Blue Local Bronze 7500 (local network with Atrium Health) Plan Details for 2021- HealthPocket
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Blue Local Bronze 7500 (local network with Atrium Health)

$307.15/mo
View BrochureProduct BenefitsProvider DirectoryList of Covered Drugs

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Zip Code28269
Applicant1/16/1986 Male

Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameBlue Local Bronze 7500 (local network with Atrium Health)
Plan IDqhp-11512NC0140007
Plan Year2020
Insurance ProviderBlue Cross Blue Shield of North Carolina
Metal LevelExpanded Bronze
Plan TypePOS
Deductible$7,500
Out-of-Pocket Maximum$8,150
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$45 Copay
Specialist Visit$115 Copay
Laboratory Outpatient and Professional Services40.00% Coinsurance after deductible
X-rays and Diagnostic Imaging40.00% Coinsurance after deductible
Deductible - Family$15000
Out-of-Pocket Maximum - Family$16300

Prescription drug coverage

Generic Drugs$10 Copay
Preferred Brand Drugs$40 Copay
Non-Preferred Brand Drugs$80 Copay
Specialty Drugs25% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttps://healthnav.bcbsnc.com/?ci=COMMERCIAL&network_id=9

Hospital services

Emergency Room Services$650 Copay
Inpatient Hospital Services (e.g., Hospital Stay)40% Coinsurance after deductible
Inpatient Physician and Surgical Services40% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care40.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient ServicesNot Applicable
Mental/Behavioral Health Inpatient Services40.00% Coinsurance after deductible

Vision Coverage

Routine Eye Exam for ChildrenNot Applicable
Eye Glasses for Children50.00%

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Hospice Services
Infertility Treatment
Private-Duty Nursing
Urgent Care Centers or Facilities
Home Health Care Services
Inpatient Physician and Surgical Services
Bariatric Surgery
Skilled Nursing Facility
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Durable Medical Equipment
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Preventive Care/Screening/Immunization
Routine Foot Care
Dental Check-Up for Children
Rehabilitative Speech Therapy
Rehabilitative Occupational and Rehabilitative Physical Therapy
Well Baby Visits and Care
Transplant
Accidental Dental
Dialysis
Allergy Testing
Chemotherapy
Radiation
Diabetes Education
Infusion Therapy
Treatment for Temporomandibular Joint Disorders
Nutritional Counseling
Reconstructive Surgery
Non-Emergency Care When Traveling Outside of the U.S.
Dental Anesthesia
Diabetes Care Management
Clinical Trials
Congenital Anomaly, including Cleft Lip/Palate
Tier 2 Rx
Tier 6 Rx
Prenatal and Postnatal Care - Non-Global Maternity
More Excluded BenefitsLong-Term/Custodial Nursing Home Care
Cosmetic Surgery
Acupuncture
Weight Loss Programs
Abortion for Which Public Funding is Prohibited
Prosthetic Devices
Off-label Prescription Drugs
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  • Phone Number
    (704) 863-9830
  • Office Locations
    5727 Prosperity Crossing Drive
    Charlotte, NC 28269
5727 Prosperity Crossing Drive Charlotte NC, 28269

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HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Benefytt Technologies, Inc. family of companies.