Blue Value Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | Statewide Doctors - 11512NC0100011 Health Insurance Plan
Blue Cross and Blue Shield of NC health insurance plan with the Plan ID 11512NC0100011. The plan is called Blue Value Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | 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 | 11512NC0100011 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 11512NC0100011-02 | ||||||||||||||||||
| Provider Network(s) | ['NCN002'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 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 | Wed, 01 Mar 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefits of Blue Value Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | Statewide Doctors Health Insurance Plan, 11512NC0100011-02
| 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
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 |
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
$0 for first 3 Mental/Behavioral health or Substance Use office services. For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | No Charge |
No Charge |
| 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 |
No Charge |
| Nutritional Counseling
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
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 |
No Charge |
| Prenatal and Postnatal Care
Typically covered as part of global maternity fee. |
YES | No Charge |
No Charge |
| 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 |
No Charge |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
No Charge |
| Primary Care Visit to Treat an Injury or Illness
$0 for first 3 visits |
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
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 |
No Charge |
| Substance Abuse Disorder Inpatient Services
|
YES | No Charge |
No Charge |
| Substance Abuse Disorder Outpatient Services
$0 for first 3 Mental/Behavioral health or Substance Use office services. For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | No Charge |
No Charge |
| 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 |
No Charge |
| 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 |
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 | Statewide Doctors (AI/AN) Health Insurance Plan Variant 11512NC0100011-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1 |
| 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 | 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, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 1 |
| First Tier Utilization | 100% |
| Formulary ID | NCF023 |
| Formulary URL | URL |
| HIOS Product ID | 11512NC010 |
| 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 | 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 | 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 | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 11512NC0100011-02 |
| Plan Marketing Name | Blue Value Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | Statewide Doctors |
| Plan Type | POS |
| Plan Variant Marketing Name | Blue Value $0 | 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 | 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 | $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 Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | Statewide Doctors Health Insurance Plan, 11512NC0100011
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Blue Value Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | Statewide Doctors, 11512NC0100011 Health Insurance Plan, 11512NC0100011
-
Does Blue Value Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | Statewide Doctors Health Insurance Plan, 11512NC0100011 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (11512NC0100011) Health Insurance Plan, Variant (11512NC0100011-02) offer Disease Management Programs?
Does (11512NC0100011) Health Insurance Plan, Variant (11512NC0100011-02) have Out Of Country Coverage?
Does (11512NC0100011) Health Insurance Plan, Variant (11512NC0100011-02) have Out of Service Area Coverage?
Does (11512NC0100011) Health Insurance Plan, Variant (11512NC0100011-02) offer Disease Management Programs?
Does Blue Value $0 | Statewide Doctors (AI/AN) Health Insurance Plan, Variant (11512NC0100011-02) offer Disease Management Programs for Asthma?
Does Blue Value $0 | Statewide Doctors (AI/AN) Health Insurance Plan, Variant (11512NC0100011-02) offer Disease Management Programs for Heart disease?
Does Blue Value $0 | Statewide Doctors (AI/AN) Health Insurance Plan, Variant (11512NC0100011-02) offer Disease Management Programs for Diabetes?
Does Blue Value $0 | Statewide Doctors (AI/AN) Health Insurance Plan, Variant (11512NC0100011-02) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Blue Value $0 | Statewide Doctors (AI/AN) Health Insurance Plan, Variant (11512NC0100011-02) offer Disease Management Programs for Pregnancy?
Does Blue Value $0 | Statewide Doctors (AI/AN) Health Insurance Plan, Variant (11512NC0100011-02) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 23 Apr 2024 07:07 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