North Carolina health plan · 2026

Blue Local Gold Premier A | 3 Free PCP | $10 Tier 1 Rx | with Atrium Health · 11512NC0410016

Blue Cross Blue Shield of North Carolina offers this marketplace health insurance plan (Plan ID 11512NC0410016) so you can compare premiums, coverage levels, and provider access against other health plan insurance options. Use the modules below to decide whether this is the best health insurance plan for your household or if another insurance health plan fits better.

Metal level: Gold Plan type: EPO CSR: Standard Gold Off Exchange Plan Issuer: Blue Cross Blue Shield of North Carolina
Telehealth Data pending HSA eligible No Dental Child Vision Child
Pay / Manage Plan View issuer site

CMS AV Calculator output: 78.01% (21.99% member share on average). Learn about AV methodology.

2026 cost summary

Key premiums & cost sharing

Rates mirror the latest CMS import (Tue, 02 Dec 2025 06:13 GMT). Personalize costs with your ZIP, age, and subsidies in the plan finder.

Monthly premium

$394 – $1545

Before subsidies

Estimate after subsidies

Deductible

N/A

N/A

See deductible details

Max out-of-pocket

$10,600

$21200 per group

Review MOOP rules

Office visits

Primary care $15.00
Specialist $40.00
HSA Not eligible

Drug tiers

Generic $10.00
Preferred brand $35.00 Copay after deductible

View formulary tiers

$540 / mo before subsidies

≈ $6477 per year before tax credits.

Start with this unsubsidized premium, then apply marketplace tax credits to see your final monthly payment.

  • Ideal for shoppers comparing Bronze vs. Silver budgets.
  • Update your Marketplace application to apply premium tax credits.

$1710 / mo before subsidies

≈ $20526 per year before tax credits.

Pre-subsidy rate for a couple with one dependent. Switch to Silver CSR plans if you qualify to reduce these numbers.

  • Compares well against PPO vs HMO networks when planning for childcare and telehealth needs.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$2072 / mo before subsidies

≈ $24858 per year before tax credits.

Pairs with cost-sharing reductions (CSR) when you select a Silver tier and qualify based on income.

  • Use this estimate before adding childcare, dental, or vision extras.
  • CSR Silver variants can lower deductibles dramatically for eligible incomes.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$1316 / mo before subsidies

≈ $15798 per year before tax credits.

Shows the combined pre-subsidy rate for two adults. Add dependents or subsidies in your application to refine it.

  • Great for households deciding between PPO and HMO networks.
  • Telehealth and HSA perks (when offered) apply to both members.
Issuer profile See benefits

Preventive Care/Screening/Immunization

No Charge

Emergency Room Services

30.00% Coinsurance after deductible

Durable Medical Equipment

30.00% Coinsurance after deductible

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Enrollment guidance

Stay on top of 2026 ACA deadlines

Open Enrollment window

Marketplace enrollment for 2026 coverage typically runs Nov 1 – Jan 15 (dates may vary slightly in North Carolina). Submit changes before the deadline to avoid a coverage gap.

  • Enroll by Dec 15 for Jan 1 starts.
  • Finalize plan switches before the window closes.

Special Enrollment Periods

You can change plans mid-year if you experience a qualifying life event (move, childbirth, marriage, loss of other coverage).

  • Report the event within 60 days.
  • Keep documentation handy for Healthcare.gov or your state exchange.

CSR & subsidy reminders

Premium tax credits and cost-sharing reductions (CSR) update annually when you re-submit your marketplace application.

  • Enter accurate income to maximize Advanced Premium Tax Credits.
  • Standard Gold Off Exchange Plan plans like this one keep deductibles and copays lower if you qualify.

Thinking about switching?

Before you leave your current plan, compare networks, drug coverage, and total cost using the cards on this page.

  • Match provider networks so ongoing care isn’t disrupted.
  • Confirm prescriptions stay on-formulary or budget for tier changes.

