BlueCross BlueShield of North Carolina: Blue Value Silver$$start$$ 3000
Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 01/01/2014 - 12/31/2014 Coverage for: Individual Plan Type: POS

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbsnc.com or by calling 1-877-258-3334. Important Questions Answers $3,000 person/$6,000 family in-network. $6,000 person/$12,000 family outof-network. Doesn't apply to In-Network preventive care. Coinsurance and copayments do not apply to the deductible. Yes. $200 for prescription drugs. There are no other specific deductibles. Yes. For In-Network $6,350 person/$12,700 family For Out-Of-Network $12,700 person/$25,400 family Premiums, balance-billed charges and health care this plan doesn't cover No. Yes. For a list of InNetwork providers, see www.bcbsnc.com/content/ Why this Matters: You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

What is the overall deductible?

Are there other deductibles for specific services? Is there an out-ofpocket limit on my expenses? What is not included in the out-of-pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers?

You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you