Blue Cross Blue Shield of North Dakota health insurance plan with the Plan ID 37160ND2410005. The plan is called BlueCare Gold $25 PCP Copay ($5 Value Based Drug List).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 79.06% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 20.94% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.85% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.15% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
Health Insurance Plan ID | 37160ND2410005 | ||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Health Insurance Plan Year | 2025 | ||||||||||||||||||
State | North Dakota | ||||||||||||||||||
Health Insurance Issuer | Blue Cross Blue Shield of North Dakota | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 37160ND2410005-00 | ||||||||||||||||||
Provider Network(s) | PREFERRED IN-NETWORK | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT). |
|
||||||||||||||||||
Available Variants of the Health Plan | Standard Off Exchange Plan - 37160ND2410005-00 Standard On Exchange Plan - 37160ND2410005-01 |
||||||||||||||||||
Last Plan Update Date | Fri, 18 Oct 2024 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 10 Dec 2024 06:32 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
Exclusions: Not covered except for those necessary to prevent the death of the woman. No benefits are available for removal of all or part of a multiple gestation. |
NO | ||
Accidental Dental
An accidental injury is defined as an injury that is the result of an external force causing a specific impairment to the jaw, sound natural teeth, dentures, mouth or face. Covered Services must be initiated within 6 months of the date of injury and completed within 24 months of the start of treatment or longer if a dental treatment plan approved by BCBSND is in place. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Acupuncture
|
NO | ||
Allergy Testing
Benefit includes serum, direct skin testing and patch testing when ordered by a Professional Health Care Provider and performed in accordance with medical guidelines and criteria established by BCBSND. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Bariatric Surgery
Limit: 1.0 Procedure(s) per Lifetime Bariatric surgery when Precertification is received from BCBSND. Covered Services must be received from a surgical facility approved by BCBSND. Benefits are subject to a Lifetime Maximum of 1 operative procedure per Member. Psychiatric and substance use services are excluded from the Lifetime Maximum. Guidelines and criteria are available upon request. Benefits for all proposed surgical procedures for the treatment of complications resulting from any or all types of bariatric surgery are available only when Precertification is received from BCBSND. |
YES | 30.00% Coinsurance after deductible |
100.00% |
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Chemotherapy
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Chiropractic Care
Limit: 20.0 Visit(s) per Benefit Period Exclusions: Maintenance care that is typically long-term. This includes care provided after maximum therapeutic improvement, without a trial of withdrawal of treatment, to prevent symptomatic deterioration or it may be initiated with patients without symptoms in order to promote health and to prevent further problems. All forms of thermography for all uses and indications. Clinical ecology, orthomolecular therapy, vitamins or dietary nutritional supplements, or related testing. Chiropractic services provided on an inpatient or outpatient basis when Medically Appropriate and Necessary as determined by BCBSND and within the scope of licensure and practice of a Chiropractor, to the extent services would be covered if provided by a Physician. |
YES | $25.00 |
50.00% Coinsurance after deductible |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
Exclusions: Collection and storage of umbilical cord blood. Abortion except for those necessary to prevent the death of the woman. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Dental Check-Up for Children
Limit: 2.0 Exam(s) per Benefit Period |
YES | $40.00 |
50.00% Coinsurance after deductible |
Diabetes Education
Diabetes Prevention Program for Members age 18 and older |
YES | 30.00% |
100.00% |
Dialysis
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Durable Medical Equipment
Exclusions: Benefits are not available for prosthetic limbs or components required for work-related tasks, leisure or recreational activities or to allow a member to participate in sport activities. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Emergency Room Services
|
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
Emergency Transportation/Ambulance
Medically Appropriate and Necessary Ambulance Services to the nearest facility equipped to provide the required level of care, including transportation: from the home or site of an Emergency Medical Condition; between hospitals; and between a Hospital and Skilled Nursing Facility. Benefits for air transportation are available only when ground transportation is not Medically Appropriate and Necessary as determined by BCBSND. |
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period Frames are limited to one every other benefit period. Lenses are limited to one pair per benefit period. |
YES | 30.00% Coinsurance after deductible |
100.00% |
Gender Affirming Care
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Generic Drugs
