Knowing these words and phrases will help you better understand how your health plan works.
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You can manage your health better if you understand how your health plan works. And by using built-in benefits like preventive care, telehealth, nutrition counseling, discount programs and more, you can save money while you gain control of your health.
Blue Cross and Blue Shield of North Carolina (Blue Cross NC) created this educational page as a reference. Bookmark it and return when you have questions or when you have new health needs.
Common health insurance terms
An allowed amount is the amount in-network doctors and health care facilities have agreed to accept as full payment on covered services for Blue Cross NC members. It’s usually lower than their normal charge.
Your copayment (copay) is how much you pay for medical services when you receive them. It’s a fixed cost you pay when you check out at the doctor’s office (usually around $20 or so – though the cost varies by plan). Not all plans have a copay.
Your deductible is the set amount you pay toward medical services before Blue Cross NC starts paying toward those services during your benefit period (plan year).
Your coinsurance is the share of medical costs you pay after you’ve met your deductible for your benefit period (plan year). Coinsurance amounts (usually 10–30%) vary based on plan and type of provider. Not all plans have coinsurance.
This is the limit on the amount of money you can pay during a plan year. If you meet the out-of-pocket limit, we pay 100% of covered medical services and procedures.
Where’s my member ID card?
Log in to your Blue Connect℠ account. It’s right there on the homepage.
Our Blue Connect member site and Blue Connect Mobile NC app make it easy for you to manage care, check claims, improve your well-being and more. Watch this short video to see how.
Download the Blue Connect Mobile NC app using the links below to access your digital member ID card.
Know when you can make changes to your plan
The Open Enrollment Period (OEP) is the one time a year when you can make changes for the next plan year. Your employer will tell you when your OEP is and give you information to help you make coverage decisions. If you have questions, your Human Resources (HR) department can help.
What if I need to make a change outside the OEP?
You can make changes at other times if you have a qualifying life event. You’ll find a list of the most common qualifying life events below. Check this list and talk to your company’s HR department to see if you can make changes to your plan outside of OEP. (Having a situation on this list is not a guarantee that you can make changes. Please talk to your HR representative.)
- You involuntarily lose your main health coverage
- Your household size changes (for example, if you have a baby, or if someone is no longer your dependent)
- Your home address changes
- You’re eligible for coverage when you weren’t before
- You used to have help paying for coverage and you no longer do
- There is an error in your plan, or there was an error when you enrolled in your plan
Other life events, such as natural disasters and enrollment in government programs, may also make you eligible. Please see your HR department if you think your situation warrants a plan change.
How to contact us
The fastest way to find answers is through your Blue Connect account. To connect directly with a Customer Service specialist:
Online
Log in to Blue Connect or the Blue Connect Mobile NC app and use the secure inbox to message Customer Service.
Phone
Call the Customer Service number on the back of your member ID card. Don’t have your card? You can find the right number on Blue Connect!
Ways to save
Your plan is built around a network of doctors, hospitals and other health care facilities. Blue Cross NC has negotiated special lower rates with these groups, and we pass those savings on to you. It’s how we help you save money. Remember – if you don’t stay in-network, you don’t get those savings.
Find Care in Your Plan’s Network
One of the best ways to save money is to visit an in-network doctor or hospital. Our thoughtfully crafted networks provide savings and more coordinated care. When your primary care provider (PCP) is in your network, your out-of-pocket costs are lower. If you need a specialist, the network matters even more since costs can be higher.
What you pay for medical services can vary based on where you go. Different doctors charge different rates for the same service. Sometimes, working with the same doctor can cost you more at a different facility. Good news – we have a tool that lets you compare estimated costs for a range of services and procedures covered by your plan.
Get special deals with Blue365
Your plan includes Blue365, which helps you get exclusive deals on health and fitness products.1
With Blue365, you’ll find weekly discounts from health and wellness categories including:
- Apparel & Footwear
- Fitness
- Hearing & Vision
- Home & Family
- Nutrition
- Personal Care
Joining Blue365 is easy – and taking advantage of the discounts is even easier.
Visiting the doctor
Preventive care is routine health care that includes screenings, services and counseling to help you avoid developing health problems. It also includes well-baby visits and immunizations.
