2017 HEALTH PLANS For individuals and families

Transcription

1 2017 HEALTH PLANS For idividuals ad families

2 HEALTH CARE HAS CHANGED We re here to help There s a lot to thik about whe it comes to choosig health isurace. As the oly homegrow, local isurer i all 100 couties of the state, Blue Cross ad Blue Shield of North Carolia (BCBSNC) is here for you. With our expertise ad broad rage of plas, you ca fid the coverage that s right for you ad your budget. Take advatage of beefits like aual welless visits, coverage for emergecy services, programs to help you stop smokig, a 24-hour urse hotlie ad a variety of other i-etwork services. Discover how a BCBSNC pla ca help you access ad pay for the health care you eed. With our plas you ll ejoy: + Customer service to make usig isurace easier Our customer service professioals are ready to aswer your questios quickly ad accurately. + Olie member tools Blue Coect SM is your source for all tools ad what you eed to kow about your health pla. Ad you ca use it o ay mobile phoe, tablet or laptop. Need to fid a doctor? Plaig for surgery? Ca t remember all of your beefits? Blue Coect is customizable so what you eed is ready for you right away. It s desiged to make health care easier. Ad it s yet aother beefit of choosig Blue. + Doctor ad hospital choices BCBSNC offers a rage of etwork choices to meet your eeds ad budget. A etwork is a group of doctors, hospitals, pharmacies ad other health care experts. Blue Advatage, our broadest pla, has a etwork that icludes more tha 92% of doctors ad 98% of the hospitals i North Carolia. 1 Other plas, like Blue Local, 2 feature care from specific health care systems. + Your health pla goes where you go With BlueCard your coverage exteds worldwide, which meas you have coverage at home ad whe you travel. 3 2

3 Our Plas Offer Key Beefits:4 The beefits that are importat for gettig ad stayig healthy are at the core of all of our plas. We offer a wide rage of optios to help you fid what fits your eeds ad budget. It s what makes BCBSNC the right choice for you. + No waitig period for pre-existig coditios All BCBSNC health isurace plas are available with o pre-existig coditio(s) waitig periods.5 + Prevetive care beefits For all BCBSNC idividual plas metioed i this brochure, prevetive services are covered at 100% whe you go to a i-etwork doctor.6 These covered services iclude aual exams, colooscopies, mammograms ad more. See bcbsc.com/prevetive for a full list of covered services. + Essetial health beefits All BCBSNC plas metioed i this brochure provide coverage for essetial health beefits, which are required by law. These services iclude: Prevetive care Professioal services Hospital services Outpatiet services Urget ad emergecy services Materity services Metal health/chemical depedecy services Pediatric detal ad pediatric visio care For a complete list, visit bcbsc.com/essetial. To see a sample member booklet, visit bcbsc.com/booklets. + No lifetime maximums There are o lifetime dollar maximums o the plas featured i this brochure. + Detal isurace Detal coverage is available through Detal Blue for IdividualsSM, a separate pla that provides detal-oly coverage at a additioal cost to your health pla premium.7 You may also purchase detal isurace with or without the purchase of BCBSNC health coverage. 3

4 HEALTH CARE REFORM The basics The Affordable Care Act (ACA) is also kow as health care reform. Here s what you should kow: The aual erollmet period is November 1, Jauary 31, You must have health isurace coverage The federal govermet ow requires that most idividuals purchase health isurace. Those who do t may be subject to a tax pealty. 8 + Fiacial help is available if you meet certai requiremets Fiacial assistace (also kow as a subsidy) from the federal govermet may help you pay for your health isurace. 9 Your local authorized BCBSNC aget ca help you estimate your subsidy. Remember, your actual subsidy is decided by the federal govermet. I order to receive a subsidy, you must purchase your pla through the Marketplace. + Aual ope erollmet is betwee November 1, 2016, ad Jauary 31, 2017 Aual erollmet is the oly time you kow for certai you ca buy health isurace. Apply by December 15 to get coverage that starts Jauary 1, Oce ope erollmet eds you may still be able to buy health isurace if you have what is called a qualifyig life evet. If you get married, have a ew baby, or lose your health coverage, you may qualify. 10 Documetatio may be required. METALLIC LEVELS Health care reform established metallic levels (broze, silver ad gold) to idicate the value of coverage i a pla. This helps you easily compare plas with differet deductibles, copaymets ad coisurace requiremets to determie which pla works best for you. BRONZE SILVER GOLD Good for people who wat lower mothly premiums ad do t expect to eed a lot of medical services. Good for people who wat to keep mothly premiums ad out-of-pocket medical costs more balaced. Good for people who receive medical services regularly ad who are okay with a higher mothly premium to have lower out-of-pocket costs. Metallic levels do ot take ito accout all health pla features, such as provider etwork. Be sure to check if your doctor is i-etwork. 4

