Blue Local Bronze | 3 Free PCP | $20 Tier 1 Rx | Integrated | with Atrium Health – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$7,000 per person $7,000 per person
Out-of-pocket max	$9,450 per person $18,900 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	$100 copay
Specialist visit	$150 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$150 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	$150 copay

Maternitowny and Pregnancy

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

Pharmacy, Drugs, and Medication

Generic	$20 copay
Brand	50% coinsurance after deductible
Non-preferred Brand	50% coinsurance 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	$100 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_Local_Bronze_7000_with_Atrium_Health_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=9