Medical – Liberty Healthcare

Which Medical Plan is Right?

Liberty Health offers employees a choice of four (4) medical plans through Blue Cross Blue Shield of North Carolina. The HPN plan is only available for employees who live in these markets: RTP, Triad, Charlotte, Hickory/Statesville, Miami, Memphis.

You are eligible to enroll in the medical plan after the first of the month following 30 days of full-time employment. Eligible dependents include your spouse and your dependent children through the end of the month in which they turn 26.

The following chart is a high-level overview of coverage. Please refer to actual plan documents or contact BCBS of NC customer service at 1.800.517.8072 for benefit verification.

Medical Plan Comparison

Basic, Standard, Premium Plans

			Basic			Standard			Premium
Benefit Highlights			In-Network	Out of Network	In-Network	Out of Network	In-Network	Out of Network
Deductible	Individual	$3,000	$6,000	$1,000	$2,000	$500	$1,000
	Family	$6,000	$12,000	$2,000	$4,000	$1,000	$2,000
	Deductible Timing	Plan Year			Plan Year			Plan Year
	Deductible Basis	Embedded			Embedded			Embedded
	Deductible & Copays Included in OOP Max	Yes			Yes			Yes
Coinsurance		30%	50%	20%	40%	20%	40%
Max Out of Pocket	Individual	$7,150	$14,300	$6,750	$13,500	$6,350	$12,700
	Family	$14,300	$28,600	$13,500	$27,000	$12,700	$25,400
Hospital		30% after Deductible	50% after Deductible	20% after Deductible	40% after Deductible	20% after Deductible	40% after Deductible
Outpatient		30% after Deductible	50% after Deductible	20% after Deductible	40% after Deductible	20% after Deductible	40% after Deductible
Office Visits	PCP	$30 Copay	50% after Deductible	$25 Copay	40% after Deductible	$15 Copay	40% after Deductible
	Specialist	$60 Copay	50% after Deductible	$50 Copay	40% after Deductible	$40 Copay	40% after Deductible
	Preventive Care	100% Covered per ACA Guidelines	50% after Deductible	100% Covered per ACA Guidelines	40% after Deductible	100% Covered	40% after Deductible
	Teladoc	$0 Acute Care/Behavioral Health $60 Dermatology	Not Covered	$0 Acute Care/Behavioral Health $50 Dermatology	Not Covered	$0 Acute Care/Behavioral Health $40 Dermatology	Not Covered
	Chiropractic Care	30% after Deductible 30 visit limit per benefit period	50% after Deductible 30 visit limit per benefit period	20% after Deductible 30 visit limit per benefit period	40% after Deductible 30 visit limit per benefit period	20% after Deductible 30 visit limit per benefit period	40% after Deductible 30 visit limit per benefit period
	Routine Vision Exam	100% Covered	Not Covered	100% Covered	Not Covered	100% Covered	Not Covered
	Cologuard	100% Covered		100% Covered		100% Covered
Prescription	Retail- 30 day supply NetResults 5 tier	Tiers 1 & 2: $10 Tiers 3, 4 & 5: 100% to $125			Tiers 1 & 2: $10 Tiers 3, 4 & 5: 50% to $100, Min $50			Tiers 1 & 2: $10 Tier 3: $30 Tiers 4 & 5: 25% to $100, Min $50
	Mail Order (McNeill's Pharmacy) - 31 to 90 day supply - only option for mail order	Tiers 1 & 2: $0 Tiers 3, 4 & 5: 100% to $125			Tiers 1 & 2: $0 Tiers 3, 4 & 5: 50% to $100, Min $50			Tiers 1 & 2: $0 Tier 3: $30 Tiers 4 & 5: 25% to $100, Min $50
	Formulary	NetResults 5 tier restricted formulary			NetResults 5 tier restricted formulary			NetResults 5 tier restricted formulary
Emergency Care	ER Copay	$500 Copay			$350 Copay			$250 Copay
	Urgent Care	$50 Copay			$40 Copay			$30 Copay
Nutritional Counseling		100% Covered Unlimited Visits	50% after Deductible Unlimited Visits	100% Covered Unlimited Visits	40% after Deductible Unlimited Visits	100% Covered Unlimited Visits	40% after Deductible Unlimited Visits

HPN Plan

Only Available for employees who live in these markets: RTP, Triad, Charlotte, Hickory/Statesville, Miami, Memphis

			HPN In-Network Coverage Only
Benefit Highlights			In-Network
Deductible	Individual	$3,000
	Family	$6,000
	Deductible Timing	Plan Year
	Deductible Basis	Embedded
	Deductible & Copays Included in OOP Max	Yes
Coinsurance		30%
Max Out of Pocket	Individual	$7,150
	Family	$14,300
Hospital		30% after Deductible
Outpatient		30% after Deductible
Office Visits	PCP	$30 Copay
	Specialist	$60 Copay
	Preventive Care	100% Covered per ACA Guidelines
	Teladoc	$0 Acute Care/Behavioral Health $60 Dermatology
	Chiropractic Care	30% after Deductible 30 visit limit per benefit period
	Routine Vision Exam	100% Covered
	Cologuard	100% Covered
Prescription	Retail- 30 day supply NetResults 5 tier	Tiers 1 & 2: $10 Tiers 3, 4 & 5: 100% to $125
	Mail Order (McNeill's Pharmacy) - 31 to 90 day supply - only option for mail order	Tiers 1 & 2: $0 Tiers 3, 4 & 5: 100% to $125
	Formulary	NetResults 5 tier restricted formulary
Emergency Care	ER Copay	$500 Copay
	Urgent Care	$50 Copay
Nutritional Counseling		100% Covered Unlimited Visits