Medical & Prescription Plan Benefits

Blue Cross Blue Shield of North Carolina

Your medical benefits are provided through Blue Cross Blue Shield of NC. Hafele America Co. offers a comprehensive prescription program with all our medical plans. You pay a co-payment for prescriptions filled at a network pharmacy, or through the mail order prescription service, on the Core and Buy-Up plans. On the Medical HSA plan, prescription coverage is applied to the deductible. After the deductible has been met, you will pay a co-payment for prescriptions filled at a network pharmacy.

If you enroll in the Medical HSA plan, you will be eligible to enroll in a Health Savings Account, which allows you to set aside pre-tax dollars to pay for eligible medical expenses. All our plans are designed to offer comprehensive coverage when care is provided through network providers.

The Limited plan only offers in-network coverage through a carefully selected network of doctors and hospitals that provide great care at lower costs. This network is the BlueHighPerformanceNetwork or BlueHPN. Only emergencies are covered out-of-network.

You are eligible to enroll in the Limited plan only if you live in one of the counties within a BlueHPN service area. If you live outside these counties, you will not be able to enroll in the Limited plan. You can look up in-network providers at: BlueCrossNC.com/HPNdoctors.

Note that in NC, Cone and Novant are NOT in the BlueHPN network.

Core Plan Benefits

Col1	Col2	Col3
Benefit Provision	In-Network	Out-of-Network
Deductible (per Calendar Year) • Individual • Family	$5,000 $10,000	$10,000 $20,000
Out-of-Pocket Maximum • Individual • Family	(Includes Deductible & Copays) $7,000 $14,000	(Includes Deductible & Copays) $14,000 $28,000
Coinsurance	You pay 30% after Deductible (unless noted otherwise)	You pay 50% after Deductible (unless noted otherwise)
Office Visits • Preventive Care • PCP • Primary360 (virtual PCP) • Specialist • Virtual Visit (Teladoc) • Mental Health • Chiropractic Care (20 visit per calendar year) • Nutritional Counseling (30 visits per calendar year)	100% Covered $35 copay First 3 visits to selected PCP $0 $0 copay $70 copay $0 copay $10 copay $70 copay $0 copay	30% after Deductible 50% after Deductible Not Covered 50% after Deductible Not Covered 50% after Deductible 50% after Deductible 30% after Deductible
Emergency Room Urgent Care	$500 copay $70 copay	$500 copay 50% after Deductible
Prescription Drug (per 30-day supply) • Tier 1 • Tier 2 • Tier 3 • Tier 4 • Tier 5 Mail Order (per 90-day supply) • Tier 1 • Tier 2 • Tier 3 • Tier 4 • Tier 5	$10 copay $10 copay $40 copay $105 copay $150 copay Drugs on the Preventive Drug List are covered 100% $30 copay $30 copay $120 copay $315 copay $450 copay	$10 copay $10 copay $40 copay $105 copay $150 copay Not Covered

Buy-Up Plan Benefits

Col1	Col2	Col3
Benefit Provision	In-Network	Out-of-Network
Deductible (per Calendar Year) • Individual • Family	$5,000 $10,000	$10,000 $20,000
Out-of-Pocket Maximum • Individual • Family	(Includes Deductible & Copays) $7,000 $14,000	(Includes Deductible & Copays) $14,000 $28,000
Coinsurance	You pay 20% after Deductible (unless noted otherwise)	You pay 50% after Deductible (unless noted otherwise)
Office Visits • Preventive Care • PCP • Primary360 (virtual PCP) • Specialist • Virtual Visit (Teladoc) • Mental Health • Chiropractic Care (20 visit per calendar year) • Nutritional Counseling (30 visits per calendar year)	100% Covered $25 copay First 3 visits to selected PCP $0 $0 copay $50 copay $0 copay $10 copay $50 copay $0 copay	30% after Deductible 50% after Deductible Not Covered 50% after Deductible Not Covered 50% after Deductible 50% after Deductible 30% after Deductible
Emergency Room Urgent Care	$500 copay $50 copay	$500 copay 50% after Deductible
Prescription Drug (per 30-day supply) • Tier 1 • Tier 2 • Tier 3 • Tier 4 • Tier 5 Mail Order (per 90-day supply) • Tier 1 • Tier 2 • Tier 3 • Tier 4 • Tier 5	$10 copay $10 copay $40 copay $105 copay $150 copay Drugs on the Preventive Drug List are covered 100% $30 copay $30 copay $120 copay $315 copay $450 copay	$10 copay $10 copay $40 copay $105 copay $150 copay Not Covered

Limited Plan Benefits

Col1	Col2
Benefit Provision	In-Network Coverage Only
Deductible (per Calendar Year) • Individual • Family	$5,000 $10,000
Out-of-Pocket Maximum • Individual • Family	(Includes Deductible & Copays) $9,100 $18,200
Coinsurance	You pay 30% after Deductible (unless noted otherwise)
Office Visits • Preventive Care • PCP • Specialist • Virtual Visit (Teladoc) • Mental Health • Chiropractic Care (20 visit per calendar year) • Nutritional Counseling (30 visits per calendar year)	100% Covered $35 copay First 3 visits to selected PCP $0 $70 copay $0 copay $10 copay $70 copay $0 copay
Emergency Room Urgent Care	$500 copay $70 copay
Prescription Drug (per 30-day supply) • Tier 1 • Tier 2 • Tier 3 • Tier 4 • Tier 5 Mail Order (per 90-day supply) • Tier 1 • Tier 2 • Tier 3 • Tier 4 • Tier 5	$10 copay $35 copay $60 copay 25% of the cost of the drug to $100 Maximum 25% of the cost of the drug to $100 Maximum Drugs on the Preventive Drug List are covered 100% $30 copay $105 copay $180 copay 25% to $300 Maximum 25% to $300 Maximum

Blue Connect and Teladoc

Limited Plan Network

Following is a snapshot of the BlueHPN markets across Hafele America Co.:

Greensboro-Winston Salem-High Point (“Triad”) | NC

Geographic Footprint
The MSA includes all or parts of the following three-digit ZIP codes:
270 – 274, 286