Many preventive care services from in-network doctors are covered at 100% with no out-of-pocket costs for most members.2
Common preventive care services
Immunizations, like the flu shot
Annual wellness visit
Well-baby and well-child visits
Counseling and support:
- Alcohol misuse
- Nutrition
- Sexually transmitted infections
- Tobacco cessation
Screenings and tests:
- Blood pressure
- Cancer screenings, such as colon, breast and cervical
- Cholesterol
- Diabetes
Services that are not considered preventive care
Below are examples of health services that are not identified as preventive care by the Affordable Care Act (ACA). This means they are not 100% covered, and may cost you money at your doctor’s office or lab:
- Chest X-rays
- EKGs (electrocardiograms)
- Hormone tests
- Thyroid tests
- Urinalysis
- Vitamin D tests
This is not a complete list. Check your benefit booklet, ask your doctor, or contact Blue Cross NC Customer Service with questions about coverage, including whether a service is considered preventive care.
Beyond preventive care, you'll find a detailed list of services covered by your health plan in your benefit booklet. Read through it carefully to help avoid any unexpected costs when you go to the doctor.
Avoid extra costs
Our preventive care flyer has more information on common covered services and questions to ask your doctor to avoid a surprise bill later.
Get top-rated care at a Blue Distinction Center
The Blue Distinction Center3 program helps you find hospitals that meet specific quality standards for patient safety and outcomes. Blue Distinction Centers (BDC) are recognized for their specialty care expertise, and Blue Distinction Centers+ (BDC+) meet all the Blue Distinction quality standards but also deliver care at lower costs.
These highly-rated Centers feature:
- Doctors, nurses and staff with a great deal of specialized experience
- The highest level of patient support at all stages of treatment
- Fewer complications after treatment
Specialty care areas include:
- Bariatric Surgery
- Cardiac Care
- Knee and Hip Replacement
- Maternity Care
- Spine Surgery
- Substance Use Treatment and Recovery
- Transplants
At the pharmacy
Save money on your medications.
If you have prescription drug coverage with Blue Cross NC, your Blue Connect account includes a Prescriptions section. From there, you can:
- Find in-network pharmacies
- Use the Find a Drug tool to look for lower cost options
- See how to cut down on medication costs
- Manage your prescriptions
- Choose between picking up prescriptions at a local retail pharmacy or having them delivered to your home via mail order
Understanding these terms will help you get the most value from your pharmacy benefit
A list of prescription drugs covered by your health benefit plan. Also called a drug list.
A select group of pharmacies that have contracted with Blue Cross NC to provide members access to medications at agreed-upon prices.
All medications are grouped into tiers within each formulary, which define coverage and copayment amounts. Generics are often in the lower tiers, while more specialized drugs are in higher tiers.
Some medications require approval from Blue Cross NC before they’re covered. This process helps manage costs and ensures that the member receives the correct medication at the proper dosage. Also called prior authorization.
For non-preferred prescription drugs, Blue Cross NC requires that a member first try a preferred drug in our formulary. Members may receive coverage for a non-preferred drug if the preferred equivalent proves not to work for them.
For more tips on managing your prescriptions, check out this interactive learning tool.
NOTE: If your employer does not provide prescription drug coverage through Blue Cross NC, you will not have access to the Blue Connect Prescriptions page. Check your benefit booklet for more information on your coverage.
What are copayment tiers?
Medications are assigned to categories known as copayment or coinsurance tiers. They’re assigned based on drug usage, cost and clinical effectiveness. The lower the tier, the lower the cost to you. This means you can save money if you find an equally effective drug in a lower tier!
Our prescription drug search tool, available on Blue Connect, can show you which tier applies to a specific medication based on your benefits plan.
From our blog: Point of Blue
Mental health and more
Mind + Body = Total Health
Your well-being depends on both physical and mental health. Blue Cross NC is working with both PCPs (primary care providers) and behavioral health (mental health + substance use) providers to help you get the care you need at the right time. We have programs, partnerships and tools to connect your health care team and find and treat any behavioral health concerns early, so you can live your best life.
Mental health resources:
- If you are in crisis, call the National Suicide Prevention Lifeline:4 800-273-8255.
- Access our Blue Connect member site to find an in-network provider. Search for keywords like: Psychologist, Psychiatrist, Social Worker, Therapist, Substance Use Facility or Counselor.
- Talk to your primary care provider. They can address your concerns in the office or refer you to a behavioral health provider. Get tips on how to talk to your doctor about mental health.
- Call Blue Cross NC: 800-359-2422. We will help connect you to a high-quality behavioral health provider or program.
- Use your Employee Assistance Program (EAP), if available.5
- Access therapy or psychiatry through your telehealth benefit, if available.6
- Use Shatterproof’s ATLAS® to find an addiction and substance use disorder treatment facility for you or a loved one.7
For health and wellness
So much of any person's health depends on the choices they make every day. We offer tools and resources to help you build a healthy lifestyle.
