Mark III Employee Benefits - Henderson County, NC

Physician Office 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.
Primary Care Provider
Specialist

Preventive Care
Routine Examinations, Well-Child Care, Immunizations, Pap Smears, Mammograms, Prostate Specific Antigen Tests (PSAs)
Primary Care Provider
Specialist
*Pap Smears, Mammograms, and PSAs are covered Out-of-Network.

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

participating¹

$15 copayment
$30 copayment

$15 copayment
$30 copayment

$15 copayment
$30 copayment

Urgent Care Centers and Emergency Room

Urgent Care Centers
Emergency Room Visit

$30 copayment
$150 copayment

Ambulatory Surgical Center
100% after deductible

Inpatient and Outpatient Hospital Services
Hospital and Hospital Based Services
Outpatient Clinic Services
Physicians Services
Hospital and Professional
Outpatient Labs and Mammograms with surgery or other services.
Outpatient Labs and Mammograms without surgery or other services
Outpatient X-rays, ultrasounds, and other diagnostic tests such as EEG’s and EKG’s
CT scans, MRI’s, MRA’s and PET scans in any location, including physicians office

100% after deductible
100% after deductible
100% after deductible

100% after deductible
100%
100% after deductible
100% 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 and 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

100% after deductible

100% after deductible

100% after deductible
100% after deductible

100% after deductible
100% after deductible

$15 copayment
$30 copayment
100% after deductible
100% after deductible

$15 copayment

Lifetime Maximum, Deductibles & coinsurance Maximums
(The following Deductibles and Coinsurance Maximums apply to the services in the previous sections:

Lifetime Benefit Maximum

Deductibles
Employee Coverage (per Benefit Period)
Family Coverage (per Benefit Period)

Coinsurance Maximum
Employee Coverage (per Benefit Period)
Family Coverage (per Benefit Period)

$5,000,000

$250
$500

$0
$0

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 Lifetime Maximum. MAC B Pricing, Brand Penalty

Tier 1(Generic)
Tier 2 (Preferred Brand)
Tier 3 (Brand)

$10 copayment
$20 copayment
$35 copayment

Mental Health and Substance Abuse Services
*Inpatient/Outpatient Certification is required. Call Magellan Behavioral Health at
1-800-359-2422.

Mental Health Services
Office (30 visits per Benefit Period)
Inpatient (30 Days per Benefit Period)

Substance Abuse Services
Office Visit
Inpatient/Outpatient

Benefit Period Maximum
Lifetime Maximum
Certified*

$30 copayment
100%

$30 copayment
100%

$8,000
$16,000

¹ NOTICE: Deductible and coinsurance are calculated using the Allowed Amount. Members may be billed by out-of-network providers for the full provider's charge.

Additional Information About THE Blue Care HMO PLAN 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.

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.

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.

Participating providers are responsible for obtaining certifications. The member will bear no financial penalties if the participating provider fails to obtain the appropriate authorization. The member is responsible for obtaining certification for services rendered by a non-participating provider. Obtaining certification for Mental Health and Substance Abuse services is the member’s responsibility.

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 (with the exception of insulin)

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.

These benefit highlights are summaries of Blue Care 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 Care benefit booklet from BCBSNC Customer Services.

