Blue Advantage FAQs
Q: How do I know if I am eligible
for Blue Advantage coverage?
A: To be eligibile for Blue Advantage, you must be a North
Carolina resident, under 65 years old, and not covered by
other health insurance including Medicare. 1
Q: How does the prescription coverage
work?
A: Always present your BCBSNC ID at the
pharmacy in order to receive your pharmacy benefit. Our
4-Tier Drug Formulary places prescription drugs into four
categories based on clinical effectiveness, usage and cost.
Be sure to discuss generic options with your physician,
as generic drugs are placed on Tier 1 and have the lowest
copayment. While there is no benefit period maximum per
member for generic drugs, there is a $2000 maximum per member
per benefit period for brand drugs that cost less than $500.
With your BCBSNC pharmacy benefit, there are no claims to
file. Additionally, with Plan A, there are no deductibles
to pay.
Q: How does the maternity option work?
A: The maternity benefit is available for
an extra charge when you first purchase your policy, when
you renew, or if you have a family status change like marriage.
If you purchase the maternity option, services are subject
to deductible and coinsurance. Remember, even if you purchase
the maternity option after your initial enrollment, medical
approval will be required (you or your spouse cannot be
pregnant at the time of application). Approved changes made
at renewal are effective January 1, and premium adjustments
for any changes will apply effective January 1.
Q: Am I still covered if I visit a
doctor or hospital outside the network?
A: Sure, you can see any doctor you choose.
But remember, you save money when you visit a participating
provider. There are more than 18,000 health professionals
and over 100 North Carolina hospitals in the Blue Advantage
network!2 Visit our online provider search to see if your
physician is in our network.
Q: What does a routine exam include?
A: All services that are recommended by
the American Medical Association guidelines and other services
that are medically necessary as determined by your doctor.
Q: What are my premium payment options?
A: As a Blue Advantage member, you can
have your health insurance premium payment deducted directly
from your bank account. Log into My Member Services and
click on Manage Billing and Payments. Then click on the
Make A Payment link. You can choose to make a one-time bank
draft payment, or set up automatic monthly bank draft payments.
By choosing automatic (recurring) monthly bank draft payments,
you won’t ever have to worry about postage or forgetting
to mail in your payment again. Each month your payment will
automatically be deducted from your bank account and you
will see the transaction on your monthly bank statement.
We don’t charge members for this convenient service,
but some banks may charge a fee for automatic bank drafts.
Check with your bank for terms and details.
You also have the option to make your payment by postal
mail. By mail you can pay by personal check, money order
or credit card. At this time BCBSNC is unable to accept
payments by phone.
For additional information, please visit the Billing and
Payments FAQ page.
Q: What are benefit period deductibles?
A: This is the amount you pay for some
services before Blue Advantage pays its portion. Once three
family members meet their individual deductibles, no additional
individual deductibles are required for the remainder of
the benefit period.
Deductible Options - Choose the deductible
that best meets your needs:
Plan A $250 $500 $1000 $2500
Plan B $500 $1000 $2500 $5000
Plan C $1000 $2500 $3500 $5000
Q: When will my coverage begin?
A: When you apply for Blue Advantage, you
can choose for your policy to take effect on the 1st or
15th of the month. (Your effective date must be at least
15 days from the date of your application.) If you need
coverage to begin sooner, apply for Short Term Health Care.
This temporary policy, lasting up to 90 days, can prevent
a lapse in coverage.
If you plan to apply for Short Term Health Care and Blue
Advantage, be sure to apply for Short Term Health Care first.
We cannot process your Short Term Health Care application
if you apply for Blue Advantage first.
Q: How do I renew my coverage?
A: Your coverage is automatically renewed
when you continue to pay premiums as they are due. BCBSNC
must renew your policy unless we discontinue all policies
like yours.
Q: How often do premiums change? When
will I be notified of the changes?
A: You won't be singled out for a premium
change, although your premiums may be adjusted as you age,
add or remove eligible dependents, or if you move. You will
be notified 31 days in advance of any change. Currently
our rates are adjusted on January 1st each year.
Q: What services require prior approval
or a referral?
A: Most inpatient admissions, skilled nursing
facility admissions, and all private duty nursing services
require prior approval from BCBSNC. In addition, BCBSNC
requires prior approval for certain other outpatient services
received on or after July 1, 2005.
For maternity admissions, your doctor is not required to
obtain prior approval from BCBSNC for prescribing a length
of stay up to 48 hours for a normal vaginal delivery or
up to 96 hours for delivery by cesarean section. You or
your doctor must request prior approval for coverage for
additional days. Although no prior approval is required
for emergency situations, please notify BCBSNC of your inpatient
admission as soon as reasonably possible.
The list of services that must be approved in advance, may
change from time to time. For the current list of services
requiring prior approval, please refer to our prior approval
list or call the Customer Service number on the back of
your BCBSNC ID card.
Additionally, some prescription drugs require prior approval
to be covered. Some prescription drugs are also subject
to quantity limits based on criteria developed by BCBSNC.
For these drugs, prior approval is required before excess
quantities will be covered. To get a list of these types
of prescription drugs, visit our Prior approval and quantity
limitations page or call the Customer Service number on
your BCBSNC ID card. Please note that BCBSNC may occasionally
change the list of these prescription drugs. Prior approval
will be waived for restricted access drugs and devices if
the member's provider certifies that a nonrestricted formulary
drug or device has been harmful or ineffective in treating
the member's condition.
If your services are out-of-network or you receive services
outside of North Carolina, you are responsible for requesting
or having your provider request prior approval for those
services that require preauthorization from BCBSNC.
Q: How do I get prior approval or
a referral?
A: Prior Approval
Participating providers or specialists will coordinate prior
approvals or precertification for you. You may want to check
with your participating provider to make sure prior approval
has been obtained. For services from a nonparticipating
provider or out-of-state, you are responsible or having
your provider request preauthorization for those services
that require prior approval from BCBSNC.
Referrals
You do not need to get a referral from your primary care
provider to receive covered services from a participating
specialist. However, some participating specialists may
require a new patient introduction from your treating doctor.
Q: If I have been denied prior approval
or if I have concerns about decisions that have been made
regarding coverage of my medical procedures, who can I contact?
A: To make sure you have access to quality,
cost-effective health care, we manage utilization through
a variety of programs including precertification, transplant
management, concurrent and retrospective review, and case
management. For those services requiring plan authorization,
the member is ultimately responsible for ensuring that appropriate
authorization has been received.
If you have a concern regarding the final determination
of your care, you have the right to appeal the decision.
For more information, please write to us at:
Utilization Management Dept.
Blue Cross and Blue Shield of North Carolina
PO Box 2291, Durham, NC 27702
