60 . TX-G-P-2023 CERTIFICATE OF COVERAGE Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve . California Physicians Service DBA Blue Shield of California 1999-2023. | 2023 SUMMARY OF BENEFITS Blue Cross Medicare Advantage (PPO) Core, Comfort, Choice and Complete Plans Metro Region H5959 January 1, 2023 - December 31, 2023 . Your 2023 plan information will be available online . . SBC Glossary of Health Coverage and Medical Terms. Base PPO Plan (70/30) The Base PPO Plan (70/30) is a Preferred Provider Organization (PPO) plan administered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC). 2023 Blue Cross and Blue Shield of North Carolina. Learn more about our non-discrimination policy and no-cost services available to you. For 2022medical plans, the Summary of Benefits (SOBs) include coverage information in a simplified format, making it easier for members to read and understand their plan benefits. 2022 Summary of Benefits (SOBs)|2021 Summary of Benefits (SOBs)|2020 Summary of Benefits (SOBs)|Evidence of Coverage (EOCs)|SBC Forms and Other Resources|Sales Resources and Collateral|Rates|Changes To|Dental Plans|Vision Plans|Life and AD&D Plans. Blue Cross NC is an abbreviation for Blue Cross and Blue Shield of North Carolina. 2023 Blue Cross and Blue Shield Service Benefit Plan Brochure - FEP Blue Focus, 2022 Blue Cross and Blue Shield Service Benefit Plan Brochure - Standard and Basic Options, 2022 Blue Cross and Blue Shield Service Benefit Plan Brochure - FEP Blue Focus, 2021 Blue Cross and Blue Shield Service Benefit Plan Brochure - Standard and Basic Option, 2021 Blue Cross and Blue Shield Service Benefit Plan Brochure - FEP Blue Focus.      Questions about the brochures? Benefit Booklets - Blue Cross and Blue Shield of Alabama Register Now, Ancillary and Specialty Benefits for Employees. Get 24/7 access to tools like the Blue Health Assessment and Online Health Coach plus resources that help you keep your health care spending in check, like the Financial Dashboard and FEP Healthcare Cost Advisor tool. Y0118_23_051B_C 02012023 You are leaving our website and going to a website/app not hosted by us. Plan requirements, benefits and coverage: Plan Year 2023 Master Benefit Plan Documents: Plan Year 2022 Master Benefit Plan Documents: Plan Year 2024 Summary of Benefits and Coverage documents: Plan Year 2023 Summary of Benefits and Coverage documents: Vea estos documentos en espaolen la versin en espaol de esta pgina. We removed the limit on covered non-sibling donors for transplant services. The protection of your privacy will be governed by the privacy policy of that site. Health Plans for Individuals and Families, Get a Quote for Individual and Family Plans, Non-Discrimination Policy and Accessibility Services, Blue Advantage Gold 1800 | 3 Free PCP | $10 Tier 1 Rx | Nationwide Doctors, Blue Advantage $0 | Nationwide Doctors (AI/AN), Blue Advantage Gold Standard 2000 | Nationwide Doctors, Blue Advantage Gold Standard $0 | Nationwide Doctors (AI/AN), Blue Advantage Silver Total 3500 | 3 Free PCP | $15 Tier 1 Rx | Nationwide Doctors, Blue Advantage Silver Total 3400 | 3 Free PCP | $15 Tier 1 Rx | Nationwide Doctors (CSR 73%), Blue Advantage Silver Total 675 | 3 Free PCP | $4 Tier 1 Rx | Nationwide Doctors (CSR 87%), Blue Advantage Silver Total | $0 Deductible | $0 PCP | $4 Tier 1 Rx | Nationwide Doctors (CSR 94%), Blue Advantage Silver Simple | 3 Free PCP | Nationwide Doctors, Blue Advantage Silver Simple | 3 Free PCP | Nationwide Doctors (CSR 73%), Blue Advantage Silver Simple | 3 Free PCP | Nationwide Doctors (CSR 87%), Blue Advantage