Monthly rates

Employee Only	$0
Employee + Child(ren)	$85.00
Employee + Family	$245.00

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Physician Office Services In-Network Out-of-Network¹ 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. Primary Care Provider Specialist Preventive Care Routine Examinations, Well-Child Care, Immunizations, Pap Smears, Mammograms, Prostate Specific Antigen Tests (PSAs) Primary Care Provider Specialist Pap Smears, Mammograms, and PSAs are covered Out-of-Network. 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	In-Network $15 copayment $30 copayment $15 copayment $30 copayment $15 copayment $30 copayment	Out-of-Network¹ 70% after deductible 70% after deductible Not Available* Not Available* 70% after deductible 70% after deductible
Urgent Care Centers and Emergency Room Urgent Care Centers Emergency Room Visit	$30 copayment $150 copayment	$30 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 Physicians Services Hospital and Professional Outpatient Labs and Mammograms with surgery or other services. Outpatient Labs and Mammograms without surgery or other services Outpatient X-rays, ultrasounds, and other diagnostic tests such as EEG’s and EKG’s CT scans, MRI’s, MRA’s and PET scans in any location, including physicians 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 and 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 90% after deductible $15 copayment $30 copayment 90% after deductible 90% after deductible $15 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 70% after deductible Benefits not available
Lifetime Maximum, Deductibles & Coinsurance Maximums (The following Deductibles and Coinsurance Maximums apply to the services in the previous sections: Lifetime Benefit Maximum Deductibles Employee Coverage (per Benefit Period) Family Coverage (per Benefit Period) Coinsurance Maximum Employee Coverage (per Benefit Period) $2,000 $4,000 Family Coverage (per Benefit Period) $6,000 $12,000	$5,000,000 $250 $750 $0 $0	$5,000,000 $500 $1,500 $1,250 $3,750
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 Lifetime Maximum. MAC B Pricing, Brand Penalty Tier 1 Generic Tier 2 Preferred Brand Tier 3 Non-preferred Brand	$10 copayment $30 copayment $45 copayment	Copayment + charge over allowed amount Copayment + charge over allowed amount Copayment + charge over allowed amount
Mental Health and Substance Abuse Services Inpatient/Outpatient Certification is required. Call Magellan Behavioral Health at 1-800-359-2422. Mental Health Services* Office (20 visits per Benefit Period) Inpatient (30 Days per Benefit Period) Substance Abuse Services Office Visit Inpatient/Outpatient Benefit Period Maximum Lifetime Maximum	Certified* $30 copayment 90% coinsurance $30 copayment 90% coinsurance $8,000 $16,000	Non-Certified¹ 70% coinsurance 70% coinsurance 70% coinsurance 70% coinsurance
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.

Physician Office 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. Primary Care Provider Specialist Preventive Care Routine Examinations, Well-Child Care, Immunizations, Pap Smears, Mammograms, Prostate Specific Antigen Tests (PSAs) Primary Care Provider Specialist Pap Smears, Mammograms, and PSAs are covered Out-of-Network. 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	participating¹ $15 copayment $30 copayment $15 copayment $30 copayment $15 copayment $30 copayment
Urgent Care Centers and Emergency Room Urgent Care Centers Emergency Room Visit	$30 copayment $150 copayment
Ambulatory Surgical Center	100% after deductible
Inpatient and Outpatient Hospital Services Hospital and Hospital Based Services Outpatient Clinic Services Physicians Services Hospital and Professional Outpatient Labs and Mammograms with surgery or other services. Outpatient Labs and Mammograms without surgery or other services Outpatient X-rays, ultrasounds, and other diagnostic tests such as EEG’s and EKG’s CT scans, MRI’s, MRA’s and PET scans in any location, including physicians office	100% after deductible 100% after deductible 100% after deductible 100% after deductible 100% 100% after deductible 100% 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 and 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	100% after deductible 100% after deductible 100% after deductible 100% after deductible 100% after deductible 100% after deductible $15 copayment $30 copayment 100% after deductible 100% after deductible $15 copayment
Lifetime Maximum, Deductibles & coinsurance Maximums (The following Deductibles and Coinsurance Maximums apply to the services in the previous sections: Lifetime Benefit Maximum Deductibles Employee Coverage (per Benefit Period) Family Coverage (per Benefit Period) Coinsurance Maximum Employee Coverage (per Benefit Period) Family Coverage (per Benefit Period)	$5,000,000 $250 $500 $0 $0
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 Lifetime Maximum. MAC B Pricing, Brand Penalty Tier 1(Generic) Tier 2 (Preferred Brand) Tier 3 (Brand)	$10 copayment $20 copayment $35 copayment
Mental Health and Substance Abuse Services Inpatient/Outpatient Certification is required. Call Magellan Behavioral Health at 1-800-359-2422. Mental Health Services* Office (30 visits per Benefit Period) Inpatient (30 Days per Benefit Period) Substance Abuse Services Office Visit Inpatient/Outpatient Benefit Period Maximum Lifetime Maximum	Certified* $30 copayment 100% $30 copayment 100% $8,000 $16,000
¹ NOTICE: Deductible and coinsurance are calculated using the Allowed Amount. Members may be billed by out-of-network providers for the full provider's charge.

Employee Only	$0
Employee + Child(ren)	$70.00
Employee + Family	$170.00