Lab services are covered based on place of service.Examples:Angela’s doctor administers her lab tests in his offi ce and sends them to a BCBSNC-contracted lab (e.g., LabCorp®1

or Quest Diagnostics®2or Quest Diagnostics®2or Quest Diagnostics ) for analysis. These lab services are covered at Level 1.

Jane has blood drawn in her doctor’s offi ce and the samples are sent to an outpatient hospital or outpatient clinic setting for analysis. These lab services are covered at Level 3.

OB/GYNs are considered primary care providers.You can see OB/GYNs for primary care/preventive services or for a specifi c diagnosis, and their services are covered at Level 1. If you’re not sure that a doctor is a primary care provider, check the BCBSNC provider directory online. Visit bcbsnc.comand click Find a Doctor.

There are a few things to remember when using this plan. You need to be aware of:

+ Who is providing the service

+ Where the service is provided

And, in the case of tests and procedures:

+ Where the results will be analyzed

+ The possibility that the level of benefi t coverage can change, if additional services are performed at the same time

The good news is in-network primary care and preventive services will be covered with just a copayment. Inpatient hospital stays and other inpatient services are covered at the highest level of coinsurance.

Tips to help you get the most out of your health planPreventive service = Level 1 Preventive service + additional service additional service = Level 3Preventive care, if performed without additional services and Preventive care, if performed without additional services and regardless of where it is performed, is covered at Level 1, even regardless of where it is performed, is covered at Level 1, even when provided by a specialist. If other services are included,when provided by a specialist. If other services are included,1

the entire claim will be covered at Level 3.

Examples:A colonoscopy is covered at Level 1 as a routine preventive A colonoscopy is covered at Level 1 as a routine preventive service, unless additional services are performed as a result service, unless additional services are performed as a result of what is found during the procedure. For example, during of what is found during the procedure. For example, during Ronnie’s routine colonoscopy, his doctor discovers and Ronnie’s routine colonoscopy, his doctor discovers and removes some polyps. Because of this additional service, removes some polyps. Because of this additional service, Ronnie’s entire claim is covered at Level 3.Ronnie’s entire claim is covered at Level 3.

A mammogram is covered at Level 1 as a routine preventive A mammogram is covered at Level 1 as a routine preventive service, unless additional services are performed as a result service, unless additional services are performed as a result of what is found during the screening. For example, during of what is found during the screening. For example, during Christine’s mammogram, her doctor decides that a biopsy Christine’s mammogram, her doctor decides that a biopsy is necessary. Because of the additional service performed, is necessary. Because of the additional service performed, Christine’s entire claim is covered at Level 3.Christine’s entire claim is covered at Level 3.

How to get the most out of Blue Options 1-2-3

Using this plan effectively

1 Some services and supplies received by members in an offi ce setting or in connection with an offi ce visit are in fact outpatient hospital-based services provided by hospital-owned or operated practices. These services and supplies may be subject to your deductible and coinsurance. Please see the BCBSNC provider listing online at bcbsnc.com to identify these providers.

HOWCAN WE

HELP?

When in doubt about your coverage, check your BCBSNC benefi t booklet and/or call BCBSNC Customer Service at the toll-free number listed on your ID card.

Blue Options 1-2-3 at a glanceLevel 1A copayment for most primary care offi ce visits and services such as annual exams, immunizations and common screening procedures

Level 2Coinsurance coverage for acute care such as admitted hospital stays (subject to deductible and a per-admission copayment if applicable)

Level 3A lower level of coinsurance coverage, subject to deductible, for services such as specialist visits and outpatient hospital services

Primary care/covered preventive services received in the doctor’s offi ce

✔✔

If other services are performed as well

Inpatient hospital stays ✔

Inpatient services ✔

Routine wellness exams/screening services received in an outpatient clinic or setting (excludes mammograms and colonoscopies)

✔

Outpatient hospital services ✔

Lab tests

✔The member’s doctor administers the lab test in his/her offi ce OR

sends it to a BCBSNC-contracted reference lab (e.g. LabCorp or

Quest) for analysis

✔The member’s doctor administers

the lab test in his/her offi ce and sends it to an outpatient hospital or outpatient clinic

setting for analysis

OB/GYN services, whether preventive or for a specifi c diagnosis ✔

Mammograms✔

Performed alone as a preventive screening

✔If other services

are also performed

Routine prenatal services billed as part of the pregnancy and delivery costs, including routine prenatal and postnatal offi ce visits

✔

Colonoscopies✔

Performed alone as a preventive screening

✔If other services

are also performed

Durable medical equipment ✔

® , SM Marks of the Blue Cross and Blue Shield Association. SM1 Mark of Blue Cross and Blue Shield of North Carolina. ®1 is a registered trademark of Laboratory Corporation of America. ®2 is a registered trademark of Quest Diagnostics. An independent licensee of the Blue Cross and Blue Shield Association. U6541, 2/10