5 YOUR CHECKLIST for buyig health isurace How to sig up, step-by-step: Sig up betwee November 1, 2016, ad Jauary 31, 2017 durig the aual erollmet period Outside the aual erollmet period, if you get married, have a baby, move from aother state, or lose your health isurace, you may be able to buy coverage durig special erollmet 10 Fid out if you may receive subsidies to help pay for your health isurace (BCBSNC ca help) 9 Check the map o the ext page to see which plas are available where you live Thik about your health care eeds which metallic level (broze, silver or gold) works best? Thik about your etwork eeds make sure your favorite doctors ad hospitals are i the etwork of the pla you select Submit your applicatio to BCBSNC Pay for your pla your ew health isurace will ot become effective util BCBSNC receives ad processes your first moth s premium Two ways to pay for medical expeses: Choose a pla with predictable copaymets or deductible ad coisurace. Copaymet plas offer a fixed copaymet (or copay) for thigs like office visits ad prescriptios. While you ll kow what you re goig to pay with copay plas, they come at a higher mothly premium cost. These plas are ideal for someoe who wats predictable costs ad does t mid payig more i premiums. ad coisurace plas have lower premiums tha copaymet plas. If you do t expect a lot of medical expeses ad wat to save moey o premiums, these may be the plas for you. For these plas, you pay the full cost of your medical expeses util you meet your deductible. (A deductible is the amout a perso pays for health care before your isurace starts to pay.) The you pay a coisurace percetage, sharig the cost with BCBSNC util you reach your out-of-pocket limit. After that, BCBSNC pays all covered costs. Some plas are also Health Savigs Accout (HSA) eligible which meas a HSA ca be used to pay for certai medical expeses. 5

6 WHICH PLANS are available where you live? Start by fidig the couty where you live. The look at the color key below to fid which BCBSNC plas you ca choose. Leged Blue Advatage, Blue Select Blue Advatage, Blue Select, Blue Value Blue Advatage, Blue Select, Blue Local with Carolias HealthCare System Blue Value, Blue Local with Carolias HealthCare System Blue Value, Blue Local with Duke Medicie ad WakeMed Blue Value 6

7 CHOOSE THE NETWORK that s right for you PROVIDER LOCATIONS DOCTOR & HOSPITAL NETWORK PHARMACY NETWORK CHOOSE THIS PLAN IF YOU 11 BLUE LOCAL with Duke Medicie ad WakeMed Limited, regioal etwork Limited pharmacy etwork Wat care from Duke Medicie ad WakeMed doctors ad hospitals ad a limited pharmacy etwork BLUE LOCAL with Carolias HealthCare System Limited, regioal etwork Limited pharmacy etwork Wat care from Carolias HealthCare System ad affiliated providers ad a limited pharmacy etwork BLUE VALUE Limited etwork Limited pharmacy etwork Wat to save o mothly premiums by usig limited provider ad pharmacy etworks BLUE SELECT Tier 1 Tier 2 Broad etwork with tiered beefits Limited pharmacy etwork Wat to maage costs by usig select doctors ad hospitals ad a limited pharmacy etwork BLUE ADVANTAGE Broadest etwork of doctors ad hospitals i North Carolia 1 Broad pharmacy etwork Wat access to our broad provider ad pharmacy etworks To fid out which etworks iclude your favorite doctors ad hospitals, go to bcbsc.com ad click o Fid a Doctor. For more ifo Cotact your local authorized BCBSNC aget. He or she will be happy to help you. 7