Exclusions: Drugs for weight loss, hair loss, cosmetic purposes, sexual dysfunction, infertility and medications obtained without a prescription order. Drugs and associated expenses and devices not approved by the FDA for a particular use except as required by law (unless the practitioner certifies off-label use with a letter of medical necessity). Prescription Medications or Drugs and nonprescription diabetic supplies are subject to a dispensing limit of a 90-day supply. Prescription Medication listed on the Value Drug list will apply a $5 copayment amount, then 100% of allowed charge. Preventive medications required under PPACA and the USPSTF are covered at 100%. An additional drug list is being added to address higher out-of-pocket costs on a sub-set of medications for individuals diagnosed with diabetes, hypertension, high cholesterol, asthma, etc.; i.e. chronic conditions. |
YES | $5.00 |
100.00% |
Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period Habilitative Physical Therapy, Occupational Therapy, or Speech Therapy. Therapy is care provided for conditions which have limited the normal age appropriate motor, sensory or communication development. To be considered habilitative, functional improvement and measurable progress must be made toward achieving functional goals within a predictable period of time toward a Member?s maximum potential. Functional skills are defined as essential activities of daily life common to all Members such as dressing, feeding, swallowing, mobility, transfers, fine motor skills, age appropriate activities and communication. Problems such as hearing impairment including deafness, a speech or language impairment, a visual impairment including blindness, serious emotional disturbance, an orthopedic impairment, autism spectrum disorders, traumatic brain injury, deaf-blindness, or multiple disabilities may warrant Habilitative Therapies. Measurable progress emphasizes accomplishment of functional skills and independence in the context of the Member?s potential ability as specified within a care plan or treatment goals. Benefits are subject to the Maximum Benefit Allowance listed in the Schedule of Benefits, Section 1, for each type of therapy under an individual medical plan (IMP) developed for each Member. Benefits are not available for Maintenance Care. Psychiatric and substance use services are excluded from the Maximum Benefit Allowance. |
YES | $25.00 |
50.00% Coinsurance after deductible |
Hearing Aids
Limit: 1.0 Visit(s) per 3 Years Exclusions: No benefits are available for a tinnitus masker. Subject to a Maximum Benefit Allowance per Member of 1 hearing aid per ear every 3 years. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Home Health Care Services
Limit: 40.0 Visit(s) per Benefit Period Covered Services include: 1. The professional services of an R.N., Licensed Vocational Nurse or L.P.N.; 2. Physical, Occupational or Speech Therapy; 3. Medical and surgical supplies; 4. Administration of prescribed drugs; 5. Oxygen and the administration of oxygen; and 6. Health aide services for a Member who is receiving covered Skilled Nursing Services or Therapy Services. A visit is considered up to 4 continuous hours. Psychiatric and substance use services are excluded from the Maximum Benefit Allowance. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Hospice Services
Hospice benefits are provided only for the treatment of Members diagnosed with a condition where there is a life expectancy of 6 months or less. Precertification is required. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Imaging (CT/PET Scans, MRIs)
PET Scan Benefits are available every six months per Member per Benefit Period with a Prostate Cancer Diagnosis. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Infertility Treatment
|
NO | ||
Infusion Therapy
Covered Services include the provision of nutrients, antibiotics, and other drugs and fluids intravenously, through a feeding tube, or by inhalation; all Medically Appropriate and Necessary supplies; and therapeutic drugs or other substances. Covered Services also include Medically Appropriate and Necessary enteral feedings when such feedings are the sole source of nutrition for a Member age 1 and older. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: Inpatient services performed primarily for diagnostic examinations, physical therapy, rest cure, convalescent care, custodial care, maintenance care or sanitaria care. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Inpatient Physician and Surgical Services
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Laboratory Outpatient and Professional Services
Exclusions: Genetic testing when performed in the absence of symptoms or high risk factors for a heritable disease; genetic testing when knowledge of genetic status will not affect treatment decisions, frequency of screening for the disease, or reproductive choices; genetic testing that has been performed in response to direct to consumer marketing and not under the direction of the members physician. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
Diagnosis and treatment of periodontal disease when recommended by a Health Care Provider based on health related impacts or further deterioration in existing acute or chronic disease state due to gum disease, including but not limited to periodontal scaling and root planing. |
NO | ||
Major Dental Care - Child
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Mental/Behavioral Health Inpatient Services
