2012

Some benefit features are only available with certain plan combinations. Your premium will vary depending on the plan selected. Your benefits are listed in the same row as the coinsurance percentage you select.

plans

First,
select your deductible
Benefit period deductible2 The benefit period deductible is the amount or expense for covered services that you must pay before your insurance benefits apply for all or part of the remaining cost of covered services Network

Then,
select your coinsurance for the deductible you choose Coinsurance Coinsurance is the percentage of the allowed amounts for covered services that BCBSNC will pay after you meet your deductible Prescription drugs The amount you pay for generic or brand-name drugs.

Now,
view your benefits
Preventive care Routine physical exams and screening tests; well-baby and wellchild care (including periodic assessments and 3 immunizations) Network
7

Total out-of-pocket maximum2 Your maximum out-ofpocket expense, including your deductible and your share of the coinsurance expense

Annual contribution limit The maximum amount you can contribute to an HSA in any year you are eligible4, 5

Network
7

Network OUT
7

Network OUT
7

Coverage for one person

100% 70% 100% 70% 100% 70% $2,700 $6,650

Individual

IN

OUT

IN

IN

OUT

IN

IN

OUT7

$2,700 deductible

Not subject to deductible

$2,700

$5,400

80%

50%

80%

50%

100%

50%

$5,000

$10,000

$3,100

50%

50%

50%

50%

100%

50%

$5,000

$10,000

$5,000 deductible

$5,000

$10,000

100%

70%

100%

70%

100%

70%

$5,000

$11,250

$3,100

Network

Network
7

Network OUT
7

Network
7

Network OUT
7

Coverage for more than one person

Family

IN

OUT

IN

IN

OUT

IN

IN

OUT7 $13,400

100%

70%

100%

70%

100%

70%

$5,450

$5,450 deductible

Not subject to deductible

$5,450

$10,900

80%

50%

80%

50%

100%

50%

$10,000

$20,000

$6,250

50%

50%

50%

50%

100%

50%

$10,000

$20,000

$10,000 deductible

$10,000

$20,000

100%

70%

100%

70%

100%

70%

$10,000

$22,500

$6,250

PAGE 1 of 3

2012
Benefit type

plans

Benefit description

Health plan benefits

In-network coverage6
You pay:6 Coinsurance after deductible You pay: $03 You pay:9 After deductible, 0%, 20% or 50% coinsurance depending on the plan you select Deductible options:10 Individual $2,700, $5,000; Family $5,450, $10,000 Benefits vary depending on the deductible you select You pay: After deductible, 0%, 20% or 50% coinsurance depending on the plan you select. Depending on the plan you select, Individual: $2,700 - $5,000 out-of-pocket maximum Family: $5,450 - $10,000 out-of-pocket maximum Unlimited Inpatient, you pay: Coinsurance after deductible

Office visits in network Preventive care Prescription drugs Deductible Coinsurance Total out-of-pocket maximum Lifetime maximum Hospital Urgent care centers Emergency room services Ambulatory surgery centers Mental health and substance abuse Vision Other services Maternity rider* Child-only coverage

Primary doctors and specialists, including surgery, lab work, therapy and radiology performed by the same doctor on the same day in office. Routine physical exams, including gynecological exam; well-child and well-baby care, including periodic assessments and immunizations. The amount you pay for generic or brand-name drugs.

The amount you pay during the benefit period for some services before BCBSNC pays its portion.

The percentage of covered medical expenses that you pay after youve paid your deductible.

The total amount of money you pay out of pocket in a benefit period.

The maximum amount BCBSNC will pay per member for covered services. Inpatient and outpatient facility services, drugs, blood, supplies, medical care, surgical care, therapy services, diagnostic tests, X-rays and lab work. Provide services for a sudden or unexpected condition requiring prompt diagnosis or treatment to prevent chronic illness, prolonged impairment or a more hazardous treatment. Examples: sprains, some lacerations and dizziness. Services for the sudden onset of a condition that a person could reasonably expect the absence of immediate medical attention to result in placing ones health at risk. A licensed or certified non-hospital facility which has permanent facilities and equipment for the primary purpose of performing surgical procedures on an outpatient basis and does not provide inpatient accommodations.

You pay: Coinsurance after deductible

You pay: Coinsurance after deductible

You pay: Coinsurance after deductible

Inpatient and outpatient professionals. Includes 10 office (or) outpatient visits and five inpatient day limits. Routine eye exam. Durable medical equipment, home health care, home infusion therapy, hospice care, private duty nursing, ambulance services, skilled nursing facilities (to 60 days per year) and dental accident. Pre- and post-natal coverage. Coverage for children 18 years of age and younger. No full-time student requirement.

You pay: Coinsurance after deductible You pay: Coinsurance after deductible You pay: Coinsurance after deductible Rider available. You pay coinsurance after deductible. Health benefits available. No HSA for children under 18.

*Excludes dependent children.

