Blue Care Bronze HSA Eligible | Integrated | Statewide Doctors

Blue Cross and Blue Shield of NC

Expanded BronzeHSA eligible

Ind. deductible: $8,500
Family deductible: $8,500
Ind. OOP max: $8,500
Family OOP max: $8,500

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	$533	—
30	$605	—
40	$681	—
50	$952	—
60	$1,446	—

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	0.00% Coinsurance after deductible

Specialist

Benefit	In-network
Specialist Visit	No charge

Hospital

Benefit	In-network
Emergency Room Services	0.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	No charge
Outpatient Surgery Physician/Surgical Services	0.00% Coinsurance after deductible
Urgent Care Centers or Facilities	0.00% Coinsurance after deductible

Pharmacy

Benefit	In-network
Generic Drugs	0.00% Coinsurance after deductible
Non-Preferred Brand Drugs	No charge
Preferred Brand Drugs	0.00% Coinsurance after deductible
Specialty Drugs	0.00% Coinsurance after deductible

Mental Health

Benefit	In-network
Mental/Behavioral Health Inpatient Services	No charge
Mental/Behavioral Health Outpatient Services	No charge

Other

Benefit	In-network
Abortion for Which Public Funding is Prohibited	Not covered
Accidental Dental	0.00% Coinsurance after deductible
Acupuncture	Not covered
Allergy Testing	0.00% Coinsurance after deductible
Bariatric Surgery	0.00% Coinsurance after deductible
Basic Dental Care - Adult	Not covered
Basic Dental Care - Child	0.00% Coinsurance after deductible
Chemotherapy	0.00% Coinsurance after deductible
Chiropractic Care	0.00% Coinsurance after deductible
Cosmetic Surgery	Not covered
Delivery and All Inpatient Services for Maternity Care	0.00% Coinsurance after deductible
Dental Check-Up for Children	No charge
Diabetes Education	0.00% Coinsurance after deductible
Dialysis	No charge
Durable Medical Equipment	0.00% Coinsurance after deductible
Emergency Transportation/Ambulance	No charge
Eye Glasses for Children	0.00% Coinsurance after deductible
Habilitation Services	0.00% Coinsurance after deductible
Hearing Aids	No charge
Home Health Care Services	0.00% Coinsurance after deductible
Hospice Services	0.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)	0.00% Coinsurance after deductible
Reconstructive Surgery	0.00% Coinsurance after deductible
Infertility Treatment	0.00% Coinsurance after deductible
Infusion Therapy	0.00% Coinsurance after deductible
Inpatient Physician and Surgical Services	0.00% 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	0.00% Coinsurance after deductible
Nutritional Counseling	No charge
Orthodontia - Adult	Not covered
Orthodontia - Child	0.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)	0.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	0.00% Coinsurance after deductible
Outpatient Rehabilitation Services	0.00% Coinsurance after deductible
Prenatal and Postnatal Care	0.00% Coinsurance after deductible
Private-Duty Nursing	No charge
Prosthetic Devices	Not covered
Radiation	0.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy	No charge
Rehabilitative Speech Therapy	0.00% Coinsurance after deductible
Routine Dental Services (Adult)	Not covered
Routine Eye Exam (Adult)	Not covered
Routine Eye Exam for Children	No charge
Routine Foot Care	0.00% Coinsurance after deductible
Sex-Trait Modification	Not covered
Skilled Nursing Facility	No charge
Substance Abuse Disorder Inpatient Services	0.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services	0.00% Coinsurance after deductible
Tier 2 Rx	0.00% Coinsurance after deductible
Transplant	0.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders	0.00% Coinsurance after deductible
Weight Loss Programs	Not covered
Well Baby Visits and Care	No charge
X-rays and Diagnostic Imaging	0.00% Coinsurance after deductible

Plan rules

Service area

This plan covers 90 geographic areas.