Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health - 11512NC0420040 Health Insurance Plan

Blue Cross and Blue Shield of NC health insurance plan with the Plan ID 11512NC0420040. The plan is called Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 59.86% (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 40.14% 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 11512NC0420040
Health Insurance Plan Year 2023
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 11512NC0420040-00
Provider Network(s) ['NCN012']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 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 - 11512NC0420040-00

Standard On Exchange Plan - 11512NC0420040-01

Open to Indians below 300% FPL - 11512NC0420040-02

Open to Indians above 300% FPL - 11512NC0420040-03

Last Plan Update Date Wed, 01 Mar 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health Health Insurance Plan, 11512NC0420040-00

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 after deductible

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

No Charge after deductible

100.00%
Bariatric Surgery
YES

No Charge after deductible

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

No Charge after deductible

100.00%
Chemotherapy

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

YES

No Charge after deductible

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

No Charge after deductible

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

No Charge after deductible

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

No Charge after deductible

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

No Charge after deductible

100.00%
Durable Medical Equipment

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

YES

No Charge after deductible

100.00%
Emergency Room Services
YES

No Charge after deductible

No Charge after deductible
Emergency Transportation/Ambulance
YES

No Charge after deductible

Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

YES

No Charge after deductible

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

No Charge after deductible

100.00%
Generic Drugs

Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. Six 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 after deductible

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

No Charge after deductible

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

No Charge after deductible

100.00%
Home Health Care Services
YES

No Charge after deductible

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

No Charge after deductible

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

No Charge after deductible

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

No Charge after deductible

100.00%
Infusion Therapy

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

YES

No Charge after deductible

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

No Charge after deductible

100.00%
Inpatient Physician and Surgical Services
YES

No Charge after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

No Charge after deductible

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

No Charge after deductible

100.00%
Mental/Behavioral Health Inpatient Services
YES

No Charge after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

No Charge after deductible

100.00%
Non-Preferred Brand Drugs

Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. Six 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 after deductible

100.00%
Nutritional Counseling

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

YES

No Charge

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
YES

No Charge after deductible

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

No Charge after deductible

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

No Charge after deductible

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

No Charge after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

No Charge after deductible

100.00%
Preferred Brand Drugs

Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. Six 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 after deductible

100.00%
Prenatal and Postnatal Care

Typically covered as part of global maternity fee.

YES

No Charge after deductible

100.00%
Prenatal and Postnatal Care - Non-Global Maternity

Services that are not part of the global maternity benefit. For global maternity benefit, see Prenatal and Postnatal Care.

YES

No Charge after deductible

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

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

No Charge after deductible

100.00%
Private-Duty Nursing
YES

No Charge after deductible

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

No Charge after deductible

100.00%
Reconstructive Surgery
YES

No Charge after deductible

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

No Charge after deductible

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

No Charge after deductible

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

No Charge after deductible

100.00%
Skilled Nursing Facility

Limit: 60.0 Days per Benefit Period

YES

No Charge after deductible

100.00%
Specialist Visit
YES

No Charge after deductible

100.00%
Specialty Drugs

Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. Six 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 after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

No Charge after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

No Charge after deductible

100.00%
Tier 2 Rx

Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. Six 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 after deductible

100.00%
Tier 6 Rx

Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. Six 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 after deductible

100.00%
Transplant
YES

No Charge after deductible

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

No Charge after deductible

100.00%
Urgent Care Centers or Facilities
YES

No Charge after deductible

0.00% Coinsurance after deductible
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

No Charge after deductible

100.00%

Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health Health Insurance Plan Variant 11512NC0420040-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.598552346
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Bronze Off Exchange Plan
Dental Only Plan No
Design Type Design 1
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID NCF032
Formulary URL URL
HIOS Product ID 11512NC042
Import Date 3/1/2023 1:01
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 Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Bronze
Multiple In Network Tiers No
National Network No
Network ID NCN012
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 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 11512NC0420040-00
Plan Marketing Name Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health
Plan Type EPO
Plan Variant Marketing Name Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $9,100
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $5,400
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 $2,800
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID NCS068
Source Name HIOS
Plan ID 11512NC0420040
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
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), Default Coinsurance 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $18200 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $9100 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $9,100
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
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $18200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9100 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,100
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 Bronze 9100 | Integrated | with Wake Forest Baptist Health Health Insurance Plan, 11512NC0420040

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

Frequently Asked Questions(FAQ) about Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health, 11512NC0420040 Health Insurance Plan, 11512NC0420040

  • Does Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health Health Insurance Plan, 11512NC0420040 support Mail Ordering?

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

  • Does (11512NC0420040) Health Insurance Plan, Variant (11512NC0420040-00) 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 (11512NC0420040) Health Insurance Plan, Variant (11512NC0420040-00) 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 (11512NC0420040) Health Insurance Plan, Variant (11512NC0420040-00) 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 (11512NC0420040) Health Insurance Plan, Variant (11512NC0420040-00) 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 Bronze 9100 | Integrated | with Wake Forest Baptist Health Health Insurance Plan, Variant (11512NC0420040-00) offer Disease Management Programs for Asthma?

    Yes, the Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health Health Insurance Plan Variant 11512NC0420040-00 offers Disease Management Program for Asthma.

    Does Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health Health Insurance Plan, Variant (11512NC0420040-00) offer Disease Management Programs for Heart disease?

    Yes, the Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health Health Insurance Plan Variant 11512NC0420040-00 offers Disease Management Program for Heart disease.

    Does Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health Health Insurance Plan, Variant (11512NC0420040-00) offer Disease Management Programs for Diabetes?

    Yes, the Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health Health Insurance Plan Variant 11512NC0420040-00 offers Disease Management Program for Diabetes.

    Does Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health Health Insurance Plan, Variant (11512NC0420040-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health Health Insurance Plan Variant 11512NC0420040-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health Health Insurance Plan, Variant (11512NC0420040-00) offer Disease Management Programs for Pregnancy?

    Yes, the Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health Health Insurance Plan Variant 11512NC0420040-00 offers Disease Management Program for Pregnancy.

    Does Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health Health Insurance Plan, Variant (11512NC0420040-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health Health Insurance Plan Variant 11512NC0420040-00 offers Disease Management Program for Weight loss programs.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 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