Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health
11512NC0420042
Bronze
EPO
Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health is a Bronze EPO plan by Blue Cross and Blue Shield of NC.
IMPORTANT: You are viewing the 2023 version of Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health 11512NC0420042. You can enroll in this plan if you qualify for special enrollment until the end of 2023.
Locations
Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health is offered in the following counties.
Plan Overview
This is a plan overview for 2023 version of Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health 11512NC0420042.
| Insurer: | Blue Cross and Blue Shield of NC |
| Network Type: | EPO |
| Metal Type: | Bronze |
| HSA Eligible?: | No |
| Plan ID: | 11512NC0420042 |
Cost-Sharing Overview
Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $9,100.00 | $9100 per person | $18200 per group |
| Deductible: | $9,100.00 | $9100 per person | $18200 per group |
| Coinsurance: | 0.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | Not Applicable | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | Not Applicable | per person not applicable | per group not applicable |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $9,100.00 |
| Copayment: | $0.00 |
| Coinsurance: | $0.00 |
| Limit: | $60.00 |
| Deductible: | $5,400.00 |
| Copayment: | $0.00 |
| Coinsurance: | $0.00 |
| Limit: | $20.00 |
| Deductible: | $2,800.00 |
| Copayment: | $0.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
Notes:
- Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
- You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904
Plan Features
Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health offers the following features and referral requirements.
| Wellness Program: | Yes |
| Disease Program: | Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs |
| Notice Pregnancy: | No |
| Referral Specialist: | No |
| Specialist Requiring Referral: | |
| Plan Exclusions: | |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health covers when you are out of the service area or out of the country.
| Out of Country Coverage: | No |
| Out of Country Coverage Description: | No coverage except for Urgent and Emergent care |
| Out of Service Area Coverage: | No |
| Out of Service Area Coverage Description: | No coverage except for Urgent and Emergent care |
| National Network: | No |
Additional Benefits and Cost-Sharing
Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health includes the following benefits at the cost sharing rates listed below.
| Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
|---|---|---|---|
| Primary Care Visit to Treat an Injury or Illness Covered | No Charge after deductible | 100.00% | |
| Specialist Visit Covered | No Charge after deductible | 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | No Charge after deductible | 100.00% | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | No Charge after deductible | 100.00% | |
| Outpatient Surgery Physician/Surgical Services Covered | No Charge after deductible | 100.00% | |
| Hospice Services Covered | No Charge after deductible | 100.00% | Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less. |
| Routine Dental Services (Adult) | |||
| Infertility Treatment Covered | No Charge after deductible | 100.00% | 3 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 Blue Cross NC medical policies, which are guides considered by Blue Cross NC when making coverage determinations. For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
| Long-Term/Custodial Nursing Home Care | |||
| Private-Duty Nursing Covered | No Charge after deductible | 100.00% | |
| Routine Eye Exam (Adult) | |||
| Urgent Care Centers or Facilities Covered | No Charge after deductible | 0.00% Coinsurance after deductible | |
| Home Health Care Services Covered | No Charge after deductible | 100.00% | |
| Emergency Room Services Covered | No Charge after deductible | No Charge after deductible | |
| Emergency Transportation/Ambulance Covered | No Charge after deductible | ||
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | No Charge after deductible | 100.00% | |
| Inpatient Physician and Surgical Services Covered | No Charge after deductible | 100.00% | |
| Bariatric Surgery Covered | No Charge after deductible | 100.00% | |
| Cosmetic Surgery | |||
| Skilled Nursing Facility Covered | No Charge after deductible | 100.00% | 60 Days per Benefit Period |
| Prenatal and Postnatal Care Covered | No Charge after deductible | 100.00% | Typically covered as part of global maternity fee. |
| Delivery and All Inpatient Services for Maternity Care Covered | No Charge after deductible | 100.00% | |
| Mental/Behavioral Health Outpatient Services Covered | No Charge after deductible | 100.00% | |
| Mental/Behavioral Health Inpatient Services Covered | No Charge after deductible | 100.00% | |
| Substance Abuse Disorder Outpatient Services Covered | No Charge after deductible | 100.00% | |
| Substance Abuse Disorder Inpatient Services Covered | No Charge after deductible | 100.00% | |
| Generic Drugs Covered | No Charge after deductible | 100.00% | Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. Six tier levels apply to prescription drug coverage. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits may apply. See formulary. |
| Preferred Brand Drugs Covered | No Charge after deductible | 100.00% | Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. Six tier levels apply to prescription drug coverage. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits may apply. See formulary. |
| Non-Preferred Brand Drugs Covered | No Charge after deductible | 100.00% | Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. Six tier levels apply to prescription drug coverage. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits may apply. See formulary. |
| Specialty Drugs Covered | No Charge after deductible | 100.00% | Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. Six tier levels apply to prescription drug coverage. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits may apply. See formulary. |
