2017315U400048

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 - 12/31/2018Blue Cross and Blue Shield of North Carolina: Blue Select Gold 2500 Coverage for: Individual + Family Plan Type: PPO

B0004601

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would sharethe cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsnc.com/booklets. Forgeneral definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see theGlossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call 1-888-206-4697 to request a copy.

Important Questions Answers Why this Matters:

What is the overalldeductible?

In-Network $2,500 Individual /$5,000 Family Total.Out-of-Network $5,000 Individual /$10,000 Family Total.

Generally, you must pay all of the costs from providers up to the deductible amount before thisplan begins to pay. If you have other family members on the plan, each family member mustmeet their own individual deductible until the total amount of deductible expenses paid by allfamily members meets the overall family deductible.

Are there services coveredbefore you meet yourdeductible?

Yes. Preventive care and mostservices that may require acopayment.

This plan covers some items and services even if you haven’t yet met the deductible amount.But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of coveredpreventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductiblesfor specific services?

Yes, $200 for prescription drug coverage. There are no otherspecific deductibles.

You must pay all of the costs for these services up to the specific deductible amount before thisplan begins to pay for these services.

What is the out–of–pocket limit for this plan?

In-Network $7,350 Individual /$14,700 Family Total.Out-of-Network $14,700 Individual/ $29,400 Family Total.

The out-of-pocket limit is the most you could pay in a year for covered services. If you haveother family members in this plan, they have to meet their own out-of-pocket limits until theoverall family out-of-pocket limit has been met.

What is not includedin the out–of–pocket limit?

Premiums, balance-billingcharges, health care this plandoesn’t cover and penalties forfailure to obtain pre-authorizationfor services.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

2 of 11* For more information about limitations and exceptions, see plan or policy document at www.bcbsnc.com/booklets

Important Questions Answers Why this Matters:

Will you pay less if you usea network provider?

Yes. See www.bcbsnc.com/FindADoctoror call 1-888-206-4697 for a list ofnetwork providers.

You pay the least if you use a provider in (Tier 1). You pay more if you use a provider in (Tier 2).You will pay the most if you use an out-of-network provider, and you might receive a bill from aprovider for the difference between the provider's charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services(such as lab work). Check with your provider before you get services.

Do you need a referral tosee a specialist?

No You can see the specialist you choose without a referral.

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3 of 11* For more information about limitations and exceptions, see plan or policy document at www.bcbsnc.com/booklets

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event

Services You MayNeed

What You Will Pay

Network Provider(You will pay the least)

Out-of-Network Provider(You will pay the most)

Limitations, Exceptions, & OtherImportant Information

If you visit a healthcare provider's office orclinic

Primary care visit to treat aninjury or illness

$5 copayment / visit40% after deductible /visit

None

Specialist visit$30 copayment / visit forTier 1; $60 copayment /visit for Tier 2

40% after deductible /visit

None

Preventivecare/screening/immunization

No Charge Not Covered

You may have to pay for services that aren’tpreventive. Ask your provider if the servicesyou need are preventive. Then check what yourplan will pay for. Limits may apply.

If you have a test

Diagnostic test (x-ray, bloodwork)

10% after deductible /visit for Tier 1; 30% afterdeductible / visit for Tier 2

40% after deductible None

Imaging (CT/PET scans,MRIs)

10% after deductible /visit for Tier 1; 30% afterdeductible / visit for Tier 2

40% after deductiblePrior review and certification of services may berequired or services will not be covered

4 of 11* For more information about limitations and exceptions, see plan or policy document at www.bcbsnc.com/booklets

Common Medical Event

Services You MayNeed

What You Will Pay

Network Provider(You will pay the least)

Out-of-Network Provider(You will pay the most)

Limitations, Exceptions, & OtherImportant Information

If you need drugs to treatyour illness or conditionMore information about prescription drugcoverage is available at www.bcbsnc.com/rxinfo

Tier 1 Drugs$4 copayment afterprescription drugdeductible

$4 copayment afterprescription drugdeductible

Tier 2 Drugs$10 copayment afterprescription drugdeductible

$10 copayment afterprescription drugdeductible

Tier 3 Drugs$35 copayment afterprescription drugdeductible

$35 copayment afterprescription drugdeductible

No coverage for drugs in excess of quantitylimits, or therapeutically equivalent to an overthe counter drug. Other coverage limits mayapply. *See Prescription Drug Section.

Tier1 Drugs

Tier 4 Drugs$80 copayment afterprescription drugdeductible

$80 copayment afterprescription drugdeductible

Same as above.

Tier 5 Drugs25% after prescriptiondrug deductible

25% after prescriptiondrug deductible

Same as above.

Tier 6 Drugs35% after prescriptiondrug deductible

35% after prescriptiondrug deductible

Same as above.