8 CHOOSE your pla If you would like a closer relatioship with your doctors, ad ejoy the beefits of world-class 12 health care at a lower cost, 13 the this could be the right pla for you. BCBSNC ad our parters Duke Medicie ad WakeMed Health & Hospitals are givig the Triagle a choice i health coverage. BLUE LOCAL offers: + Your choice of a primary care provider (PCP) for better coordiated care + Savigs o your mothly premiums + A etwork that icludes Duke Medicie raked as oe of the best health systems i the coutry 12 + Access to WakeMed hospitals ad more tha 1,000 physicias through WakeMed Key Commuity Care 14 + Two ways to pay for medical expeses: a pla with predictable copaymets or a deductible ad coisurace pla + Better coordiatio of care through a itegrated health care system DEDUCTIBLE & COINSURANCE PLANS BLUE LOCAL WITH DUKE MEDICINE AND WAKEMED BRONZE 7150 BLUE LOCAL WITH DUKE MEDICINE AND WAKEMED BRONZE (HSA ELIGIBLE) IN-NETWORK BENEFIT Idividual Idividual Out-ofpocket Max Coisurace Prescriptio Drug Beefit $7,150 $7,150 0% Itegrated $5,500 $6,550 20% Itegrated Availability Blue Local with Duke Medicie ad WakeMed is available to residets of these Triagle area couties: + Caswell + Orage + Chatham + Perso + Durham + Wake + Johsto COPAY PLANS BLUE LOCAL WITH DUKE MEDICINE AND WAKEMED SILVER 5000 BLUE LOCAL WITH DUKE MEDICINE AND WAKEMED SILVER 3500 BLUE LOCAL WITH DUKE MEDICINE AND WAKEMED GOLD 1500 Idividual Idividual Out-of-pocket Maximum IN-NETWORK BENEFIT Coisurace Primary Care Provider Copay Specialist/ Urget Care Copay Prescriptio Drug $5,000 $7,150 30% $10 $40 $200 $3,500 $7,150 30% $10 $40 $200 $1,500 $7,150 10% $5 $30 $200 Prescriptio Drug Beefit $10/$25/$40/ $10/$25/$40/ $4/$10/$35/ 8 Out-of-etwork (OON) deductible ad OON out-of-pocket maximum (OOPM) are four times the i-etwork deductible ad i-etwork OOPM Member pays 30% more coisurace whe seekig services out of etwork Itegrated prescriptio drug beefits subject to the same deductible ad coisurace as other medical services Prescriptio drug deductible must be met before receivig beefits Emergecy room copay is $500 o Gold Metallic copay plas ad $600 o Silver Metallic copay plas after the deductible is met Emergecy room visits are subject to deductible ad coisurace o Broze ad Catastrophic plas

9 Now you ca get access to all of the doctors, specialists ad hospitals withi Carolias HealthCare System ad its affiliates. This system cetered etwork aturally leds itself to more coordiated care. BLUE LOCAL offers: + A provider etwork limited to Carolias HealthCare System ad its affiliates + Better coordiatio of care through a itegrated health care system + Two ways to pay for medical expeses: a pla with predictable copaymets or a deductible ad coisurace pla DEDUCTIBLE & COINSURANCE PLANS BLUE LOCAL WITH CAROLINAS HEALTHCARE SYSTEM BRONZE 7150 BLUE LOCAL WITH CAROLINAS HEALTHCARE SYSTEM BRONZE (HSA ELIGIBLE) IN-NETWORK BENEFIT Idividual Idividual Out-ofpocket Max Coisurace Prescriptio Drug Beefit $7,150 $7,150 0% Itegrated $5,500 $6,550 20% Itegrated Availability Blue Local with Carolias HealthCare System is available to residets of these metro-charlotte area couties: + Aso + Meckleburg + Cabarrus + Rowa + Clevelad + Staly + Gasto + Uio + Licol COPAY PLANS BLUE LOCAL WITH CAROLINAS HEALTHCARE SYSTEM SILVER 5000 BLUE LOCAL WITH CAROLINAS HEALTHCARE SYSTEM SILVER 3500 BLUE LOCAL WITH CAROLINAS HEALTHCARE SYSTEM GOLD 1500 Idividual Idividual Out-of-pocket Maximum IN-NETWORK BENEFIT Coisurace Primary Care Provider Copay Specialist/ Urget Care Copay Prescriptio Drug $5,000 $7,150 30% $10 $40 $200 $3,500 $7,150 30% $10 $40 $200 $1,500 $7,150 10% $5 $30 $200 Out-of-etwork (OON) deductible ad OON out-of-pocket maximum (OOPM) are four times the i-etwork deductible ad i-etwork OOPM Member pays 30% more coisurace whe seekig services out of etwork Itegrated prescriptio drug beefits subject to the same deductible ad coisurace as other medical services Prescriptio drug deductible must be met before receivig beefits Emergecy room copay is $500 o Gold Metallic copay plas ad $600 o Silver Metallic copay plas after the deductible is met Emergecy room visits are subject to deductible ad coisurace o Broze ad Catastrophic plas Prescriptio Drug Beefit $10/$25/$40/ $10/$25/$40/ $4/$10/$35/ 9

