Blue Home Gold Standard | with UNC Health Alliance - 11512NC0390004 Health Insurance Plan
Blue Cross and Blue Shield of NC health insurance plan with the Plan ID 11512NC0390004. The plan is called Blue Home Gold Standard | with UNC Health Alliance.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.06% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.94% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 11512NC0390004 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | North Carolina | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross and Blue Shield of NC | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 11512NC0390004-00 | ||||||||||||||||||
| Provider Network(s) | ['NCN013'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Sep 2025 15:17 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 11512NC0390004-00 Standard On Exchange Plan - 11512NC0390004-01 |
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| Last Plan Update Date | Sat, 02 Nov 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 16 Sep 2025 15:17 GMT |
Benefits of Blue Home Gold Standard | with UNC Health Alliance Health Insurance Plan, 11512NC0390004-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: nan nan |
NO | ||
| Accidental Dental
Exclusions: nan For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Acupuncture
Exclusions: nan nan |
NO | ||
| Allergy Testing
Exclusions: nan For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | $60.00 |
100.00% |
| Bariatric Surgery
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Child
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chemotherapy
Exclusions: nan For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 30.0 Visit(s) per Benefit Period Exclusions: nan Combined 30 visit limit for occupational and physical therapies and chiropractic services. For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | $30.00 |
100.00% |
| Cosmetic Surgery
Exclusions: nan nan |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Limit: 2.0 Exam(s) per Benefit Period Exclusions: nan nan |
YES | $0.00 |
100.00% |
| Diabetes Education
Exclusions: nan For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | $30.00 |
100.00% |
| Dialysis
Limit: 3.0 Treatment(s) per Week Exclusions: nan Three treatments per week, more treatments are available if medically necessary. For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
Exclusions: nan Orthotic devices for correction of positional plagiocephaly are limited to 1 device per lifetime. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period Exclusions: nan nan |
YES | 50.00% |
100.00% |
| Gender Affirming Care
Exclusions: nan For services rendered in an office setting, please refer to the Primary Care visit or the Specialist visit benefit. For services rendered in an inpatient hospital setting, please refer to the Inpatient Hospital and Physician services benefit. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
Exclusions: nan Quantity limits may apply. See formulary. |
YES | $15.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period Exclusions: nan Combined 30 visit limit for occupational and physical therapies and chiropractic services. For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | $30.00 |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years Exclusions: nan One hearing aid per hearing impaired ear, and replacement hearing aids based on medical necessity. Once every 36 months. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Exclusions: nan Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
Limit: 3.0 Treatment(s) per Lifetime Exclusions: nan Infertility Services- Benefits are provided for certain services related to the diagnosis, treatment, and correction of any underlying causes of infertility for all members. Benefits are limited to three medical ovulation induction cycles per lifetime per member. Prescription Drug Benefits- Certain prescription drugs related to treatment of infertility. Infertility drugs are limited to benefit lifetime maximums per member. The lifetime maximums are described in Blue Cross NC medical policies, which are guides considered by Blue Cross NC when making coverage determinations. For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | $60.00 |
100.00% |
| Infusion Therapy
Exclusions: nan For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
Exclusions: nan nan |
NO | ||
| Major Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Major Dental Care - Child
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Inpatient Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Exclusions: nan Virtual/telehealth visits with certain providers may be covered at no cost. |
YES | $30.00 |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: nan Quantity limits may apply. See formulary. |
YES | $60.00 |
100.00% |
| Nutritional Counseling
Limit: 30.0 Visit(s) per Benefit Period Exclusions: nan Nutritional counseling visits are separate from the obesity-related office visits. |
YES | 0.00% |
100.00% |
| Orthodontia - Adult
Exclusions: nan nan |
NO | ||
| Orthodontia - Child
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: nan nan |
YES | $60.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Benefit Period Exclusions: Cognitive therapy Combined 30 visit limit for occupational and physical therapies and chiropractic services. For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Exclusions: nan Quantity limits may apply. See formulary. |
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
Exclusions: nan Typically covered as part of global maternity fee. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: nan nan |