If you haveoutpatient surgery

Facility fee (e.g., ambulatorysurgery center)

10% after deductible /visit for Tier 1; 30% afterdeductible / visit for Tier 2

40% after deductible None

Physician/surgeon fees10% after deductible /visit for Tier 1; 30% afterdeductible / visit for Tier 2

40% after deductible None

5 of 11* For more information about limitations and exceptions, see plan or policy document at www.bcbsnc.com/booklets

Common Medical Event

Services You MayNeed

What You Will Pay

Network Provider(You will pay the least)

Out-of-Network Provider(You will pay the most)

Limitations, Exceptions, & OtherImportant Information

If you need immediatemedical attention

Emergency room care$500 copayment afterdeductible / visit

$500 copayment afterdeductible / visit

None

Emergency medical transportation

10% after deductible 10% after deductible None

Urgent care $30 copayment / visit $30 copayment / visit None

If you have a hospitalstay

Facility fee (e.g., hospitalroom)

10% after deductible /visit for Tier 1; $500 peradmission copay then30% after deductible /visit for Tier 2

$500 per admissioncopay then 40% afterdeductible

Prior review and certification of services may berequired or services will not be covered

Physician/surgeon fees10% after deductible /visit for Tier 1; 30% afterdeductible / visit for Tier 2

40% after deductible None

If you need mentalhealth, behavioral health,or substance abuseservices

Outpatient services

$5 copayment / officevisit; 10% afterdeductible / outpatient forTier 1 / $60 copayment /office visit; 30% afterdeductible / outpatient forTier 2

40% after deductiblePrior review and certification of services may berequired or services will not be covered

Inpatient services

10% after deductible /visit for Tier 1; 30% afterdeductible / admissionthen $500 per admissioncopay / visit for Tier 2

$500 per admissioncopay then 40% afterdeductible

Precertification may be required.

6 of 11* For more information about limitations and exceptions, see plan or policy document at www.bcbsnc.com/booklets

Common Medical Event

Services You MayNeed

What You Will Pay

Network Provider(You will pay the least)

Out-of-Network Provider(You will pay the most)

Limitations, Exceptions, & OtherImportant Information

If you are pregnant

Office visits $5 copayment / visit40% after deductible /visit

*See Family planning section.

Childbirth/deliveryprofessional services

10% after deductible /visit for Tier 1; 30% afterdeductible / visit for Tier 2

40% after deductible None

Childbirth/delivery facilityservices

10% after deductible /visit for Tier 1; $500 peradmission copay /admission then 30% afterdeductible / visit for Tier 2

$500 per admissioncopay then 40% afterdeductible

Precertification may be required

If you need helprecovering or have otherspecial health needs

Home health care 10% after deductible 40% after deductiblePrior review and certification of services may berequired or services will not be covered.

Rehabilitation services $30 copayment 40% after deductible30 visits / benefit period for physical /occupational therapy and chiropractic services.30 visits / benefit period for speech therapy

Habilitation services $30 copayment 40% after deductible30 visits / benefit period for physical /occupational therapy and chiropractic services.30 visits / benefit period for speech therapy

Skilled nursing care 10% after deductible 40% after deductible

Coverage is limited to 60 days per benefitperiod. Prior review and certification of servicesmay be required or services will not be coveredfor all plans.

Durable medical equipment 10% after deductible 40% after deductiblePrior review and certification of services may berequired or services will not be covered. Limitsmay apply.

Hospice services 10% after deductible 40% after deductiblePrecertification may be required for inpatientservices.

7 of 11* For more information about limitations and exceptions, see plan or policy document at www.bcbsnc.com/booklets

Common Medical Event

Services You MayNeed

What You Will Pay

Network Provider(You will pay the least)

Out-of-Network Provider(You will pay the most)

Limitations, Exceptions, & OtherImportant Information

If your child needs dentalor eye care

Children's eye exam $5 copayment 40% after deductible Limits may apply.

Children's glasses 50% no deductible 50% no deductibleLimited to one pair of glasses or contacts perbenefit period.

Children's dental check-up No Charge 30% after deductible Limited to twice per benefit period.

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

• Acupuncture• Cosmetic Surgery• Dental Care (Adult)• Routine Eye Care (Adult)

• Long Term Care, Respite Care, Rest Cures • Routine Foot Care• Weight Loss Programs• Abortion (Except in cases of rape, incest, or when

the life of the mother is endangered)

Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)

• Bariatric Surgery• Chiropractic Care

• Hearing aids up to age 22• Infertility Treatment

• Private duty nursing

• Non-emergency care when traveling outside the U.S. Coverage outside of the United States see www.bcbsnc.com

8 of 11* For more information about limitations and exceptions, see plan or policy document at www.bcbsnc.com/booklets

Your Rights to Continue Coverage:There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is North Carolina Insurance ConsumerAssistance Program at www.ncdoi.com/Smart or 1-855-408-1212 or contact BCBSNC at 1-888-206-4697 or BlueConnectNC.com. Other coverage options may beavailable to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.healthcare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights:Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Health Insurance Smart NC at 1201 Mail Service Center, Raleigh, NC 27699-1201, or toll free 1-855-408-1212.