Benefits are available for the inpatient treatment of psychiatric illness, including management of medical problems related to an eating disorder diagnosis, when provided by an appropriately licensed and credentialed Hospital or Psychiatric Care Facility. Precertification may be required for Inpatient Hospital Admissions. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Mental/Behavioral Health Outpatient Services
Exclusions: Special education, Including lessons in sign language to instruct a Member whose ability to speak has been lost or impaired to function without that ability. Counseling or therapy services, Including bereavement, codependency, marital dysfunction, family dysfunction, sex or interpersonal relationship. Home and Office Visits Including assessment, counseling, case management services, Behavioral Modification Intervention for Autism Spectrum Disorder (Including Applied Behavioral Analysis (ABA), treatment planning, coordination of care, psychotherapy and group therapy; precertification may be required. Precertification is required for residential treatment.The cost sharing that displays applies to outpatient office visits only. All other outpatient services may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
YES | $25.00 |
50.00% Coinsurance after deductible |
Non-Preferred Brand Drugs
Exclusions: Drugs for weight loss, hair loss, cosmetic purposes, sexual dysfunction, infertility and medications obtained without a prescription order. Drugs and associated expenses and devices not approved by the FDA for a particular use except as required by law (unless the practitioner certifies off-label use with a letter of medical necessity). |
YES | $100.00 |
100.00% |
Nutritional Counseling
Limit: 12.0 Visit(s) per Benefit Period 12 visits each per benefit period for hyperlipedemia, gestational diabetes, diabetes mellitus, hypertension and other diabetes related diagnosis or a chronic illness or condition. Intensive Behavioral Interventions for Obesity allow 26 visits per Member per Benefit Period. Psychiatric and substance use services are excluded from the Maximum Benefit Allowance. |
YES | No Charge |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
Limit: 1.0 Treatment(s) per Lifetime Only for 'the treatment of improper alignment of biting or chewing surfaces of upper and lower teeth through the installation of orthodontic appliances.' |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: Services provided and billed by a registered nurse (other than an advanced practice registered nurse), intern (professionals in training), licensed athletic trainer or other paramedical personnel. Virtual Care and E-visits are $0 copay. |
YES | $25.00 |
50.00% Coinsurance after deductible |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Includes dental anesthesia and hospitalization for dental care to members under age 9 who have a medical condition that requires hospitalization. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Benefit Period Exclusions: Therapy Maintenance Care, work hardening programs, prevocational evaluation, functional capacity evaluations or group speech therapy services. Health and athletic club membership or facility use, and all services provided by the facility, including physical therapy, sports medicine therapy and physical exercise. Rehabilitative Services: therapies that are designed to restore function following a surgery or medical procedure, injury or illness. 30-visit limit is for each of PT, OT, and ST. Psychiatric and substance use services are excluded from the Maximum Benefit Allowance. Benefits are not available for Maintenance Care. |
YES | $25.00 |
50.00% Coinsurance after deductible |
Outpatient Surgery Physician/Surgical Services
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Preferred Brand Drugs
Exclusions: Drugs for weight loss, hair loss, cosmetic purposes, sexual dysfunction, infertility and medications obtained without a prescription order. Drugs and associated expenses and devices not approved by the FDA for a particular use except as required by law (unless the practitioner certifies off-label use with a letter of medical necessity). Prescription Medication listed on the Value Drug list will apply a $5 copayment amount, then 100% of allowed charge. Preventive medications required under PPACA and the USPSTF are covered at 100%. An additional drug list is being added to address higher out-of-pocket costs on a sub-set of medications for individuals diagnosed with diabetes, hypertension, high cholesterol, asthma, etc.; i.e. chronic conditions. Formulary insulin drugs & diabetes supplies obtainable with a Prescription Order shall not exceed a Cost Sharing Amount of $25.00 for a 30-day supply. Cost Sharing Amounts shall not exceed $25.00 for a 30-day supply of Nonformulary insulin drugs & diabetes supplies obtainable with a Prescription Order, when the Member follows the exceptions process for clinically appropriate drugs not listed on the formulary listing. |
YES | $50.00 |
100.00% |
Prenatal and Postnatal Care
Office visits for pre and post-natal care waive all cost sharing amounts. |
YES | No Charge |
50.00% Coinsurance after deductible |
Preventive Care/Screening/Immunization
Exclusions: Immunizations for Foreign Travel. Contraceptive products that do not require a prescription order or dispensing by a healthcare provider. Evaluations and related procedures to evaluate sterilization reversal procedures and the sterilzation reversal procedure. Preventive screening services for Members age 6 and older according to A or B Recommendations of the U.S. Preventive Services Task Force and issued by the Health Resources and Services Administration. |
