Eligibility for each of Duke's five different medical plans is based on the employee's permanent home zip code:
| Employees who live in NC with zip codes that begin with 272, 273, 275, 276 or 277... | Employees who live in NC but not in zip codes that begin with 272, 273, 275, 276 or 277... | Employees who live outside of North Carolina... |
|---|---|---|
...may enroll in:
| ...may enroll in:
| ...may enroll in:
|
The following charts give an overview of the differences between each of Duke's medical plans.
- Employees Permanently Residing in A Zip Code That Begins with 272, 273, 275, 276 or 277
- Employees Permanently Residing In a Zip Code NOT Beginning with 272, 273, 275, 276 or 277
Employees Permanently Residing in A Zip Code that begins with 272, 273, 275, 276 or 277
| Duke Select HMO | Duke Basic HMO | Blue Care Blue Cross NC HMO | Duke Options Blue Cross Blue Shield PPO (IN NETWORK) | Duke Options Blue Cross Blue Shield PPO (OUT OF NETWORK) | |
|---|---|---|---|---|---|
| Annual Deductible | |||||
| Individual | None | $6001 | None | $1301 | $650 |
| Family | None | $1,8001 | None | $3901 | $1,950 |
| Out of Pocket Limit2 | |||||
| Individual | $3,000 | $3,000 | $3,000 | $3,000 | $6,000 |
| Family | $6,000 | $6,000 | $6,000 | $6,000 | $12,000 |
| Physician Office Visit | |||||
| PCP | $20 copay | $25 copay | $20 copay | $20 copay | You pay 30% after deductible3 |
| Specialist | $55 copay | $75 copay | $55 copay | $55 copay | You pay 30% after deductible3 |
| MRI, CT, PET Scan | $150 copay | $150 copay | 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 Preventive Visit | Covered in full | Covered in full | Covered in full | Covered in full | Not covered |
| Mammogram | Covered in full | Covered in full | Covered in full | Covered in full | You pay 30% after deductible3 |
| Colonoscopy | Covered in full | Covered in full | Covered in full | Covered in full | You pay 30% after deductible3 |
| OB/GYN Exams | $20 copay primary care $55 copay specialist | $25 copay primary care $75 copay specialist | $20 copay primary care $55 copay specialist | $20 copay primary care $55 copay specialist | Well visits not covered; you pay 30% after deductible3 for PAP smear, mammogram, and sick visits |
| Well Baby / Well Child Visits | Covered in full | Covered in full | Covered in full | Covered in full | Not covered |
| Maternity Care | $20 copay primary care or $55 copay specialist first visit, then professional services covered in full | $75 copay specialist first visit, then professional services covered in full | $20 copay first visit, then professional services covered in full | $20 copay primary care or $55 copay specialist first visit, then professional services covered in full | You pay 30% after deductible3 for professional services |
| Hospital Care | |||||
| Inpatient | $600 per admission copay4, then covered in full | Subject to $600 annual deductible; you pay 10% coinsurance | $600 or $700 per admission copay5, then covered in full | After $600 or $700 per admission copay5 and deductible, you pay 10% coinsurance | 70% after $900 per admission copay and deductible3 |
| Outpatient | $250 copay | You pay 10% after deductible | $250 copay | You pay 10% after deductible | You pay 30% after deductible3 |
| Emergency Care | $250 copay, waived if admitted | $250 copay, waived if admitted | $250 copay, waived if admitted | $250 copay, waived if admitted | $250 copay, waived if admitted |
| Urgent Care | $35 copay | $50 copay | $35 copay | $35 copay | $35 copay |
| Ambulance | Covered in full when medically necessary | $250 copay when medically necessary | Covered in full when medically necessary | $250 copay when medically necessary | You pay 10% after deductible when medically necessary |
| Other Services | |||||
| Infertility | Provided only at the Duke Fertility Center7 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 Center7 for employees with two years of service; limits apply6 | Not covered |
| Infertility Testing and Treatment, Subject to Precertification | Fixed price; precertification required; limits apply6 | Not covered | $20 copay primary care; $55 copay specialist; covered in full for testing6 | Fixed price; precertification required; limits apply6,7 | 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 copay; 60-day annual maximum | You pay 30% after deductible3 when authorized after $250 per admission copay; 60-day annual maximum |