Silver Simple | $0 Deductible | 3 Free PCP | Nationwide Doctors (CSR 94%), Blue Advantage Silver Preferred 3100 | 3 Free PCP | $10 Tier 1 Rx | Integrated | Nationwide Doctors, Blue Advantage Silver Preferred 2500 | 3 Free PCP | $10 Tier 1 Rx | Integrated | Nationwide Doctors (CSR 73%), Blue Advantage Silver Preferred 300 | 3 Free PCP | $5 Tier 1 Rx | Integrated | Nationwide Doctors (CSR 87%), Blue Advantage Silver Preferred | $0 Deductible | $0 PCP | $0 Tier 1 Rx | Integrated | Nationwide Doctors (CSR 94%), Blue Advantage Silver Secure 1900 | $15 PCP | $15 Tier 1 Rx | Nationwide Doctors, Blue Advantage Silver Secure 1500 | $10 PCP | $15 Tier 1 Rx | Nationwide Doctors (CSR 73%), Blue Advantage Silver Secure 75 | $10 PCP | $10 Tier 1 Rx | Nationwide Doctors (CSR 87%), Blue Advantage Silver Secure | $0 Deductible | $0 PCP & Specialist | $0 Tier 1 Rx | Nationwide Doctors (CSR 94%), Blue Advantage Silver Access 2300 | 3 Free PCP | $15 Tier 1 Rx | Nationwide Doctors, Blue Advantage Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | Nationwide Doctors, Blue Advantage Silver Choice 3700 | 3 Free PCP | $15 Tier 1 Rx | Nationwide Doctors (CSR 73%), Blue Advantage Silver Choice 700 | 3 Free PCP | $10 Tier 1 Rx | Nationwide Doctors (CSR 87%), Blue Advantage Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | Nationwide Doctors (CSR 94%), Blue Advantage Silver Standard 5800 | Nationwide Doctors, Blue Advantage Silver Standard $0 | Nationwide Doctors (AI/AN), Blue Advantage Silver Standard 5700 | Nationwide Doctors (CSR 73%), Blue Advantage Silver Standard 800 | Nationwide Doctors (CSR 87%), Blue Advantage Silver Standard $0 | Nationwide Doctors (CSR 94%), Blue Advantage Bronze 5500 | $60 PCP | $20 Tier 1 Rx | Nationwide Doctors, Blue Advantage Bronze 7000 | 3 Free PCP | $20 Tier 1 Rx | Integrated | Nationwide Doctors, Blue Advantage Bronze Standard 7500 | Nationwide Doctors, Blue Advantage Bronze Standard $0 | Nationwide Doctors (AI/AN), Blue Advantage Bronze 7500 | HSA Eligible | Integrated | Nationwide Doctors, Blue Advantage Bronze 7500 | Integrated | Nationwide Doctors, Blue Advantage Bronze 9100 | Integrated | Nationwide Doctors, Blue Advantage Catastrophic 9100 | 3 PCP $35 | Integrated | Nationwide Doctors, Blue Value Gold 1800 | 3 Free PCP | $10 Tier 1 Rx | Statewide Doctors, Blue Value $0 | Statewide Doctors (AI/AN), Blue Value Gold Standard 2000 | Statewide Doctors, Blue Value Gold Standard $0 | Statewide Doctors (AI/AN), Blue Value Silver Total 3500 | 3 Free PCP | $15 Tier 1 Rx | Statewide Doctors, Blue Value Silver Total 3400 | 3 Free PCP | $15 Tier 1 Rx | Statewide Doctors (CSR 73%), Blue Value Silver Total 675 | 3 Free PCP | $4 Tier 1 Rx | Statewide Doctors (CSR 87%), Blue Value Silver Total | $0 Deductible | $0 PCP | $4 Tier 1 Rx | Statewide Doctors (CSR 94%), Blue Value Silver Simple | 3 Free PCP | Statewide Doctors, Blue Value Silver Simple | 3 Free PCP | Statewide Doctors (CSR 73%), Blue Value Silver Simple | 3 Free PCP | Statewide Doctors (CSR 87%), Blue Value Silver Simple | $0 Deductible | 3 Free PCP | Statewide Doctors (CSR 94%), Blue Value Silver Preferred 3100 | 3 Free PCP | $10 Tier 1 Rx | Integrated | Statewide Doctors, Blue Value Silver Preferred 2500 | 3 Free PCP | $10 Tier 1 Rx | Integrated | Statewide Doctors (CSR 73%), Blue Value Silver Preferred 300 | 3 Free PCP | $5 Tier 1 Rx | Integrated | Statewide Doctors (CSR 87%), Blue Value Silver Preferred | $0 Deductible | $0 PCP | $0 Tier 1 Rx | Integrated | Statewide Doctors (CSR 94%), Blue Value Silver Secure 1900 | $15 PCP | $15 Tier 1 Rx | Statewide Doctors, Blue Value