North Carolina health plan · 2026

Complete Gold · 77264NC0010007

Ambetter of North Carolina Inc. offers this marketplace health insurance plan (Plan ID 77264NC0010007) 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: HMO CSR: Standard Gold Off Exchange Plan Issuer: Ambetter of North Carolina Inc.
Telehealth Data pending HSA eligible No Dental Not listed Vision Child
Pay / Manage Plan View issuer site

Issuer actuarial value: 81.64%. Expect to pay roughly 18.36% of covered costs out of pocket, based on issuer reporting.

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

$385 – $1923

Before subsidies

Estimate after subsidies

Deductible

$1,450

$2900 per group

See deductible details

Max out-of-pocket

$7,500

$15000 per group

Review MOOP rules

Office visits

Primary care $15.00
Specialist $35.00
HSA Not eligible

Drug tiers

Generic $3.00
Preferred brand $30.00

View formulary tiers

$528 / mo before subsidies

≈ $6336 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.

$1761 / mo before subsidies

≈ $21135 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.

$2134 / mo before subsidies

≈ $25610 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.

$1354 / mo before subsidies

≈ $16252 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

20.00% Coinsurance after deductible

Durable Medical Equipment

20.00% 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

20.00% Coinsurance after deductible

Durable Medical Equipment

20.00% 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 77264NC0010007
Coverage year 2026
State North Carolina
Issuer Ambetter of North Carolina Inc.
Formulary document Download formulary
Marketing materials View marketing kit
Variant ID 77264NC0010007-00
Available variants

Standard Off Exchange Plan · 77264NC0010007-00

Standard On Exchange Plan · 77264NC0010007-01

Open to Indians below 300% FPL · 77264NC0010007-02

Open to Indians above 300% FPL · 77264NC0010007-03
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 2950
PCPs in North Carolina 552
Telehealth support Data pending
Nationwide providers 8644
2,950 doctors statewide 552 PCPs 17 OB/GYN

Provider network(s)

Providers North Carolina All US states
All 2950 8644
PCP 552 1561
Allergy N/A 4
OB/GYN 17 52
Dentists 173 403

Drug coverage overview

4,743 drugs tracked

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

Tier Covered drugs
GENERIC 2,630
NON-PREFERREDGENERIC-NON-PREFERREDBRAND 2,113
Prior authorization Drugs
Required 1,279
Not Required 3,464
Step therapy Drugs
Required 79
Not Required 4,664
Quantity limits Drugs
Has Limit 2,146
No Limit 2,597

Customer highlights

What stands out for members

  • Issuer: Ambetter of North Carolina Inc. · Plan ID 77264NC0010007 · 2026 filing.
  • Disease management programs available: Asthma, Diabetes, Heart Disease, Pregnancy.
  • Download the latest formulary directly from the issuer here.
  • Review marketing brochures and SBC PDFs via the issuer marketing repository.
  • Variant 77264NC0010007-00 (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

$35.00
Tier 1 in-network $35.00
Out-of-network 100.00%

Limit: 30.0 Visit(s) per Year

Limited to a combined 30 visits per year for outpatient occupational therapy, physical therapy and chiropractic care.

Diabetes Education

$35.00
Tier 1 in-network $35.00
Out-of-network 100.00%

Home Health Care Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Laboratory Outpatient and Professional Services

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

Laboratory services provided to treat a behavioral health diagnosis fall under mental/behavioral health services.

Mental/Behavioral Health Urgent Care

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

Other Practitioner Office Visit (Nurse, Physician Assistant)

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

Preventive Care/Screening/Immunization

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

Covered in accordance with ACA guidelines.

Primary Care Visit to Treat an Injury or Illness

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

Unlimited Virtual 24/7 Care Visits received from Ambetter’s designated telehealth provider covered at No Charge, except for HSAs. Primary care visits provided to treat a behavioral health diagnosis fall under mental/behavioral health services.

Rehabilitative Occupational and Rehabilitative Physical Therapy

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 30.0 Visit(s) per Year

Limited to 30 visits per year for outpatient speech therapy; limited to a combined 30 visits per year for outpatient occupational therapy, physical therapy and chiropractic care.

