Blue Home Gold | 3 Free PCP | $10 Tier 1 Rx | with UNC Health Alliance – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$1,800 per person $1,800 per person
Out-of-pocket max	$9,100 per person $18,200 per family
Metal tier	Gold

Visit Copay

Primary care visit	$10 copay
Specialist visit	$40 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$40 copay
Emergency room	30% coinsurance after deductible
Ambulance	30% coinsurance after deductible
Hospital stay (facility)	30% coinsurance after deductible
Hospital stay (physician)	30% coinsurance after deductible
Outpatient procedure (facility)	30% coinsurance after deductible
Outpatient procedure (physician)	30% coinsurance after deductible
Physical rehabilitation	$40 copay

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$10 copay
Brand	$40 copay after deductible
Non-preferred Brand	$80 copay after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	30% coinsurance after deductible
Imaging (CT/PET/MRI)	30% coinsurance after deductible
Blood work	30% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$10 copay
Psychiatric hospital stay	30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.bcbsnc.com/assets/shopper/public/pdf/sbc/Blue_Home_Gold_1800_with_UNC_Health_Alliance_2024.pdf
Drug and medication plan formulary	https://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_NC_5T_HealthInsuranceMarketplace.pdf
Search doctor list	https://healthnav.bcbsnc.com/?ci=COMMERCIAL&network_id=25