PAGE 2 of 3

2012 Blue Options HSA plans

Your coverage will automatically renew. Your coverage may be canceled by Blue Cross and Blue Shield of North Carolina (BCBSNC) for fraud or intentional misrepresentation of information on your application. Coverage for dependent children ends at age 26. Members will be notified 30 days in advance of any change in coverage. A waiting period for coverage of pre-existing conditions may apply to your coverage.8 (Pre-existing conditions apply only to adults age 19 and older and do not apply to children age 18 or younger.) This brochure contains a summary of the benefits only. It is not your insurance policy. Your policy is your insurance contract. If there is any difference between this brochure and the policy, the provisions of the policy will control. PLEASE NOTE: Federal guidelines and interpretations are subject to change.
1 Blue Options HSA combines a high-deductible health plan and a health savings account (HSA). BCBSNC does not administer your HSA. BCBSNC is not affiliated with your HSA custodian or administrator. 2 Blue Options HSA plans, deductible and out-of-pocket maximum amounts are subject to change year to year in order to comply with IRS requirements. For the most up-to-date requirement information, see www.irs.gov. 3 Blue Options HSA covers preventive care services such as routine physical exams, gynecological exams, certain immunizations, and well-baby and well-child care including periodic assessments at 100% before the deductible is met when services are received in an in-network office setting. When you receive preventive care out-of-network, you may be required to pay the difference between the providers actual charge and BCBSNCs allowed amount in addition to the coinsurance amount. Other covered services may be subject to deductible and coinsurance. For more information, visit bcbsnc.com/preventive. 4 These amounts will be updated annually for inflation. For the most up-to-date information, visit www.irs.gov. 5 Amount is limited to the amount established by the IRS for each year for single or family coverage. Anyone age 55 or older can contribute an additional $1,000 to their HSA in 2012. 6 All services are limited to the allowed amount. BCBSNC allowed amount is the amount that BCBSNC determines is reasonable for covered services provided to a member, which may be established in accordance with an agreement between the provider and BCBSNC. If you use an in-network provider you will only be responsible for your deductible and any coinsurance amounts. 7 Your actual expenses for covered services may exceed the stated amount because actual provider charges may not be used to determine the payment obligations of BCBSNC or its members. 8 Pre-existing conditions are those for which medical advice, diagnosis, care or treatment was received or recommended within 12 months of the date that your Blue Options HSA coverage begins. You may receive credit toward the 12-month waiting period if we receive your completed Blue Options HSA application within 63 days of the termination of your previous health coverage. 9 For Blue Options HSA, members pay a discounted amount for all prescription drugs until they meet the deductible. Once the deductible has been met, the member then pays any required coinsurance. 10 Blue Options HSA plans, deductible and out-of-pocket maximum amounts are subject to change year to year in order to comply with IRS requirements. For the most up-to-date requirement information, see www.irs.gov.

Limitations & Exclusions

Like most health care plans, Blue Options HSA has some limitations and exclusions. If your application is approved, you will receive a Member Guide. It will contain detailed information about plan benefits, exclusions and limitations. This is a partial list of benefits that are not payable:
Services for or related to conception by artificial means or for reversal of sterilization Treatment of sexual dysfunction not related to organic disease Treatment or studies leading to or in connection with sex changes or modifications and related care Services that are investigational in nature or obsolete, including any service, drugs, procedure or treatment directly related to an investigational treatment Side effects and complications of noncovered services, except for emergency services in the case of an emergency Services that are not medically necessary Dental services provided in a hospital, except as specifically covered by your health benefit plan Services or expenses that are covered by any governmental unit except as required by Federal law Services received from an employer-sponsored dental or medical department Services received or hospital stays before (or after) the effective dates of coverage Custodial care, domiciliary care or rest cures Eyeglasses or contact lenses or refractive eye surgery Services to correct nearsightedness or refractive errors Services for cosmetic purposes Services for routine foot care Travel, except as specifically listed in the benefit booklet Services for weight control or reduction, except for morbid obesity, or as specifically covered by your health benefit plan Services for maternity or elective abortion except as provided by the maternity rider option, if purchased Inpatient admissions that are primarily for physical therapy, diagnostic studies, or environmental change Services that are rendered by or on the direction of those other than doctors, hospitals, facility and professional providers; services that are in excess of the customary charge for services usually provided by one doctor when done by multiple doctors For any condition suffered as a result of any act of war or while on active or reserve military duty Services for which a charge is not normally made in the absence of insurance, or services provided by an immediate relative Non-prescription drugs and prescription drugs or refills which exceed the maximum supply Personal hygiene, comfort and/or convenience items For telephone consultations, charges for failure to keep a scheduled visit, charges for completion of a claim form, charges for obtaining medical records, and late payment charges Services primarily for educational purposes Services for conditions related to developmental delay and/or learning differences Long-term rehabilitative therapy Services not specifically listed as covered services

To be eligible for Blue Options HSA coverage, you must: Be a North Carolina resident; Qualify medically; Not be covered by another insurance policy; Not be enrolled in Medicare. To open and fund an HSA, you must be 18 or older and not be claimed as a dependent on someone elses tax return. Policy Number: PPO-I, 6/11 , SM Marks of the Blue Cross and Blue Shield Association. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association. U3610, 10/11

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