Blue Value Gold Premier | 3 Free PCP | $10 Tier 1 Rx | Limited Statewide Doctors - 11512NC0100034 Health Insurance Plan

Blue Cross and Blue Shield of NC health insurance plan with the Plan ID 11512NC0100034. The plan is called Blue Value Gold Premier | 3 Free PCP | $10 Tier 1 Rx | Limited Statewide Doctors.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 11512NC0100034
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 11512NC0100034-02
Provider Network(s) ['NCN002']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 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 - 11512NC0100034-00

Standard On Exchange Plan - 11512NC0100034-01

Open to Indians below 300% FPL - 11512NC0100034-02

Open to Indians above 300% FPL - 11512NC0100034-03

Last Plan Update Date Sat, 02 Nov 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of Blue Value Gold Premier | 3 Free PCP | $10 Tier 1 Rx | Limited Statewide Doctors Health Insurance Plan, 11512NC0100034-02

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

No Charge

No Charge
Acupuncture
NO
Allergy Testing

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

YES

No Charge

No Charge
Bariatric Surgery
YES

No Charge

No Charge
Basic Dental Care - Adult
NO
Basic Dental Care - Child
YES

No Charge

No Charge
Chemotherapy

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

YES

No Charge

No Charge
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

No Charge

No Charge
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

No Charge

No Charge
Dental Check-Up for Children

Limit: 2.0 Exam(s) per Benefit Period

YES

No Charge

No Charge
Diabetes Education

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

YES

No Charge

No Charge
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

No Charge

No Charge
Durable Medical Equipment

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

YES

No Charge

No Charge
Emergency Room Services
YES

No Charge

No Charge
Emergency Transportation/Ambulance
YES

No Charge

No Charge
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

YES

No Charge

No Charge
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

No Charge

No Charge
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

No Charge

No Charge
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

No Charge

No Charge
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

No Charge

No Charge
Home Health Care Services
YES

No Charge

No Charge
Hospice Services

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

YES

No Charge

No Charge
Imaging (CT/PET Scans, MRIs)
YES

No Charge

No Charge
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

No Charge

No Charge
Infusion Therapy

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

YES

No Charge

No Charge
Inpatient Hospital Services (e.g., Hospital Stay)
YES

No Charge

No Charge
Inpatient Physician and Surgical Services
YES

No Charge

No Charge
Laboratory Outpatient and Professional Services
YES

No Charge

No Charge
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
YES

No Charge

No Charge
Mental/Behavioral Health Inpatient Services
YES

No Charge

No Charge
Mental/Behavioral Health Outpatient Services

Virtual/telehealth visits with certain providers may be covered at no cost.

YES

No Charge

No Charge
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

No Charge

No Charge
Nutritional Counseling

Limit: 30.0 Visit(s) per Benefit Period

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

YES

No Charge

No Charge
Orthodontia - Adult
NO
Orthodontia - Child
YES

No Charge

No Charge
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

No Charge

No Charge
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

No Charge

No Charge
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

No Charge

No Charge
Outpatient Surgery Physician/Surgical Services
YES

No Charge

No Charge
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

No Charge

No Charge
Prenatal and Postnatal Care

Typically covered as part of global maternity fee.

YES

No Charge

No Charge
Preventive Care/Screening/Immunization
YES

No Charge

No Charge
Primary Care Visit to Treat an Injury or Illness

Virtual/telehealth visits with certain providers may be covered at no cost.

YES

No Charge

No Charge
Private-Duty Nursing
YES

No Charge

No Charge
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

No Charge

No Charge
Reconstructive Surgery
YES

No Charge

No Charge
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

No Charge

No Charge
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

No Charge

No Charge
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

No Charge
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

No Charge

No Charge
Skilled Nursing Facility

Limit: 60.0 Days per Benefit Period

YES

No Charge

No Charge
Specialist Visit
YES

No Charge

No Charge
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

No Charge

No Charge
Substance Abuse Disorder Inpatient Services
YES

No Charge

No Charge
Substance Abuse Disorder Outpatient Services

Virtual/telehealth visits with certain providers may be covered at no cost.

YES

No Charge

No Charge
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

No Charge

No Charge
Transplant
YES

No Charge

No Charge
Treatment for Temporomandibular Joint Disorders

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

YES

No Charge

No Charge
Urgent Care Centers or Facilities
YES

No Charge

No Charge
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

No Charge
X-rays and Diagnostic Imaging

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

YES

No Charge

No Charge

Blue Value $0 | Limited Statewide Doctors (AI/AN) Health Insurance Plan Variant 11512NC0100034-02 Attributes

