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 94.01% (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 5.99% 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
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 11512NC0100011-06
Provider Network(s) ['NCN002']
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 - 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

87% AV Silver Plan - 11512NC0100011-05

94% AV Silver Plan - 11512NC0100011-06

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

Benefits of Blue Value Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | Statewide Doctors Health Insurance Plan, 11512NC0100011-06

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

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
Acupuncture
NO
Allergy Testing

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

YES

$25.00

70.00% Coinsurance after deductible
Bariatric Surgery
YES

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
Basic Dental Care - Adult
NO
Basic Dental Care - Child
YES

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
Chemotherapy

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

YES

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
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

$25.00

70.00% Coinsurance after deductible
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
Dental Check-Up for Children

Limit: 2.0 Exam(s) per Benefit Period

YES

No Charge

30.00% Coinsurance after deductible
Diabetes Education

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

YES

$4.00

70.00% Coinsurance after deductible
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

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
Durable Medical Equipment

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

YES

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
Emergency Room Services
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

YES

50.00%

50.00%
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

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
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

$4.00

$4.00
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

$25.00

70.00% Coinsurance after deductible
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

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
Home Health Care Services
YES

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
Hospice Services

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

YES

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)
YES

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
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

$25.00

70.00% Coinsurance after deductible
Infusion Therapy

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

YES

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
YES

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
YES

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
YES

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
YES

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
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

$4.00

70.00% Coinsurance after deductible
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

$80.00

$80.00
Nutritional Counseling

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

YES

No Charge

30.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child
YES

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$25.00

70.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

40.00% Coinsurance after deductible

70.00% 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

$25.00

70.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
YES

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
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

$20.00

$20.00
Prenatal and Postnatal Care

Typically covered as part of global maternity fee.

YES

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
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

$4.00

70.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
YES

No Charge

30.00% Coinsurance after deductible
Primary Care Visit to Treat an Injury or Illness

$0 for first 3 visits

YES

$4.00

70.00% Coinsurance after deductible
Private-Duty Nursing
YES

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
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

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
Reconstructive Surgery
YES

40.00% Coinsurance after deductible

70.00% 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

$25.00

70.00% Coinsurance after deductible
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

$25.00

70.00% Coinsurance after deductible
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

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

$25.00

70.00% Coinsurance after deductible
Skilled Nursing Facility

Limit: 60.0 Days per Benefit Period

YES

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
Specialist Visit
YES

$25.00

70.00% Coinsurance after deductible
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

50.00%

50.00%
Substance Abuse Disorder Inpatient Services
YES

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
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

$4.00

70.00% Coinsurance after deductible
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

$15.00

$15.00
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

50.00%

50.00%
Transplant
YES

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders

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

YES

$25.00

70.00% Coinsurance after deductible
Urgent Care Centers or Facilities
YES

$25.00

$50.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

30.00% Coinsurance after deductible
X-rays and Diagnostic Imaging

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

YES

40.00% Coinsurance after deductible

70.00% Coinsurance after deductible

Blue Value Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | Statewide Doctors (CSR 94%) Health Insurance Plan Variant 11512NC0100011-06 Attributes

Plan Attribute Value
AV Calculator Output Number 0.940127864
Begin Primary Care Cost-Sharing After Number Of Visits 3
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 94% AV Level Silver 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 $0 per person
Drug EHB Deductible, Combined In/Out of Network, Individual $0
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 40.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group per group not applicable
Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Drug EHB Deductible, In Network (Tier 1), Individual $0
Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
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 40.00%
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 $4000 per group
Medical EHB Deductible, Out of Network, Family Per Person $2000 per person
Medical EHB Deductible, Out of Network, Individual $2,000
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 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 11512NC0100011-06
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 Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | Statewide Doctors (CSR 94%)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,000
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 $400
SBC Scenario, Having Diabetes, Copayment $400
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $800
SBC Scenario, Treatment of a Simple Fracture, Copayment $100
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 $1950 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $975 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $975
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 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 (11512NC0100011-06) 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 (11512NC0100011) Health Insurance Plan, Variant (11512NC0100011-06) have Out Of Country Coverage?

    Yes. Details: Out of network benefits will apply

    Does (11512NC0100011) Health Insurance Plan, Variant (11512NC0100011-06) have Out of Service Area Coverage?

    Yes. Details: Out of network benefits will apply

    Does (11512NC0100011) Health Insurance Plan, Variant (11512NC0100011-06) 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 Value Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | Statewide Doctors (CSR 94%) Health Insurance Plan, Variant (11512NC0100011-06) offer Disease Management Programs for Asthma?

    Yes, the Blue Value Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | Statewide Doctors (CSR 94%) Health Insurance Plan Variant 11512NC0100011-06 offers Disease Management Program for Asthma.

    Does Blue Value Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | Statewide Doctors (CSR 94%) Health Insurance Plan, Variant (11512NC0100011-06) offer Disease Management Programs for Heart disease?

    Yes, the Blue Value Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | Statewide Doctors (CSR 94%) Health Insurance Plan Variant 11512NC0100011-06 offers Disease Management Program for Heart disease.

    Does Blue Value Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | Statewide Doctors (CSR 94%) Health Insurance Plan, Variant (11512NC0100011-06) offer Disease Management Programs for Diabetes?

    Yes, the Blue Value Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | Statewide Doctors (CSR 94%) Health Insurance Plan Variant 11512NC0100011-06 offers Disease Management Program for Diabetes.

    Does Blue Value Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | Statewide Doctors (CSR 94%) Health Insurance Plan, Variant (11512NC0100011-06) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Blue Value Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | Statewide Doctors (CSR 94%) Health Insurance Plan Variant 11512NC0100011-06 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Blue Value Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | Statewide Doctors (CSR 94%) Health Insurance Plan, Variant (11512NC0100011-06) offer Disease Management Programs for Pregnancy?

    Yes, the Blue Value Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | Statewide Doctors (CSR 94%) Health Insurance Plan Variant 11512NC0100011-06 offers Disease Management Program for Pregnancy.

    Does Blue Value Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | Statewide Doctors (CSR 94%) Health Insurance Plan, Variant (11512NC0100011-06) offer Disease Management Programs for Weight loss programs?

    Yes, the Blue Value Silver Choice | $0 Deductible | 3 Free PCP | $4 Tier 1 Rx | Statewide Doctors (CSR 94%) Health Insurance Plan Variant 11512NC0100011-06 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