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1 bcbsnc.com

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4 Deductible options: $250, $500, $1,000 or $2,500 Deductible options $500, $1,000, $2,500, $3,500 or $5,000 D or (100% coinsurnce is not vilble on the $2,500 deductible option) coinsurnce plns: $0 coinsurnce plns: $2,000 per individul, $4,000 per fmily $3,000 per individul, $6,000 per fmily $ $ Unlimited $5 million $ fter $15 copyment for primry physicins 10 or $30 copyment for specilists 2 fter $25 copyment for primry physicins 10 or $50 copyment for specilists 2 $ fter $10 copyment for generic, $35 or $50 for brndnme, or 25% member coinsurnce for specilty brnd 1 fter $200 deductible per member, then $10 copyment for generic, $35 or $50 for brnd-nme, or 25% member coinsurnce for specilty brnd 1 c 2 fter $15 copyment C p with no deductible with no deductible w fter $15 copyment for primry physicins 10 or $30 copyment for specilists 2 fter $25 copyment for primry physicins 10 or $50 copyment for specilists 2 $ fter $30 copyment fter $50 copyment fter $150 copyment 12 (copyment wived if dmitted) fter $150 copyment 12 (copyment wived if dmitted) ( C p fter benefit period deductible fter benefit period deductible d C p

5 Deductible options: $1,000, $2,500, $3,500 or $5,000 Sme s in-network The benefit is the mount you py for some services before Blue Advntge pys its portion Pln A:, Pln B:, Pln C: Coinsurnce is the percentge of the llowed mounts for covered services tht BCBSNC will py $3,000 per individul, $6,000 per fmily When using out-of-network providers, your coinsurnce mximum is twice the in-network coinsurnce mximum Once your coinsurnce mximum is met, Blue Advntge covers 100% of ll covered services for the rest of the benefit period $5 million Sme s in-network A mximum mount pid for covered services which is the extent of the Pln s lifetime libility per member fter $30 copyment for primry physicins 10 or $60 copyment for specilists 2 fter benefit Primry doctors nd specilists (including surgery, lb work, therpy nd rdiology performed by the sme doctor on the sme dy in office) fter $500 deductible per member, then $10 copyment for generic, $35 or $50 for brnd-nme, or 25% member coinsurnce for specilty brnd 1 Sme s in-network, plus the chrges exceeding the llowed mount No nnul limit for generic drugs ($2,000 mximum for brndnme drugs per person per benefit) Routine eye exm with no deductible Inptient fcility, outptient fcility, drugs, blood, supplies, medicl cre, surgicl cre, therpy services, dignostic tests, X-rys nd lb work Outptient lbortory tests nd mmmogrms performed lone fter $30 copyment for primry physicins 10 or $60 copyment for specilists 2 11 Routine physicl exm, including gynecologicl exm; wellchild nd well-bby cre (including periodic ssessments nd immuniztions) fter $60 copyment fter $150 copyment 12 (copyment wived if dmitted) fter sme copyment s in-network fter $150 copyment 12 (copyment wived if dmitted) Services provided for sudden or unexpected condition requiring prompt dignosis or tretment to prevent chronic illness, prolonged impirment or more hzrdous tretment Helth cre items nd services furnished or required to screen for or tret n emergency medicl condition until the condition is stbilized fter benefit period deductible fter benefit period deductible (Plns A & B) fter benefit period deductible (Pln C) A licensed or certified nonhospitl fcility which hs permnent fcilities nd equipment for the primry purpose of performing surgicl procedures on n outptient bsis nd does not provide inptient ccomodtions $2,000 mximum per person per benefit period, $10,000 lifetime per person; includes inptient fcility, inptient professionl nd outptient professionl Durble medicl equipment, home helth cre, nd home infusion therpy, hospice cre, privte duty nursing, mbulnce services, skilled nursing fcilities (to 60 dys per yer) nd dentl ccident

6 Register online t to mnge your helth pln nd your helth quickly nd esily. Once you become n enrolled member, you cn tke dvntge of customized progrms nd informtive resources tht help you rech your helth pln gols. Receive discounts on helth-relted products nd services. Sty motivted with rewrds for physicl ctivity. Plus, you cn mnge your helth pln 24/7. It s ll t your fingertips visit tody!