Top covered benefits

How this plan handles key care scenarios

Preventive Care/Screening/Immunization

No Charge

Emergency Room Services

30.00% Coinsurance after deductible

Durable Medical Equipment

30.00% Coinsurance after deductible

Premium snapshot

Plan identifiers & filings

Track the official identifiers, documents, and filing dates tied to this plan. Open the marketing or formulary links whenever you need the latest PDF from the issuer.

Plan ID 11512NC0410016
Coverage year 2026
State North Carolina
Issuer Blue Cross Blue Shield of North Carolina
Formulary document Download formulary
Marketing materials View marketing kit
Variant ID 11512NC0410016-00
Available variants

Standard Off Exchange Plan · 11512NC0410016-00

Standard On Exchange Plan · 11512NC0410016-01

Open to Indians below 300% FPL · 11512NC0410016-02

Open to Indians above 300% FPL · 11512NC0410016-03
Last plan update Wed, 15 Oct 2025 00:00 GMT
Last HealthPorta import Tue, 02 Dec 2025 06:13 GMT

Network stats

Provider access snapshot

Review the network branding plus the number of in-network clinicians we track from issuer filings. Counts update with each CMS import (Tue, 02 Dec 2025 06:13 GMT).

All providers in North Carolina N/A
PCPs in North Carolina N/A
Telehealth support Data pending
Nationwide providers N/A
N/A doctors statewide N/A PCPs N/A OB/GYN

Provider network(s)

['NCN015']

Providers North Carolina All US states
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A

Drug coverage overview

0 drugs tracked

Inspect tier distribution plus authorization, step therapy, and quantity-limit counts sourced from HealthPorta’s formulary import.

Prior authorization Drugs
Required 0
Not Required 0
Step therapy Drugs
Required 0
Not Required 0
Quantity limits Drugs
Has Limit 0
No Limit 0

Customer highlights

What stands out for members

  • Issuer: Blue Cross Blue Shield of North Carolina · Plan ID 11512NC0410016 · 2026 filing.
  • Disease management programs available: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs.
  • Download the latest formulary directly from the issuer here.
  • Review marketing brochures and SBC PDFs via the issuer marketing repository.
  • Variant 11512NC0410016-00 (Standard Off Exchange Plan) currently displayed.
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Benefits

Covered services & limitations

Everyday care

Office visits, preventive care, labs, imaging, and home health.

Chiropractic Care

$40.00
Tier 1 in-network $40.00
Out-of-network 100.00%

Limit: 30.0 Visit(s) per Benefit Period

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.

Diabetes Education

$15.00
Tier 1 in-network $15.00
Out-of-network 100.00%

For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit.

Home Health Care Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Laboratory Outpatient and Professional Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Other Practitioner Office Visit (Nurse, Physician Assistant)

$40.00
Tier 1 in-network $40.00
Out-of-network 100.00%

Preventive Care/Screening/Immunization

No Charge
Tier 1 in-network No Charge
Out-of-network 100.00%

Primary Care Visit to Treat an Injury or Illness

$15.00
Tier 1 in-network $15.00
Out-of-network 100.00%

$0 for first 3 visits. Virtual/telehealth visits with certain providers may be covered at no cost. For additional information, visit https://www.bluecrossnc.com/booklets

Rehabilitative Occupational and Rehabilitative Physical Therapy

$40.00
Tier 1 in-network $40.00
Out-of-network 100.00%

Limit: 30.0 Visit(s) per Benefit Period

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.

Exclusions: Cognitive therapy

Rehabilitative Speech Therapy

$40.00
Tier 1 in-network $40.00
Out-of-network 100.00%

Limit: 30.0 Visit(s) per Benefit Period

For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit.

Specialist Visit

$40.00
Tier 1 in-network $40.00
Out-of-network 100.00%

Urgent Care Centers or Facilities

$40.00
Tier 1 in-network $40.00
Out-of-network $40.00

X-rays and Diagnostic Imaging

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit.

Hospital & urgent

Emergency room, inpatient stays, ambulance, and surgeries.

Chemotherapy

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit.

Delivery and All Inpatient Services for Maternity Care

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Dialysis

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 3.0 Treatment(s) per Week

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.

