Blue Local Silver Choice | 3 Free PCP | $15 Tier 1 Rx | with Atrium Health - 11512NC0410037 Health Insurance Plan

Blue Cross and Blue Shield of NC health insurance plan with the Plan ID 11512NC0410037. The plan is called Blue Local Silver Choice | 3 Free PCP | $15 Tier 1 Rx | with Atrium Health.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 94.01% (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 5.99% 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 11512NC0410037
Health Insurance Plan Year 2024
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 11512NC0410037-06
Provider Network(s) ['NCN015']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT).

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
Available Variants of the Health Plan

Standard Off Exchange Plan - 11512NC0410037-00

Standard On Exchange Plan - 11512NC0410037-01

Open to Indians below 300% FPL - 11512NC0410037-02

Open to Indians above 300% FPL - 11512NC0410037-03

73% AV Silver Plan - 11512NC0410037-04

87% AV Silver Plan - 11512NC0410037-05

94% AV Silver Plan - 11512NC0410037-06

Last Plan Update Date Fri, 27 Oct 2023 00:00 GMT
Last Import Date Tue, 03 Dec 2024 06:24 GMT

Benefits of Blue Local Silver Choice | 3 Free PCP | $15 Tier 1 Rx | with Atrium Health Health Insurance Plan, 11512NC0410037-06

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental

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

YES

40.00%

100.00%
Acupuncture
NO
Allergy Testing

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

YES

$25.00

100.00%
Bariatric Surgery
YES

40.00%

100.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child
YES

40.00%

100.00%
Chemotherapy

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

YES

40.00%

100.00%
Chiropractic Care

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.

YES

$25.00

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

40.00%

100.00%
Dental Check-Up for Children

Limit: 2.0 Exam(s) per Benefit Period

YES

No Charge

100.00%
Diabetes Education

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

YES

$4.00

100.00%
Dialysis

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.

YES

40.00%

100.00%
Durable Medical Equipment

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

YES

40.00%

100.00%
Emergency Room Services
YES

40.00%

40.00%
Emergency Transportation/Ambulance
YES

40.00%

40.00%
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

YES

50.00%

100.00%
Gender Affirming Care

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

40.00%

100.00%
Generic Drugs

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

$4.00

100.00%
Habilitation Services

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.

YES

$25.00

100.00%
Hearing Aids

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.

YES

40.00%

100.00%
Home Health Care Services
YES

40.00%

100.00%
Hospice Services

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

YES

40.00%

100.00%
Imaging (CT/PET Scans, MRIs)
YES

40.00%

100.00%
Infertility Treatment

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.

YES

$25.00

100.00%
Infusion Therapy

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

YES

40.00%

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

40.00%

100.00%
Inpatient Physician and Surgical Services
YES

40.00%

100.00%
Laboratory Outpatient and Professional Services
YES

40.00%

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
YES

40.00%

100.00%
Mental/Behavioral Health Inpatient Services
YES

40.00%

100.00%
Mental/Behavioral Health Outpatient Services
YES

$4.00

100.00%
Non-Preferred Brand Drugs

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

$80.00

100.00%
Nutritional Counseling

Limit: 30.0 Visit(s) per Benefit Period

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

YES

No Charge

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
YES

40.00%

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$25.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

40.00%

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

40.00%

100.00%
Outpatient Surgery Physician/Surgical Services
YES

40.00%

100.00%
Preferred Brand Drugs

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

$20.00

100.00%
Prenatal and Postnatal Care

Typically covered as part of global maternity fee.

YES

40.00%

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

$4.00

100.00%
Private-Duty Nursing
YES

40.00%

100.00%
Prosthetic Devices

See Durable Medical Equipment

NO
Radiation

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

YES

40.00%

100.00%
Reconstructive Surgery
YES

40.00%

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

$25.00

100.00%
Rehabilitative Speech Therapy

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.

