The following chart gives an overview of the differences between the four medical plans.
| Duke Select (HMO) | Duke Basic (HMO) | Blue Care (Blue Cross/ Blue Shield HMO) | Duke Options (Blue Cross/Blue Shield PPO) |
||
|---|---|---|---|---|---|
| In-Network | Out-of- Network | ||||
| Annual Deductible | |||||
| Individual | None | $6001 | None | $1301 | $650 |
| Family | None | $1,8001 | None | $3901 | $1,950 |
| Co-Insurance Maximum | |||||
| Individual | None | $2,0002 | None | $2,0002 | $4,0002 |
| Family | None | $6,0002 | None | $6,0002 | $12,0002 |
| Physician Office Visit | |||||
| PCP | $20 co-pay | $25 co-pay | $20 co-pay | $20 co-pay | You pay 30% after deductible3 |
| Specialist | $55 co-pay | $75 co-pay | $55 co-pay | $55 co-pay | You pay 30% after deductible3 |
| MRI, CT, PET Scan | $150 co-pay | $150 co-pay | Covered in full | You pay 10% after deductible | You pay 30% after deductible3 |
| Lab & Other X-Ray | Covered in full | Covered in full | Covered in full | You pay 10% after deductible | You pay 30% after deductible3 |
| Annual Physical | $20 co-pay primary care $55 co-pay specialist |
$25 co-pay primary care $75 co-pay specialist |
$20 co-pay primary care $55 co-pay specialist |
$20 co-pay primary care $55 co-pay specialist |
Well visits not covered; you pay 30% after deductible3 for annual PAP smear, mammogram, or PSA |
| Mammogram | Covered in full | Covered in full | Covered in full | You pay 10% after deductible for diagnostic ($55 co-pay for screening) | You pay 30% after deductible3 |
| Colonoscopy | Covered in full | Covered in full | $250 co-pay | You pay 10% after deductible | You pay 30% after deductible3 |
| OB/GYN Exams | $20 co-pay primary care $55 co-pay specialist |
$25 co-pay primary care $75 co-pay specialist |
$20 co-pay primary care | $20 co-pay primary care $55 co-pay specialist |
Well visits not covered; you pay 30% after deductible3 for PAP smear, mammogram, and sick visits |
| Well Baby Visits (under age 2) | Covered in full | Covered in full | $20 co-pay primary care $55 co-pay specialist |
$20 co-pay primary care $55 co-pay specialist |
Not covered |
| Maternity Care: includes prenatal and post-delivery care | $20 co-pay primary care or $55 co-pay specialist first visit, then professional services covered in full | $75 co-pay specialist first visit, then professional services covered in full | $20 co-pay first visit, then professional services covered in full | You pay 10% after deductible | You pay 30% after deductible3 for professional services |
| Hospital Care | |||||
| Inpatient | $600 per admission co-pay4, then covered in full | Subject to $600 annual deductible; you pay 10% co-insurance up to maximum of $2,0001 | $600 or $700 per admission co-pay5, then covered in full | After $600 or $700 per admission co-pay5 and deductible, you pay 10% up to maximum of $2,000 | You pay 30% after $900 per admission co-pay and deductible3 |
| Outpatient | $250 co-pay | You pay 10% after deductible | $250 co-pay | You pay 10% after deductible | You pay 30% after deductible3 |
| Emergency Care | $250 co-pay, waived if admitted | $250 co-pay, waived if admitted | $250 co-pay, waived if admitted | $250 co-pay, waived if admitted | $250 co-pay, waived if admitted |
| Urgent Care | $35 co-pay | $50 co-pay | $35 co-pay | $35 co-pay | $35 co-pay |
| Ambulance | Covered in full when medically necessary | You pay 20% after deductible | Covered in full when medically necessary | You pay 10% after deductible when medically necessary | You pay 10% after deductible when medically necessary |
| Other Services | |||||
| Infertility | Provided only at the Duke Fertility Center for employees with two years of service; limits apply6 | Not covered | Does not include COH, IVF, or other types of artificial conception6 | Provided only at the Duke Fertility Center for employees with two years of service; limits apply6 | Not covered |
| Infertility Testing and Treatment, Subject to Precertification | Fixed price; recertification required; limits apply6 | Not covered | $20 co-pay primary care; $55 co-pay specialist; covered in full for testing6 | Fixed price; recertification required; limits apply6 | Not covered |
