Blue Value Bronze Standard 7500 | Statewide Doctors

11512NC0100074
Expanded Bronze
POS

Blue Value Bronze Standard 7500 | Statewide Doctors is an Expanded Bronze POS plan by Blue Cross and Blue Shield of NC.

IMPORTANT: You are viewing the 2023 version of Blue Value Bronze Standard 7500 | Statewide Doctors 11512NC0100074. You can enroll in this plan during open enrollment 2023, which started November 1st and ends January 15th, 2023, in most states.

Locations

Blue Value Bronze Standard 7500 | Statewide Doctors is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Blue Value Bronze Standard 7500 | Statewide Doctors 11512NC0100074.
Insurer: Blue Cross and Blue Shield of NC
Network Type: POS
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 11512NC0100074

Cost-Sharing Overview

Blue Value Bronze Standard 7500 | Statewide Doctors offers the following cost-sharing.

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 Value Bronze Standard 7500 | Statewide Doctors?

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 Value Bronze Standard 7500 | Statewide Doctors 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 Value Bronze Standard 7500 | Statewide Doctors covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Out of network benefits will apply
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Out of network benefits will apply
National Network: No

Additional Benefits and Cost-Sharing

Blue Value Bronze Standard 7500 | Statewide Doctors includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Hearing Aids
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible1 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
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
Covered
No Charge 30.00% Coinsurance after deductible
Routine Foot Care
Covered
$100.00 80.00% Coinsurance after deductible 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 30.00% Coinsurance after deductible1 Exam(s) per Benefit Period
Eye Glasses for Children
Covered
50.00% 50.00%1 Item(s) per Benefit Period
Dental Check-Up for Children
Covered
No Charge 30.00% Coinsurance after deductible2 Exam(s) per Benefit Period
Rehabilitative Speech Therapy
Covered
$50.00 80.00% Coinsurance after deductible30 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
$50.00 80.00% Coinsurance after deductible30 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 30.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit.
Basic Dental Care – Child
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible
Orthodontia – Child
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible
Major Dental Care – Child
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible
Basic Dental Care – Adult
Orthodontia – Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Transplant
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible
Accidental Dental
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit.
Dialysis
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible3 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
$100.00 80.00% Coinsurance after deductible For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit.
Chemotherapy
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit.
Radiation
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit.
Diabetes Education
Covered
$50.00 80.00% Coinsurance after deductible 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
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit.
Treatment for Temporomandibular Joint Disorders
Covered
$100.00 80.00% Coinsurance after deductible For services received in a hospital or facility outpatient setting, please refer to the Hospital Based Services benefit.
Nutritional Counseling
Covered
No Charge 30.00% Coinsurance after deductible30 Visit(s) per Benefit Period Nutritional counseling visits are separate from the obesity-related office visits.
Reconstructive Surgery
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible
Gender Affirming Care
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible 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
$25.00 $25.00 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
$500.00 Copay after deductible $500.00 Copay after deductible 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.
Primary Care Visit to Treat an Injury or Illness
Covered
$50.00 80.00% Coinsurance after deductible
Specialist Visit
Covered
$100.00 80.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$100.00 80.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible
Hospice Services
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible 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
$100.00 80.00% Coinsurance after deductible3 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
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
$75.00 $150.00
Home Health Care Services
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible
Emergency Room Services
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible
Bariatric Surgery
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible
Cosmetic Surgery
Skilled Nursing Facility
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible60 Days per Benefit Period
Prenatal and Postnatal Care
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible Typically covered as part of global maternity fee.
Delivery and All Inpatient Services for Maternity Care
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
Covered
$50.00 80.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
Covered
$50.00 80.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
Covered
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible
Generic Drugs
Covered
$25.00 $25.00 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
$50.00 Copay after deductible $50.00 Copay after deductible 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
$100.00 Copay after deductible $100.00 Copay after deductible 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
$500.00 Copay after deductible $500.00 Copay after deductible 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
$100.00 80.00% Coinsurance after deductible30 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
$100.00 80.00% Coinsurance after deductible30 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
$50.00 80.00% Coinsurance after deductible30 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
50.00% Coinsurance after deductible 80.00% Coinsurance after deductible Orthotic devices for correction of positional plagiocephaly are limited to 1 device per lifetime.
Prenatal and Postnatal Care – Non-Global Maternity
Covered
$50.00 80.00% Coinsurance after deductible 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 Value Bronze Standard 7500 | Statewide Doctors 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.

Additional Resources

Below are additional resources for Blue Value Bronze Standard 7500 | Statewide Doctors 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 Value Bronze Standard 7500 | Statewide Doctors?

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

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