Review Your Benefit Options

Medical

Medical Benefits

Overview

NCFA offers four medical plan options administered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC). All plans use the same network of providers who have agreed to charge discounted rates to plan members. The amount you pay for health care will vary depending on whether or not you use in- network providers and facilities. You always have the choice to go to any provider, but you’ll pay less if you stay within the Blue Cross NC Blue Options℠ network.

Plan Highlights

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	Platinum	Gold	Silver	HDHP H.S.A
	In-Network	In-Network	In-Network	In-Network
Deductible
Individual	$1,000	$3,500	$5,000	$5,000
Family	$2,000	$7,000	$10,000	$10,000
Coinsurance	80%	70%	70%	70%
Out-of-Pocket Max.
Individual	$3,000	$7,000	$9,450	$8,050
Family	$6,000	$14,000	$18,900	$16,100
Inpatient Services
Inpatient Facility	20% Coinsurance	30% Coinsurance	$250 per admission + 30% coinsurance	30% Coinsurance
Emergency Room	Covered at 100% after $300 copay	Covered at 100% after $300 copay	50% Coinsurance	30% Coinsurance
Physician Office Visits
Preventive Care	100% Covered	100% Covered	100% Covered	100% Covered
Primary Care	$15 Copay	$25 Copay	$35 Copay	30% Coinsurance
Specialist Office	$30 Copay	$50 Copay	50% Coinsurance	30% Coinsurance
Urgent Care	$30 Copay	$50 Copay	$100 Copay	30% Coinsurance
Outpatient Services
Outpatient Surgical	20% Coinsurance	30% Coinsurance	50% Coinsurance	30% Coinsurance
Diagnostic X-Ray Lab	20% Coinsurance	30% Coinsurance	50% Coinsurance	30% Coinsurance
Mental Health / Substance Abuse	20% Coinsurance	30% Coinsurance	50% Coinsurance	30% Coinsurance
Prescription Drug Essential 5 Tier Commercial Formulary
Tier 1	$4 Copay	$15 Copay	$15 Copay	30% Coinsurance
Tier 2	$15 Copay	$45 Copay	$45 Copay	30% Coinsurance
Tier 3	$30 Copay	$85 Copay	$85 Copay	30% Coinsurance
Tier 4	$45 Copay	$105 Copay	$105 Copay	30% Coinsurance
Tier 5	25% Coinsurance* *$50 per RX minimum and $100 per RX maximum	25% Coinsurance* *$50 per RX minimum and $200 per RX maximum	25% Coinsurance* *$50 per RX minimum and $200 per RX maximum	30% Coinsurance

Total Monthly Premium

	Platinum	Gold	Silver	HDHP H.S.A
Single	$798.59	$651.02	$551.85	$458.32
Employee + Spouse	$1,759.98	$1,435.35	$1,217.14	$1,011.35
Employee + Child	$1,523.39	$1,243.02	$1,054.57	$876.86
Family	$2,484.72	$2,027.27	$1,719.81	$1,429.85

Dental

Dental Benefits

Overview

NCFA offers dental coverage to you through Blue Cross NC. Your dental plan provides coverage to help with the cost of many dental services including routine cleanings, x-rays, restorative and prosthetic services. The plan includes an extensive network of dental providers. Maximize your benefits by selecting an in-network dentist to save more on all covered services and avoid balance billing.

Plan Highlights

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	Dental Enhanced Plan	Dental Basic Plan
Benefits	In-Network	In-Network
Annual Maximum per Individual	$1,500	$1,000
Type I – Diagnostic & Preventive
Exams, Cleanings, Flouride Treatment, Space Maintainers, X-Rays, Sealants	100%	100%
Type II – Basic Services
Fillings, Simple Extractions, General Anesthesia, Oral Surgery, Endodontics	80%	80%
Type III – Major Services
Crowns, Inlays, Onlays, Bridges, Dentures, Periodontic, Implants, TMJ	50%	50%
Type IV – Orthodontic Services	50% (Child)	N/A
Calendar Year Deductible Applies to:
Individual	$50 single	$50 single
Family	$150 family	$150 family
Lifetime Orthodontia Maximum	$1,500	N/A

Total Monthly Premium

Coverage Tier	Ehanced Plan	Basic Plan
Single	$42.34	$37.23
Employee + Spouse	$84.68	$74.46
Employee + Child	$101.25	$88.77
Family	$154.75	$135.63

Vision

Vision Benefits

Overview

NCFA offers vision coverage to you through Blue Cross NC. You will receive the maximum benefits and pay less out-of-pocket by visiting an in-network provider. The network includes provider access points nationwide. A comprehensive vision exam is available every 12 months and you may purchase eyewear in the form of an eyeglass frame and lenses, or contact lenses.

Plan Highlights

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Vision Benefit Highlights ›

Class Description	In-Network	Out-of-Network
Eye Examination
Comprehensive exam of visual fuctions and prescription of corrective eye wear.	$10 Copay	$39 Allowance
Contact Lens Evaluation and Fitting		Not Covered
Elective	$130 Allowance + 15% off balance	$104 Allowance
Medically Necessary	Covered in full	$200 Allowance
Materials/ Eye wear
Single Vision Eyeglass Lenses	$25 Copay	$25 Allowance
Lined Bifocal Eyeglass Lenses	$25 Copay	$39 Allowance
Lined Trifocal Eyeglass Lenses	$25 Copay	$63 Allowance
Lenticular Eyeglass Lenses	$25 Copay	$163 Allowance
Frame Allowance
Standard Frame	$130 Allowance + 20% off balance	$65 Allowance
Lens Upgrades
PolyCarbonate (single vision/multi-vision)	$40	Not Covered
Anti-Reflective (single vision/multi-vision)	$45-20% off	Not Covered
Scratch Resistant (single vision/multi-vision)	$15	Not Covered
Transitions / Photochromic (single vision/ multi-vision)	$75	$70 Allowance
Progressive Lenses
Tier 1	$85	$39 Allowance
Tier 2	$95	$39 Allowance
Tier 3	$110	$39 Allowance
Laser Vision Correction	15% off Laser Correction

Total Monthly Premium

Coverage Tier	Rate
Employee Only	$12.75
Employee + Spouse	$20.63
Employee + Child(ren)	$21.50
Employee + Family	$29.73

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