| Home Health Care | Covered in full when authorized by doctor; up to 100 visits per calendar year | $25 copay 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 deductible | 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 copay; 40 visits per calendar year for combined PT and OT8 | $75 copay; 40 visits per calendar year for combined PT and OT | $55 copay for PT and OT; 40 visits per calendar year for combined PT and OT8 | $55 copay; 40 visits per calendar year for combined PT, OT, and chiropractic in and out of network8 | You pay 30% after deductible; 40 visits per calendar year for combined PT, OT, and chiropractic in and out of network3 |
| Chiropractic Care | $55 copay | $75 copay | $55 copay; 20 visits per calendar year | $55 copay; 40 visits per calendar year for combined PT, OT, and chiropractic in and out of network | You pay 30% after deductible3; 40 visits per calendar year for combined PT, OT, and chiropractic in and out of network |
| Nutrition | $20 copay; 6 visits per calendar year; visits provided as treatment for behavioral health not subject to visit limit | $25 copay; 6 visits per calendar year; visits provided as treatment for behavioral health not subject to visit limit | Covered in full up to 6 visits per calendar year; visits provided as treatment for behavioral health not subject to visit limit | Covered in full up to 6 visits per calendar year; visits provided as treatment for behavioral health not subject to visit limit | Not covered |
| Speech Therapy | $20 copay; 20 visits per calendar year; precertification required8 | $75 copay; 20 visits per calendar year; precertification required | $55 copay; 20 visits per calendar year8 | $55 copay; 20 visits per calendar year for combined in and out of network8 | You pay 30% after deductible3; 20 visits per calendar year for combined in and out of network |
| Vision Exam | $55 copay; limit 1 per calendar year | $75 copay; limit 1 per calendar year | $20 copay; limit 1 per calendar year; 30% lens and frame discount at point of purchase; 15% disposable contacts discount at point of purchase | $55 copay; 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 surgical copay | Not covered | $2,500 surgical copay | $2,500 surgical copay10 | Not covered |
| Gender Affirmation Surgery9 | Not covered | Not covered | $600 or $700 per admission copay5 then covered in full | After $600 or $700 per admission copay and deductible, you pay 10% coinsurance | You pay 30% after $900 per admission copay and deductible3 |
| Behavioral Health and Substance Abuse | |||||
| Outpatient | $20 copay for individual/family therapy11 | $25 copay for individual/family therapy11 | $20 copay for individual/family therapy11 | $20 copay for individual/family therapy11 | You pay 30% after $650 annual deductible3; no visit limit applies |
| Inpatient | $600 per admission copay applies; must be pre-certified12 | $600 per admission copay applies; must be pre-certified12 | $600 per admission copay applies; must be pre-certified12 | $600 per admission copay applies; must be pre-certified12 | You pay 30% after $900 per admission copay and deductible3; no day limit applies |
Employees Permanently Residing In a Zip code NOT Beginning with 272, 273, 275, 276 or 277
| Blue Care Blue Cross NC HMO | Duke Options PPO (IN NETWORK) | Duke Options PPO (OUT OF NETWORK) | Duke USA PPO (IN NETWORK) | Duke USA PPO (OUT OF NETWORK) | |
|---|---|---|---|---|---|
| Annual Deductible | |||||
| Individual | None | $1301 | $650 | $2,000 | $6,000 |
| Family | None | $3901 | $1,950 | $6,000 | $12,000 |
| Out of Pocket Limit3 | |||||
| Individual | $3,000 | $3,000 | $6,000 | $6,800 | $13,600 |
| Family | $6,000 | $6,000 | $12,000 | $13,600 | $27,200 |
| Physician Office Visit | |||||
| PCP | $20 copay | $20 copay | You pay 30% after deductible3 | $25 copay | You pay 40% after deductible3 |
| Specialist | $55 copay | $55 copay | You pay 30% after deductible3 | $55 copay | You pay 40% after deductible3 |
| MRI, CT, PET Scan | Covered in full | You pay 10% after deductible | You pay 30% after deductible3 | You pay 20% after deductible | You pay 40% after deductible3 |
| Lab & Other X-Ray | Covered in full | You pay 10% after deductible | You pay 30% after deductible3 | You pay 20% after deductible | You pay 40% after deductible3 |
| Annual Preventive Visit | Covered in full | Covered in full | Not covered | Covered in full | Not covered |
| Mammogram | Covered in full | Covered in full | You pay 30% after deductible3 | Covered in full | You pay 40% after deductible3 |