Durable Medical Equipment

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Orthotic devices for correction of positional plagiocephaly are limited to 1 device per lifetime.

Emergency Room Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 30.00% Coinsurance after deductible

Emergency Transportation/Ambulance

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 30.00% Coinsurance after deductible

Hospice Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less.

Inpatient Hospital Services (e.g., Hospital Stay)

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Inpatient Physician and Surgical Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Mental/Behavioral Health Inpatient Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Mental/Behavioral Health Outpatient Services

$15.00
Tier 1 in-network $15.00
Out-of-network 100.00%

This cost-share is for the office visit setting. $0 for first 3 office visits. For outpatient services, the plan's deductible, then coinsurance applies. Virtual/telehealth visits with certain providers may be covered at no cost. For additional information, visit https://www.bluecrossnc.com/booklets

Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Outpatient Rehabilitation Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 30.0 Visit(s) per Benefit Period

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.

Exclusions: Cognitive therapy

Outpatient Surgery Physician/Surgical Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Radiation

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit.

Skilled Nursing Facility

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 60.0 Days per Benefit Period

Substance Abuse Disorder Inpatient Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Substance Abuse Disorder Outpatient Services

$15.00
Tier 1 in-network $15.00
Out-of-network 100.00%

This cost-share is for the office visit setting - $0 for first 3 office visits. For outpatient services, the plan's deductible, then coinsurance applies. Virtual/telehealth visits with certain providers may be covered at no cost. For additional information, visit https://www.bluecrossnc.com/booklets

Transplant

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Hearing Aids

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 1.0 Item(s) per 3 Years

One hearing aid per hearing impaired ear, and replacement hearing aids based on medical necessity. Once every 36 months.

Major Dental Care - Child

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Prenatal and Postnatal Care

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Typically covered as part of global maternity fee.

Routine Eye Exam for Children

No Charge
Tier 1 in-network No Charge
Out-of-network 100.00%

Limit: 1.0 Exam(s) per Benefit Period

Well Baby Visits and Care

No Charge
Tier 1 in-network No Charge
Out-of-network 100.00%

Pharmacy & drugs

Generic, brand, specialty, and mail order tiers.

Generic Drugs

$10.00
Tier 1 in-network $10.00
Out-of-network 100.00%

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.

Non-Preferred Brand Drugs

$75.00 Copay after deductible
Tier 1 in-network $75.00 Copay after deductible
Out-of-network 100.00%

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.

Preferred Brand Drugs

$35.00 Copay after deductible
Tier 1 in-network $35.00 Copay after deductible
Out-of-network 100.00%

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.

Specialty Drugs

50.00% Coinsurance after deductible
Tier 1 in-network 50.00% Coinsurance after deductible
Out-of-network 100.00%

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.

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit.

Basic Dental Care - Adult

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Dental Check-Up for Children

No Charge
Tier 1 in-network No Charge
Out-of-network 100.00%

Limit: 2.0 Exam(s) per Benefit Period

Infusion Therapy

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit.

Major Dental Care - Adult

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Nutritional Counseling

No Charge
Tier 1 in-network No Charge
Out-of-network 100.00%

Limit: 30.0 Visit(s) per Benefit Period

Nutritional counseling visits are separate from the obesity-related office visits.

Orthodontia - Adult

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Orthodontia - Child

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Prosthetic Devices

Coverage details pending

See Durable Medical Equipment

Routine Dental Services (Adult)

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Weight Loss Programs

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Additional benefits

Other plan-specific services and limitations.

Abortion for Which Public Funding is Prohibited

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Acupuncture

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Allergy Testing

$40.00
Tier 1 in-network $40.00
Out-of-network 100.00%

For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit.

Bariatric Surgery

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Cosmetic Surgery

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Eye Glasses for Children

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

Limit: 1.0 Item(s) per Benefit Period

Habilitation Services

$40.00
Tier 1 in-network $40.00
Out-of-network 100.00%

Limit: 30.0 Visit(s) per Benefit Period

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.