YES | No Charge |
100.00% |
Primary Care Visit to Treat an Injury or Illness
Virtual Care and E-visits are $0 copay. |
YES | $25.00 |
50.00% Coinsurance after deductible |
Private-Duty Nursing
|
NO | ||
Prosthetic Devices
Precertification is required. Benefits are available for externally worn breast prostheses and surgical bras, including necessary replacements following mastectomy, subject to a Maximum Benefit Allowance of 2 external prostheses and 2 bras per Member per Benefit Period. For a double mastectomy, allow a Maximum Benefit Allowance of 4 external prostheses and 2 bras per Member per Benefit Period. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Radiation
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Reconstructive Surgery
Exclusions: Services or procedures with the primary purpose to improve appearance and not primary to restore bodily function or correct deformity resulting from disease, trauma, congenital or developmental anomalies or previous therapeutic processes, or which primarily improve or alter body features which are variations of normal development. Reconstructive surgery to restore bodily function or correct deformity resulting from disease, trauma, congenital or developmental anomalies or previous therapeutic processes. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Exclusions: Therapy Maintenance Care, work hardening programs, prevocational evaluation and functional capacity evaluations. Health and athletic club membership or facility use, and all services provided by the facility, including physical therapy, sports medicine therapy and physical exercise. Rehabilitative Services: therapies that are designed to restore function following a surgery or medical procedure, injury or illness. 30-visit limit is for each of PT, OT, and ST. Psychiatric and substance use services are excluded from the Maximum Benefit Allowance. Benefits are not available for Maintenance Care. |
YES | $25.00 |
50.00% Coinsurance after deductible |
Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Exclusions: Speech Therapy Maintenance Care and group speech therapy services. Rehabilitative Services: therapies that are designed to restore function following a surgery or medical procedure, injury or illness. |
YES | $25.00 |
50.00% Coinsurance after deductible |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
|
NO | ||
Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Benefit Period |
YES | $40.00 |
100.00% |
Routine Foot Care
Covered services include custom diabetic shoes and inserts, and the care of corns, calluses and toenails when medically appropriate and necessary for members with diabetes. Benefits are available for the care of corns, calluses and toenails when medically appropriate and necessary for members with circulatory disorders of the legs or feet. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Skilled Nursing Facility
Limit: 30.0 Days per Benefit Period Precertification is required. Psychiatric and substance use services are excluded from the Maximum Benefit Allowance. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Specialist Visit
|
YES | $45.00 |
50.00% Coinsurance after deductible |
Specialty Drugs
Exclusions: Drugs for weight loss, hair loss, cosmetic purposes, sexual dysfunction, infertility and medications obtained without a prescription order. Drugs and associated expenses and devices not approved by the FDA for a particular use except as required by law (unless the practitioner certifies off-label use with a letter of medical necessity). Preferred and Non-Preferred Specialty Drugs are subject to a dispensing limit of a 30-day supply. In limited circumstances Specialty Drugs may be available for a greater than 30-day supply. Non-Preferred Specialty drugs apply deductible and 50% coinsurance. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
Exclusions: Services by a vocational residential rehab center, a community reentry program, halfway house or group home. Benefits are available for the inpatient treatment of substance use, including medically managed inpatient detoxification, medically monitored inpatient detoxification, medically managed intensive inpatient treatment or medically monitored intensive inpatient treatment, when provided at an appropriately licensed and credentialed Substance Use Facility. Benefits available for residential treatment. Benefits available for partial hospitalization. Precertification is required. For SUD, Precertification is required for inpatient and residential. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Substance Abuse Disorder Outpatient Services
Home and Office Visits: Benefits Including assessment, counseling, case management services, treatment planning, coordination of care, psychotherapy, group therapy and Opioid Treatment Program provided by a licensed and/or credentialed independent provider in accordance with the Health Care Provider's scope of licensure as provided by law. Precertification may be required. Outpatient benefits include diagnostic, evaluation and treatment services provided by a licensed and credentialed indepedent provider in accordance with the health care provider's scope of licensure as provided by law. |
YES | $25.00 |
50.00% Coinsurance after deductible |
Transplant
