Make the most of your plan

The maximum amount that Blue Cross NC determines is reasonable for covered services provided to a member. The allowed amount includes any Blue Cross NC payment to the provider, plus any deductible, coinsurance, or copayment. (In-network providers accept this negotiated rate as payment in full. If you visit an out-of-network provider, they may charge you more than the allowed amount. That's why it is important to use in-network providers to get the best savings.)

The sharing of charges by Blue Cross NC and you for covered services, after you have met your benefit period deductible. This is stated as a percentage. The coinsurance listed is your share of the cost of a covered service.

The fixed dollar amount you must pay for some covered services at the time you receive them, if this health benefit plan includes copayments. Copays are not credited to the deductible; however, they are credited to the total out-of-pocket limit.

The amount of money you must pay for covered services in a benefit period before Blue Cross NC begins to pay for covered services. The deductible does not include coinsurance, charges in excess of the allowed amount, amounts exceeding any maximum, or charges for noncovered services.

The maximum amount of coinsurance that is payable by the member in a benefit period before Blue Cross NC pays 100% of covered services. It does not include the deductible or any applicable copayments.

Your annual Open Enrollment Period (OEP) is when you can make changes for the next plan year. Ask your employer’s Human Resources (HR) department about your OEP dates and other details.

You may be able to make changes at other times if you have a qualifying life event, such as:

• You get married or divorced
• You have or adopt a child
• You move
• Your job situation changes
• You lose your main health coverage (or a source of help with paying for coverage)
• You have an error in your plan / enrollment
• You experience a natural disaster or other life-changing event

(NOTE: These examples don't always apply to every person or situation. Your HR representative can confirm what applies to you.)

Special enrollment periods (SEPs) are available for individuals with qualifying life events. Details regarding SEP requirements can be found at www.healthcare.gov⁠.

Screenings

• Abdominal aortic aneurysm
• Blood pressure
• Cholesterol
• Colon cancer
• Depression
• Diabetes
• Lung cancer

Other services

• Immunizations, including flu shot
• Nutrition counseling
• Obesity screening and counseling
• Quitting tobacco
• Sexually transmitted infection (STI) counseling

Screenings

• Blood pressure
• Breast cancer counseling for genetic testing
• Cervical cancer screening (Pap test and / or HPV)
• Chlamydia and gonorrhea
• Cholesterol
• Colon cancer
• Depression
• Diabetes
• Lung cancer
• Mammogram (breast cancer)
• Osteoporosis

Other services

• Contraception
• Immunizations, including flu shot
• Intimate partner violence screening
• Nutrition counseling
• Obesity screening and counseling
• Quitting tobacco
• Sexually transmitted infection (STI) counseling

Screenings

• Bacteria in urine
• Gestational diabetes
• Hepatitis B
• Iron deficiency anemia
• Postpartum depression

Services

• Breastfeeding support, supplies, and counseling
• Folic acid supplementation

Routine screenings / services

• Developmental and behavioral
• Fluoride dental varnish and oral health check
• Hearing / vision test
• Immunizations, including flu shot
• Newborn and infant screenings
• Well-baby / well-child care

Other services

• Depression screening
• Lead exposure test
• Nutrition counseling
• Obesity counseling
• Sexually transmitted infection (STI) screening and counseling
• Tobacco and alcohol use counseling

• Chest X-rays
• Electrocardiograms (EKGs)
• Hormone tests
• Thyroid tests
• Urine test
• Vitamin D tests

The Blue Distinction^® Center program helps you find hospitals and other health care facilities that meet specific quality standards. Blue Distinction Centers are recognized for their specialty care expertise. Facilities with the Blue Distinction Centers+ designation meet these standards and also deliver care at lower costs. Depending on your plan, you may be eligible for a 10% discount when you use these facilities.³

Blue Distinction Centers feature:

• Doctors, nurses, and staff with a great deal of specialized experience
• The highest level of patient support at all stages of treatment
• Fewer complications after treatment

• Bariatric surgery
• Cancer care
• Cardiac care
• Knee and hip replacement
• Maternity care
• Spine surgery
• Substance use treatment and recovery
• Transplants

Availability may vary depending on your location.

Use the Find Care tool in your member portal and look for the BDC symbol next to the facility's name. Or, use the nationwide BDC Finder⁠ to search by state and area of specialty care needed.

If you have prescription drug coverage with Blue Cross NC, your member portal includes a Prescriptions section. From there, you can:

• Find in-network pharmacies
• Use the Find a Medication tool to look for lower cost options
• See other ways to cut down on medication costs
• Manage your prescriptions
• Opt for home delivery of eligible prescriptions

• Formulary: The list of outpatient prescription drugs, insulin, and certain over-the-counter drugs that may be available to members.
• Network: The group of health care providers, facilities, and pharmacies that have contracted with a specific health insurance plan to provide services to insured people at negotiated rates.
• Tiers: Categories of medications within your formulary, based on drug usage, cost, and clinical effectiveness. This helps determine how much you may have to pay for your medicine.
• Prior review (or prior authorization): The consideration of benefits for an admission, availability of care, continued stay, or other services, supplies, or drugs, based on the information provided and requirements for a determination of medical necessity of services and supplies, appropriateness, health care setting, or level of care and effectiveness.
• Step therapy: Covered prescription drugs or devices for which reimbursement by Blue Cross NC is conditioned on: 1) Blue Cross NC’s giving certification to prescribe the drug or device, or 2) the provider prescribing one or more alternative drugs or devices before prescribing the drug or device in question.
• Brand-name medicine: The proprietary name of the prescription drug that the manufacturer owning the patent places upon a drug product or on its container, label, or wrapping at the time of packaging.
• Generic medicine: A prescription drug that has the same active ingredient as a brand-name drug, has the same dosage form, and strength as the brand-name drug, and has the same mechanism of action in the body as the brand-name drug.

Learn more about these and see other definitions.

Check out this presentation⁠ for more tips on managing your prescriptions.

Medications are sorted into copayment or coinsurance tiers. The lower the tier, the lower the cost is to you. You can save money if you find an equally effective drug in a lower tier!

Our prescription drug search tool within your member portal can show you which tier applies to a specific medication based on your benefits plan.

Blue Cross NC works with both primary care providers and behavioral health (mental health + substance use) providers to help you get the care you need at the right time. We connect you with your health care team so they can find and treat any behavioral health concerns early.

• If you are in crisis, call or text the National Suicide and Crisis Lifeline at 988.⁴
• Call the Mental Health number on the back of your member ID card for questions around mental health benefits or claims.
• Use the member portal to find an in-network provider. Search for keywords like: Psychologist, Psychiatrist, Social Worker, Therapist, Substance Use Facility, or Counselor. You may be able to work with providers remotely through telehealth.⁵
• Talk to your primary care provider (PCP). They are the best starting point. If needed, they can refer you to a behavioral health provider. Get tips on how to talk to your doctor about mental health.
• Contact our Care Navigation team for help getting the right mental health support. Use the Find Care tool in the member portal or call the Care Navigation line at 800-755-0798.
• Use your Employee Assistance Program (EAP), if available.⁶ (Ask your employer’s HR representative about your options.)