Imaging (CT/PET Scans, MRIs)

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Infertility Treatment

$40.00
Tier 1 in-network $40.00
Out-of-network 100.00%

Limit: 3.0 Treatment(s) per Lifetime

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.

Long-Term/Custodial Nursing Home Care

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Private-Duty Nursing

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Reconstructive Surgery

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Routine Eye Exam (Adult)

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Routine Foot Care

$40.00
Tier 1 in-network $40.00
Out-of-network 100.00%

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.

Exclusions: Routine foot care that is palliative or cosmetic.

Sex-Trait Modification

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

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.

Tier 2 Rx

$25.00 Copay after deductible
Tier 1 in-network $25.00 Copay after deductible
Out-of-network 100.00%

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.

Treatment for Temporomandibular Joint Disorders

$40.00
Tier 1 in-network $40.00
Out-of-network 100.00%

For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit.

Variant attributes

Blue Local Gold Premier A | 3 Free PCP | $10 Tier 1 Rx | with Atrium Health · Variant 11512NC0410016-00

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2026

CSR Variation Type

Standard Gold Off Exchange Plan

HIOS Product ID

11512NC041

Metal Level

Gold

Plan ID (Standard Component ID with Variant)

11512NC0410016-00

Plan Marketing Name

Blue Local Gold Premier A | 3 Free PCP | $10 Tier 1 Rx | with Atrium Health

Plan Variant Marketing Name

Blue Local Gold Premier A | 3 Free PCP | $10 Tier 1 Rx | with Atrium Health

Issuer & service area

Issuer-provided metadata for this variant.

Issuer ID

11512

Issuer Marketplace Marketing Name

Blue Cross and Blue Shield of NC

Market Coverage

Individual

Multiple In Network Tiers

No

National Network

No

Network ID

NCN015

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

Service Area ID

NCS076

State Code

NC

URL for Summary of Benefits & Coverage

Open link

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

AV Calculator Output Number

0.780077487

Begin Primary Care Deductible Coinsurance After Number Of Copays

0

Drug EHB Deductible, In Network (Tier 1), Default Coinsurance

30.00%

Inpatient Copayment Maximum Days

0

Medical Drug Deductibles Integrated

No

Medical Drug Maximum Out of Pocket Integrated

Yes

Medical EHB Deductible, In Network (Tier 1), Default Coinsurance

30.00%

SBC Scenario, Having a Baby, Coinsurance

$3,200

SBC Scenario, Having a Baby, Copayment

$10

SBC Scenario, Having a Baby, Deductible

$1,800

SBC Scenario, Having Diabetes, Coinsurance

$0

SBC Scenario, Having Diabetes, Copayment

$1,000

SBC Scenario, Having Diabetes, Deductible

$500

SBC Scenario, Treatment of a Simple Fracture, Coinsurance

$100

SBC Scenario, Treatment of a Simple Fracture, Copayment

$200

SBC Scenario, Treatment of a Simple Fracture, Deductible

$1,800

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

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group

$21200 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person

$10600 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual

$10,600

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

Enrollment & documents

Issuer-provided metadata for this variant.

Formulary ID

NCF008

Formulary URL

Open link

Plan Brochure

Open link

SBC Scenario, Having a Baby, Limit

$60

SBC Scenario, Having Diabetes, Limit

$20

SBC Scenario, Treatment of a Simple Fracture, Limit

$0

URL for Enrollment Payment

Open link

Additional attributes

Issuer-provided metadata for this variant.