| Colonoscopy | Covered in full | Covered in full | You pay 30% after deductible3 | Covered in full | You pay 40% after deductible3 |
| OB/GYN Exams | $20 copay primary care $55 copay specialist | $20 copay primary care $55 copay specialist | Well visits not covered; you pay 30% after deductible3 for Pap smear, mammogram, and sick visits | $25 copay primary care $55 copay specialist | Well visits not covered; you pay 40% after deductible3 for Pap smear, mammogram, and sick visits |
| Well Baby / Well Child Visits | Covered in full | Covered in full | Not covered | Covered in full | Not covered |
| Maternity Care | $20 copay first visit, then professional services covered in full | $20 copay primary care or $55 copay specialist first visit, then professional services covered in full | You pay 30% after deductible3 for professional services | $25 copay primary care or $55 copay specialist first visit, then professional services covered in full | You pay 40% after deductible3 for professional services |
| Hospital Care | |||||
| Inpatient | $600 or $700 per admission copay5, then covered in full | After $600 or $700 per admission copay5 and deductible, you pay 10% coinsurance | You pay 30% after $900 per admission copay and deductible3 | After $600 or $700 per admission copay5 and deductible, you pay 20% coinsurance | You pay 40% after $900 per admission copay and deductible3 |
| Outpatient | $250 copay | You pay 10% after deductible | You pay 30% after deductible3 | You pay 20% after deductible | You pay 40% after deductible3 |
| Emergency Care | $250 copay, waived if admitted | $250 copay, waived if admitted | $250 copay, waived if admitted | $250 copay, waived if admitted | $250 copay, waived if admitted |
| Urgent Care | $35 copay | $35 copay | $35 copay | $50 copay | $50 copay |
| Ambulance | Covered in full when medically necessary | $250 copay when medically necessary | $250 copay when medically necessary | $250 copay when medically necessary | $250 copay when medically necessary |
| Other Services | |||||
| Infertility | Does not include COH, IVF, or other types of artificial conception6 | Employees must have two years continuous fulltime service;7 limits apply6 | Not covered | Does not include COH, IVF, or other types of artificial conception6 | Not covered |
| Infertility Testing and Treatment, Subject to Precertification | $20 copay primary care; $55 copay specialist; covered in full for testing6 | Precertification required; limits apply6,7 | Not covered | $25 copay primary care; $55 copay specialist; covered in full for testing6 | Not covered |
| Skilled Nursing Facility | Covered in full when authorized by doctor; 60-day annual maximum | You pay 10% after deductible when authorized after $250 per admission copay; 60-day annual maximum | You pay 30% after deductible3 when authorized after $250 per admission copay; 60-day annual maximum | You pay 20% after deductible when authorized after $250 per admission copay; 60-day annual maximum | You pay 40% after deductible3 when authorized after $250 per admission copay; 60-day annual maximum |
| Home Health Care | 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 | You pay 20% after deductible when authorized; 100 combined in and out of network visits per calendar year | You pay 40% 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 | You pay 10% after deductible | You pay 30% after deductible3 | You pay 20% after deductible | You pay 40% after deductible3 |
| Durable Medical Equipment | Covered in full | You pay 10% after deductible | You pay 30% after deductible3 | You pay 20% after deductible | You pay 40% after deductible3 |
| Prosthetics | Covered in full | You pay 10% after deductible | You pay 30% after deductible3 | You pay 20% after deductible | You pay 40% after deductible3 |
| Physical Therapy (PT) Occupational Therapy (OT) | $55 copay for PT and OT; 40 visits per calendar year for combined PT and OT7 | $55 copay; 40 visits per calendar year for combined PT, OT, and chiropractic in and out of network8 | You pay 30% after deductible; 40 visits per calendar year for combined PT, OT, and chiropractic in and out of network3 | $55 copay; 40 visits per calendar year for combined PT, OT, and chiropractic in and out of network | You pay 40% after deductible; 40 visits per calendar year for combined PT, OT, and chiropractic in and out of network3 |
