NC SmartChoice PPO Plans
Member Out-of-Pocket Responsibility
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| Type of Service | Place of Service | Member In-Network Responsibility | Member Out-of-Network Responsibility |
| Office Visit - Primary Care | Physician's Office | Primary Care Copay | Out-of-Network Deductible & Coinsurance |
| Office Visit - Primary Care | Hospital-Based Practice | In-Network Deductible & Coinsurance | Out-of-Network Deductible & Coinsurance |
| Office Visit - Specialist | Physician's Office | Specialist Copay | Out-of-Network Deductible & Coinsurance |
| Office Visit - Specialist | Hospital-Based Practice | In-Network Deductible & Coinsurance | Out-of-Network Deductible & Coinsurance |
| Colonoscopy | Physician's Office | Specialist Copay | Out-of-Network Deductible & Coinsurance |
| Colonoscopy | Outpatient Hospital | In-Network Deductible & Coinsurance | Out-of-Network Deductible & Coinsurance |
| Routine Eye Exam | Physician's Office | Primary Care Copay | Not Covered |
| Maternity Care - Prenatal | Physician's Office | Primary Care Copay - initial office visit only, then 100% | Out-of-Network Deductible & Coinsurance |
| Maternity Care - Delivery | Inpatient Hospital | In-Network Deductible & Coinsurance | Out-of-Network Deductible & Coinsurance |
| Diagnostic Testing (EKG, Lab, etc.) | Physician's Office - Primary Care | Primary Care Copay for office visit - testing covered 100% | Out-of-Network Deductible & Coinsurance |
| Diagnostic Testing | Outpatient Hospital | In-Network Deductible & Coinsurance | Out-of-Network Deductible & Coinsurance |