| Skilled Nursing Facility | Covered in full when authorized by doctor; 60-day annual maximum | Covered in full when authorized by doctor; 60-day annual maximum | Covered in full when authorized by doctor; 60-day annual maximum | You pay 10% after deductible when authorized after $250 per admission co-pay; 60-day annual maximum | You pay 30% after deductible3 when authorized after $250 per admission co-pay; 60-day annual maximum |
| Home Health Care | Covered in full when authorized by doctor; up to 100 visits per calendar year | $25 co-pay per visit when authorized by doctor; up to 100 visits per calendar year | Covered in full when authorized by doctor; up to 100 visits per calendar year | You pay 10% after deductible when authorized; 100 combined in- and out-of-network visits per calendar year | You pay 30% after deductible3 when medically necessary; 100 combined in- and out-of-network visits per calendar year |
| Hospice Care | Covered in full when authorized by doctor | Covered in full when authorized by doctor | Covered in full when authorized by doctor | You pay 10% after deductible | You pay 30% after deductible3 |
| Durable Medical Equipment | You pay 10% | You pay 20% after deductible | Covered in full | You pay 10% after deductible7 | You pay 30% after deductible3 |
| Prosthetics | You pay 10% | You pay 20% after deductible | Covered in full | You pay 10% after deductible | You pay 30% after deductible3 |
| Physical Therapy (PT) Occupational Therapy (OT) |
$20 co-pay; 20 visits per injury or illness each calendar year for combined PT and OT7 | $75 co-pay; 20 visits per injury or illness each calendar year for combined PT and OT | $55 co-pay for PT and OT; 30 visits per calendar year for combined PT and OT | $55 co-pay; 30 visits per calendar year for combined PT, OT, and chiropractic in- and out-of-network7 | You pay 30% after deductible; 30 visits per calendar year for combined PT, OT, and chiropractic in- and out-of-network3, 7 |
| Chiropractic Care | $55 co-pay | $75 co-pay | $55 co-pay; 20 visits per calendar year | $55 co-pay; 30 visits per calendar year for combined PT, OT, and chiropractic in- and out-of-network | You pay 30% after deductible3; 30 visits per calendar year for combined PT, OT, and chiropractic in- and out-of-network |
| Nutrition | $20 co-pay; 6 visits per calendar year | $25 co-pay; 6 visits per calendar year | Covered in full up to 6 visits per calendar year | Covered in full up to 6 visits per calendar year | Not covered |
| Speech Therapy | $20 co-pay; 20 visits per calendar year; precertification required7 | $75 co-pay; 20 visits per calendar year; precertification required8 | $55 co-pay; 20 visits per calendar year | $55 co-pay; 20 visits per calendar year for combined in- and out-of-network7 | You pay 30% after deductible3; 20 visits per calendar year for combined in- and out-of-network |
| Vision Exam | $55 co-pay; limit 1 per calendar year | $75 co-pay; limit 1 per calendar year | $20 co-pay; limit 1 per calendar year; 30% lens and frame discount at point of purchase; 15% disposable contacts discount at point of purchase | $55 co-pay; limit 1 per calendar year; 30% lens and frame discount at point of purchase; 15% disposable contacts discount at point of purchase | Not covered |
| Bariatric Surgery9 | $2,500 co-pay | Not covered | $2,500 co-pay | $2,500 co-pay | Not covered |
- Deductible does not apply to office visits for primary care and specialist.
- Excluding deductibles, co-pays, prescription drug co-pays, urgent care and emergency room co-pays and developmental disabilities co-pays and co-insurance.
- All payments are based on the allowable charge. You are liable for charges over the allowable charge when receiving out-of-network services.
- Wake Med is considered in-network only for obstetrics and most pediatric admissions.
- $600 per admission co-pay for Duke Hospital, Duke Regional Hospital, and Duke Raleigh Hospital facilities and $700 for all others in-network.
- See the Member Guide and Summary of Benefits and Coverage for details.
- For children under 18 with significant disability, the plan will pay 100 percent for in-network benefits after appropriate co-pay per visit to an annual maximum of $10,000 in charges for employees hired prior to January 1, 1997. After $10,000 in charges, plan pays 75 percent. Treatment must be received at Duke Hospital and its outpatient clinics.
- There are no benefits available under this plan for children with developmental disabilities.
- For qualified patients only. See Summary of Benefits and Coverage for details.