Diabetes Silver 4000 $0 Select Drugs & Specialized Services - 13591NC0010010 Health Insurance Plan
CareSource North Carolina Co. health insurance plan with the Plan ID 13591NC0010010. The plan is called Diabetes Silver 4000 $0 Select Drugs & Specialized Services.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.95% (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 28.05% 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 | 13591NC0010010 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | North Carolina | ||||||||||||||||||
| Health Insurance Issuer | CareSource North Carolina Co. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 13591NC0010010-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 24 Dec 2024 06:21 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 13591NC0010010-00 Standard On Exchange Plan - 13591NC0010010-01 Open to Indians below 300% FPL - 13591NC0010010-02 Open to Indians above 300% FPL - 13591NC0010010-03 73% AV Silver Plan - 13591NC0010010-04 |
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| Last Plan Update Date | Fri, 11 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 24 Dec 2024 06:21 GMT |
Benefits of Diabetes Silver 4000 $0 Select Drugs & Specialized Services Health Insurance Plan, 13591NC0010010-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Injury as a result of chewing or biting is not considered an accidental injury. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
Bariatric surgery will be available when medically necessary. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 30.0 Visit(s) per Benefit Period Combined 30 visit limit for Physical, Occupational, and Manipulation Therapy. |
YES | $50.00 |
100.00% |
| Cosmetic Surgery
Cosmetic Procedures do not include coverage for procedures or services that change or improve appearance without significantly improving physiological function, other than those mandated by State or Federal law. |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | $600.00 Copay after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | $600.00 Copay after deductible |
$600.00 Copay after deductible |
| Emergency Transportation/Ambulance
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period Limited to one pair of glasses or contact lenses per benefit year. |
YES | 0.00% |
100.00% |
| Gender Affirming Care
Surgery determined to be Medically Necessary is Covered |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
Select Diabetes Drugs and Supplies are covered at no charge. Refer to the plan brochure for more information. |
YES | $3.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period Combined 30 visit limit for Physical, Occupational, and Manipulation Therapy. |
YES | $30.00 |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years One hearing aid per hearing impaired ear, and replacement hearing aids for members once every 36 months. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
|
YES | 50.00% Coinsurance 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 | 50.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $300.00 Copay 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 BCBSNC medical policies, which are guides considered by BCBSNC when making coverage determinations. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Infusion Therapy
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $600.00 Copay per Stay after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $75.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | $600.00 Copay per Stay after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
The cost sharing that displays applies to office visits only. All other services are subject to the Outpatient Professional Services cost share.? |
YES | $30.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Nutritional counseling visits are separate from the obesity-related office visits. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Benefit Period Combined 30 visit limit for Physical, Occupational, and Manipulation Therapy. Speech Therapy (including Post Cochlear Rehabilitation) limited to 30 visits. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $70.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $50.00 |
100.00% |
| Preventive Care/Screening/Immunization
All preventive care that is not state mandated is not covered OON. |
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 |
100.00% |
| Private-Duty Nursing
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
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 after cataract surgery. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Benefits include coverage for congenital defects of newborn, adopted, and foster children; reconstruction following a mastectomy. |
YES | 50.00% Coinsurance after deductible |
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 | $30.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Benefit Period |
YES | $30.00 |
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 |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $50.00 |
100.00% |
| Specialty Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $600.00 Copay per Stay after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
The cost sharing that displays applies to office visits only. All other services are subject to the Outpatient Professional Services cost share.? |
YES | $30.00 |
100.00% |
| Transplant
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 | 50.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
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. benefits are provided for surgical correction of malocclusion when surgical management of the TMJ is MEDICALLY NECESSARY. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $70.00 |
$70.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $250.00 Copay after deductible |
100.00% |
Diabetes Silver 4000 $0 Select Drugs & Specialized Services Health Insurance Plan Variant 13591NC0010010-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7195497341728578 |
| 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 Silver Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | NCF007 |
| Formulary URL | URL |
| HIOS Product ID | 13591NC001 |
| Import Date | 2024-10-11 01:02:00 |
| 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 | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 13591 |
| Issuer Marketplace Marketing Name | CareSource |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| 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 Services Only |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 13591NC0010010-00 |
| Plan Marketing Name | Diabetes Silver 4000 $0 Select Drugs & Specialized Services |
| Plan Type | HMO |
| Plan Variant Marketing Name | Diabetes Silver 4000 $0 Select Drugs & Specialized Services |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $700 |
| SBC Scenario, Having a Baby, Deductible | $4,000 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $100 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,300 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NCS001 |
| Source Name | HIOS |
| Plan ID | 13591NC0010010 |
| State Code | NC |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $17600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $8800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $8,800 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $8000 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $4000 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $4,000 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $8000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $4000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $4,000 |
| 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 | $17600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,800 |
| 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 Diabetes Silver 4000 $0 Select Drugs & Specialized Services Health Insurance Plan, 13591NC0010010
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Diabetes Silver 4000 $0 Select Drugs & Specialized Services, 13591NC0010010 Health Insurance Plan, 13591NC0010010
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Does Diabetes Silver 4000 $0 Select Drugs & Specialized Services Health Insurance Plan, 13591NC0010010 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (13591NC0010010) Health Insurance Plan, Variant (13591NC0010010-00) offer Disease Management Programs?
Does (13591NC0010010) Health Insurance Plan, Variant (13591NC0010010-00) have Out Of Country Coverage?
Does (13591NC0010010) Health Insurance Plan, Variant (13591NC0010010-00) have Out of Service Area Coverage?
Does (13591NC0010010) Health Insurance Plan, Variant (13591NC0010010-00) offer Disease Management Programs?
Does Diabetes Silver 4000 $0 Select Drugs & Specialized Services Health Insurance Plan, Variant (13591NC0010010-00) offer Disease Management Programs for Asthma?
Does Diabetes Silver 4000 $0 Select Drugs & Specialized Services Health Insurance Plan, Variant (13591NC0010010-00) offer Disease Management Programs for Heart disease?
Does Diabetes Silver 4000 $0 Select Drugs & Specialized Services Health Insurance Plan, Variant (13591NC0010010-00) offer Disease Management Programs for Depression?
Does Diabetes Silver 4000 $0 Select Drugs & Specialized Services Health Insurance Plan, Variant (13591NC0010010-00) offer Disease Management Programs for Diabetes?
Does Diabetes Silver 4000 $0 Select Drugs & Specialized Services Health Insurance Plan, Variant (13591NC0010010-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Diabetes Silver 4000 $0 Select Drugs & Specialized Services Health Insurance Plan, Variant (13591NC0010010-00) offer Disease Management Programs for Low back pain?
Does Diabetes Silver 4000 $0 Select Drugs & Specialized Services Health Insurance Plan, Variant (13591NC0010010-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 24 Dec 2024 06:21 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