Nutrition Counseling
Did you know personalized nutrition counseling is covered by most Blue Cross NC plans as preventive care? Check your benefit booklet for details. You can log in to Blue Connect to learn more, or find a nutrition counselor in your network with our Find a Doctor tool.
Finally quit for good
QuitlineNC offers Blue Cross NC members counseling and nicotine replacement therapy at no extra cost to you.8
Call 844-8NCQUIT (844-862-7848) to quit for good.
Focus on small steps to better health
Little things – done day-by-day – build healthy habits that can last a lifetime. The wellness resources and education information on Blue Connect can help. Keep an eye out for our emails and letters, too. You may find an invitation to join a special program or take a specific action to improve your health!
Disclosures:
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Blue365 offers access to savings on items that members may purchase directly from independent vendors, which are different from items that are covered under the policies with Blue Cross NC. Any disputes regarding these products and services may be subject to the Blue Cross NC grievance process. Blue Cross and Blue Shield Association (BCBSA) may receive payments from Blue365 vendors. Neither Blue Cross NC nor BCBSA recommends, endorses, warrants or guarantees any specific Blue365 vendor or item. This program may be modified or discontinued at any time without prior notice.
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Preventive care services as defined by recent federal regulations are covered at no charge to you in-network. Federal and state-mandated preventive services are available out-of-network, for which members will pay deductible and coinsurance, plus charges over the allowed amount. Visit BlueCrossNC.com/Preventive for examples of preventive care services.
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Blue Distinction Centers (BDC) met overall quality measures, developed with input from the medical community. A Local Blue Plan may require additional criteria for providers located in its own service area; for details, contact your Local Blue Plan. Blue Distinction Centers+ (BDC+) also met cost measures that address consumers’ need for affordable health care. Each provider’s cost of care is evaluated using data from its Local Blue Plan. Providers in CA, ID, NY, PA, and WA may lie in two Local Blue Plans’ areas, resulting in two evaluations for cost of care; and their own Local Blue Plans decide whether one or both cost of care evaluation(s) must meet BDC+ national criteria. National criteria for BDC and BDC+ are displayed on www.bcbs.com. Individual outcomes may vary. For details on a provider’s in-network status or your own policy’s coverage, contact your Local Blue Plan and ask your provider before making an appointment. Neither Blue Cross and Blue Shield Association nor any Blue Plans are responsible for non-covered charges or other losses or damages resulting from Blue Distinction or other provider finder information or care received from Blue Distinction or other providers. Shatterproof, a national non-profit dedicated to reversing the addiction crisis in the U.S., is leading the implementation of ATLAS, a quality measurement system for addiction treatment facilities. Shatterproof does not offer Blue Cross or Blue Shield products or services.
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Learn more and get help on the National Suicide Prevention Lifeline website: www.suicidepreventionlifeline.org. The National Suicide Prevention Lifeline is a 24-hour, toll-free, confidential suicide prevention hotline available to anyone in suicidal crisis or emotional distress. The Lifeline is offered by the Suicide Prevention Resource Center. Neither Blue Cross NC nor the Blue Cross and Blue Shield Association (BCBSA) recommends, endorses, warrants or guarantees any specific result or service provided by another organization.
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EAP is a confidential, voluntary, work-based program that offers free counseling for work-related and/or personal problems. Ask your employer if there's an EAP program where you work.
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Telehealth benefits are available on all plans either from Blue Cross NC or through the provider network. Blue Cross NC provides the telehealth program for your convenience and is not liable in any way for the goods or services received. Blue Cross NC reserves the right to discontinue or change the program at any time without prior notice. Decisions regarding your care should be made with the advice of a doctor. Depending on your plan, selected programs may not be available to you at this time. Check with Blue Cross NC Customer Service to determine your eligibility. Blue Cross NC has contracted with a third-party vendor independent from Blue Cross NC to bring you telehealth benefits.
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Shatterproof, a national non-profit dedicated to reversing the addiction crisis in the US is leading the implementation of ATLAS, a quality measurement system for addiction treatment facilities. Shatterproof does not offer Blue Cross NC products or services.
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QuitlineNC is an independent organization that is solely responsible for the smoking cessation services it provides. QuitlineNC does not offer Blue Cross or Blue Shield products or services.
Blue Cross and Blue Shield of North Carolina (Blue Cross NC) offers several decision-support tools to aid you in making decisions around your health care experience. These tools are offered for your convenience and should be used only as reference tools. You should consult your own legal counsel, tax advisor or personal physician as applicable throughout your health care experience.
U44265, 12/23
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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