| Outpatient Rehabilitation Services Covered | No Charge after deductible | 100.00% | 30 Visit(s) per Benefit Period Cognitive therapy Combined 30 visit limit for occupational and physical therapies and chiropractic services. For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
| Habilitation Services Covered | No Charge after deductible | 100.00% | 30 Visit(s) per Benefit Period Combined 30 visit limit for occupational and physical therapies and chiropractic services. For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
| Chiropractic Care Covered | No Charge after deductible | 100.00% | 30 Visit(s) per Benefit Period Combined 30 visit limit for occupational and physical therapies and chiropractic services. For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
| Durable Medical Equipment Covered | No Charge after deductible | 100.00% | Orthotic devices for correction of positional plagiocephaly are limited to 1 device per lifetime. |
| Hearing Aids Covered | No Charge after deductible | 100.00% | 1 Item(s) per 3 Years One hearing aid per hearing impaired ear, and replacement hearing aids based on medical necessity. Once every 36 months. |
| Imaging (CT/PET Scans, MRIs) Covered | No Charge after deductible | 100.00% | |
| Preventive Care/Screening/Immunization Covered | No Charge | 100.00% | |
| Routine Foot Care Covered | No Charge after deductible | 100.00% | Routine foot care that is palliative or cosmetic. Routine Foot Care services are covered only in presence of a medical condition. For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
| Acupuncture | |||
| Weight Loss Programs | |||
| Routine Eye Exam for Children Covered | No Charge | 100.00% | 1 Exam(s) per Benefit Period |
| Eye Glasses for Children Covered | No Charge after deductible | 100.00% | 1 Item(s) per Benefit Period |
| Dental Check-Up for Children Covered | No Charge | 100.00% | 2 Exam(s) per Benefit Period |
| Rehabilitative Speech Therapy Covered | No Charge after deductible | 100.00% | 30 Visit(s) per Benefit Period For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | No Charge after deductible | 100.00% | 30 Visit(s) per Benefit Period Cognitive therapy Combined 30 visit limit for occupational and physical therapies and chiropractic services. For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
| Well Baby Visits and Care Covered | No Charge | 100.00% | |
| Laboratory Outpatient and Professional Services Covered | No Charge after deductible | 100.00% | |
| X-rays and Diagnostic Imaging Covered | No Charge after deductible | 100.00% | For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
| Basic Dental Care – Child Covered | No Charge after deductible | 100.00% | |
| Orthodontia – Child Covered | No Charge after deductible | 100.00% | |
| Major Dental Care – Child Covered | No Charge after deductible | 100.00% | |
| Basic Dental Care – Adult | |||
| Orthodontia – Adult | |||
| Major Dental Care – Adult | |||
| Abortion for Which Public Funding is Prohibited | |||
| Transplant Covered | No Charge after deductible | 100.00% | |
| Accidental Dental Covered | No Charge after deductible | 100.00% | For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
| Dialysis Covered | No Charge after deductible | 100.00% | 3 Treatment(s) per Week Three treatments per week, more treatments are available if medically necessary. For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
| Allergy Testing Covered | No Charge after deductible | 100.00% | For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
| Chemotherapy Covered | No Charge after deductible | 100.00% | For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
| Radiation Covered | No Charge after deductible | 100.00% | For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
| Diabetes Education Covered | No Charge after deductible | 100.00% | For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
| Prosthetic Devices Not Covered | See Durable Medical Equipment | ||
| Infusion Therapy Covered | No Charge after deductible | 100.00% | For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
| Treatment for Temporomandibular Joint Disorders Covered | No Charge after deductible | 100.00% | For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit. |
| Nutritional Counseling Covered | No Charge | 100.00% | 30 Visit(s) per Benefit Period Nutritional counseling visits are separate from the obesity-related office visits. |
| Reconstructive Surgery Covered | No Charge after deductible | 100.00% | |
| Gender Affirming Care Covered | No Charge after deductible | 100.00% | For services rendered in an office setting, please refer to the Primary Care visit or the Specialist visit benefit. For services rendered in an inpatient hospital setting, please refer to the Inpatient Hospital and Physician services benefit. |
| Tier 2 Rx Covered | No Charge after deductible | 100.00% | Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. Six tier levels apply to prescription drug coverage. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits may apply. See formulary. |
| Tier 6 Rx Covered | No Charge after deductible | 100.00% | Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. Six tier levels apply to prescription drug coverage. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits may apply. See formulary. |
| Prenatal and Postnatal Care – Non-Global Maternity Covered | No Charge after deductible | 100.00% | Services that are not part of the global maternity benefit. For global maternity benefit, see Prenatal and Postnatal Care. |
Free Preventive Services
There is no copayment or coinsurance for any of the following Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health preventive services. This is true even if you haven’t met your yearly deductible.
Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.
| Summary of Benefits: | Summary of Benefits Link |
| Plan Brochure: | Plan Brochure Link |
| Formulary: | Formulary Link |
| Premium Payment Website: | Premium Payment Link |
Ready to sign up for Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904