Plan Attribute Value
AV Calculator Output Number 1.0
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 Zero Cost Sharing Plan Variation
Drug EHB Deductible, Combined In/Out of Network, Family Per Group $0 per group
Drug EHB Deductible, Combined In/Out of Network, Family Per Person $0 per person
Drug EHB Deductible, Combined In/Out of Network, Individual $0
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 0.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
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 $0 per group
Drug EHB Deductible, Out of Network, Family Per Person $0 per person
Drug EHB Deductible, Out of Network, Individual $0
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID NCF007
Formulary URL URL
HIOS Product ID 11512NC010
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 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 0.00%
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 $0 per group
Medical EHB Deductible, Out of Network, Family Per Person $0 per person
Medical EHB Deductible, Out of Network, Individual $0
Metal Level Gold
Multiple In Network Tiers No
National Network No
Network ID NCN002
Out of Country Coverage Yes
Out of Country Coverage Description Out of Network benefits will apply
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Out of Network benefits will apply
Plan Brochure URL
Plan Effective Date 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 11512NC0100034-02
Plan Marketing Name Blue Value Gold Premier | 3 Free PCP | $10 Tier 1 Rx | Limited Statewide Doctors
Plan Type POS
Plan Variant Marketing Name Blue Value $0 | Limited Statewide Doctors (AI/AN)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
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 $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID NCS055
Source Name HIOS
Plan ID 11512NC0100034
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 $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $0
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $0
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered Yes

Copay & Coinsurance of Blue Value Gold Premier | 3 Free PCP | $10 Tier 1 Rx | Limited Statewide Doctors Health Insurance Plan, 11512NC0100034

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

Frequently Asked Questions(FAQ) about Blue Value Gold Premier | 3 Free PCP | $10 Tier 1 Rx | Limited Statewide Doctors, 11512NC0100034 Health Insurance Plan, 11512NC0100034

  • Does Blue Value Gold Premier | 3 Free PCP | $10 Tier 1 Rx | Limited Statewide Doctors Health Insurance Plan, 11512NC0100034 support Mail Ordering?

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

  • Does (11512NC0100034) Health Insurance Plan, Variant (11512NC0100034-02) offer Disease Management Programs?

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

    Does (11512NC0100034) Health Insurance Plan, Variant (11512NC0100034-02) have Out Of Country Coverage?

    Yes. Details: Out of Network benefits will apply

    Does (11512NC0100034) Health Insurance Plan, Variant (11512NC0100034-02) have Out of Service Area Coverage?

    Yes. Details: Out of Network benefits will apply

    Does (11512NC0100034) Health Insurance Plan, Variant (11512NC0100034-02) offer Disease Management Programs?

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

    Does Blue Value $0 | Limited Statewide Doctors (AI/AN) Health Insurance Plan, Variant (11512NC0100034-02) offer Disease Management Programs for Asthma?

    Yes, the Blue Value $0 | Limited Statewide Doctors (AI/AN) Health Insurance Plan Variant 11512NC0100034-02 offers Disease Management Program for Asthma.

    Does Blue Value $0 | Limited Statewide Doctors (AI/AN) Health Insurance Plan, Variant (11512NC0100034-02) offer Disease Management Programs for Heart disease?

    Yes, the Blue Value $0 | Limited Statewide Doctors (AI/AN) Health Insurance Plan Variant 11512NC0100034-02 offers Disease Management Program for Heart disease.

    Does Blue Value $0 | Limited Statewide Doctors (AI/AN) Health Insurance Plan, Variant (11512NC0100034-02) offer Disease Management Programs for Depression?

    Yes, the Blue Value $0 | Limited Statewide Doctors (AI/AN) Health Insurance Plan Variant 11512NC0100034-02 offers Disease Management Program for Depression.

    Does Blue Value $0 | Limited Statewide Doctors (AI/AN) Health Insurance Plan, Variant (11512NC0100034-02) offer Disease Management Programs for Diabetes?

    Yes, the Blue Value $0 | Limited Statewide Doctors (AI/AN) Health Insurance Plan Variant 11512NC0100034-02 offers Disease Management Program for Diabetes.

    Does Blue Value $0 | Limited Statewide Doctors (AI/AN) Health Insurance Plan, Variant (11512NC0100034-02) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Blue Value $0 | Limited Statewide Doctors (AI/AN) Health Insurance Plan Variant 11512NC0100034-02 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Blue Value $0 | Limited Statewide Doctors (AI/AN) Health Insurance Plan, Variant (11512NC0100034-02) offer Disease Management Programs for Pregnancy?

    Yes, the Blue Value $0 | Limited Statewide Doctors (AI/AN) Health Insurance Plan Variant 11512NC0100034-02 offers Disease Management Program for Pregnancy.

    Does Blue Value $0 | Limited Statewide Doctors (AI/AN) Health Insurance Plan, Variant (11512NC0100034-02) offer Disease Management Programs for Weight loss programs?

    Yes, the Blue Value $0 | Limited Statewide Doctors (AI/AN) Health Insurance Plan Variant 11512NC0100034-02 offers Disease Management Program for Weight loss programs.

 

Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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