Silver Secure 1500 | $10 PCP | $15 Tier 1 Rx | Statewide Doctors (CSR 73%), Blue Value Silver Secure 75 | $10 PCP | $10 Tier 1 Rx | Statewide Doctors (CSR 87%), Blue Value Silver Secure | $0 Deductible | $0 PCP & Specialist | $0 Tier 1 Rx | Statewide Doctors (CSR 94%), Blue Value Silver Access 2300 | 3 Free PCP | $15 Tier 1 Rx | Statewide Doctors, Blue Value Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | Statewide Doctors, Blue Value Silver Choice 3700 | 3 Free PCP | $15 Tier 1 Rx | Statewide Doctors (CSR 73%), Blue Value Silver Choice 700 | 3 Free PCP | $10 Tier 1 Rx | Statewide Doctors (CSR 87%), Blue Value Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | Statewide Doctors (CSR 94%), Blue Value Silver Standard 5800 | Statewide Doctors, Blue Value Silver Standard $0 | Statewide Doctors (AI/AN), Blue Value Silver Standard 5700 | Statewide Doctors (CSR 73%), Blue Value Silver Standard 800 | Statewide Doctors (CSR 87%), Blue Value Silver Standard $0 | Statewide Doctors (CSR 94%), Blue Value Bronze 5500 | $60 PCP | $20 Tier 1 Rx | Statewide Doctors, Blue Value Bronze 7000 | 3 Free PCP | $20 Tier 1 Rx | Integrated | Statewide Doctors, Blue Value Bronze Standard 7500 | Statewide Doctors, Blue Value Bronze Standard $0 | Statewide Doctors (AI/AN), Blue Value Bronze 7500 | HSA Eligible | Integrated | Statewide Doctors, Blue Value Bronze 7500 |Integrated | Statewide Doctors, Blue Value Bronze 9100 | Integrated | Statewide Doctors, Blue Value Catastrophic 9100 | 3 PCP $35 | Integrated | Statewide Doctors, Blue Local Gold 1800 | 3 Free PCP | $10 Tier 1 Rx | with Atrium Health, Blue Local $0 | with Atrium Health (AI/AN), Blue Local Gold Standard 2000 | with Atrium Health, Blue Local Gold Standard $0 | with Atrium Health (AI/AN), Blue Local Silver Total 3500 | 3 Free PCP | $15 Tier 1 Rx | with Atrium Health, Blue Local Silver Total 3400 | 3 Free PCP | $15 Tier 1 Rx | with Atrium Health (CSR 73%), Blue Local Silver Total 675 | 3 Free PCP | $4 Tier 1 Rx | with Atrium Health (CSR 87%), Blue Local Silver Total | $0 Deductible | $0 PCP | $4 Tier 1 Rx | with Atrium Health (CSR 94%), Blue Local Silver Simple | 3 Free PCP | with Atrium Health, Blue Local Silver Simple | 3 Free PCP | with Atrium Health (CSR 73%), Blue Local Silver Simple | 3 Free PCP | with Atrium Health (CSR 87%), Blue Local Silver Simple | $0 Deductible | 3 Free PCP | with Atrium Health (CSR 94%), Blue Local Silver Preferred 3100 | 3 Free PCP | $10 Tier 1 Rx | Integrated | with Atrium Health, Blue Local Silver Preferred 2500 | 3 Free PCP | $10 Tier 1 Rx | Integrated | with Atrium Health (CSR 73%), Blue Local Silver Preferred 300 | 3 Free PCP | $5 Tier 1 Rx | Integrated | with Atrium Health (CSR 87%), Blue Local Silver Preferred | $0 Deductible | $0 PCP | $0 Tier 1 Rx | Integrated | with Atrium Health (CSR 94%), Blue Local Silver Secure 1900 | $15 PCP | $15 Tier 1 Rx | with Atrium Health, Blue Local Silver Secure 1500 | $10 PCP | $15 Tier 1 Rx | with Atrium Health (CSR 73%), Blue Local Silver Secure 75 | $10 PCP | $10 Tier 1 Rx | with Atrium Health (CSR 87%), Blue Local Silver Secure | $0 Deductible | $0 PCP & Specialist | $0 Tier 1 Rx | with Atrium Health (CSR 94%), Blue Local Silver Access 2300 | 3 Free PCP | $15 Tier 1 Rx | with Atrium Health, Blue Local Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | with Atrium Health, Blue Local Silver Choice 3700 | 3 Free PCP | $15 Tier 1 Rx | with Atrium Health (CSR 73%), Blue Local Silver Choice 700 | 3 Free PCP | $10 Tier 1 Rx | with Atrium Health (CSR 87%), Blue Local Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | with Atrium Health (CSR 94%), Blue Local Bronze 5500 | $60 PCP | $20 Tier 1 Rx | with Atrium Health, Blue Local Silver Standard 5800 | with Atrium Health, Blue Local Silver Standard $0 | with Atrium Health (AI/AN), Blue Local Silver Standard 5700 | with Atrium Health (CSR 73%), Blue Local Silver Standard 800 | with Atrium Health (CSR 87%), Blue Local Silver Standard $0 | with Atrium Health (CSR 94%), Blue Local Bronze 7000 | 3 Free PCP | $20 Tier 1 Rx | Integrated | with Atrium Health, Blue Local Bronze Standard 7500 | with Atrium Health, Blue Local Bronze Standard $0 | with Atrium Health (AI/AN), Blue Local Bronze 7500 | HSA Eligible | Integrated | with Atrium Health, Blue Local Bronze 7500 | Integrated | with Atrium Health, Blue Local Bronze 9100 | Integrated | with Atrium Health, Blue Local Catastrophic 9100 | 3 PCP $35 | Integrated | with Atrium Health, Blue Home Gold 1800 | 3 Free PCP | $10 Tier 1 Rx | with UNC Health Alliance, Blue Home $0 | with UNC Health Alliance (AI/AN), Blue Home Gold Standard 2000 | with UNC Health Alliance, Blue Home Gold Standard $0 | with UNC Health Alliance (AI/AN), Blue Home Silver Total 3500 | 3 Free PCP | $15 Tier 1 Rx | with UNC Health Alliance, Blue Home Silver Total 3400 | 3 Free PCP | $15 Tier 1 Rx | with UNC Health Alliance (CSR 73%), Blue Home Silver Total 675 | 3 Free PCP | $4 Tier 1 Rx | with UNC Health Alliance (CSR 87%), Blue Home Silver Total | $0 Deductible | $0 PCP | $4 Tier 1 Rx | with UNC Health Alliance (CSR 94%), Blue Home Silver Simple | 3 Free PCP | with UNC Health Alliance, Blue Home Silver Simple | 3 Free PCP | with UNC Health Alliance (CSR 73%), Blue Home Silver Simple | 3 Free PCP | with UNC Health Alliance (CSR 87%), Blue Home Silver Simple | $0 Deductible | 3 Free PCP | with UNC Health Alliance (CSR 94%), Blue Home Silver Preferred 3100 | 3 Free PCP | $10 Tier 1 Rx | Integrated | with UNC Health Alliance, Blue Home Silver Preferred 2500 | 3 Free PCP | $10 Tier 1 Rx | Integrated | with UNC Health Alliance (CSR 73%), Blue Home Silver Preferred 300 | 3 Free PCP | $5 Tier 1 Rx | Integrated | with UNC Health Alliance (CSR 87%), Blue Home Silver Preferred | $0 Deductible | $0 PCP | $0 Tier 1 Rx | Integrated | with UNC Health Alliance (CSR 94%), Blue Home Silver Secure 1900 | $15 PCP | $15 Tier 1 Rx | with UNC Health Alliance, Blue Home Silver Secure 1500 | $10 PCP | $15 Tier 1 Rx | with UNC Health Alliance (CSR 73%), Blue Home Silver Secure 75 | $10 PCP | $10 Tier 1 Rx | with UNC Health Alliance (CSR 87%), Blue Home Silver Secure | $0 Deductible | $0 PCP & Specialist | $0 Tier 1 Rx | with UNC Health Alliance (CSR 94%), Blue Home Silver Access 2300 | 3 Free PCP | $15 Tier 1 Rx | with UNC Health Alliance, Blue Home Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | with UNC Health Alliance, Blue Home Silver Choice 3700 | 3 Free PCP | $15 Tier 1 Rx | with UNC Health Alliance (CSR 73%), Blue Home Silver Choice 700 | 3 Free PCP | $10 Tier 1 Rx | with UNC Health Alliance (CSR 87%), Blue Home Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | with UNC Health Alliance (CSR 94%), Blue Home Silver Standard 5800 | with UNC Health Alliance, Blue Home Silver Standard $0 | with UNC Health Alliance (AI/AN), Blue Home Silver Standard 5700 | with UNC Health Alliance (CSR 73%), Blue Home Silver Standard 800 | with UNC Health Alliance (CSR 87%), Blue Home Silver Standard $0 | with UNC Health Alliance (CSR 94%), Blue Home Bronze 5500 | $60 PCP | $20 Tier 1 Rx | with UNC Health Alliance, Blue Home Bronze 7000 | 3 Free PCP | $20 Tier 1 Rx | Integrated | with UNC Health Alliance, Blue Home Bronze Standard 