy are covered under Blue Advantage or Blue Options HSA, even if you don't have the maternity rider.1
Your newborn can be added to your existing policy within 30 days of the date of birth (without medical underwriting), regardless of whether you have the maternity rider. Coverage is effective as of the baby's date of birth, so long as your policy was active on your newborn's day of birth.
1 Please refer to our Member Guide for more details.
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