10 Blue Value could be a good fit if you wat savigs o your mothly premium ad do t have a strog doctor or hospital preferece, or if you kow your doctor or hospital is i the limited etwork. BLUE VALUE offers: + Lower costs through a limited etwork of providers ad pharmacies, i most istaces + Two ways to pay for medical expeses: a pla with predictable copaymets or a deductible ad coisurace pla + A etwork that icludes Novat Health ad UNC Health Care DEDUCTIBLE & COINSURANCE PLANS BLUE VALUE BRONZE 7150 BLUE VALUE BRONZE (HSA ELIGIBLE) IN-NETWORK BENEFIT Idividual Idividual Out-ofpocket Max Coisurace Prescriptio Drug Beefit $7,150 $7,150 0% Itegrated $5,500 $6,550 20% Itegrated Availability Blue Value is available to residets of these North Carolia couties: + Alamace + Alexader + Aso + Bruswick + Burke + Cabarrus + Caldwell + Caswell + Catawba + Chatham + Columbus + Davidso + Davie + Dupli + Durham + Forsyth + Frakli + Iredell + Johsto + Lee + Meckleburg + New Haover + Oslow + Orage + Peder + Perso + Rowa + Staly + Stokes + Surry + Uio + Yadki + Wake COPAY PLANS Idividual Idividual Out-of-pocket Max IN-NETWORK BENEFIT Coisurace Primary Care Provider Copay Specialist/ Urget Care Copay Out-of-etwork (OON) deductible ad OON out-of-pocket maximum (OOPM) are four times the i-etwork deductible ad i-etwork OOPM Member pays 30% more coisurace whe seekig services out of etwork Itegrated prescriptio drug beefits subject to the same deductible ad coisurace as other medical services Prescriptio drug deductible must be met before receivig beefits Emergecy room copay is $500 o Gold Metallic copay plas ad $600 o Silver Metallic copay plas after the deductible is met Emergecy room visits are subject to deductible ad coisurace o Broze ad Catastrophic plas Prescriptio Drug Prescriptio Drug Beefit BLUE VALUE CATASTROPHIC 16 $7,150 $7,150 0% $35x3 0% Itegrated 0% BLUE VALUE SILVER 5000 BLUE VALUE SILVER 3500 BLUE VALUE GOLD 1500 $5,000 $7,150 30% $10 $40 $200 $3,500 $7,150 30% $10 $40 $200 $1,500 $7,150 10% $5 $30 $200 $10/$25/$40/ $10/$25/$40/ $4/$10/$35/ 10

11 Choose Blue Select if you wat savigs alog with access to our largest etwork of doctors, specialists ad hospitals. Blue Select offers two tiers of i-etwork beefits. You may choose from either tier, but for the highest quality ad the most savigs, choose from Tier 1. BLUE SELECT offers: + Savigs over Blue Advatage while still offerig broad etwork access + Two tiers of i-etwork beefits + Copaymets for predictable costs + Limited pharmacy etwork to help save you moey How tiers work + Tier 1 doctors ad hospitals received our top ratigs for quality outcomes, cost-efficiecy ad accessibility + Tier 2 doctors ad hospitals met our stadards for quality outcomes, cost-efficiecy ad/or accessibility 17 + Providers located outside the state are icluded as Tier 1 providers through the BlueCard etwork 3 Availability Blue Select is available i all North Carolia couties except: + Alamace + Rowa + Aso + Cabarrus + Caswell + Chatham + Durham + Frakli + Johsto + Lee + Meckleburg + Orage + Perso + Staly + Uio + Wake TIERED NETWORK PLANS BLUE SELECT SILVER 5000 BLUE SELECT GOLD 1500 Idividual Idividual Out-ofpocket Max Tier 1 Coisurace IN-NETWORK BENEFIT Tier 2 Coisurace Primary Care Provider Copay Tier 1 Specialist/ Urget Care Copay Tier 2 Specialist Copay Prescriptio Drug $5,000 $7,150 30% 50% $10 $40 $55 $200 $1,500 $6,000 10% 30% $5 $30 $45 $200 Prescriptio Drug Beefit $10/$25/$40/ $4/$10/$35/ Out-of-etwork (OON) deductible ad OON out-of-pocket maximum (OOPM) are two times the i-etwork deductible ad i-etwork OOPM Member pays 30% more coisurace whe seekig services out of etwork Itegrated prescriptio drug beefits subject to the same deductible ad coisurace as other medical services Prescriptio drug deductible must be met before receivig beefits Emergecy room copay is $500 o Gold Metallic copay plas ad $600 o Silver Metallic copay plas after the deductible is met 11

