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TOWN OF CARY Benefits Handbook Page 11 There's an App for that! NC Blue Connect: Look at Dashboard for personal information, pull up a temporary card and find a doctor. NC Blue Connect: Look at Dashboard for personal information, pull up a temporary card and find a doctor. NC Blue Connect: Look at Dashboard for personal information, pull up a temporary card and find a doctor. BlueConnect Mobile SM MEDICAL – HIGH DEDUCTIBLE HEALTH PLAN (HDHP) OVERVIEW The chart reflects your responsibility for common services under the High Deductible Health Plan. COVERED SERVICES IN NETWORK OUT-OF-NETWORK Deductible Individual (per Benefit Period) Family (per Benefit Period) $3,200 $6,400 $6,400 $12,800 Employee Medical Out-of-Pocket Limit Total of deductible, includes copays (office visits, urgent care, Emergency Dept.) and coinsurance $3,200 $6,400 $6,400 $12,800 Office Visit Primary Care Provider Specialist Mental Health Teladoc Telehealth (Acute and Behavioral Health) 100% after deductible 100% after deductible 100% after deductible 100% after deductible 30% after deductible 30% after deductible 30% after deductible N/A Preventive Care (Primary Preventive Diagnosis Only) for list see bcbsnc.com/preventive Primary Care Provider Specialist covered at 100% covered at 100% 30% after deductible 30% after deductible Urgent and Emergency Care Urgent Care Centers Emergency Room Visit (First Visit) Subsequent Emergency Room Visits Ambulance 100% after deductible 100% after deductible 100% after deductible 100% after deductible 30% after deductible 30% after deductible 30% after deductible 30% after deductible Inpatient Hospital Services 100% after deductible 30% after deductible Outpatient Services Facility Services Diagnostic Services Professional Services Facility Services Outpatient Mammography Outpatient X-rays, ultrasounds, and other diagnostic tests such as EEGs and EKGs 100% after deductible 100% after deductible 100% after deductible 100% after deductible covered at 100% 100% after deductible 30% after deductible 30% after deductible 30% after deductible 30% after deductible 30% after deductible 30% after deductible Other Services Skilled Nursing Facility Home Health Care and Hospice Durable Medical Equipment, Prosthetics/Orthodontics CT scans, MRIs, MRAs and PET scans 100% after deductible 100% after deductible 100% after deductible 100% after deductible 30% after deductible 30% after deductible 30% after deductible 30% after deductible NEWS FLASH Save money by going to an in-network provider. Use the BCBSNC Find a Provider Tool. Teladoc Health offers easy access to high- quality telehealth and telemedicine care for a variety of conditions, including physical and behavioral health challenges at a lower cost! QUESTIONS? About the plan, claims, lost ID cards, etc, contact the BCBSNC Customer Service Team 1-877-258-3334 ? Medical Insurance

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