Bronze Elite + PCP Saver Plus - 69803NC0010005 Health Insurance Plan
Oscar Health Plan of North Carolina, Inc health insurance plan with the Plan ID 69803NC0010005. The plan is called Bronze Elite + PCP Saver Plus.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.63% (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 35.37% 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 | 69803NC0010005 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | North Carolina | ||||||||||||||||||
| Health Insurance Issuer | Oscar Health Plan of North Carolina, Inc | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 69803NC0010005-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 69803NC0010005-00 Standard On Exchange Plan - 69803NC0010005-01 |
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| Last Plan Update Date | Fri, 11 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Bronze Elite + PCP Saver Plus Health Insurance Plan, 69803NC0010005-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Exclusions: Excludes injury related to chewing or biting. |
YES | $350.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $125.00 |
100.00% |
| Bariatric Surgery
|
YES | $3,000.00 |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 50.00% |
100.00% |
| Chiropractic Care
Limit: 30.0 Visit(s) per Benefit Period 30 visit limits for PT and OT combined (including chiropractic). |
YES | $125.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
The per day copayment will apply for a maximum of two (2) days. See plan documents for separate professional services cost shares. |
YES | $3,000.00 |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $0.00 |
100.00% |
| Dialysis
|
YES | 50.00% |
100.00% |
| Durable Medical Equipment
Exclusions: Appliances and accessories that serve no medical purpose or that are primarily for comfort or convenience; repair or replacement of equipment due to abuse or desire for new equipment Orthotic devices for correction of POSITIONAL PLAGIOCEPHALY are limited to 1 device per lifetime. |
YES | 50.00% |
100.00% |
| Emergency Room Services
|
YES | $2,000.00 |
$2,000.00 |
| Emergency Transportation/Ambulance
Exclusions: Excludes services provided primarily for the convenience of travel, transportation to or from a doctor's office or dialysis center, transportation for the purpose of receiving services that are not considered Covered Services |
YES | $2,000.00 |
$2,000.00 |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period |
YES | 50.00% |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document |
YES | Tier 1: $3.00 Tier 2: $30.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period Exclusions: Cognitive Therapy. Group classes for pulmonary rehabilitation. Combined 30 visit limit for occupational and physical therapies and chiropractic services. |
YES | $125.00 |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years One hearing aid per hearing impaired ear, and replacement hearing aids, once every 36 months. |
YES | 50.00% |
100.00% |
| Home Health Care Services
Exclusions: Excludes homemaker services, such as cooking and housekeeping; Dietitian services or meals; Services that are provided by a close relative or a member of the household. |
YES | $125.00 |
100.00% |
| Hospice Services
Exclusions: Excludes homemaker services, such as cooking, housekeeping, and food or meal preparation. Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less. |
YES | 50.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: Lab tests that are not ordered by Doctor of Other Provider. |
YES | $750.00 |
100.00% |
| Infertility Treatment
Limit: 3.0 Treatment(s) per Lifetime |
YES | 50.00% |
100.00% |
| Infusion Therapy
|
YES | 50.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: Admissions primarily for the purpose of receiving diagnostic services or a physical examination; admissions primarily for the purpose of receiving therapy services, except when the admission is a continuation of treatment following care at an inpatient facility for an illness or accident requiring therap The per day copayment will apply for a maximum of two (2) days. |
YES | $3,000.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | $350.00 |
100.00% |
| Laboratory Outpatient and Professional Services
Exclusions: Lab tests that are not ordered by a Doctor or Other Provider. |
YES | $50.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Exclusions: Excludes, "Inpatient confinements that are primarily intended as a change of environment"; Counseling with relatives of a patient The per day copayment will apply for a maximum of two (2) days. |
YES | $3,000.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
Exclusions: Excludes counseling with relatives about a patient The cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
YES | $125.00 |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Nutritional counseling visits are separate from the obesity-related office visits |
YES | $40.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $40.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $1,200.00 |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Benefit Period Exclusions: Applied Behavior Analysis (ABA) therapy; Cognitive therapy; Speech therapy for stammering or stuttering; Group classes for pulmonary rehabilitation; music therapy, remedial reading, recreational or activity therapy, all forms or special education and supplies or equipment used similarly; maintenance therapy; massage therapy. Combined 30 visit limit for occupational and physical therapies and chiropractic services. |
YES | $125.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $350.00 |
100.00% |
| Preferred Brand Drugs
Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document |
YES | $100.00 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | 0.00% |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Cost share applies to both in-person and telemedicine services. |
YES | $40.00 |
100.00% |
| Private-Duty Nursing
Exclusions: Excludes services provided by a close relative or a member of the household |
YES | $125.00 |
100.00% |
| Prosthetic Devices
Exclusions: Dental appliances except when medically necessary for the treatment of temporomandibular joint disease or obstructive sleep apnea; cosmetic improvements, such as implants of hair follicles and skin tone enhancements; lenses for keratoconus or any other eye procedure except as specifically covered under the health plan. Prosthetic appliance must replace all or part of a body part or its function. Therapeutic contact lenses may be covered when used as a corneal bandage for a medical condition; benefits include a one-time replacement of eyeglass or contact lenses due to a prescription change following cataract surgery. |
YES | 50.00% |
100.00% |
| Radiation
