Blue Home Bronze Complete | $60 PCP | $20 Tier 1 Rx | with UNC Health Alliance

Blue Cross and Blue Shield of NC

Expanded BronzeHSA eligible

Ind. deductible: $4,000
Family deductible: $4,000
Ind. OOP max: $10,600
Family OOP max: $10,600

Other cost-sharing reduction variants for this plan:

Limited Cost Sharing Plan Variation Standard Bronze Off Exchange Plan Zero Cost Sharing Plan Variation

Monthly premiums by age

Age	Individual	Individual + tobacco
21	$425	—
30	$482	—
40	$543	—
50	$758	—
60	$1,152	—

Live premium estimate

Benefits & cost sharing

Primary Care

Benefit	In-network
Preventive Care/Screening/Immunization	No charge
Primary Care Visit to Treat an Injury or Illness	No charge

Specialist

Benefit	In-network
Specialist Visit	No charge

Hospital

Benefit	In-network
Emergency Room Services	50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services	50.00% Coinsurance after deductible
Urgent Care Centers or Facilities	$120.00

Pharmacy

Benefit	In-network
Generic Drugs	$20.00
Non-Preferred Brand Drugs	$150.00 Copay after deductible
Preferred Brand Drugs	No charge
Specialty Drugs	50.00% Coinsurance after deductible

Mental Health

Benefit	In-network
Mental/Behavioral Health Inpatient Services	50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services	$60.00

Other

Benefit	In-network
Abortion for Which Public Funding is Prohibited	Not covered
Accidental Dental	50.00% Coinsurance after deductible
Acupuncture	Not covered
Allergy Testing	$120.00
Bariatric Surgery	50.00% Coinsurance after deductible
Basic Dental Care - Adult	Not covered
Basic Dental Care - Child	50.00% Coinsurance after deductible
Chemotherapy	50.00% Coinsurance after deductible
Chiropractic Care	$120.00
Cosmetic Surgery	Not covered
Delivery and All Inpatient Services for Maternity Care	No charge
Dental Check-Up for Children	No charge
Diabetes Education	$60.00
Dialysis	50.00% Coinsurance after deductible
Durable Medical Equipment	50.00% Coinsurance after deductible
Emergency Transportation/Ambulance	No charge
Eye Glasses for Children	No charge
Habilitation Services	No charge
Hearing Aids	50.00% Coinsurance after deductible
Home Health Care Services	50.00% Coinsurance after deductible
Hospice Services	50.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)	50.00% Coinsurance after deductible
Radiation	No charge
Reconstructive Surgery	50.00% Coinsurance after deductible
Infertility Treatment	$120.00
Infusion Therapy	No charge
Inpatient Physician and Surgical Services	50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services	No charge
Long-Term/Custodial Nursing Home Care	Not covered
Major Dental Care - Adult	Not covered
Major Dental Care - Child	No charge
Nutritional Counseling	No charge
Orthodontia - Adult	Not covered
Orthodontia - Child	No charge
Other Practitioner Office Visit (Nurse, Physician Assistant)	$120.00
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	50.00% Coinsurance after deductible
Outpatient Rehabilitation Services	No charge
Prenatal and Postnatal Care	50.00% Coinsurance after deductible
Private-Duty Nursing	50.00% Coinsurance after deductible
Prosthetic Devices	Not covered
Rehabilitative Occupational and Rehabilitative Physical Therapy	$120.00
Rehabilitative Speech Therapy	$120.00
Routine Dental Services (Adult)	Not covered
Routine Eye Exam (Adult)	Not covered
Routine Eye Exam for Children	No charge
Routine Foot Care	$120.00
Sex-Trait Modification	Not covered
Skilled Nursing Facility	No charge
Substance Abuse Disorder Inpatient Services	50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services	No charge
Tier 2 Rx	$25.00 Copay after deductible
Transplant	No charge
Treatment for Temporomandibular Joint Disorders	No charge
Weight Loss Programs	Not covered
Well Baby Visits and Care	No charge
X-rays and Diagnostic Imaging	50.00% Coinsurance after deductible

Plan rules

Service area

This plan covers 1 geographic area.