7500 | with UNC Health Alliance, Blue Home Bronze Standard $0 | with UNC Health Alliance (AI/AN), Blue Home Bronze 7500 | HSA Eligible | Integrated | with UNC Health Alliance, Blue Home Bronze 7500 | Integrated | with UNC Health Alliance, Blue Home Bronze 9100 | Integrated | with UNC Health Alliance, Blue Home Catastrophic 9100 | 3 PCP $35 | Integrated | with UNC Health Alliance, Blue Local Gold 1800 | 3 Free PCP | $10 Tier 1 Rx | with Wake Forest Baptist Health, Blue Local $0 | with Wake Forest Baptist Health (AI/AN), Blue Local Gold Standard 2000 | with Wake Forest Baptist Health, Blue Local Gold Standard $0 | with Wake Forest Baptist Health (AI/AN), Blue Local Silver Total 3500 | 3 Free PCP | $15 Tier 1 Rx | with Wake Forest Baptist Health, Blue Local Silver Total 3400 | 3 Free PCP | $15 Tier 1 Rx | with Wake Forest Baptist Health (CSR 73%), Blue Local Silver Total 675 | 3 Free PCP | $4 Tier 1 Rx | with Wake Forest Baptist Health (CSR 87%), Blue Local Silver Total | $0 Deductible | $0 PCP | $4 Tier 1 Rx | with Wake Forest Baptist Health (CSR 94%), Blue Local Silver Simple | 3 Free PCP | with Wake Forest Baptist Health, Blue Local Silver Simple | 3 Free PCP | with Wake Forest Baptist Health (CSR 73%), Blue Local Silver Simple | 3 Free PCP | with Wake Forest Baptist Health (CSR 87%), Blue Local Silver Simple | $0 Deductible | 3 Free PCP | with Wake Forest Baptist Health (CSR 94%), Blue Local Silver Preferred 3100 | 3 Free PCP | $10 Tier 1 Rx | Integrated | with Wake Forest Baptist Health, Blue Local Silver Preferred 2500 | 3 Free PCP | $10 Tier 1 Rx | Integrated | with Wake Forest Baptist Health (CSR 73%), Blue Local Silver Preferred 300 | 3 Free PCP | $5 Tier 1 Rx | Integrated | with Wake Forest Baptist Health (CSR 87%), Blue Local Silver Preferred | $0 Deductible | $0 PCP | $0 Tier 1 Rx | Integrated | with Wake Forest Baptist Health (CSR 94%), Blue Local Silver Secure 1900 | $15 PCP | $15 Tier 1 Rx | with Wake Forest Baptist Health, Blue Local Silver Secure 1500 | $10 PCP | $15 Tier 1 Rx | with Wake Forest Baptist Health (CSR 73%), Blue Local Silver Secure 75 | $10 PCP | $10 Tier 1 Rx | with Wake Forest Baptist Health (CSR 87%), Blue Local Silver Secure | $0 Deductible | $0 PCP & Specialist | $0 Tier 1 Rx | with Wake Forest Baptist Health (CSR 94%), Blue Local Silver Access 2300 | 3 Free PCP | $15 Tier 1 Rx | with Wake Forest Baptist Health, Blue Local Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | with Wake Forest Baptist Health, Blue Local Silver Choice 3700 | 3 Free PCP | $15 Tier 1 Rx | with Wake Forest Baptist Health (CSR 73%), Blue Local Silver Choice 700 | 3 Free PCP | $10 Tier 1 Rx | with Wake Forest Baptist Health (CSR 87%), Blue Local Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | with Wake Forest Baptist Health (CSR 94%), Blue Local Silver Standard 5800 | with Wake Forest Baptist Health, Blue Local Silver Standard $0 | with Wake Forest Baptist Health (AI/AN), Blue Local Silver Standard 5700 | with Wake Forest Baptist Health (CSR 73%), Blue Local Silver Standard 800 | with Wake Forest Baptist Health (CSR 87%), Blue Local Silver Standard $0 | with Wake Forest Baptist Health (CSR 94%), Blue Local Bronze 5500 | $60 PCP | $20 Tier 1 Rx | with Wake Forest Baptist Health, Blue Local Bronze 7000 | 3 Free PCP | $20 Tier 1 Rx | Integrated | with Wake Forest Baptist Health, Blue Local Bronze Standard 7500 | with Wake Forest Baptist Health, Blue Local Bronze Standard $0 | with Wake Forest Baptist Health (AI/AN), Blue Local Bronze 7500 | HSA Eligible | Integrated | with Wake Forest Baptist Health, Blue Local Bronze 7500 | Integrated | with Wake Forest Baptist Health, Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health, Blue Local Catastrophic 9100 | 3 PCP $35 | Integrated | with Wake Forest Baptist Health, Blue Home Gold 1800 | 3 Free PCP | $10 Tier 1 Rx | with Novant Health, Blue Home $0 | with Novant Health (AI/AN), Blue Home Gold Standard 2000 | with Novant Health, Blue Home Gold Standard $0 | with Novant Health (AI/AN), Blue Home Silver Total 3500 | 3 Free PCP | $15 Tier 1 Rx | with Novant Health, Blue Home Silver Total 3400 | 3 Free PCP | $15 Tier 1 Rx | with Novant Health (CSR 73%), Blue Home Silver Total 675 | 3 Free PCP | $4 Tier 1 Rx | with Novant Health (CSR 87%), Blue Home Silver Total | $0 Deductible | $0 PCP | $4 Tier 1 Rx | with Novant Health (CSR 94%), Blue Home Silver Simple | 3 Free PCP | with Novant Health, Blue Home Silver Simple | 3 Free PCP | with Novant Health (CSR 73%), Blue Home Silver Simple | 3 Free PCP | with Novant Health (CSR 87%), Blue Home Silver Simple | $0 Deductible | 3 Free PCP | with Novant Health (CSR 94%), Blue Home Silver Preferred 3100 | 3 Free PCP | $10 Tier 1 Rx | Integrated | with Novant Health, Blue Home Silver Preferred 2500 | 3 Free PCP | $10 Tier 1 Rx | Integrated | with Novant Health (CSR 73%), Blue Home Silver Preferred 300 | 3 Free PCP | $5 Tier 1 Rx | Integrated | with Novant Health (CSR 87%), Blue Home Silver Preferred | $0 Deductible | $0 PCP | $0 Tier 1 Rx | Integrated | with Novant Health (CSR 94%), Blue Home Silver Secure 1900 | $15 PCP | $15 Tier 1 Rx | with Novant Health, Blue Home Silver Secure 1500 | $10 PCP | $15 Tier 1 Rx | with Novant Health (CSR 73%), Blue Home Silver Secure 75 | $10 PCP | $10 Tier 1 Rx | with Novant Health (CSR 87%), Blue Home Silver Secure | $0 Deductible | $0 PCP & Specialist | $0 Tier 1 Rx | with Novant Health (CSR 94%), Blue Home Silver Access 2300 | 3 Free PCP | $15 Tier 1 Rx | with Novant Health, Blue Home Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | with Novant Health, Blue Home Silver Choice 3700 | 3 Free PCP | $15 Tier 1 Rx | with Novant Health (CSR 73%), Blue Home Silver Choice 700 | 3 Free PCP | $10 Tier 1 Rx | with Novant Health (CSR 87%), Blue Home Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | with Novant Health (CSR 94%), Blue Home Silver Standard 5800 | with Novant Health, Blue Home Silver Standard $0 | with Novant Health (AI/AN), Blue Home Silver Standard 5700 | with Novant Health (CSR 73%), Blue Home Silver Standard 800 | with Novant Health (CSR 87%), Blue Home Silver Standard $0 | with Novant Health (CSR 94%), Blue Home Bronze 5500 | $60 PCP | $20 Tier 1 Rx | with Novant Health, Blue Home Bronze 7000 | 3 Free PCP | $20 Tier 1 Rx | Integrated | with Novant Health, Blue Home Bronze Standard 7500 | with Novant Health, Blue Home Bronze Standard $0 | with Novant Health (AI/AN), Blue Home Bronze 7500 | HSA Eligible | Integrated | with Novant Health, Blue Home Bronze 7500 | Integrated | with Novant Health, Blue Home Bronze 9100 | Integrated | with Novant Health, Blue Home Catastrophic 9100 | 3 PCP $35 | Integrated | with Novant Health, Blue Advantage Silver 3700 + 3 Free PCP-1, Blue Advantage Silver 2500 + 3 Free PCP-I, Blue Advantage Silver 200 + 3 Free PCP-II, Blue Advantage Silver 3800 + 3 Free PCP-1, Blue Local Gold 2500 + 3 Free PCP with Atrium Health, Blue Local Silver 3800 + 3 Free PCP with Atrium Health, Blue Local Silver 3700 + 3 Free PCP-1 with Atrium Health, Blue Local Silver 675 + 3 Free PCP-2 with Atrium Health, Blue Local Silver H $0 Deductible-3 with Atrium Health, Blue Local Silver $0 Deductible with Atrium Health, Blue Local