Blue Advantage Silver Choice A | 3 Free PCP | $15 Tier 1 Rx | Nationwide Doctors

Blue Cross and Blue Shield of NC

Silver

Ind. deductible: $3,000
Family deductible: $3,000
Ind. OOP max: $10,600
Family OOP max: $10,600

Other cost-sharing reduction variants for this plan:

73% AV Level Silver Plan 87% AV Level Silver Plan 94% AV Level Silver Plan Limited Cost Sharing Plan Variation Standard Silver Off Exchange Plan Zero Cost Sharing Plan Variation

Monthly premiums by age

Age	Individual	Individual + tobacco
21	$688	—
30	$781	—
40	$880	—
50	$1,229	—
60	$1,868	—

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	$45.00

Specialist

Benefit	In-network
Specialist Visit	$25.00

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	No charge

Pharmacy

Benefit	In-network
Generic Drugs	$5.00
Non-Preferred Brand Drugs	$80.00 Copay after deductible
Preferred Brand Drugs	$40.00 Copay after deductible
Specialty Drugs	50.00% Coinsurance after deductible

Mental Health

Benefit	In-network
Mental/Behavioral Health Inpatient Services	40.00%
Mental/Behavioral Health Outpatient Services	$5.00

Other

Benefit	In-network
Major Dental Care - Child	40.00% Coinsurance after deductible
Basic Dental Care - Child	50.00% Coinsurance after deductible
Chemotherapy	40.00% Coinsurance after deductible
Abortion for Which Public Funding is Prohibited	Not covered
Accidental Dental	50.00% Coinsurance after deductible
Acupuncture	Not covered
Allergy Testing	No charge
Bariatric Surgery	50.00% Coinsurance after deductible
Basic Dental Care - Adult	Not covered
Chiropractic Care	$90.00
Cosmetic Surgery	Not covered
Delivery and All Inpatient Services for Maternity Care	No charge
Dental Check-Up for Children	No charge
Diabetes Education	$45.00
Dialysis	50.00% Coinsurance after deductible
Durable Medical Equipment	40.00% Coinsurance after deductible
Emergency Transportation/Ambulance	40.00% Coinsurance after deductible
Eye Glasses for Children	No charge
Habilitation Services	$90.00
Hearing Aids	50.00% Coinsurance after deductible
Home Health Care Services	50.00% Coinsurance after deductible
Hospice Services	40.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)	40.00%
Infertility Treatment	No charge
Infusion Therapy	50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services	50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services	40.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care	Not covered
Major Dental Care - Adult	Not covered
Nutritional Counseling	No charge
Orthodontia - Adult	Not covered
Orthodontia - Child	50.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)	$90.00
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	50.00% Coinsurance after deductible
Outpatient Rehabilitation Services	50.00% Coinsurance after deductible
Prenatal and Postnatal Care	40.00% Coinsurance after deductible
Private-Duty Nursing	40.00% Coinsurance after deductible
Prosthetic Devices	Not covered
Radiation	No charge
Reconstructive Surgery	No charge
Rehabilitative Occupational and Rehabilitative Physical Therapy	$25.00
Rehabilitative Speech Therapy	$90.00
Routine Dental Services (Adult)	Not covered
Routine Eye Exam (Adult)	Not covered
Routine Eye Exam for Children	No charge
Routine Foot Care	$25.00
Sex-Trait Modification	50.00% Coinsurance after deductible
Skilled Nursing Facility	50.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services	50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services	$45.00
Tier 2 Rx	$30.00 Copay after deductible
Transplant	50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders	$90.00
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 90 geographic areas.