Review Your Benefit Options

Medical

Medical Benefits

Overview

NCRMA offers nine medical plan options administered by BlueCross and BlueShield of North Carolina (BlueCross NC). All plans use the same network of providers who have agreed to charge discounted rates to plan members. The amount you pay for health care will vary depending on whether or not you use in- network providers and facilities. You always have the choice to go to any provider, but you’ll pay less if you stay within the BlueCross NC Blue OptionsSM network.

Plan Year	All Copay High	Blue Options High	Blue Options 1-2-3 $2K
Deductible
Deductible (Individual/Family)	$0 / $0	$2,000 / $4,000	$2,000 / $4,000
Out-of-Pocket Maximum (Individual/Family)	$3,500 / $7,000	$4,000 / $8,000	$4,000 / $8,000
Coinsurance	0%	80% / 20%	Level 2: 90% / 10% Level 3: 70% / 30%
Office Visits
Preventive Care	$0	$0	$0
Primary Care Office Visits	$20	$25	$25
Lab Tests	$20	20% after deductible	30% after deductible
Urgent Care	$40	$50	$100
Specialist Office Visits	$40	$50	30% after deductible
Imaging Services
X-Rays, Ultrasounds, EEG, and EKG	$40	20% after deductible	30% after deductible
CT Scans, MRI’s, MRA’s, and PET	$250	20% after deductible	30% after deductible
Inpatient Services
Inpatient Services	$2,000	20% after deductible	$250 copay; then 10% after deductible
Emergency Room (with Admission)	$2,000	20% after deductible	10% after deductible
Emergency Room (no Admission)	$500	$300	30% after deductible
Outpatient Services
Outpatient Hospital Facility Services	$750	20% after deductible	30% after deductible
Prescription Drug
Tier 1	$15	$15	$15
Tier 2	$30	$45	$45
Tier 3	$45	$85	$85
Tier 4	$85	$105	$105
Tier 5	$200	25% after deductible	25% after deductible

Plan Year	Blue Options Low	All Copay Low	H.S.A Plan High
Deductible
Deductible (Individual/Family)	$3,000 / $6,000	$0 / $0	$2,500 / $5,000
Out-of-Pocket Maximum (Individual/Family)	$6,000 / $12,000	$9,200 / $18,400	$5,000 / $7,000
Coinsurance	70% / 30%	0%	80% / 20%
Office Visits
Preventive Care	$0	$0	$0
Primary Care Office Visits	$35	$50	20% after deductible
Lab Tests	30% after deductible	$50	20% after deductible
Urgent Care	$70	$100	20% after deductible
Specialist Office Visits	$70	$100	20% after deductible
Imaging Services
X-Rays, Ultrasounds, EEG, and EKG	30% after deductible	$100	20% after deductible
CT Scans, MRI’s, MRA’s, and PET	30% after deductible	$650	20% after deductible
Inpatient Services
Inpatient Services	30% after deductible	$7,500	20% after deductible
Emergency Room (with Admission)	30% after deductible	$7,500	20% after deductible
Emergency Room (no Admission)	$500	$1,500	20% after deductible
Outpatient Services
Outpatient Hospital Facility Services	30% after deductible	$2,000	20% after deductible
Prescription Drug
Tier 1	$15	$15	20% after deductible
Tier 2	$45	$30	20% after deductible
Tier 3	$85	$45	20% after deductible
Tier 4	$105	$85	20% after deductible
Tier 5	25% after deductible	$200	20% after deductible

Plan Year	Blue Options 1-2-3 $3.5K	Blue Options 1-2-3 $5K	H.S.A Plan Low
Deductible
Deductible (Individual/Family)	$3,500 / $7,000	$5,000 / $10,000	$5,000 / $10,000
Out-of-Pocket Maximum (Individual/Family)	$7,000 / $14,000	$9,200 / $18,400	$8,300 / $16,600
Coinsurance	Level 2: 90% / 10% Level 3: 70% / 30%	Level 2: 90% / 10% Level 3: 70% / 30%	70% / 30%
Office Visits
Preventive Care	$0	$0	$0
Primary Care Office Visits	$35	$35	30% after deductible
Lab Tests	50% after deductible	50% after deductible	30% after deductible
Urgent Care	$100	$100	30% after deductible
Specialist Office Visits	50% after deductible	50% after deductible	30% after deductible
Imaging Services
X-Rays, Ultrasounds, EEG, and EKG	50% after deductible	50% after deductible	20% after deductible
CT Scans, MRI’s, MRA’s, and PET	50% after deductible	50% after deductible	20% after deductible
Inpatient Services
Inpatient Services	$250 copay; then 30% after deductible	$250 copay; then 30% after deductible	30% after deductible
Emergency Room (with Admission)	30% after deductible	30% after deductible	30% after deductible
Emergency Room (no Admission)	50% after deductible	50% after deductible	30% after deductible
Outpatient Services
Outpatient Hospital Facility Services	50% after deductible	50% after deductible	30% after deductible
Prescription Drug
Tier 1	$15	$15	30% after deductible
Tier 2	$45	$45	30% after deductible
Tier 3	$85	$85	30% after deductible
Tier 4	$105	$105	30% after deductible
Tier 5	25% after deductible	25% after deductible	30% after deductible

Dental

Dental Benefits

Overview

NCRMA offers dental coverage to you through BlueCross NC. Your dental plan provides coverage to help with the cost of many dental services including routine cleanings, x-rays, restorative and prosthetic services. The plan includes an extensive network of dental providers. Maximize your benefits by selecting an in-network dentist to save more on all covered services and avoid balance billing.

	BlueCross NC w/ rollover
Plan Year	Low	High
Plan Year	In-Network	In-Network
Deductible
Individual Deductible	$50	$50
Family Deductible	$150	$150
Maximums
Plan Maximum	$1,000	$1,500
Orthodontia Lifetime Maximum	N/A	$1,500
Services
Preventive	100%	100%
Basic	80%	80%
Major	50%	50%
Ortho	N/A	50%

Total Monthly Premium

	Low	High
Coverage Tier	In-Network	In-Network
Employee Only	$37.92	$42.99
Employee + Spouse	$75.84	$85.98
Employee + Child(ren)	$90.46	$102.85
Employee + Family	$138.22	$157.20

Vision

Vision Benefits

Overview

NCRMA offers vision coverage to you through Blue Cross NC. You will receive the maximum benefits and pay less out-of-pocket by visiting an in-network provider. The network includes provider access points nationwide. A comprehensive vision exam is available every 12 months and you may purchase eyewear in the form of an eyeglass frame and lenses, or contact lenses.

	Blue 20/20
Plan Year	In-Network	Out-of-Network
Exams – Once every 12 months
Eye Exam	$10 Copay	Up to $39
Retinal Imaging	Covered up to $39	Not Covered
Contact Lens Fit & Follow-Up (Standard Fit)	Covered up to $55	Not Covered
Lenses – Once every 12 months
Single	$25 Copay	Up to $25
Bifocal	$25 Copay	Up to $39
Trifocal	$25 Copay	Up to $63
Lenticular	$25 Copay	Up to $63
Frames – Once every 12 months
Standard Frame	$130 allowance + discounts at participating providers	Up to $65
Contacts – Once every 12 months
Medically Necessary	Covered in full	Up to $200
Elective	$130 allowance	Up to $104
Plan Provisions
Rate Guarantee	3 year	3 year

Total Monthly Premium

	Blue 20/20
Rates	Option #3
Employee Only	$12.75
Employee + Spouse	$20.63
Employee + Child(ren)	$21.50
Employee + Family	$29.73

Complete Participating Employer Agreement

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