Silver $0 Deductible-1 with Atrium Health, Blue Local Silver $0 Deductible-2 with Atrium Health, Blue Local Silver $0 Deductible-3 with Atrium Health, Blue Local Silver 5300 + 3 Free PCP with Atrium Health, Blue Local Silver 2500 + 3 Free PCP-I with Atrium Health, Blue Local Silver 200 + 3 Free PCP-II with Atrium Health, Blue Local Silver $0 Deductible-III with Atrium Health, Blue Local Silver 2800 + $15 PCP with Atrium Health, Blue Local Silver 850 + $10 PCP-1 with Atrium Health, Blue Local Silver 50 + $5 PCP-2 with Atrium Health, Blue Local Silver $0 PCP-3 with Atrium Health, Blue Local Silver 2000 + 3 Free PCP with Atrium Health, Blue Local Silver 6000 + 3 Free PCP with Atrium Health, Blue Local Silver 3800 + 3 Free PCP-1 with Atrium Health, Blue Local Silver 700 + 3 Free PCP-2 with Atrium Health, Blue Local Silver L $0 Deductible-3 with Atrium Health, Blue Local Bronze 7000 Copay with Atrium Health, Blue Local Bronze 7000 + 3 Free PCP with Atrium Health, Blue Local Bronze 7000 HSA Eligible with Atrium Health, Blue Local Bronze 7000 with Atrium Health, Blue Local Bronze 8700 with Atrium Health, Blue Local Catastrophic with Atrium Health, Blue Home Gold 2500 + 3 Free PCP with UNC Health Alliance, Blue Home Silver 3800 + 3 Free PCP with UNC Health Alliance, Blue Home Silver 3700 + 3 Free PCP-1 with UNC Health Alliance, Blue Home Silver 675 + 3 Free PCP-2 with UNC Health Alliance, Blue Home Silver H $0 Deductible-3 with UNC Health Alliance, Blue Home Silver $0 Deductible with UNC Health Alliance, Blue Home Silver $0 Deductible-1 with UNC Health Alliance, Blue Home Silver $0 Deductible-2 with UNC Health Alliance, Blue Home Silver $0 Deductible-3 with UNC Health Alliance, Blue Home Silver 5300 + 3 Free PCP with UNC Health Alliance, Blue Home Silver 2500 + 3 Free PCP-I with UNC Health Alliance, Blue Home Silver 200 + 3 Free PCP-II with UNC Health Alliance, Blue Home Silver $0 Deductible-III with UNC Health Alliance, Blue Home Silver 2800 + $15 PCP with UNC Health Alliance, Blue Home Silver 850 + $10 PCP-1 with UNC Health Alliance, Blue Home Silver 50 + $5 PCP-2 with UNC Health Alliance, Blue Home Silver $0 PCP-3 with UNC Health Alliance, Blue Home Silver 2000 + 3 Free PCP with UNC Health Alliance, Blue Home Silver 6000 + 3 Free PCP with UNC Health Alliance, Blue Home Silver 3800 + 3 Free PCP-1 with UNC Health Alliance, Blue Home Silver 700 + 3 Free PCP-2 with UNC Health Alliance, Blue Home Silver L $0 Deductible-3 with UNC Health Alliance, Blue Home Bronze 7000 Copay with UNC Health Alliance, Blue Home Bronze 7000 + 3 Free PCP with UNC Health Alliance, Blue Home Bronze 7000 HSA Eligible with UNC Health Alliance, Blue Home Bronze 7000 with UNC Health Alliance, Blue Home Bronze 8700 with UNC Health Alliance, Blue Home Catastrophic with UNC Health Alliance, Blue Local Gold 2500 + 3 Free PCP with Wake Forest Baptist Health, Blue Local $0 with Wake Forest Baptist Health, Blue Local Silver 3800 + 3 Free PCP with Wake Forest Baptist Health, Blue Local Silver 3700 + 3 Free PCP-1 with Wake Forest Baptist Health, Blue Local Silver 675 + 3 Free PCP-2 with Wake Forest Baptist Health, Blue Local Silver H $0 Deductible-3 with Wake Forest Baptist Health, Blue Local Silver $0 Deductible with Wake Forest Baptist Health, Blue Local Silver $0 Deductible-1 with Wake Forest Baptist Health, Blue Local Silver $0 Deductible-2 with Wake Forest Baptist Health, Blue Local Silver $0 Deductible-3 with Wake Forest Baptist Health, Blue Local Silver 5300 + 3 Free PCP with Wake Forest Baptist Health, Blue Local Silver 2500 + 3 Free PCP-I with Wake Forest Baptist Health, Blue