| Chiropractic Care | $55 copay; 20 visits per calendar year | $55 copay; 40 visits per calendar year for combined PT, OT, and chiropractic in and out of network | You pay 30% after deductible3 ; 40 visits per calendar year for combined PT, OT, and chiropractic in and out of network | $55 copay; 40 visits per calendar year for combined PT, OT, and chiropractic in and out of network | 40% after deductible3 ; 40 visits per calendar year for combined PT, OT, and chiropractic in and out of network |
| Nutrition | Covered in full up to 6 visits per calendar year; visits provided as treatment for behavioral health not subject to visit limit | Covered in full up to 6 visits per calendar year; visits provided as treatment for behavioral health not subject to visit limit | Not covered | Covered in full up to 6 visits per calendar year; visits provided as treatment for behavioral health not subject to visit limit | Not covered |
| Speech Therapy | $55 copay; 20 visits per calendar year7 | $55 copay; 20 visits per calendar year for combined in and out of network8 | You pay 30% after deductible3 ; 20 visits per calendar year for combined in and out of network | $55 copay; 20 visits per calendar year for combined in and out of network | 40% after deductible3 ; 20 visits per calendar year for combined in and out of network |
| Vision Exam | $20 copay; limit 1 per calendar year; 30% lens and frame discount at point of purchase; 15% disposable contacts discount at point of purchase | $55 copay; limit 1 per calendar year; 30% lens and frame discount at point of purchase; 15% disposable contacts discount at point of purchase | Not covered | Not covered | Not covered |
| Bariatric Surgery9 | $2,500 surgical copay | $2,500 surgical copay8,9 | Not covered | Not covered | Not covered |
| Gender Affirmation Surgery9 | $600 or $700 per admission copay5 then covered in full | After $600 or $700 per admission copay and deductible, you pay 10% coinsurance | You pay 30% after $900 per admission copay and deductible3 | After $600 or $700 per admission copay and deductible, you pay 20% coinsurance | You pay 40% after $900 per admission copay and deductible3 |
| Behavioral Health and Substance Abuse | |||||
| Outpatient | $20 copay for individual/family therapy11 | $20 copay for individual/family therapy | You pay 30% after $650 annual deductible3; no visit limit applies | $25 copay for individual/family therapy | You pay 40% after $650 annual deductible3 |
| Inpatient | $600 per admission copay applies; must be pre-certified10 | After $600 or $700 per admission copay5 and deductible, you pay 10% coinsurance | After $900 per admission copay and deductible, you pay 30% coinsurance2 | After $600 or $700 per admission copay3 and deductible, you pay 20% coinsurance | After $900 per admission copay and deductible, you pay 40% coinsurance2 |
- Deductible does not apply to office visits for primary care and specialist.
- Includes the combined amounts that you spend on your medical and pharmacy copayments, deductibles, and coinsurance. Premiums, balance billed charges, and charges the plan does not cover are excluded. Infertility Benefits and SaveOnSP prescription medications do not count towards a member's Out of Pocket Limit.
- 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 for only certain services including OBGYN, Pediatrics, Rehabilitation, and ER.
- $600 per admission copay 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 members with a permanent home address outside of the state of North Carolina, access to a provider other than a Duke Fertility provider is covered, as long as the member meets the eligibility requirements and medical policy criteria. Prior authorization may be required.
- For children under 18 with significant disability, the plan will pay 100 percent for in network benefits after appropriate copay per visit to an annual maximum of $10,000 in charges for employees hired prior to January 1, 1997. After $10,000 in charges, the plan pays 75 percent. Treatment must be received at Duke Hospital and its outpatient clinics.
- For qualified patients only. See Summary of Benefits and Coverage for details.
- Out of network benefits limited to 20 days per calendar year for Duke Select, Duke Basic, and Blue Care. Member pays 30% of the allowable charge after $900 per admission copay and annual deductible have been met.
- Out of network benefits limited to 20 visits per calendar year for Duke Select, Duke Basic, and Blue Care. Member pays 30% of the allowable charge after $650 annual deductible has been met.