Robeson County, NC | Plan Year: August 1, 2008 - July 31, 2009
   
 

Medical Plan
 

 

BCBSNC Blue Options PPO
 

Rates

     
 

BCBSNC Contact

  
     
     
     
 

 
     
 

 
 

 
 

Please call your Personnel Office for
all questions concerning this plan.

  
     
     

Flexible Spending Accounts  |  Accident Plan |  Cancer Plan | Dental Plan | Vision Plan | Medical Plan

Short Term Disability Plan  |  Long Term Disability Plan  |  Term Life Insurance  |  Whole Life Insurance 
 
 

 

 

 

BlueCross BlueShield Blue OptionsSM PPO Plan

In-Network

Out-of Network1
 

Physician Office Services
(See "Outpatient Clinic Services for "outpatient clinic" or "hospital-based" services)

Office Visit
Includes Office Surgery, Consultation, X-rays and Lab, and a benefit period maximum of 4 office visits for the assessment of obesity in and out of network. See "Inpatient & Outpatient Services"

Primary Care Provider
Specialist
 

 

 

 

 


$20 copayment
$40 copayment

 

 

 

 


70% after deductible
70% after deductible

Preventive Care

Routine Examinations, Well-Child Care, Immunizations, Pap Smears, Mammograms, Prostate specific, Antigen Tests (PSAs)

Primary Care Provider
Specialist

*Pap Smears, Mammograms, PSAs are covered Out-of Network
 

 





$20 copayment
$40 copayment

 





Not Available*
Not Available*

Therapies

Short term Rehabilitative Therapies (Maximums apply to Home, Office, and Outpatient Settings)

Physical/Occupational: 30 visits per Benefit Period; Speech Therapy: 30 visits per Benefit Period

Primary Care Provider
Specialist
 

 

 

 



$20 copayment
$40 copayment

 

 

 



70% after deductible
70% after deductible

Urgent Care and Emergency Room

Urgent care Centers
Emergency Room Visit
(Inpatient Hospital benefits apply if admitted. If held for observation, outpatient benefits apply. See "Inpatient and Outpatient Hospital Services".)
 

 

$40 copayment
$150 copayment

 

$40 copayment
$150 copayment

Ambulatory Surgical Center
 

90% after deductible

70% after deductible

Inpatient and Outpatient Hospital Services

Hospital and Hospital Based Services
Outpatient Clinic Services
Professional Services

Hospital and Professional
Outpatient Labs & Mammograms with surgery or other services

Outpatient Labs & Mammograms without surgery or other services

Outpatient X-rays, ultrasounds, and other diagnostic tests such as EEG’s & EKG’s

CT scans, MRI’s, MRA’s and PET scans in any location, including physician’s office.
 

 

90% after deductible
90% after deductible
90% after deductible


90% after deductible


100%


90% after deductible


90% after deductible

 

70% after deductible
70% after deductible
70% after deductible


70% after deductible


70% after deductible


70% after deductible


70% after deductible

Other Services

Skilled Nursing Facility (60 days per Benefit Period)

Home Health Care, Ambulance, Durable Medical Equipment and Hospice

Maternity
(Maternity Delivery includes Prenatal & Post- delivery care)Hospital Services (Delivery)
Professional Services (Delivery)

Transplants
Hospital Services
Professional Services

Infertility and Sexual Dysfunction Services
Up to $5,000 per lifetime
Primary Care Provider
Specialist
Hospital Services
Inpatient and Outpatient Professional Services

Vision Care
Comprehensive Eye Exam
 

 

90% after deductible

90% after deductible

 


90% after deductible
90% after deductible


90% after deductible
90% after deductible

 

$20 copayment
$40 copayment
90% after deductible
90% after deductible


$20 copayment

 

70% after deductible

70% after deductible

 


70% after deductible
70% after deductible


70% after deductible
70% after deductible

 

70% after deductible
70% after deductible
70% after deductible
70% after deductible


Benefits Not Available

Lifetime Maximum, Deductibles & Coinsurance Maximums

The following Deductibles and Coinsurance Maximums only apply to the services above.
 

Lifetime Benefit Maximum

Deductibles
Individual (per Benefit Period)
Family (per Benefit Period)
 

$5,000,000


$500
$1,500

$5,000,000


$1,000
$3,000

Coinsurance Maximum
Individual (per Benefit Period)
Family (per Benefit Period)
 


$2,000
$6,000


$4,000
$12,000

Prescription Drugs
Up to 30 day supply. 31-60 day supply is two copayments and 61-90 day supply is three copayments.

Infertility Drugs up to $5,000 per Lifetime Maximum.

MAC B Pricing, Brand Penalty

Tier 1 (Generic)
 

Tier 2 (Preferred Brand)
 

Tier 3 (Brand)

 

 

 



$10 copayment
 

$25 copayment
 

$40 copayment

 

 

 



Copayment + Charge over In-Network allowed amount

Copayment + Charge over In-Network allowed amount

Copayment + Charge over In-Network allowed amount
 

Mental Health and Substance Abuse Services
*Inpatient/Outpatient Certification is provided by Magellan Behavorial Health at 1-800-359-2422.