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: nan Virtual/telehealth visits with certain providers may be covered at no cost. |
YES | $30.00 |
100.00% |
| Private-Duty Nursing
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
Exclusions: nan See Durable Medical Equipment |
NO | ||
| Radiation
Exclusions: nan For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Benefit Period Exclusions: Cognitive therapy Combined 30 visit limit for occupational and physical therapies and chiropractic services. For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | $30.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Benefit Period Exclusions: nan For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | $30.00 |
100.00% |
| Routine Dental Services (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Benefit Period Exclusions: nan nan |
YES | $0.00 |
100.00% |
| Routine Foot Care
Exclusions: Routine foot care that is palliative or cosmetic. Routine Foot Care services are covered only in presence of a medical condition. For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | $60.00 |
100.00% |
| Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
Exclusions: nan nan |
YES | $60.00 |
100.00% |
| Specialty Drugs
Exclusions: nan Quantity limits may apply. See formulary. |
YES | $250.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Exclusions: nan Virtual/telehealth visits with certain providers may be covered at no cost. |
YES | $30.00 |
100.00% |
| Tier 2 Rx
Exclusions: nan Five tier levels apply to prescription drug coverage. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits may apply. See formulary. |
YES | ||
| Transplant
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: nan For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | $60.00 |
100.00% |
| Urgent Care Centers or Facilities
Exclusions: nan nan |
YES | $45.00 |
$45.00 |
| Weight Loss Programs
Exclusions: nan nan |
NO | ||
| Well Baby Visits and Care
Exclusions: nan nan |
YES | 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
Exclusions: nan For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | 25.00% Coinsurance after deductible |
100.00% |
Blue Home Gold Standard | with UNC Health Alliance Health Insurance Plan Variant 11512NC0390004-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.780612576352931 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| Disease Management Programs Offered | Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | NCF046 |
| Formulary URL | URL |
| HIOS Product ID | 11512NC039 |
| Import Date | 2024-11-02 01:02:12 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 11512 |
| Issuer Marketplace Marketing Name | Blue Cross and Blue Shield of NC |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | NCN013 |
| Out of Country Coverage | No |
| Out of Country Coverage Description | No coverage except for Urgent and Emergent care |
| Out of Service Area Coverage | No |
| Out of Service Area Coverage Description | No coverage except for Urgent and Emergent care |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 11512NC0390004-00 |
| Plan Marketing Name | Blue Home Gold Standard | with UNC Health Alliance |
| Plan Type | EPO |
| Plan Variant Marketing Name | Blue Home Gold Standard | with UNC Health Alliance |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,800 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $900 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NCS065 |
| Source Name | HIOS |
| Plan ID | 11512NC0390004 |
| State Code | NC |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $15600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,800 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Blue Home Gold Standard | with UNC Health Alliance Health Insurance Plan, 11512NC0390004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Blue Home Gold Standard | with UNC Health Alliance, 11512NC0390004 Health Insurance Plan, 11512NC0390004
-
Does Blue Home Gold Standard | with UNC Health Alliance Health Insurance Plan, 11512NC0390004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (11512NC0390004) Health Insurance Plan, Variant (11512NC0390004-00) offer Disease Management Programs?
Does (11512NC0390004) Health Insurance Plan, Variant (11512NC0390004-00) have Out Of Country Coverage?
Does (11512NC0390004) Health Insurance Plan, Variant (11512NC0390004-00) have Out of Service Area Coverage?
Does (11512NC0390004) Health Insurance Plan, Variant (11512NC0390004-00) offer Disease Management Programs?
Does Blue Home Gold Standard | with UNC Health Alliance Health Insurance Plan, Variant (11512NC0390004-00) offer Disease Management Programs for Asthma?
Does Blue Home Gold Standard | with UNC Health Alliance Health Insurance Plan, Variant (11512NC0390004-00) offer Disease Management Programs for Heart disease?
Does Blue Home Gold Standard | with UNC Health Alliance Health Insurance Plan, Variant (11512NC0390004-00) offer Disease Management Programs for Depression?
Does Blue Home Gold Standard | with UNC Health Alliance Health Insurance Plan, Variant (11512NC0390004-00) offer Disease Management Programs for Diabetes?
Does Blue Home Gold Standard | with UNC Health Alliance Health Insurance Plan, Variant (11512NC0390004-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Blue Home Gold Standard | with UNC Health Alliance Health Insurance Plan, Variant (11512NC0390004-00) offer Disease Management Programs for Pregnancy?
Does Blue Home Gold Standard | with UNC Health Alliance Health Insurance Plan, Variant (11512NC0390004-00) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 16 Sep 2025 15:17 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API