12 Blue Advatage is a good optio if you wat a broad choice of doctors, specialists ad hospitals alog with flexibility i how much you pay for doctor visits ad prescriptio drugs. BLUE ADVANTAGE offers: + More tha 92% of physicias ad 98% of the hospitals i North Carolia i-etwork 1 + Broad pharmacy etwork + Two ways to pay for medical expeses: a pla with predictable copaymets or a deductible ad coisurace pla DEDUCTIBLE & COINSURANCE PLANS IN-NETWORK BENEFIT Idividual Idividual Out-of-pocket Max Coisurace Prescriptio Drug Beefit BLUE ADVANTAGE BRONZE 7150 $7,150 $7,150 0% Itegrated BLUE ADVANTAGE BRONZE (HSA ELIGIBLE) $5,500 $6,550 20% Itegrated Availability Blue Advatage is available i all North Carolia couties except: + Alamace + Aso + Cabarrus + Caswell + Chatham + Durham + Frakli + Johsto + Lee + Meckleburg + Orage + Perso + Rowa + Staly + Uio + Wake IN-NETWORK BENEFIT COPAY PLANS Idividual Idividual Out-ofpocket Max Coisurace Primary Care Provider Copay Specialist/ Prescriptio Urget Care Drug Copay Prescriptio Drug Beefit BLUE ADVANTAGE CATASTROPHIC 16 $7,150 $7,150 0% $35x3 0% Itegrated 0% BLUE ADVANTAGE SILVER 5000 $5,000 $7,150 30% $10 $40 $200 BLUE ADVANTAGE SILVER 3500 $3,500 $7,150 30% $10 $40 $200 BLUE ADVANTAGE GOLD 1500 $1,500 $7,150 10% $5 $30 $200 $10/$25/$40/ $10/$25/$40/ $4/$10/$35/ Out-of-etwork (OON) deductible ad OON out-of-pocket maximum (OOPM) are two times the i-etwork deductible ad i-etwork OOPM Member pays 30% more coisurace whe seekig services out of etwork Itegrated prescriptio drug beefits subject to the same deductible ad coisurace as other medical services Prescriptio drug deductible must be met before receivig beefits Emergecy room copay is $500 o Gold Metallic copay plas ad $600 o Silver Metallic copay plas after the deductible is met Emergecy room visits are subject to deductible ad coisurace o Broze ad Catastrophic plas 12

13 MAKING HEALTH CARE more affordable Subsidies ca help 9 To help make health isurace more affordable ad effective, the federal govermet offers fiacial assistace, also called subsidies, to idividuals ad families who qualify based o their icome ad household size. These subsidies reduce the mothly cost of a health isurace pla for those who qualify. To qualify for a subsidy uder health care reform, you must: 9 + Be betwee 100% ad 400% of the Federal Poverty Level (FPL). + Not be eligible for public coverage, such as Medicaid, the Childre s Health Isurace Program (CHIP), Medicare or coverage through the armed services. + Not have access to isurace through a employer. (A exceptio ca be made if the employer s pla does t provide required miimum value [also kow as miimum essetial coverage] or if the pla is cosidered uaffordable the premium is more tha 9.66% of the employee s icome.) More help I additio to premium subsidies there are also cost-sharig reductios (CSRs), aother type of subsidy that provides further help for those betwee 100% ad 250% of the Federal Poverty Level. CSRs lower the amout you have to pay for outof-pocket costs like deductibles, coisurace ad copaymets. Thik of a CSR as a upgrade i your beefits. Based o your icome level, the govermet will help to cover some of the costs of your medical services. That meas you pay less moey for those services. Keep i mid, to get these beefits you must choose a Silver pla o the federal isurace marketplace. The big picture Overall, subsidies ad CSRs ca help lower your health isurace costs sigificatly if you qualify based o icome. Be sure to lear more about them to see if you qualify. Eve a family of four with a household icome of as much as $97,200 may be eligible for a subsidy The credits are paid directly to your health isurace compay you pay the differece betwee the full premium ad the subsidy o your mothly bill. Who s eligible for subsidies ad cost-sharig reductios? People with icomes: + Betwee 100% ad 250% of the Federal Poverty Level (FPL) are eligible for both premium tax credit subsidies ad costsharig reductios. Cost-sharig reductios require the purchase of a Silver pla. + Betwee 250% ad 400% of the FPL are eligible for premium tax credit subsidies oly. FPL guidelies help determie the level of the subsidy. + People with icomes below 100% of the FPL or above 400% of the FPL are ieligible for subsidies. For more ifo Cotact your local authorized BCBSNC aget. He or she will be happy to help you. Federal Poverty Level (FPL) guidelies 18 ANNUAL HOUSEHOLD INCOME HOUSEHOLD SIZE 100% FPL 250% FPL 400% FPL 1 $11,880 $29,700 $ 47,520 2 $16,020 $40,050 $ 64,080 3 $20,160 $50,400 $ 80,640 4 $24,300 $60,750 $ 97,200 5 $28,440 $71,100 $113,760 6 $32,580 $81,450 $130,320 13