Mental Health Services

Office
(30 Visits per Benefit Period)
 Inpatient/Outpatient
(30 days per Benefit Period)
 

Certified*

 



$40 copayment

90% coinsurance

 Not-Certified1

 



70% coinsurance

70% coinsurance
 

Substance Abuse Services

Office Visit
Inpatient/Outpatient

Benefit Period Maximum
Lifetime Maximum
 

 

$40 copayment
90% coinsurance

 

70% coinsurance
70% coinsurance


$8,000
$16,000
1 NOTICE: Your actual expenses for covered services may exceed the stated coinsurance percentage or co-payment amount because actual provider charges may not be used to determine the payment obligations for BCBSNC and its members.

ADDITIONAL INFORMATION ABOUT BLUE OPTIONS FROM BCBSNC

Benefit Period
The period of time, usually 12 months as stated in the group contract, during which charges for covered services provided to a member must be incurred in order to be eligible for payment by BCBSNC. A charge shall be considered incurred on the date the service or supply was provided to a member.

Allowed Amount
The charge that BCBSNC determines using a methodology which is applied to comparable providers for similar services under a similar health benefit plan.

Coinsurance Maximum
The dollar amount of coinsurance a member must pay prior to BCBSNC paying 100% for certain services.

NOTE: In some plans, there is no coinsurance maximum; members are responsible for coinsurance once the deductible has been met.

Day and Visit Maximums
All day and visit maximums are on a combined In- and Out-of Network basis.

Utilization Management
To make sure you have access to high quality, cost-effective health care, we manage utilization through a variety of programs including certification, transplant management, concurrent and retrospective review.

If you have a concern regarding the final determination of your care, you have the right to appeal the decision. If you would like a copy of a benefit booklet providing more information about our Utilization Management programs, call the toll free number listed in your information packet.

Certification
Certification is a program designed to make sure that your care is given in a cost effective setting and efficient manner. If you need to be hospitalized, you must obtain certification. Non-emergency and non-maternity hospital admissions must be certified prior to the hospitalization. If the admission is not certified, a penalty will be applied.

For maternity admissions, your provider is not required to obtain certification from BCBSNC for prescribing a length of stay up to 48 hours for a normal vaginal delivery, or up to 96 hours for delivery by cesarean section. You or your provider must request certification for coverage for additional days, which will be given by BCBSNC, if medically necessary.

All inpatient and outpatient Mental Health and Substance Abuse services must be certified in advance by Magellan Behavioral Health.

In-network providers are responsible for obtaining certifications. The member will bear no financial penalties if the in-network provider fails to obtain the appropriate authorization. The member is responsible for obtaining certification for services rendered by an out-of-network provider. Obtaining certification for Mental Health and Substance Abuse services is the member’s responsibility. Failure to obtain certification for Mental Health and Substance Abuse services will result in these services being paid at the out-of-network benefit level.

Health and Wellness Program
Because we want to help you stay healthy, we offer a variety of wellness benefits and services. You can take advantage of HealthLine Blue, our 24-hour health information service, a health topics library, asthma and diabetes management and a prenatal program. You will also receive Active Blue, our quarterly health magazine, and have access to online health and wellness information at www.bcbsnc.com. With our program you can get health advice anytime you need it, so you can learn how to take charge of your health.

What is Not Covered?
The following are summaries of some of the coverage restrictions. A full explanation and listing of restrictions will be found in your benefit booklet. Your health benefit plan does not cover services, supplies, drugs or charges that are:

• Not medically necessary
• For injury or illness resulting from an act of war
• For personal hygiene and convenience items
• For inpatient admissions that are primarily for diagnostic studies
• For palliative or cosmetic foot care
• For investigative or experimental purposes
• For hearing aids or tinnitus maskers
• For cosmetic services or cosmetic surgery
• For custodial care, domiciliary care or rest cures
• For treatment of obesity, except for surgical treatment of morbid obesity, or as specifically covered by your health benefit plan
• For reversal of sterilization
• For treatment of sexual dysfunction not related to organic disease
• For conception by artificial means
• For self-injectable drugs in the provider’s office

A waiting period for coverage of pre-existing conditions may apply to your coverage. BCBSNC defines pre-existing conditions as those conditions for which medical advice, diagnosis, care or treatment was received or recommended within 6 months of the date that your [BCBSNC] coverage begins. You may receive credit toward the 12-month waiting period if your enrollment date is within 63 days of the termination of your previous health coverage.

The benefit highlights is a summary of Blue Options benefits. This is meant only to be a summary. Final interpretation and a complete listing of benefits and what is not covered are in and governed by the group contract and benefit booklet. You may preview the benefit booklet by requesting a copy of the Blue Options benefit booklet from BCBSNC Customer Services.

 

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Monthly Rates
 

Monthly Rates For Paricipants (Wellness)

Employee

No Cost to Employee

Employee & Child

$170.65
Employee & Family $311.20

 
Monthly Rates for Non-Participants (Wellness)

Employee (County pays $503.70)

$50.00

Employee & Child

$220.65
Employee & Family $361.20

 

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