Make the most of your plan

Knowing these words and phrases will help you better understand how your health plan works.

Log in to your Blue Connect^℠ account. It’s right there on the homepage.

An allowed amount is the amount in-network doctors and health care facilities have agreed to accept as full payment on covered services for Blue Cross NC members. It’s usually lower than their normal charge.

Your copayment (copay) is how much you pay for medical services when you receive them. It’s a fixed cost you pay when you check out at the doctor’s office (usually around $20 or so – though the cost varies by plan). Not all plans have a copay.

Your deductible is the set amount you pay toward medical services  before  Blue Cross NC starts paying toward those services during your benefit period (plan year).

Your coinsurance is the share of medical costs you pay after you’ve met your deductible for your benefit period (plan year). Coinsurance amounts (usually 10–30%) vary based on plan and type of provider. Not all plans have coinsurance.

This is the limit on the amount of money you can pay during a plan year. If you meet the out-of-pocket limit, we pay 100% of covered medical services and procedures.

The Open Enrollment Period (OEP) is the one time a year when you can make changes for the next plan year. Your employer will tell you when your OEP is and give you information to help you make coverage decisions. If you have questions, your Human Resources (HR) department can help.

You can make changes at other times if you have a qualifying life event. You’ll find a list of the most common qualifying life events below. Check this list and talk to your company’s HR department to see if you can make changes to your plan outside of OEP. (Having a situation on this list is not a guarantee that you can make changes. Please talk to your HR representative.)

The fastest way to find answers is through your Blue Connect account. To connect directly with a Customer Service specialist:

Log in to Blue Connect or the Blue Connect Mobile NC app and use the secure inbox to message Customer Service.

Call the Customer Service number on the back of your member ID card. Don’t have your card? You can find the right number on Blue Connect!

• You involuntarily lose your main health coverage
• Your household size changes (for example, if you have a baby, or if someone is no longer your dependent)
• Your home address changes
• You’re eligible for coverage when you weren’t before
• You used to have help paying for coverage and you no longer do
• There is an error in your plan, or there was an error when you enrolled in your plan

Other life events, such as natural disasters and enrollment in government programs, may also make you eligible. Please see your HR department if you think your situation warrants a plan change.

One of the best ways to save money is to visit an in-network doctor or hospital. Our thoughtfully crafted networks provide savings and more coordinated care. When your primary care provider (PCP) is in your network, your out-of-pocket costs are lower. If you need a specialist, the network matters even more since costs can be higher.

What you pay for medical services can vary based on where you go. Different doctors charge different rates for the same service. Sometimes, working with the same doctor can cost you more at a different facility. Good news – we have a tool that lets you compare estimated costs for a range of services and procedures covered by your plan.

• Apparel & Footwear
• Fitness
• Hearing & Vision
• Home & Family
• Nutrition
• Personal Care

Joining Blue365 is easy – and taking advantage of the discounts is even easier.

Immunizations, like the flu shot

Annual wellness visit

Well-baby and well-child visits

Counseling and support:

• Alcohol misuse
• Nutrition
• Sexually transmitted infections
• Tobacco cessation

Screenings and tests:

• Blood pressure
• Cancer screenings, such as colon, breast and cervical
• Cholesterol
• Diabetes

Below are examples of health services that are not identified as preventive care by the Affordable Care Act (ACA). This means they are not 100% covered, and may cost you money at your doctor’s office or lab:

• Chest X-rays
• EKGs (electrocardiograms)
• Hormone tests
• Thyroid tests
• Urinalysis
• Vitamin D tests

This is not a complete list. Check your benefit booklet, ask your doctor, or contact Blue Cross NC Customer Service with questions about coverage, including whether a service is considered preventive care.

Beyond preventive care, you'll find a detailed list of services covered by your health plan in your benefit booklet. Read through it carefully to help avoid any unexpected costs when you go to the doctor.

The Blue Distinction Center³ program helps you find hospitals that meet specific quality standards for patient safety and outcomes. Blue Distinction Centers (BDC) are recognized for their specialty care expertise, and Blue Distinction Centers+ (BDC+) meet all the Blue Distinction quality standards but also deliver care at lower costs.

These highly-rated 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

Specialty care areas include:

• Bariatric Surgery
• Cardiac Care
• Knee and Hip Replacement
• Maternity Care
• Spine Surgery
• Substance Use Treatment and Recovery
• Transplants

Save money on your medications.

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

• Find in-network pharmacies
• Use the Find a Drug tool to look for lower cost options
• See how to cut down on medication costs
• Manage your prescriptions
• Choose between picking up prescriptions at a local retail pharmacy or having them delivered to your home via mail order

NOTE: If your employer does not provide prescription drug coverage through Blue Cross NC, you will not have access to the Blue Connect Prescriptions page. Check your benefit booklet for more information on your coverage.

A list of prescription drugs covered by your health benefit plan. Also called a drug list.

A select group of pharmacies that have contracted with Blue Cross NC to provide members access to medications at agreed-upon prices.

All medications are grouped into tiers within each formulary, which define coverage and copayment amounts. Generics are often in the lower tiers, while more specialized drugs are in higher tiers.

Some medications require approval from Blue Cross NC before they’re covered. This process helps manage costs and ensures that the member receives the correct medication at the proper dosage. Also called prior authorization.

For non-preferred prescription drugs, Blue Cross NC requires that a member first try a preferred drug in our formulary. Members may receive coverage for a non-preferred drug if the preferred equivalent proves not to work for them.

Medications are assigned to categories known as copayment or coinsurance tiers. They’re assigned based on drug usage, cost and clinical effectiveness. The lower the tier, the lower the cost to you. This means you can save money if you find an equally effective drug in a lower tier!

Our prescription drug search tool, available on Blue Connect, can show you which tier applies to a specific medication based on your benefits plan.

Your well-being depends on both physical and mental health. Blue Cross NC is working with both PCPs (primary care providers) and behavioral health (mental health + substance use) providers to help you get the care you need at the right time. We have programs, partnerships and tools to connect your health care team and find and treat any behavioral health concerns early, so you can live your best life.

• If you are in crisis, call the National Suicide Prevention Lifeline:⁴  800-273-8255.
• Access our Blue Connect member site to find an in-network provider. Search for keywords like: Psychologist, Psychiatrist, Social Worker, Therapist, Substance Use Facility or Counselor.
• Talk to your primary care provider. They can address your concerns in the office or refer you to a behavioral health provider. Get tips on how to talk to your doctor about mental health.
• Call Blue Cross NC: 800-359-2422. We will help connect you to a high-quality behavioral health provider or program.
• Use your Employee Assistance Program (EAP), if available.⁵
• Access therapy or psychiatry through your telehealth benefit, if available.⁶
• Use Shatterproof’s ATLAS^®⁠ to find an addiction and substance use disorder treatment facility for you or a loved one.⁷

Did you know personalized nutrition counseling is covered by most Blue Cross NC plans as preventive care? Check your benefit booklet for details. You can log in to Blue Connect to learn more, or find a nutrition counselor in your network with our Find a Doctor tool.

QuitlineNC offers Blue Cross NC members counseling and nicotine replacement therapy at no extra cost to you.⁸

Call  844-8NCQUIT (844-862-7848)  to quit for good.

Little things – done day-by-day – build healthy habits that can last a lifetime. The wellness resources and education information on Blue Connect can help. Keep an eye out for our emails and letters, too. You may find an invitation to join a special program or take a specific action to improve your health!