14 WORDS you ll wat to kow Affordable Care Act (ACA) The law iteded to address issues with our health care system by icreasig access to health isurace, itroducig a umber of health care reforms ad improvig quality. Advaced premium tax credits, or subsidies These subsidies from the federal govermet are available to help low- ad middle-icome Americas with their health isurace premiums. Allowed amout The maximum amout that BCBSNC determies is reasoable for covered services provided to a member. The allowed amout icludes ay BCBSNC paymet to the provider, plus ay deductible, coisurace or copaymet. Beefit period The specified period of time durig which charges for covered services provided to a policy member must be icurred i order to be eligible for paymet. Coisurace Whe you pay a percetage of the cost of a covered service, after you ve met your deductible. Say your pla has 25% coisurace. After you meet your deductible, if a doctor s visit costs $100, you would pay $25 ad isurace would pay $75. You stop payig coisurace whe you meet your out-of-pocket maximum. Copaymet A fixed dollar amout you may pay for a covered service at the time you receive it. Copaymets ca vary depedig o the service. The amout you or your family owe for certai covered services durig a beefit period before your health isurace begis to pay. Federal Poverty Level (FPL) A idex of icome level (by family size) that determies eligibility for premium tax credits. For example, i 2017 a family of four that makes as much as $97,200 a year (or 400% of FPL) may be eligible for a subsidy to help with health isurace premiums. 18 Health Isurace Marketplace A olie isurace marketplace where idividuals ca compare, shop for ad buy qualified health isurace plas. Also kow as a Exchage. Itegrated prescriptio drug beefit Your prescriptio drug beefits are subject to the same deductible ad coisurace as other medical services. Limited Network A etwork where you have full access to a smaller umber of health care providers. Member A member is a perso i a health pla; someoe with isurace coverage. Network The hospitals, doctors, pharmacies ad other providers your health isurer or pla has cotracted with to provide health care services. Out-of-pocket limit The maximum you will pay from your ow fuds for covered services i a beefit period. Oce you have met this amout, BCBSNC will pay 100% of your remaiig covered services. s, copaymets ad coisurace for covered medical ad drug beefits apply to this limit. Premiums ad o-covered services as well as out-of-etwork charges beyod the allowed amout do ot apply to the out-of-pocket limit. Outpatiet Perso who gets hospital care but is ot admitted to the hospital. Premium A premium is the periodic paymet made to BCBSNC to keep your health isurace policy active. Premiums are separate from other health isurace out-of-pocket costs, like copaymets, deductibles ad coisurace. 14 Primary Care Provider (PCP) A physicia, urse practitioer, urse specialist or physicia assistat who provides or coordiates health care for patiets.