YES

$25.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Benefit Period

YES

No Charge

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

$25.00

100.00%
Skilled Nursing Facility

Limit: 60.0 Days per Benefit Period

YES

40.00%

100.00%
Specialist Visit
YES

$25.00

100.00%
Specialty Drugs

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

50.00%

100.00%
Substance Abuse Disorder Inpatient Services
YES

40.00%

100.00%
Substance Abuse Disorder Outpatient Services
YES

$4.00

100.00%
Tier 2 Rx

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

$15.00

100.00%
Transplant
YES

40.00%

100.00%
Treatment for Temporomandibular Joint Disorders

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

YES

$25.00

100.00%
Urgent Care Centers or Facilities
YES

$25.00

$25.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging

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

YES

40.00%

100.00%

Blue Local Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | with Atrium Health (CSR 94%) Health Insurance Plan Variant 11512NC0410037-06 Attributes

Plan Attribute Value
AV Calculator Output Number 0.94006487287859
Begin Primary Care Cost-Sharing After Number Of Visits 3
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2024
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type 94% AV Level Silver Plan
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), Default Coinsurance 40.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group per group not applicable
Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Drug EHB Deductible, In Network (Tier 1), Individual $0
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, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID NCF016
Formulary URL URL
HIOS Product ID 11512NC041
Import Date 2023-10-27 01:01:58
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan New
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 No
Medical Drug Maximum Out of Pocket Integrated Yes
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), Default Coinsurance 40.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Medical EHB Deductible, In Network (Tier 1), Individual $0
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
Metal Level Silver
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
Plan Brochure URL
Plan Effective Date 2024-01-01
Plan Expiration Date 2024-12-31
Plan ID (Standard Component ID with Variant) 11512NC0410037-06
Plan Marketing Name Blue Local Silver Choice | 3 Free PCP | $15 Tier 1 Rx | with Atrium Health
Plan Type EPO
Plan Variant Marketing Name Blue Local Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | with Atrium Health (CSR 94%)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,000
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $400
SBC Scenario, Having Diabetes, Copayment $400
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $800
SBC Scenario, Treatment of a Simple Fracture, Copayment $200
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID NCS076
Source Name HIOS
Plan ID 11512NC0410037
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
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $2050 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $1025 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $1,025
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 Local Silver Choice | 3 Free PCP | $15 Tier 1 Rx | with Atrium Health Health Insurance Plan, 11512NC0410037

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Blue Local Silver Choice | 3 Free PCP | $15 Tier 1 Rx | with Atrium Health, 11512NC0410037 Health Insurance Plan, 11512NC0410037

  • Does Blue Local Silver Choice | 3 Free PCP | $15 Tier 1 Rx | with Atrium Health Health Insurance Plan, 11512NC0410037 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (11512NC0410037) Health Insurance Plan, Variant (11512NC0410037-06) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs

    Does (11512NC0410037) Health Insurance Plan, Variant (11512NC0410037-06) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan). Details: No coverage except for Urgent and Emergent care

    Does (11512NC0410037) Health Insurance Plan, Variant (11512NC0410037-06) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan). Details: No coverage except for Urgent and Emergent care

    Does (11512NC0410037) Health Insurance Plan, Variant (11512NC0410037-06) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs

    Does Blue Local Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | with Atrium Health (CSR 94%) Health Insurance Plan, Variant (11512NC0410037-06) offer Disease Management Programs for Asthma?

    Yes, the Blue Local Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | with Atrium Health (CSR 94%) Health Insurance Plan Variant 11512NC0410037-06 offers Disease Management Program for Asthma.

    Does Blue Local Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | with Atrium Health (CSR 94%) Health Insurance Plan, Variant (11512NC0410037-06) offer Disease Management Programs for Heart disease?

    Yes, the Blue Local Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | with Atrium Health (CSR 94%) Health Insurance Plan Variant 11512NC0410037-06 offers Disease Management Program for Heart disease.

    Does Blue Local Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | with Atrium Health (CSR 94%) Health Insurance Plan, Variant (11512NC0410037-06) offer Disease Management Programs for Diabetes?

    Yes, the Blue Local Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | with Atrium Health (CSR 94%) Health Insurance Plan Variant 11512NC0410037-06 offers Disease Management Program for Diabetes.

    Does Blue Local Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | with Atrium Health (CSR 94%) Health Insurance Plan, Variant (11512NC0410037-06) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Blue Local Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | with Atrium Health (CSR 94%) Health Insurance Plan Variant 11512NC0410037-06 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Blue Local Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | with Atrium Health (CSR 94%) Health Insurance Plan, Variant (11512NC0410037-06) offer Disease Management Programs for Pregnancy?

    Yes, the Blue Local Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | with Atrium Health (CSR 94%) Health Insurance Plan Variant 11512NC0410037-06 offers Disease Management Program for Pregnancy.

    Does Blue Local Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | with Atrium Health (CSR 94%) Health Insurance Plan, Variant (11512NC0410037-06) offer Disease Management Programs for Weight loss programs?

    Yes, the Blue Local Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | with Atrium Health (CSR 94%) Health Insurance Plan Variant 11512NC0410037-06 offers Disease Management Program for Weight loss programs.

 

Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 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