HDHP Preventive Silver 5500 $0 Select Drugs - 13591NC0010015 Health Insurance Plan
CareSource North Carolina Co. health insurance plan with the Plan ID 13591NC0010015. The plan is called HDHP Preventive Silver 5500 $0 Select Drugs.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 73.08% (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 26.92% 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 | 13591NC0010015 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 13591NC0010015-04 | ||||||||||||||||||
| 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 - 13591NC0010015-00 Standard On Exchange Plan - 13591NC0010015-01 Open to Indians below 300% FPL - 13591NC0010015-02 Open to Indians above 300% FPL - 13591NC0010015-03 73% AV Silver Plan - 13591NC0010015-04 |
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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 HDHP Preventive Silver 5500 $0 Select Drugs Health Insurance Plan, 13591NC0010015-04
| 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 | No Charge after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge after deductible |
100.00% |
| Bariatric Surgery
Bariatric surgery will be available when medically necessary. |
YES | No Charge after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | No Charge 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 | No Charge after deductible |
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 | No Charge after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | No Charge after deductible |
100.00% |
| Dialysis
|
YES | No Charge after deductible |
100.00% |
| Durable Medical Equipment
|
YES | No Charge after deductible |
100.00% |
| Emergency Room Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
|
YES | No Charge after deductible |
No Charge 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 | No Charge after deductible |
100.00% |
| Generic Drugs
Select Preventive Drugs and Supplies are covered at no charge. Refer to the plan brochure for more information. |
YES | No Charge after deductible |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period Combined 30 visit limit for Physical, Occupational, and Manipulation Therapy. |
YES | No Charge after deductible |
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 | No Charge after deductible |
100.00% |
| Home Health Care Services
|
YES | No Charge 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 | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge 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 | No Charge after deductible |
100.00% |
| Infusion Therapy
|
YES | No Charge after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | No Charge after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | No Charge after deductible |
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 | No Charge 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 | No Charge after deductible |
100.00% |
| Non-Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
| Nutritional Counseling
Nutritional counseling visits are separate from the obesity-related office visits. |
YES | No Charge after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | No Charge after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge 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 | No Charge after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge after deductible |
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 | No Charge after deductible |
100.00% |
| Private-Duty Nursing
|
YES | No Charge 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 | No Charge after deductible |
100.00% |
| Radiation
|
YES | No Charge after deductible |
100.00% |
| Reconstructive Surgery
Benefits include coverage for congenital defects of newborn, adopted, and foster children; reconstruction following a mastectomy. |
YES | No Charge 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 | No Charge after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Benefit Period |
YES | No Charge after deductible |
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 | No Charge after deductible |
100.00% |
| Specialist Visit
|
YES | No Charge after deductible |
100.00% |
| Specialty Drugs
|
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | No Charge 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 | No Charge after deductible |
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 | No Charge 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 | No Charge after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
No Charge after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | No Charge after deductible |
100.00% |
HDHP Preventive Silver 4550 $0 Select Drugs Health Insurance Plan Variant 13591NC0010015-04 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7308191255891329 |
| 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 | 73% AV Level Silver 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 | NCF010 |
| 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 | Yes |
| New/Existing Plan | New |
| 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) | 13591NC0010015-04 |
| Plan Marketing Name | HDHP Preventive Silver 5500 $0 Select Drugs |
| Plan Type | HMO |
| Plan Variant Marketing Name | HDHP Preventive Silver 4550 $0 Select Drugs |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $4,550 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $1,500 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| 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 | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NCS001 |
| Source Name | HIOS |
| Plan ID | 13591NC0010015 |
| State Code | NC |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $9100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $4550 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $4,550 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $9100 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $4550 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $4,550 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $9100 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $4550 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $4,550 |
| 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 | $9100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $4550 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $4,550 |
| 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 HDHP Preventive Silver 5500 $0 Select Drugs Health Insurance Plan, 13591NC0010015
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about HDHP Preventive Silver 5500 $0 Select Drugs, 13591NC0010015 Health Insurance Plan, 13591NC0010015
-
Does HDHP Preventive Silver 5500 $0 Select Drugs Health Insurance Plan, 13591NC0010015 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (13591NC0010015) Health Insurance Plan, Variant (13591NC0010015-04) offer Disease Management Programs?
Does (13591NC0010015) Health Insurance Plan, Variant (13591NC0010015-04) have Out Of Country Coverage?
Does (13591NC0010015) Health Insurance Plan, Variant (13591NC0010015-04) have Out of Service Area Coverage?
Does (13591NC0010015) Health Insurance Plan, Variant (13591NC0010015-04) offer Disease Management Programs?
Does HDHP Preventive Silver 4550 $0 Select Drugs Health Insurance Plan, Variant (13591NC0010015-04) offer Disease Management Programs for Asthma?
Does HDHP Preventive Silver 4550 $0 Select Drugs Health Insurance Plan, Variant (13591NC0010015-04) offer Disease Management Programs for Heart disease?
Does HDHP Preventive Silver 4550 $0 Select Drugs Health Insurance Plan, Variant (13591NC0010015-04) offer Disease Management Programs for Depression?
Does HDHP Preventive Silver 4550 $0 Select Drugs Health Insurance Plan, Variant (13591NC0010015-04) offer Disease Management Programs for Diabetes?
Does HDHP Preventive Silver 4550 $0 Select Drugs Health Insurance Plan, Variant (13591NC0010015-04) offer Disease Management Programs for High blood pressure & high cholesterol?
Does HDHP Preventive Silver 4550 $0 Select Drugs Health Insurance Plan, Variant (13591NC0010015-04) offer Disease Management Programs for Low back pain?
Does HDHP Preventive Silver 4550 $0 Select Drugs Health Insurance Plan, Variant (13591NC0010015-04) 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