|
YES | 50.00% |
100.00% |
| Reconstructive Surgery
Benefits include coverage for congenital defects of newborn, adopted, and foster children; reconstruction following a mastectomy. |
YES | $3,000.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Benefit Period Combined 30 visit limit for occupational and physical therapies and chiropractic services |
YES | $125.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Benefit Period |
YES | $125.00 |
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 | $0.00 |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period The per day copayment will apply for a maximum of two (2) days. |
YES | $3,000.00 Copay per Day |
100.00% |
| Specialist Visit
Cost share applies to both in-person and telemedicine services. |
YES | $125.00 |
100.00% |
| Specialty Drugs
Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: Excludes, "Inpatient confinements that are primarily intended as a change of environment"; Counseling with relatives of a patient The per day copayment will apply for a maximum of two (2) days. |
YES | $3,000.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
Exclusions: Excludes counseling with relatives about a patient The cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
YES | $125.00 |
100.00% |
| Transplant
Exclusions: The purchase price of organs or tissue if any organ or tissue is sold rather than donated to the recipient member; the procurement of organs, tissue, bone marrow, or peripheral blood stem cells or any other donor services if a recipient is not a member; transplants, including high dose chemotherapy, considered experimental or investigational; services for or related to the transplantation of animal or artificial organ or tissues. Benefits are provided for reasonable and necessary services related to the search for a donor up to a maximum of $10,000 per transplant; 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 |
YES | $3,000.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: Excludes Treatment for periodontal disease; Dental implants or root canals; Crowns and bridges; Orthodontic brace; Occlusal (bite) adjustments; Extractions. Therapeutic benefits for TMJ disease include splinting and use of intra-oral PROSTHETIC APPLIANCES to reposition the bones. Surgical benefits for TMJ disease are limited to SURGERY performed on the temporomandibular joint. If TMJ is caused by malocclusion, benefits are provided for surgical correction of malocclusion when surgical management of the TMJ is MEDICALLY NECESSARY. |
YES | 50.00% |
100.00% |
| Urgent Care Centers or Facilities
Virtual urgent care services provided by Oscar-designated virtual care providers are covered in full. |
YES | $75.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
Exclusions: Lab tests that are not ordered by a Doctor or Other Provider. |
YES | $125.00 |
100.00% |
Bronze Elite + PCP Saver Plus Health Insurance Plan Variant 69803NC0010005-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.646347333903356 |
| 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 Bronze Off Exchange 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 | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $13000 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $6500 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $6,500 |
| Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 50.00% |
| Drug EHB Deductible, In Network (Tier 2), Family Per Group | $13000 per group |
| Drug EHB Deductible, In Network (Tier 2), Family Per Person | $6500 per person |
| Drug EHB Deductible, In Network (Tier 2), Individual | $6,500 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 44% |
| Formulary ID | NCF001 |
| Formulary URL | URL |
| HIOS Product ID | 69803NC001 |
| Import Date | 2024-10-11 01:02:00 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 2 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 69803 |
| Issuer Marketplace Marketing Name | Oscar Health Plan of North Carolina, Inc |
| 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 | 50.00% |
| 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, In Network (Tier 2), Default Coinsurance | 50.00% |
| Medical EHB Deductible, In Network (Tier 2), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 2), Individual | $0 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | Yes |
| National Network | No |
| Network ID | NCN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency and Urgent Services Only |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 69803NC0010005-00 |
| Plan Marketing Name | Bronze Elite + PCP Saver Plus |
| Plan Type | HMO |
| Plan Variant Marketing Name | Bronze Elite + PCP Saver Plus |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $4,100 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $600 |
| SBC Scenario, Having Diabetes, Deductible | $4,200 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $2,100 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 56% |
| Service Area ID | NCS001 |
| Source Name | HIOS |
| Plan ID | 69803NC0010005 |
| 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 | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,200 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $9,200 |
| 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 | No |
Copay & Coinsurance of Bronze Elite + PCP Saver Plus Health Insurance Plan, 69803NC0010005
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Bronze Elite + PCP Saver Plus, 69803NC0010005 Health Insurance Plan, 69803NC0010005
-
Does Bronze Elite + PCP Saver Plus Health Insurance Plan, 69803NC0010005 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (69803NC0010005) Health Insurance Plan, Variant (69803NC0010005-00) offer Disease Management Programs?
Does (69803NC0010005) Health Insurance Plan, Variant (69803NC0010005-00) have Out Of Country Coverage?
Does (69803NC0010005) Health Insurance Plan, Variant (69803NC0010005-00) have Out of Service Area Coverage?
Does (69803NC0010005) Health Insurance Plan, Variant (69803NC0010005-00) offer Disease Management Programs?
Does Bronze Elite + PCP Saver Plus Health Insurance Plan, Variant (69803NC0010005-00) offer Disease Management Programs for Asthma?
Does Bronze Elite + PCP Saver Plus Health Insurance Plan, Variant (69803NC0010005-00) offer Disease Management Programs for Heart disease?
Does Bronze Elite + PCP Saver Plus Health Insurance Plan, Variant (69803NC0010005-00) offer Disease Management Programs for Depression?
Does Bronze Elite + PCP Saver Plus Health Insurance Plan, Variant (69803NC0010005-00) offer Disease Management Programs for Diabetes?
Does Bronze Elite + PCP Saver Plus Health Insurance Plan, Variant (69803NC0010005-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 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