Blue Value Gold Standard | Limited Statewide Doctors - 11512NC0100072 Health Insurance Plan
Blue Cross and Blue Shield of NC health insurance plan with the Plan ID 11512NC0100072. The plan is called Blue Value Gold Standard | Limited Statewide Doctors.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.06% (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 21.94% 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 | 11512NC0100072 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | North Carolina | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross and Blue Shield of NC | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 11512NC0100072-00 | ||||||||||||||||||
| Provider Network(s) | ['NCN002'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 11512NC0100072-00 Standard On Exchange Plan - 11512NC0100072-01 |
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| Last Plan Update Date | Sat, 02 Nov 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Blue Value Gold Standard | Limited Statewide Doctors Health Insurance Plan, 11512NC0100072-00
| 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 | 25.00% Coinsurance after deductible |
55.00% 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 | $60.00 |
55.00% Coinsurance after deductible |
| Bariatric Surgery
|
YES | 25.00% Coinsurance after deductible |
55.00% Coinsurance after deductible |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
YES | 25.00% Coinsurance after deductible |
55.00% Coinsurance after deductible |
| Chemotherapy
For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | 25.00% Coinsurance after deductible |
55.00% 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 | $30.00 |
55.00% Coinsurance after deductible |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% Coinsurance after deductible |
55.00% Coinsurance after deductible |
| Dental Check-Up for Children
Limit: 2.0 Exam(s) per Benefit Period |
YES | $0.00 |
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 | $30.00 |
55.00% 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 | 25.00% Coinsurance after deductible |
55.00% Coinsurance after deductible |
| Durable Medical Equipment
Orthotic devices for correction of positional plagiocephaly are limited to 1 device per lifetime. |
YES | 25.00% Coinsurance after deductible |
55.00% Coinsurance after deductible |
| Emergency Room Services
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 25.00% Coinsurance after deductible |
25.00% 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 | 25.00% Coinsurance after deductible |
55.00% Coinsurance after deductible |
| Generic Drugs
Quantity limits may apply. See formulary. |
YES | $15.00 |
$15.00 |
| 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 | $30.00 |
55.00% 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 | 25.00% Coinsurance after deductible |
55.00% Coinsurance after deductible |
| Home Health Care Services
|
YES | 25.00% Coinsurance after deductible |
55.00% 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 | 25.00% Coinsurance after deductible |
55.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
55.00% 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 | $60.00 |
55.00% Coinsurance after deductible |
| Infusion Therapy
For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
YES | 25.00% Coinsurance after deductible |
55.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 25.00% Coinsurance after deductible |
55.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
55.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | 25.00% Coinsurance after deductible |
55.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
YES | 25.00% Coinsurance after deductible |
55.00% Coinsurance after deductible |
| Mental/Behavioral Health Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
55.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
Virtual/telehealth visits with certain providers may be covered at no cost. |
YES | $30.00 |
55.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
Quantity limits may apply. See formulary. |
YES | $60.00 |
$60.00 |
| Nutritional Counseling
Limit: 30.0 Visit(s) per Benefit Period Nutritional counseling visits are separate from the obesity-related office visits. |
YES | 0.00% |
30.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
YES | 25.00% Coinsurance after deductible |
55.00% Coinsurance after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $60.00 |
55.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% Coinsurance after deductible |
55.00% 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% Coinsurance after deductible |
55.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
55.00% Coinsurance after deductible |
| Preferred Brand Drugs
Quantity limits may apply. See formulary. |
YES | $30.00 |
$30.00 |
| Prenatal and Postnatal Care
Typically covered as part of global maternity fee. |
YES | 25.00% Coinsurance after deductible |
55.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
30.00% Coinsurance after deductible |
| Primary Care Visit to Treat an Injury or Illness
Virtual/telehealth visits with certain providers may be covered at no cost. |
YES | $30.00 |
55.00% Coinsurance after deductible |
| Private-Duty Nursing
|