Local Silver 200 + 3 Free PCP-II with Wake Forest Baptist Health, Blue Local Silver $0 Deductible-III with Wake Forest Baptist Health, Blue Local Silver 2800 + $15 PCP with Wake Forest Baptist Health, Blue Local Silver 850 + $10 PCP-1 with Wake Forest Baptist Health, Blue Local Silver 50 + $5 PCP-2 with Wake Forest Baptist Health, Blue Local Silver $0 PCP-3 with Wake Forest Baptist Health, Blue Local Silver 2000 + 3 Free PCP with Wake Forest Baptist Health, Blue Local Silver 6000 + 3 Free PCP with Wake Forest Baptist Health, Blue Local Silver 3800 + 3 Free PCP-1 with Wake Forest Baptist Health, Blue Local Silver 700 + 3 Free PCP-2 with Wake Forest Baptist Health, Blue Local Silver L $0 Deductible-3 with Wake Forest Baptist Health, Blue Local Bronze 7000 Copay with Wake Forest Baptist Health, Blue Local Bronze 7000 + 3 Free PCP with Wake Forest Baptist Health, Blue Local Bronze 7000 HSA Eligible with Wake Forest Baptist Health, Blue Local Bronze 7000 with Wake Forest Baptist Health, Blue Local Bronze 8700 with Wake Forest Baptist Health, Blue Local Catastrophic with Wake Forest Baptist Health, Blue Home Gold 2500 + 3 Free PCP with Novant Health, Blue Home Silver 3800 + 3 Free PCP with Novant Health, Blue Home Silver 3700 + 3 Free PCP-1 with Novant Health, Blue Home Silver 675 + 3 Free PCP-2 with Novant Health, Blue Home Silver H $0 Deductible-3 with Novant Health, Blue Home Silver $0 Deductible with Novant Health, Blue Home Silver $0 Deductible-1 with Novant Health, Blue Home Silver $0 Deductible-2 with Novant Health, Blue Home Silver $0 Deductible-3 with Novant Health, Blue Home Silver 5300 + 3 Free PCP with Novant Health, Blue Home Silver 2500 + 3 Free PCP-I with Novant Health, Blue Home Silver 200 + 3 Free PCP-II with Novant Health, Blue Home Silver $0 Deductible-III with Novant Health, Blue Home Silver 2800 + $15 PCP with Novant Health, Blue Home Silver 850 + $10 PCP-1 with Novant Health, Blue Home Silver 50 + $5 PCP-2 with Novant Health, Blue Home Silver $0 PCP-3 with Novant Health, Blue Home Silver 2000 + 3 Free PCP with Novant Health, Blue Home Silver 6000 + 3 Free PCP with Novant Health, Blue Home Silver 3800 + 3 Free PCP-1 with Novant Health, Blue Home Silver 700 + 3 Free PCP-2 with Novant Health, Blue Home Silver L $0 Deductible-3 with Novant Health, Blue Home Bronze 7000 Copay with Novant Health, Blue Home Bronze 7000 + 3 Free PCP with Novant Health, Blue Home Bronze 7000 HSA Eligible with Novant Health, Blue Home Catastrophic with Novant Health, Blue Local with Wake Forest Baptist Health Coinsurance, Blue Local with Wake Forest Baptist Health Copay. In some cases, your actual policy document may be available through the links below. , How Medicare affects your current coverage. The protection of your privacy will be governed by the privacy policy of that site. You can use this card to log in to our new member portal at bluecrossmn.com/bca and access information regarding Blue Cross Vision, Blue Cross Dental, Rewards, and other Health and Wellness programs. Effective January 1, 2022 WELCOME TO THE PREMERA BLUE CROSS STANDARD PLAN Amazon.com Services, LLC ("Amazon") is pleased to provide you with this Summary Plan Description ("SPD") which describes medical benefits available to you and your covered family members under the Group Health and Welfare Plan. Blue Cross and Blue Shield Service Benefit Plan Brochures 2023 Blue Cross and Blue Shield Service Benefit Plan Brochure - Standard and Basic Options 2023 Blue Cross and Blue Shield Service Benefit Plan Brochure - FEP Blue Focus
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