Rehabilitative Speech Therapy

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 30.0 Visit(s) per Year

Specialist Visit

$35.00
Tier 1 in-network $35.00
Out-of-network 100.00%

Specialist visits provided to treat a behavioral health diagnosis fall under mental/behavioral health services.

Substance Use Disorder Urgent Care

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

Urgent Care Centers or Facilities

$35.00
Tier 1 in-network $35.00
Out-of-network 100.00%

X-rays and Diagnostic Imaging

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Hospital & urgent

Emergency room, inpatient stays, ambulance, and surgeries.

Chemotherapy

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Delivery and All Inpatient Services for Maternity Care

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Dialysis

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Durable Medical Equipment

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Emergency Room Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Emergency Transportation/Ambulance

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing.

Hospice Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Respite Care is covered as part of hospice services only.

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

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Inpatient Physician and Surgical Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Mental/Behavioral Health Emergency Room

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Mental/Behavioral Health Emergency Transportation/Ambulance

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing.

Mental/Behavioral Health Inpatient Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Prior authorization may be required - please contact the number listed on your ID card.

Mental/Behavioral Health Outpatient Other Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% 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%

Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization.

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

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Outpatient Rehabilitation Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 30.0 Visit(s) per Year

Limited to 30 visits per year for outpatient speech therapy; limited to a combined 30 visits per year for outpatient occupational therapy, physical therapy and chiropractic care.

Outpatient Surgery Physician/Surgical Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Radiation

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Skilled Nursing Facility

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 60.0 Days per Year

Substance Abuse Disorder Inpatient Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Prior authorization may be required - please contact the number listed on your ID card.

Substance Abuse Disorder Outpatient Services

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

Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization.

Substance Use Disorder Emergency Room

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Substance Use Disorder Emergency Transportation/Ambulance

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing.

Substance Use Disorder Outpatient Other Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Transplant

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Both the recipient and the donor are entitled to benefits of this coverage when the recipient is a MEMBER. Benefits provided to the donor will be charged against the recipient's coverage.

Mental health & substance use

Behavioral health visits and substance use treatment.

Mental/Behavioral Health ER Physician Fee

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Substance Use Disorder ER Physician Fee

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

Coverage details pending

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

Hearing Aids

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 2.0 Item(s) per 3 Years

Cochlear Implants and Bone Anchored Hearing Aids are a covered benefit.

Major Dental Care - Child

Coverage details pending

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

Prenatal and Postnatal Care

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

Routine Eye Exam for Children

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

Limit: 1.0 Exam(s) per Year

Well Baby Visits and Care

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

Covered in accordance with ACA guidelines.

Pharmacy & drugs

Generic, brand, specialty, and mail order tiers.

Generic Drugs

$3.00
Tier 1 in-network $3.00
Out-of-network 100.00%

Cost sharing shown applies to Tier 1a-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 1b-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information.

Non-Preferred Brand Drugs

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

Preferred Brand Drugs

$30.00
Tier 1 in-network $30.00
Out-of-network 100.00%

Specialty Drugs

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

Tier 1b Generic Drugs

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

Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. Refer to the prescription drug list for more information.

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

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

Coverage details pending

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

Infusion Therapy

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Major Dental Care - Adult

Coverage details pending

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

Nutritional Counseling

$35.00
Tier 1 in-network $35.00
Out-of-network 100.00%

Nutritional counseling provided to treat a behavioral health diagnosis falls under mental/behavioral health services.

Orthodontia - Adult

Coverage details pending

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

Orthodontia - Child

Coverage details pending

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

Prosthetic Devices

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

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

$35.00
Tier 1 in-network $35.00
Out-of-network 100.00%

Bariatric Surgery

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% 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

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

Limit: 1.0 Item(s) per Year

Habilitation Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 30.0 Visit(s) per Year

Limited to 30 visits per year for outpatient speech therapy; limited to a combined 30 visits per year for outpatient occupational therapy, physical therapy and chiropractic care. Habilitation services provided to treat a behavioral health diagnosis fall under mental/behavioral health services. Limits do not apply to mental/behavioral health services.

