Blue Cross and Blue Shield of NC health insurance plan with the Plan ID 11512NC0100011. The plan is called Blue Value Silver Choice | 3 Free PCP | $15 Tier 1 Rx | Limited Statewide Doctors.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.01% (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 29.99% 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 | 11512NC0100011 | ||||||||||||||||||
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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 | 11512NC0100011-00 | ||||||||||||||||||
Provider Network(s) | ['NCN002'] | ||||||||||||||||||
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 - 11512NC0100011-00 Standard On Exchange Plan - 11512NC0100011-01 Open to Indians below 300% FPL - 11512NC0100011-02 Open to Indians above 300% FPL - 11512NC0100011-03 73% AV Silver Plan - 11512NC0100011-04 |
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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 |
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 | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
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 | $90.00 |
80.00% Coinsurance after deductible |
Bariatric Surgery
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Basic Dental Care - Adult
Exclusions: nan nan |
NO | ||
Basic Dental Care - Child
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Chemotherapy
Exclusions: nan For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
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 | $90.00 |
80.00% Coinsurance after deductible |
Cosmetic Surgery
Exclusions: nan nan |
NO | ||
Delivery and All Inpatient Services for Maternity Care
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Dental Check-Up for Children
Limit: 2.0 Exam(s) per Benefit Period Exclusions: nan nan |
YES | No Charge |
30.00% Coinsurance after deductible |
Diabetes Education
Exclusions: nan For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | $45.00 |
80.00% Coinsurance after deductible |
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 | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Durable Medical Equipment
Exclusions: nan Orthotic devices for correction of positional plagiocephaly are limited to 1 device per lifetime. |
YES | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Emergency Room Services
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Emergency Transportation/Ambulance
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period Exclusions: nan nan |
YES | 50.00% |
50.00% |
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 | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Generic Drugs
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 | $15.00 |
$15.00 |
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 | $90.00 |
80.00% Coinsurance after deductible |
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 | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Home Health Care Services
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
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 | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Imaging (CT/PET Scans, MRIs)
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
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 | $90.00 |
80.00% Coinsurance after deductible |
Infusion Therapy
Exclusions: nan For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Inpatient Physician and Surgical Services
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Laboratory Outpatient and Professional Services
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
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 | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Mental/Behavioral Health Inpatient Services
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Mental/Behavioral Health Outpatient Services
Exclusions: nan Virtual/telehealth visits with certain providers may be covered at no cost. |
YES | $45.00 |
80.00% Coinsurance after deductible |
Non-Preferred Brand Drugs
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 | $80.00 Copay after deductible |
$80.00 Copay after deductible |
Nutritional Counseling
Limit: 30.0 Visit(s) per Benefit Period Exclusions: nan Nutritional counseling visits are separate from the obesity-related office visits. |
YES | No Charge |
30.00% Coinsurance after deductible |
Orthodontia - Adult
Exclusions: nan nan |
NO | ||
Orthodontia - Child
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: nan nan |
YES | $90.00 |
80.00% Coinsurance after deductible |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
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 | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Outpatient Surgery Physician/Surgical Services
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Preferred Brand Drugs
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 | $40.00 Copay after deductible |
$40.00 Copay after deductible |
Prenatal and Postnatal Care
Exclusions: nan Typically covered as part of global maternity fee. |
YES | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Preventive Care/Screening/Immunization
Exclusions: nan nan |
YES | No Charge |
30.00% Coinsurance after deductible |
Primary Care Visit to Treat an Injury or Illness
Exclusions: nan Virtual/telehealth visits with certain providers may be covered at no cost. |
YES | $45.00 |
80.00% Coinsurance after deductible |
Private-Duty Nursing
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
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 | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Reconstructive Surgery
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
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 | $90.00 |
80.00% Coinsurance after deductible |
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 | $90.00 |
80.00% Coinsurance after deductible |
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 | No Charge |
30.00% Coinsurance after deductible |
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 | $90.00 |
80.00% Coinsurance after deductible |
Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Specialist Visit
Exclusions: nan nan |
YES | $90.00 |
80.00% Coinsurance after deductible |
Specialty Drugs
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 | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Substance Abuse Disorder Inpatient Services
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Substance Abuse Disorder Outpatient Services
Exclusions: nan Virtual/telehealth visits with certain providers may be covered at no cost. |
YES | $45.00 |
80.00% Coinsurance after deductible |
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 | $30.00 Copay after deductible |
$30.00 Copay after deductible |
Transplant
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
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 | $90.00 |
80.00% Coinsurance after deductible |
Urgent Care Centers or Facilities
Exclusions: nan nan |
YES | $90.00 |
$90.00 |
Weight Loss Programs
Exclusions: nan nan |
NO | ||
Well Baby Visits and Care
Exclusions: nan nan |
YES | No Charge |
30.00% Coinsurance after deductible |
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 | 50.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.700116459858323 |
Begin Primary Care Cost-Sharing After Number Of Visits | 3 |
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 Silver Off Exchange 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 | $250 per person |
Drug EHB Deductible, Combined In/Out of Network, Individual | $250 |
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
Drug EHB Deductible, In Network (Tier 1), Family Per Group | per group not applicable |
Drug EHB Deductible, In Network (Tier 1), Family Per Person | per person not applicable |
Drug EHB Deductible, In Network (Tier 1), Individual | Not Applicable |
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 | 1.0 |
First Tier Utilization | 100% |
Formulary ID | NCF015 |
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 | 50.00% |
Medical EHB Deductible, In Network (Tier 1), Family Per Group | $6000 per group |
Medical EHB Deductible, In Network (Tier 1), Family Per Person | $3000 per person |
Medical EHB Deductible, In Network (Tier 1), Individual | $3,000 |
Medical EHB Deductible, Out of Network, Family Per Group | $30000 per group |
Medical EHB Deductible, Out of Network, Family Per Person | $15000 per person |
Medical EHB Deductible, Out of Network, Individual | $15,000 |
Metal Level | Silver |
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) | 11512NC0100011-00 |
Plan Marketing Name | Blue Value Silver Choice | 3 Free PCP | $15 Tier 1 Rx | Limited Statewide Doctors |
Plan Type | POS |
Plan Variant Marketing Name | Blue Value Silver Choice | 3 Free PCP | $15 Tier 1 Rx | Limited Statewide Doctors |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $4,800 |
SBC Scenario, Having a Baby, Copayment | $10 |
SBC Scenario, Having a Baby, Deductible | $3,000 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $1,000 |
SBC Scenario, Having Diabetes, Deductible | $1,200 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $600 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,100 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | NCS040 |
Source Name | HIOS |
Plan ID | 11512NC0100011 |
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 | $18400 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9200 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,200 |
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 |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
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