15 Limitatios & Exclusios Like most health care plas, Blue Local with Carolias HealthCare System, Blue Local with Duke Medicie ad WakeMed, Blue Advatage, Blue Select ad Blue Value have some limitatios ad exclusios. Oce you re erolled, a Member Guide will be made available to you. It will cotai detailed iformatio about your pla beefits, exclusios ad limitatios. This is a partial list of beefits that are ot covered for Blue Local with Carolias HealthCare System, Blue Local with Duke Medicie ad WakeMed, Blue Advatage, Blue Select ad Blue Value members: For ay coditio suffered as a result of ay act of war or while o active or reserve military duty Services for which a charge is ot ormally made i the absece of isurace, or services provided by a immediate relative Prescriptio drugs or refills which exceed the maximum supply Persoal hygiee, comfort ad/or coveiece items Services for or related to assisted reproductive techology or for reversal of sterilizatio Treatmet of sexual dysfuctio ot related to orgaic disease Services that are ivestigatioal i ature or obsolete, icludig ay service, drugs, procedure or treatmet directly related to a ivestigatioal treatmet, except as specifically covered by this health beefit pla Side effects ad complicatios of o-covered services, except for emergecy services i the case of a emergecy Services that are ot medically ecessary Detal services provided i a hospital, except as specifically covered by your health beefit pla Services or expeses that are covered by ay govermetal uit except as required by federal law Services received from a employer-sposored detal or medical departmet Services received or hospital stays before (or after) the effective dates of coverage Custodial care, domiciliary care or rest cures Eyeglasses or cotact leses or refractive eye surgery, except as specifically covered by your health beefit pla Routie eye examiatios for adults Services for cosmetic purposes, except as specifically covered by this health beefit pla Services for routie foot care that is palliative or cosmetic Travel, except as covered by your health beefit pla Ipatiet admissios that are primarily for physical therapy, diagostic studies, or evirometal chage Services that are redered by or o the directio of those other tha doctors, hospitals, facility ad professioal providers; services that are i excess of the customary charge for services usually provided by oe doctor whe doe by multiple doctors No-prescriptio drugs, except as specifically covered by your health beefit pla For telephoe cosultatios, charges for failure to keep a scheduled visit, charges for completio of a claim form, charges for obtaiig medical records, ad late paymet charges Services primarily for educatioal purposes Services ot specifically listed as covered services Your coverage will automatically reew. Your coverage may be caceled by BCBSNC for fraud or itetioal misrepresetatio of material fact o your applicatio. Coverage for depedet childre eds at the ed of the moth they become age 26. Members will be otified 30 days i advace of ay chage i coverage. The policy form umber for Blue Value, Blue Local is ACAPOS-I, 5/16. The policy form umber for Blue Select ad Blue Advatage is NGFPPO-I, 5/16. This brochure cotais a summary of the beefits oly. It is ot your isurace policy. Your policy ad applicatio are your cotract. If there is ay differece betwee this brochure ad the policy, the provisios of the policy will cotrol. Visit bcbsc.com for more iformatio. Foototes 1 C osortium Health Plas, Ic., MarketQuest Network Compare, March Percetages idicated represet BCBSNC s PPO etwork. Note: Not all plas are available i all areas. 2 B CBSNC has collaborated with Carolia Health Systems ad Duke/ WakeMed. Blue Local is a health isurace pla offered by BCBSNC with a limited provider etwork. Carolia Health Systems ad Duke/ WakeMed are idepedet compaies ad each oe is solely resposible for the physicias ad medical facilities it ows/operates ad does ot offer BCBS products or services. 3 B lue Cross ad Blue Shield Associatio Iteral Data: bcbs.com/ shop-for-health-isurace/coverage-home-ad-away.html (accessed September, 2016). 4 All iformatio discussed i this brochure pertais to BCBSNC idividual-market, medical health isurace plas that are eligible for sale i 2017 ad meet Affordable Care Act guidelies. The iformatio cotaied does ot apply to plas that are gradfathered, trasitioal, group, detal-oly or other pla types. All details regardig pla beefits ad desig cotaied herei are for iformatioal purposes oly. Please see the product beefit booklet for all terms ad coditios that apply. 5 Eligibility requiremets apply. See beefit booklet for details. 6 Prevetive care services as defied by recet federal regulatios are covered at o charge to you. For Blue Advatage, Blue Select ad Blue Value ad Blue Local: Coverage for certai prevetive care services (such as routie physical exams, well-baby ad well-child care, ad immuizatios) is limited to i-etwork beefits oly. However, state-madated prevetive services are available out-ofetwork, for which members will pay deductible ad coisurace, plus charges over the allowed amout. Visit bcbsc.com/prevetive for more details. 7 Detal Blue for Idividuals has a six-moth waitig period for basic services ad a 12-moth waitig period for major services. Detal Blue for Idividuals is ot part of the covered health isurace beefits of ay BCBSNC plas. Detal Blue for Idividuals must be purchased separately. For costs ad further details about Detal Blue for Idividuals, icludig exclusios ad reductios or limitatios ad terms uder which the policy may be cotiued i force, cotact your aget or BCBSNC. 8 If you qualify for a health coverage exemptio you do t have to pay the fee. More iformatio at healthcare.gov/fees-exemptios/ exemptios-from-the-fee/ 9 Subsidies oly available for plas purchased through the federal health isurace marketplace. Eligibility for ad actual amout of ay subsidy is determied by the federal marketplace. 10 You must have a qualifyig life evet to eroll i the federal marketplace outside of the ope erollmet period. The federal marketplace determies if you qualify. 11 Chart provides a overview of key beefits. For full beefits see your beefit booklet. 12 U.S. News & World Report, As compared to our other BCBSNC plas. 14 Source: orgaizatio (accessed September, 2016) HSA Aggregate Cost Share Startig i 2016, the self-oly dollar limit will apply to each covered perso. Thus, each covered family member may reach the self-oly limit or the family limit, whichever comes first. 16 You must be uder 30 years of age whe the pla begis or qualify for a hardship exemptio through the federal govermet to be eligible for a Catastrophic pla. Visit bcbsc.com for more details. 17 Tier 2 providers may ot have met oe or more of the stadards ecessary for iclusio i Tier Source: familiesusa.org/product/federal-poverty-guidelies (accessed Jue, 2016). These 2016 FPL guidelies are for the 48 cotiguous states ad Washigto D.C. 15

16 EASY STEPS to eroll It s easy to apply for coverage! Step 1 Step 2 Step 3 Cotact your local authorized BCBSNC aget. He or she will be happy to help you complete the applicatio ad select a pla. Your policy will ot become effective util your first moth s premium paymet has bee received ad processed. Oce your paymet has bee received ad processed, your ID card will be mailed to you. Aual ope erollmet is betwee November 1, 2016, ad Jauary 31, 2017 Aual erollmet is the oly time you kow for certai you ca buy health isurace. Apply by December 15 to get coverage that starts Jauary 1, Oce ope erollmet eds you may still be able to buy health isurace if you have what is called a qualifyig life evet. If you get married, have a ew baby, or lose your health coverage, you may qualify. 10 Documetatio may be required. To be eligible for coverage, you must be a North Carolia residet ad ot be erolled i Medicare. For more ifo Cotact your local authorized BCBSNC aget. He or she will be happy to help you. A BLUE CROSS, BLUE SHIELD, the Cross ad Shield symbols ad service marks are marks of the Blue Cross ad Blue Shield Associatio, a associatio of idepedet Blue Cross ad Blue Shield Plas. All other marks are the property of their respective owers. Blue Cross ad Blue Shield of North Carolia is a idepedet licesee of the Blue Cross ad Blue Shield Associatio. U9144b, 9/16 16 bcbsc.com

