Blue Home Silver Choice | 3 Free PCP | $15 Tier 1 Rx | with UNC Health Alliance – EPO

Network type: EPO
Coverage tier: Silver
Primary care visit: $50 copay
Specialist visit: $100 copay
Urgent care visit: $100 copay

Description

Health Care Plan Details

Network type EPO
Deductible $3,500 per person $3,500 per person
Out-of-pocket max $9,450 per person $18,900 per family
Metal tier Silver

Visit Copay

Primary care visit $50 copay
Specialist visit $100 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $100 copay
Emergency room 50% coinsurance after deductible
Ambulance 50% coinsurance after deductible
Hospital stay (facility) 50% coinsurance after deductible
Hospital stay (physician) 50% coinsurance after deductible
Outpatient procedure (facility) 50% coinsurance after deductible
Outpatient procedure (physician) 50% coinsurance after deductible
Physical rehabilitation $100 copay

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic $15 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 50% coinsurance after deductible
Imaging (CT/PET/MRI) 50% coinsurance after deductible
Blood work 50% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services $50 copay
Psychiatric hospital stay 50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://www.bcbsnc.com/assets/shopper/public/pdf/sbc/Blue_Home_Silver_Choice_3500_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