7 Like most helth cre plns, Blue Advntge hs some limittions nd exclusions. When your ppliction is pproved, you will receive benefit booklet. It will contin detiled informtion bout pln benefits, exclusions nd limittions. This is prtil list of benefits tht re not pyble: Your coverge utomticlly renews. Your coverge my be cnceled by BCBSNC for filure to py premiums nd for flse sttements on your ppliction, mong other resons. Coverge for dependent children ends t ge 26. Members will be notified 30 dys in dvnce of ny chnge in coverge. Any chnge in your rte will be preceded by 30-dy notice nd is gurnteed for 12 months. A witing period for coverge of pre-existing conditions my pply to your coverge. 13 This brochure contins summry of benefits only. It is not your insurnce policy. Your M58, 7/07 policy is your insurnce contrct. If there is ny difference between this brochure nd the policy, the provisions of the policy will control. Plese note: Blue Advntge is not High Deductible Helth Pln (HDHP) under the Tx Code, nd therefore is not intended to be pired with Helth Svings Account. 1 Prescription drug benefits re divided into four drug-formulry tiers with vrying copyment/coinsurnce mounts bsed on the tier plcement of drug. Specific drug informtion cn be found on the Prescription Drug Serch tool t bcbsnc.com. Dibetic supplies re covered t 75% under the prescription drug benefit. In ddition, benefits re provided for overthe-counter drugs when listed s covered in the formulry nd provider s prescription for tht drug is presented t the phrmcy. Specilty brnd drugs require member coinsurnce. 2 Some services nd supplies received by members in n office setting or in connection with n office visit re in fct outptient hospitl-bsed services provided by hospitl-owned or operted prctices. These services nd supplies my be subject to your deductible nd coinsurnce. Plese see the BCBSNC provider listing to identify these providers. 3 Referrls my be needed for mentl helth nd substnce buse services. 4 Blue Cross nd Blue Shield Assocition Internl Dt: press/fcts/bluecrd.html (2007). 5 Certin limittions my pply. Plese refer to your insurnce contrct for more detils. 6 Blue Advntge Pln B requires $200 prescription drug deductible. Pln C requires $500 prescription drug deductible. 7 BCBSNC provides the Blue Extrs SM, Member Helth Prtnerships SM1, Online Helthy Living Progrms nd/or Blue Points SM progrms for your convenience nd is not lible in ny wy for the goods or services received. Any discounts on third-prty goods or services received through Blue Extrs re outside of your helth pln benefits. Decisions regrding your cre should be mde with the dvice of your doctor. BCBSNC reserves the right to discontinue or chnge these progrms t ny time. Online Helthy Living progrms re provided through MiVit, Inc., third-prty vendor independent BCBSNC. Online Helthy Living progrms provide tools to id you in improving your helth; results re not gurnteed. BCBSNC provides the Decision Support Tools for member convenience. These tools re ment to be reference tools only nd re not intended to provide legl, medicl or tx dvice. 8 All services subject to the llowed mount. 9 Your ctul expenses for covered services my exceed the stted coinsurnce percentge or copyment mount becuse ctul provider chrges my not be used to determine the helth benefit pln s nd member s pyment obligtions. 10 Primry physicins re in-network providers designted by BCBSNC s primry cre provider (PCP). Plese check with BCBSNC to confirm your provider is in our network. 11 Only gynecologicl exms, cervicl cncer screening, ovrin cncer screening, screening mmmogrms, colorectl screening nd prostte specific ntigen (PSA) tests re covered out-of-network subject to benefit nd coinsurnce. 12 If dmitted to the hospitl from the emergency room, inptient hospitl benefits pply to ll covered services provided. If held for observtion, outptient benefits pply to ll covered services provided. If you re sent to the emergency room from n urgent cre center, you my be responsible for both the emergency room copyment nd the urgent cre copyment. 13 Pre-existing conditions re those for which medicl dvice, dignosis, cre or tretment ws received or recommended within 12 months of the dte tht your Blue Advntge coverge begins. You my receive credit towrd the 12-month witing period if we receive your completed Blue Advntge ppliction nd proof of prior coverge within 63 dys of the termintion of your previous helth coverge. 14 Dentl Blue for Individuls hs 6-month witing period for bsic services; 12-month witing period for mjor services.

8 To be eligible for Blue Advntge coverge, you must be North Crolin resident, under 65 yers old, not covered by nother helth insurnce policy nd not qulified for Medicre. You cn purchse coverge for your children only, if necessry. Complete the ppliction. Be sure to nswer ll the questions. Sign nd dte the ppliction. Remember, your ctul rte my be higher or lower depending on your helth sttus. Your gent will forwrd your completed ppliction nd initil premium to Blue Cross nd Blue Shield of North Crolin. Allow t lest 30 dys for processing. You cn choose for your coverge effective dte to be the 1st or the 15th dy of ech month, following the pprovl of your ppliction. Some pplicnts my be required to hve simple prmedic exmintion. If you need immedite coverge, cll your gent to lern bout Short-Term Helth Cre policy from BCBSNC. Once your ppliction is pproved, we ll send your Benefit Booklet nd ID crd for your review. If you re not completely stisfied, simply notify BCBSNC within 10 dys nd we ll refund your initil premium. Whether you hve specific question or you re just looking for better wy to blnce the helth cre eqution, we re here to help. As your prtner in helth cre, we ll help you find the right solutions for your compny. bcbsnc.com