17 No-Discrimiatio ad Accessibility Notice Discrimiatio is Agaist the Law Blue Cross ad Blue Shield of North Carolia ( BCBSNC ) complies with applicable Federal civil rights laws ad does ot discrimiate o the basis of race, color, atioal origi, age, disability, or sex. BCBSNC does ot exclude people or treat them differetly because of race, color, atioal origi, age, disability, or sex. BCBSNC: Provides free aids ad services to people with disabilities to commuicate effectively with us, such as: - Qualified iterpreters - Writte iformatio i other formats (large prit, audio, accessible electroic formats, other formats) Provides free laguage services to people whose primary laguage is ot Eglish, such as: - Qualified iterpreters - Iformatio writte i other laguages If you eed these services, cotact Customer Service , TTY ad TDD, call If you believe that BCBSNC has failed to provide these services or discrimiated i aother way o the basis of race, color, atioal origi, age, disability, or sex, you ca file a grievace with: BCBSNC, PO Box 2291, Durham, NC 27702, Attetio: Civil Rights Coordiator- Privacy, Ethics & Corporate Policy Office, Telephoe , Fax , TTY civilrightscoordiator@bcbsc.com You ca file a grievace i perso or by mail, fax, or . If you eed help filig a grievace, Civil Rights Coordiator - Privacy, Ethics & Corporate Policy Office is available to help you. You ca also file a civil rights complait with the U.S. Departmet of Health ad Huma Services, Office for Civil Rights, electroically through the Office for Civil Rights Complait Portal, available at or by mail or phoe at: U.S. Departmet of Health ad Huma Services 200 Idepedece Aveue, SW Room 509F, HHH Buildig Washigto, D.C , (TDD). Complait forms are available at This Notice ad/or attachmets may have importat iformatio about your applicatio or coverage through BCBSNC. Look for key dates. You may eed to take actio by certai deadlies to keep your health coverage or help with costs. You have the right to get this iformatio ad help i your laguage at o cost. Call Customer Service Marks of the Blue Cross ad Blue Shield Associatio, a associatio of idepedet Blue Cross ad Blue Shield Plas. Blue Cross ad Blue Shield of North Carolia is a idepedet licesee of the Blue Cross ad Blue Shield Associatio. v. 10/16

18 ATTENTION: If you speak aother laguage, laguage assistace services, free of charge, are available to you. Call (TTY: ). ATENCIÓN: Si habla español, tiee a su disposició servicios gratuitos de asistecia ligüística. Llame al (TTY: ). 注意 : 如果您講廣東話或普通話, 您可以免費獲得語言援助服務 請致電 (TTY: ) CHÚ Ý: Nếu bạ ói Tiếg Việt, có các dịch vụ hỗ trợ gô gữ miễ phí dàh cho bạ. Gọi số (TTY: ). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. ATTENTION : Si vous parlez fraçais, des services d'aide liguistique vous sot proposés gratuitemet. Appelez le (ATS : ). ملحوظة: إذا كنت تتحدث اللغة العربية فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم المبرقة الكاتبة: LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: ). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). PAUNAWA: Kug agsasalita ka g Tagalog, maaari kag gumamit g mga serbisyo g tulog sa wika ag walag bayad. Tumawag sa (TTY: ). સચન : જ તમ ગજર ત બ લત હ, ત નન:સલ ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર (TTY: ). ច ណ ប រស នបរ ប កអ នកន យ យជ ភ ស ខ ម រ បសវ កម ជ ន យខ នកភ ស ម ននតលជ នសប ម រ ប កអ នកប យម នគ តថ ល ស ម ទ ន ក ទ នងត ម រយ បលម (TTY: ) ACHTUNG: We Sie Deutsch spreche, stehe Ihe kostelos sprachliche Hilfsdiestleistuge zur Verfügug. Rufummer: (TTY: ). ध य न द: यदद आप द न द ब लत त आपक दलए मफ त म भ ष स यत सव ए उपलब ध (TTY: ) पर क ल कर ໂປດຊາບ: ຖາວາ ທານເວາພາສາ ລາວ, ການບລການຊວຍເຫອດານພາສາ, ໂດຍບເສຽຄາ, ແມນມພອມໃຫທານ. ໂທຣ (TTY: ). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: ) まで お電話にてご連絡ください Marks of the Blue Cross ad Blue Shield Associatio, a associatio of idepedet Blue Cross ad Blue Shield Plas. Blue Cross ad Blue Shield of North Carolia is a idepedet licesee of the Blue Cross ad Blue Shield Associatio. v. 10/16