Imaging (CT/PET Scans, MRIs)

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Infertility Treatment

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 3.0 Treatment(s) per Lifetime

Includes certain services related to: diagnosis, correction of underlying medical conditions that cause infertility and treatment. Note: A lifetime benefit limit applies, per member, of three medical ovulation induction cycles.

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

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Reconstructive Surgery

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Member; 2. Surgery performed on a child for the correction of a cleft palate or cleft lip, removal of a port-wine stain or hemangioma (only on the face), or correction of a congenital abnormality; 3. Treatment provided when it is incidental to disease or for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from cancer surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria. Prior Authorization may be required - please contact the number listed on your ID card.

Routine Eye Exam (Adult)

Coverage details pending

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

Routine Foot Care

$35.00
Tier 1 in-network $35.00
Out-of-network 100.00%

Treatment for Temporomandibular Joint Disorders

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Variant attributes

Complete Gold · Variant 77264NC0010007-00

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2026

CSR Variation Type

Standard Gold Off Exchange Plan

HIOS Product ID

77264NC001

Metal Level

Gold

Plan ID (Standard Component ID with Variant)

77264NC0010007-00

Plan Marketing Name

Complete Gold

Plan Variant Marketing Name

Complete Gold

Issuer & service area

Issuer-provided metadata for this variant.

Issuer Actuarial Value

81.64%

Issuer ID

77264

Issuer Marketplace Marketing Name

Ambetter of North Carolina

Market Coverage

Individual

Multiple In Network Tiers

No

National Network

No

Network ID

NCN001

Out of Country Coverage

No

Out of Service Area Coverage

No

Service Area ID

NCS001

State Code

NC

URL for Summary of Benefits & Coverage

Open link

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

Begin Primary Care Deductible Coinsurance After Number Of Copays

0

Inpatient Copayment Maximum Days

0

Medical Drug Deductibles Integrated

Yes

Medical Drug Maximum Out of Pocket Integrated

Yes

SBC Scenario, Having a Baby, Coinsurance

$1,500

SBC Scenario, Having a Baby, Copayment

$300

SBC Scenario, Having a Baby, Deductible

$1,450

SBC Scenario, Having Diabetes, Coinsurance

$0

SBC Scenario, Having Diabetes, Copayment

$800

SBC Scenario, Having Diabetes, Deductible

$800

SBC Scenario, Treatment of a Simple Fracture, Coinsurance

$200

SBC Scenario, Treatment of a Simple Fracture, Copayment

$100

SBC Scenario, Treatment of a Simple Fracture, Deductible

$1,450

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, In Network (Tier 1), Default Coinsurance

20.00%

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

$15000 per group

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

$7500 per person

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

$7,500

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

NCF001

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

0

Child-Only Offering

Allows Adult and Child-Only

Composite Rating Offered

No

Dental Only Plan

No

Design Type

Not Applicable

Disease Management Programs Offered

Asthma, Diabetes, Heart Disease, Pregnancy

EHB Percent of Total Premium

1

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

Yes

Is a Referral Required for Specialist?

No

Plan Effective Date

1/1/2026

Plan Type

HMO

QHP/Non QHP

Both

Source Name

HIOS

Plan ID

77264NC0010007

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), Family Per Group

$2900 per group

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

$1450 per person

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual

$1,450

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

Unique Plan Design

Yes

Wellness Program Offered

No

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?

Complete Gold (77264NC0010007) is a Gold HMO from Ambetter of North Carolina Inc. 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 Complete Gold 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 Complete Gold 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 coverage is not listed for this plan.

Vision add-ons: Child.

Does Complete Gold 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 Complete Gold?

The issuer lists disease management resources for: Asthma, Diabetes, Heart Disease, Pregnancy.

Is there out-of-country coverage for Complete Gold?

No, out-of-country services are not covered for this plan.

Does Complete Gold cover care outside the service area?

No, the issuer indicates out-of-service-area care is not covered except for emergencies.

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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