Understand your
preventive care benefits

How your preventive care benefits work
Preventive care services are generally covered at
100 percent of the allowed amount when they meet
the following conditions:
• The service is delivered by an in-network provider.
• The service is performed in an in-network, office-based
setting or stand-alone clinic and filed as an office visit.
• The service is received only once per benefit period.
• The service does not include any additional procedures

Regular preventive care can help you stay in better overall health.
Make sure you understand how your preventive care benefits work,
and be sure to take advantage of them

Your covered preventive care services
Screening tests (adult and child)
Each of these services is covered once per benefit period:
• Pap smear
• Routine pelvic exam
• Chlamydia screening
• Clinical breast exam
• Cholesterol
• Lipid screening
• Hemoglobin
• Prostate specific antigen
• Digital rectal exam
• Osteoporosis screening

Screening tests that involve additional diagnostic services
are subject to your deductible and coinsurance.
Well baby and well child care2
• Children up to age three: Routine office visits
• Children ages three through 18: One routine office
visit per benefit period
Adult preventive care
• One routine office visit per benefit period is
covered for adults age 19 and above.
Obesity evaluation and management
• One office visit per benefit period is covered.
Additional obesity evaluation visits are subject to yourdeductible, coinsurance and a four-visit limit.

Your preventive care benefits continued

Immunizations (adult and child)2
Covered:
• Diphtheria – Pertussis – Tetanus Toxoid (DPT)
• Polio
• Influenza
• Measles – Mumps – Rubella (MMR)
• Pneumococcal vaccine
• HiB
• Hepatitis B
• HPV (girls and women ages nine to 26)
• Meningococcal vaccine
• Chicken pox
• Herpes Zoster (Shingles)
Not covered:
• Immunizations required for occupational hazard
• Immunizations required for international travel

Mammogram
• Covered once per benefit period
Routine, preventive mammograms are paid at 100 percent of
the allowed amount when performed in an in-network, office based
setting or stand-alone clinic and filed as an office visit.
Should your physician perform additional services during the
procedure, such as the removal of breast tissue for biopsy,
the service is subject to your deductible and coinsurance

Colorectal cancer screening
• Covered once per benefit period
As with other preventive services, colorectal screenings must
be performed in the physician’s office, not in an outpatient
clinic or hospital, to be covered as preventive. Should your
physician perform additional services during the procedure,
such as the removal of identified polyps, the service is subject
to your deductible and coinsurance.

Things you should know
• If you receive more than one of these services per
benefit period, the additional service may be subject to
your deductible and coinsurance

Services that are not delivered in an in-network, office based
setting or stand-alone clinic filing as an office
visit will be subject to your deductible and coinsurance

• During routine preventive visits, your health care
provider may order additional screenings not listed here.
These are subject to your deductible and coinsurance.

• Save on out-of-pocket costs. Ask your health care
provider to send your routine lab work to a contracted
BCBSNC reference lab

The Patient Protection and Affordable Care Act (PPACA) (enacted March 23, 2010) along with the Health Care and Education Reconciliation Act (enacted March 30, 2010), together referred to as “Health Care Reform,” provides that certain group health plans existing as of March 23, 2010 are only subject to certain provisions of PPACA and refers to these health plans as grandfathered health plans.

A grandfathered health plan is coverage provided by a group health plan or a health insurance issuer, in which an individual was enrolled on March 23, 2010, and the group health plan continuously covered someone since March 23, 2010 (not necessarily the same person, but at all times at least one person). Grandfathered health plans must comply with the following requirements under Health Care Reform:

· Plan documents must include a notice to members disclosing the grandfathered status. (BCBSNC will add the disclosure language to both benefit highlights and benefit booklets.)

· Records documenting the terms of the plan or coverage that were in effect on March 23, 2010, and any other necessary substantiating documents (i.e., prior and current plan documents, documentation of premiums or cost of coverage), must be maintained for as long as the group health plan takes the position the plan is grandfathered.

· Group health plan must be revised to include the following benefits:

o Extension of dependent coverage to age 26 (including married dependents)

o No pre-existing exclusions or waiting periods for enrollees under age 19

o No lifetime dollar limits on “essential benefits”

o No restricted annual dollar limits on "essential benefits”

BCBSNC will issue your renewal quote assuming your group health plan continues to be a grandfathered plan from a benefits perspective. However, if you change your contribution amount by more than 5 percentage points below your contribution rate on March 23, 2010, and therefore lose your grandfathered status, you will need to contact your BCBSNC representative to request a new quote. BCBSNC will be amending our contracts effective October 1, 2010, with specific language describing your obligation to notify BCBSNC of changes in your contribution amount which may result in the loss of grandfathered status of your group health plan.