Begin Primary Care Cost-Sharing After Number Of Visits

3

Child-Only Offering

Allows Adult and Child-Only

Composite Rating Offered

No

Drug EHB Deductible, Combined In/Out of Network, Family Per Group

per group not applicable

Drug EHB Deductible, Combined In/Out of Network, Family Per Person

per person not applicable

Drug EHB Deductible, Combined In/Out of Network, Individual

Not Applicable

Drug EHB Deductible, In Network (Tier 1), Family Per Group

per group not applicable

Drug EHB Deductible, In Network (Tier 1), Family Per Person

$400 per person

Drug EHB Deductible, In Network (Tier 1), Individual

$400

Drug EHB Deductible, Out of Network, Family Per Group

per group not applicable

Drug EHB Deductible, Out of Network, Family Per Person

per person not applicable

Drug EHB Deductible, Out of Network, Individual

Not Applicable

Dental Only Plan

No

Design Type

Not Applicable

Disease Management Programs Offered

Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs

EHB Percent of Total Premium

0.998

First Tier Utilization

100%

Import Date

10/15/2025

Limited Cost Sharing Plan Variation - Estimated Advanced Payment

$0.00

HSA Eligible

No

New/Existing Plan

Existing

Notice Required for Pregnancy

No

Is a Referral Required for Specialist?

No

Medical EHB Deductible, Combined In/Out of Network, Family Per Group

per group not applicable

Medical EHB Deductible, Combined In/Out of Network, Family Per Person

per person not applicable

Medical EHB Deductible, Combined In/Out of Network, Individual

Not Applicable

Medical EHB Deductible, In Network (Tier 1), Family Per Group

$3600 per group

Medical EHB Deductible, In Network (Tier 1), Family Per Person

$1800 per person

Medical EHB Deductible, In Network (Tier 1), Individual

$1,800

Medical EHB Deductible, Out of Network, Family Per Group

per group not applicable

Medical EHB Deductible, Out of Network, Family Per Person

per person not applicable

Medical EHB Deductible, Out of Network, Individual

Not Applicable

Plan Effective Date

1/1/2026

Plan Expiration Date

12/31/2026

Plan Type

EPO

QHP/Non QHP

Both

Source Name

HIOS

Plan ID

11512NC0410016

Unique Plan Design

No

Wellness Program Offered

Yes

Copay & coinsurance

Pharmacy cost sharing by tier

Drug tier Pharmacy type Copay amount Copay option Coinsurance rate Coinsurance option Mail order

Questions & answers

Frequently asked questions

How do I choose the right ACA plan in North Carolina?

Blue Local Gold Premier A | 3 Free PCP | $10 Tier 1 Rx | with Atrium Health (11512NC0410016) is a Gold EPO from Blue Cross Blue Shield of North Carolina in North Carolina for the 2026 coverage year.

Compare it against other options with the HealthPorta plan finder to confirm premiums, deductibles, and network access fit your household.

Does Blue Local Gold Premier A | 3 Free PCP | $10 Tier 1 Rx | with Atrium Health support telehealth or virtual urgent care?

The issuer has not published telehealth details yet. Review the Summary of Benefits and Coverage to confirm if virtual visits are included.

Is Blue Local Gold Premier A | 3 Free PCP | $10 Tier 1 Rx | with Atrium Health HSA-eligible and does it include dental or vision coverage?

It is not marked as HSA-eligible, so confirm with the issuer before relying on tax-advantaged savings.

Dental add-ons: Child.

Vision add-ons: Child.

Does Blue Local Gold Premier A | 3 Free PCP | $10 Tier 1 Rx | with Atrium Health support mail-order prescriptions?

Mail order coverage is not listed for this plan, so confirm with the issuer before relying on home delivery.

Which disease management programs come with Blue Local Gold Premier A | 3 Free PCP | $10 Tier 1 Rx | with Atrium Health?

The issuer lists disease management resources for: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs.

Is there out-of-country coverage for Blue Local Gold Premier A | 3 Free PCP | $10 Tier 1 Rx | with Atrium Health?

No, out-of-country services are not covered for this plan. Details: No coverage except for Urgent and Emergent care

Does Blue Local Gold Premier A | 3 Free PCP | $10 Tier 1 Rx | with Atrium Health cover care outside the service area?

No, the issuer indicates out-of-service-area care is not covered except for emergencies. Details: No coverage except for Urgent and Emergent care

Disclaimer: Based on the Tue, 02 Dec 2025 06:13 GMT HealthPorta import from CMS issuer filings. Data is best-effort and should be validated with the issuer directly. Sources: CMS.gov and the HealthPorta Healthcare MRF API.
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