Blue Home Gold 2500 + 3 Free PCP with UNC Health Alliance (2022) - Person - NC

Blue Home Gold 2500 + 3 Free PCP with UNC Health Alliance (2022) - Person - NC

  74 InfoPreferred Score Excellent

specifications

  • Premium 462.22 Dollar(s)
  • Deductibles 2500 Dollar(s)
  • Out of Pocket Maximum 8700 Dollar(s)
  • Covered Benefits 35 out of 40

Key Features

$ 462.22
Premium
Good
$ 2500
Deductibles
Very Good
$ 8700
Out of Pocket Maximum
Poor
35 / 40
Covered Benefits
Very Good

  • Overview

    Plan ID: 11512NC0310015
    Plan Type: POS
    Metal Level: Gold
    Covered Benefits: 35
    County: Person
    FIPS County Code: 37145
    State: NC
    SM Rating: 74

  • Cost of Medical Sharing

    Premium: 462.22
    EHB Premium: 462.22
    EHB Percent of Total Premium: 100
    Deductibles: 2500
    Out of Pocket Maximum: 8700

  • Cost Sharing

    Adult Dental Care Details: Benefit Not Covered
    Child Dental Care Details: 30% Coinsurance after deductible
    Child Dental Check Up: No Charge
    Adult Major Dental Care: Benefit Not Covered
    Child Major Dental Care: 30% Coinsurance after deductible
    Adult Routine Dental Services: Benefit Not Covered
    Eye Glasses for Children: 50%
    Adult Routine Eye Exam Details: Benefit Not Covered
    Child Routine Eye Exam Details: No Charge
    Hearing Aids Details: 30% Coinsurance after deductible
    Bariatric Surgery: 30% Coinsurance after deductible
    Chemotherapy: 30% Coinsurance after deductible
    Chiropractic Care: $40
    Dialysis: 30% Coinsurance after deductible
    Durable Medical Equipment: 30% Coinsurance after deductible
    Emergency Room Services: 30% Coinsurance after deductible
    Emergency Transportation Ambulance: 30% Coinsurance after deductible
    Habilitation Services: $40
    Imaging (CT, Pet, MRIS Scan): 30% Coinsurance after deductible
    Infertility Treatment: $40
    Inpatient Hospital Services: 30% Coinsurance after deductible
    Inpatient Physician and Surgical Services: 30% Coinsurance after deductible
    Laboratory Outpatient and Professional Services: 30% Coinsurance after deductible
    Mental Behavioral Health Inpatient Services: 30% Coinsurance after deductible
    Mental Behavioral Health Outpatient Services: $10
    Adult Orthodontia: Benefit Not Covered
    Child Orthodontia: 30% Coinsurance after deductible
    Outpatient Facility Fee: 30% Coinsurance after deductible
    Outpatient Rehabilitation Services: $40
    Outpatient Surgery Services: 30% Coinsurance after deductible
    Preventive Care Screening Immunization: No Charge
    Primary Care Visit: $10
    Private Duty Nursing: 30% Coinsurance after deductible
    Skilled Nursing Facility: 30% Coinsurance after deductible
    Specialist Visit: $40
    XRays and Diagnostic Imaging: 30% Coinsurance after deductible

  • Prescription Drug Coverage

    List of Covered Drugs URL: https://www.myprime.com/content/dam/prime/memberportal/forms/AuthorForms/HIM/2022/2022_NC_6T_HealthInsuranceMarketplace.pdf
    Generic Drugs: $10 Copay after deductible
    Non Preferred Brand Drugs: $80 Copay after deductible
    Preferred Brand Drugs: $40 Copay after deductible
    Specialty Drugs: 50% Coinsurance after deductible

  • Benefits

    Dental Benefits: 3
    Vision Benefits: 2
    Hearing Benefits: 1
    Other Benefits: 29
    Adult Dental Care:
    Child Dental Care: 1
    Adult Routine Eye Exam:
    Child Routine Eye Exam: 1
    Hearing Aids: 1
    National Network Available:
    Health Savings Account Eligibility:
    Disease Management Programs: Asthma, Diabetes, Heart Disease, High Blood Pressure and High Cholesterol, Pregnancy, Weight Loss Programs

  • Plan Documents

    Provider Directory URL: https://healthnav.bcbsnc.com/?ci=COMMERCIAL&network_id=25
    Benefits Summary URL: https://www.bluecrossnc.com/sites/default/files/document/attachment/shopper/public/pdf/sbc/Blue_Home_Gold_2500_Plus_3_Free_PCP_with_UNC_Health_Alliance_2022.pdf
    Brochure URL: http://www.bluecrossnc.com/bhuncplanbrochure_2022

  • Policy Issuer Details

    Eligible Dependents: Self, Spouse, Child, Stepson or Stepdaughter, Life Partner, Foster Child, Ward
    Issuer: Blue Cross and Blue Shield of NC
    Issuer ID: 11512
    Issuer Shop URL: http://www.bcbsnc.com/content/plans/group-insurance.htm
    Customer Service Toll free Number: 1-888-868-5594
    Area: Rating Area 11

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