Additionally, a consumer assistance program can help you file your appeal. Contact Health Insurance Smart NC at 1201 Mail Service Center, Raleigh, NC 27699-1201, or toll free 1-855-408-1212.

Does this plan provide Minimum Essential Coverage? Yes.If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from therequirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? Yes.If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be differentdepending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles,copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under differenthealth plans. Please note these coverage examples are based on self-only coverage.

Note: These numbers assume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program, you may be able to reduce your costs.For more information about the wellness program, please contact: 1-888-206-4697

The plan would be responsible for the other costs of these EXAMPLE covered services

Peg is Having a Baby(9 months of in-network pre-natal care and a

hospital delivery)The plan’s overall deductible $2,500

Specialist copayment $30copayment

Hospital (facility) coinsurance 10%

Other coinsurance 10%

This EXAMPLE event includes services like:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)Total Example Cost $12,800

In this example, Peg would pay:Cost Sharing

Deductibles $2,500Copayments $20Coinsurance $900

What isn't coveredLimits or exclusions $60

The total Peg would pay is $3,500

Managing Joe's type 2 Diabetes(a year of routine in-network care of a

well-controlled condition)The plan’s overall deductible $2,500

Specialist copayment $30copayment

Hospital (facility) coinsurance 10%

Other coinsurance 10%

This EXAMPLE event includes services like:Primary care physician office visits (includingdisease education)Diagnostic tests (blood work)Prescription drugsDurable medical equipment (glucose meter)Total Example Cost $7,400

In this example, Joe would pay:Cost Sharing

Deductibles $2,700Copayments $200Coinsurance $10

What isn't coveredLimits or exclusions $60

The total Joe would pay is $3,000

Mia's Simple Fracture(in-network emergency room visit and follow up

care)The plan’s overall deductible $2,500

Specialist copayment $30copayment

Hospital (facility) coinsurance 10%

Other coinsurance 10%

This EXAMPLE event includes services like:Emergency room care (including medical supplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy)

Total Example Cost $1,900

In this example, Mia would pay:Cost Sharing

Deductibles $1,500Copayments $80Coinsurance $0

What isn't coveredLimits or exclusions $0

The total Mia would pay is $1,600

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® Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross and Blue Shield of North Carolinais an independent licensee of the Blue Cross and Blue Shield Association.

NDM4L1001 v11. 10/11/16

Non-Discrimination and Accessibility Notice

Discrimination is Against the Law

• Blue Cross and Blue Shield of North Carolina (“BCBSNC”) complies with applicable Federal civilrights laws and does not discriminate on the basis of race, color, national origin, age, disability, orsex.

• BCBSNC does not exclude people or treat them differently because of race, color, national origin,age, disability, or sex.

BCBSNC:

Provides free aids and services to people with disabilities to communicate effectively with us,such as:

- Qualified interpreters- Written information in other formats (large print, audio, accessible electronic formats, other

formats)

Provides free language services to people whose primary language is not English, such as: - Qualified interpreters- Information written in other languages

• If you need these services, contact Customer Service 1-888-206-4697 , TTY and TDD, call 1-800-442-7028 .

• If you believe that BCBSNC has failed to provide these services or discriminated in another way onthe basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

» BCBSNC, PO Box 2291, Durham, NC 27702, Attention: Civil Rights Coordinator- Privacy,Ethics & Corporate Policy Office, Telephone 919-765-1663 , Fax 919-287-5613 ,TTY 1-888-291-1783 civilrightscoordinator@bcbsnc.com

• You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, CivilRights Coordinator - Privacy, Ethics & Corporate Policy Office is available to help you.

• You can also file a civil rights complaint with the U.S. Department of Health and Human Services,Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf , or by mail or phone at: U.S. Department of Health andHuman Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C.20201 1-800-368-1019 , 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html .

• This Notice and/or attachments may have important information about your application or coveragethrough BCBSNC. Look for key dates. You may need to take action by certain deadlines to keepyour health coverage or help with costs. You have the right to get this information and help in yourlanguage at no cost. Call Customer Service 1-888-206-4697 .

® Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross and Blue Shield of North Carolinais an independent licensee of the Blue Cross and Blue Shield Association.

NDM4L1001 v11. 10/11/16