YES | 25.00% Coinsurance after deductible |
55.00% 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 | 25.00% Coinsurance after deductible |
55.00% Coinsurance after deductible |
| Reconstructive Surgery
|
YES | 25.00% Coinsurance after deductible |
55.00% 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 | $30.00 |
55.00% 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 | $30.00 |
55.00% 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 | $0.00 |
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 | $60.00 |
55.00% Coinsurance after deductible |
| Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period |
YES | 25.00% Coinsurance after deductible |
55.00% Coinsurance after deductible |
| Specialist Visit
|
YES | $60.00 |
55.00% Coinsurance after deductible |
| Specialty Drugs
Quantity limits may apply. See formulary. |
YES | $250.00 |
$250.00 |
| Substance Abuse Disorder Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
55.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
Virtual/telehealth visits with certain providers may be covered at no cost. |
YES | $30.00 |
55.00% Coinsurance after deductible |
| Tier 2 Rx
Five tier levels apply to prescription drug coverage. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits may apply. See formulary. |
YES | ||
| Transplant
|
YES | 25.00% Coinsurance after deductible |
55.00% 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 | $60.00 |
55.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities
|
YES | $45.00 |
$45.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | 0.00% |
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 | 25.00% Coinsurance after deductible |
55.00% Coinsurance after deductible |
Blue Value Gold Standard | Limited Statewide Doctors Health Insurance Plan Variant 11512NC0100072-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7806125763529309 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | NCF045 |
| Formulary URL | URL |
| HIOS Product ID | 11512NC010 |
| Import Date | 2024-11-02 01:02:12 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 11512 |
| Issuer Marketplace Marketing Name | Blue Cross and Blue Shield of NC |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | NCN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Out of Network benefits will apply |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Out of Network benefits will apply |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 11512NC0100072-00 |
| Plan Marketing Name | Blue Value Gold Standard | Limited Statewide Doctors |
| Plan Type | POS |
| Plan Variant Marketing Name | Blue Value Gold Standard | Limited Statewide Doctors |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,800 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $900 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NCS055 |
| Source Name | HIOS |
| Plan ID | 11512NC0100072 |
| 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 | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $15000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $7500 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $7,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $15600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,800 |
| 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 Gold Standard | Limited Statewide Doctors Health Insurance Plan, 11512NC0100072
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Blue Value Gold Standard | Limited Statewide Doctors, 11512NC0100072 Health Insurance Plan, 11512NC0100072
-
Does Blue Value Gold Standard | Limited Statewide Doctors Health Insurance Plan, 11512NC0100072 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (11512NC0100072) Health Insurance Plan, Variant (11512NC0100072-00) offer Disease Management Programs?
Does (11512NC0100072) Health Insurance Plan, Variant (11512NC0100072-00) have Out Of Country Coverage?
Does (11512NC0100072) Health Insurance Plan, Variant (11512NC0100072-00) have Out of Service Area Coverage?
Does (11512NC0100072) Health Insurance Plan, Variant (11512NC0100072-00) offer Disease Management Programs?
Does Blue Value Gold Standard | Limited Statewide Doctors Health Insurance Plan, Variant (11512NC0100072-00) offer Disease Management Programs for Asthma?
Does Blue Value Gold Standard | Limited Statewide Doctors Health Insurance Plan, Variant (11512NC0100072-00) offer Disease Management Programs for Heart disease?
Does Blue Value Gold Standard | Limited Statewide Doctors Health Insurance Plan, Variant (11512NC0100072-00) offer Disease Management Programs for Depression?
Does Blue Value Gold Standard | Limited Statewide Doctors Health Insurance Plan, Variant (11512NC0100072-00) offer Disease Management Programs for Diabetes?
Does Blue Value Gold Standard | Limited Statewide Doctors Health Insurance Plan, Variant (11512NC0100072-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Blue Value Gold Standard | Limited Statewide Doctors Health Insurance Plan, Variant (11512NC0100072-00) offer Disease Management Programs for Pregnancy?
Does Blue Value Gold Standard | Limited Statewide Doctors Health Insurance Plan, Variant (11512NC0100072-00) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 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