Limit: 1.0 Exam(s) per Transplant Exclusions: Benefits are not available for transportation services for the member. Benefits are not available for artificial organs, donor search services or organ procurement if the organ or tissue is not donated. Benefits are not available if the member is the donor for transplant services. One evaluation is allowed per transplant procedure. Services must be performed at a qualified transplant center. Pre-transplant review or second opinion prior to the member's evaluation at the transplant center, are covered under the professional office visit benefit or the second surgical opinion benefit. Similarly, the post-transplant evaluation would be covered under the professional office visit benefit. |
YES | 30.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
Limit: 2.0 Treatment(s) per Lifetime Exclusions: No benefits will be provided for orthodontic services or osseointegrated implant surgery. Benefits are subject to a Lifetime Maximum of 2 surgical procedures per Member and a Maximum Benefit Allowance of 1 splint per Member per Benefit Period. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Urgent Care Centers or Facilities
|
YES | $25.00 |
50.00% Coinsurance after deductible |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
Limit: 11.0 Visit(s) per 3 Years Well Child Care through age 6, 100% of Allowed Charge. Deductible Amount is waived. |
YES | No Charge |
100.00% |
X-rays and Diagnostic Imaging
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.788540281940708 |
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2025 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | Standard Gold Off Exchange Plan |
Dental Only Plan | No |
Design Type | Not Applicable |
Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
EHB Percent of Total Premium | 1.0 |
First Tier Utilization | 100% |
Formulary ID | NDF005 |
Formulary URL | URL |
HIOS Product ID | 37160ND241 |
Import Date | 2024-10-18 01:02:01 |
Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
Inpatient Copayment Maximum Days | 0 |
HSA Eligible | No |
New/Existing Plan | Existing |
Notice Required for Pregnancy | No |
Is a Referral Required for Specialist? | No |
Issuer Actuarial Value | 79.06% |
Issuer ID | 37160 |
Issuer Marketplace Marketing Name | Blue Cross Blue Shield of North Dakota |
Market Coverage | Individual |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Gold |
Multiple In Network Tiers | No |
National Network | Yes |
Network ID | NDN001 |
Out of Country Coverage | Yes |
Out of Country Coverage Description | Medical assistance for Emergency Services (including locating a doctor or hospital) outside the BlueCard service area, the Member should call the BlueCard Worldwide Service Center at 1-800-810-BLUE (2583) or call collect at 1-804-673-1177, 24 hours a day, seven days a week. An assistance coordinator, working with a medical professional, can arrange a physician appointment or hospitalization, if necessary. |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | Whenever a member obtains healthcare services outside of the service area, claims will be processed at the in-network level if visiting providers participating with the BlueCard PPO Network. |
Plan Brochure | URL |
Plan Effective Date | 2025-01-01 |
Plan ID (Standard Component ID with Variant) | 37160ND2410005-00 |
Plan Marketing Name | BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) |
Plan Type | PPO |
Plan Variant Marketing Name | BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $3,200 |
SBC Scenario, Having a Baby, Copayment | $30 |
SBC Scenario, Having a Baby, Deductible | $2,000 |
SBC Scenario, Having a Baby, Limit | $20 |
SBC Scenario, Having Diabetes, Coinsurance | $50 |
SBC Scenario, Having Diabetes, Copayment | $500 |
SBC Scenario, Having Diabetes, Deductible | $200 |
SBC Scenario, Having Diabetes, Limit | $0 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $20 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $100 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,000 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | NDS004 |
Source Name | HIOS |
Plan ID | 37160ND2410005 |
State Code | ND |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $45000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $22500 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $22,500 |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $12000 per group |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $6000 per person |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $6,000 |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 30.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $4000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $2000 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $2,000 |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $8000 per group |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $4000 per person |
Combined Medical and Drug EHB Deductible, Out of Network, Individual | $4,000 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $15000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7500 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,500 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $30000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $15000 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $15,000 |
Unique Plan Design | Yes |
URL for Enrollment Payment | URL |
URL for Summary of Benefits & Coverage | URL |
Wellness Program Offered | Yes |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
---|
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API