BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) - 37160ND2410005 Health Insurance Plan

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).

Providers North Dakota All US States
All 8607 76745
PCP 739 1272
Allergy 1 5
OB/GYN 19 37
Dentists 226 280
Available Variants of the Health Plan

Standard Off Exchange Plan - 37160ND2410005-00

Standard On Exchange Plan - 37160ND2410005-01

Open to Indians below 300% FPL - 37160ND2410005-02

Open to Indians above 300% FPL - 37160ND2410005-03

Last Plan Update Date Fri, 18 Oct 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) Health Insurance Plan, 37160ND2410005-00

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

BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) Health Insurance Plan Variant 37160ND2410005-00 Attributes

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

Copay & Coinsurance of BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) Health Insurance Plan, 37160ND2410005

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about BlueCare Gold $25 PCP Copay ($5 Value Based Drug List), 37160ND2410005 Health Insurance Plan, 37160ND2410005

  • Does BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) Health Insurance Plan, 37160ND2410005 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (37160ND2410005) Health Insurance Plan, Variant (37160ND2410005-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does (37160ND2410005) Health Insurance Plan, Variant (37160ND2410005-00) have Out Of Country Coverage?

    Yes. Details: 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.

    Does (37160ND2410005) Health Insurance Plan, Variant (37160ND2410005-00) have Out of Service Area Coverage?

    Yes. Details: 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.

    Does (37160ND2410005) Health Insurance Plan, Variant (37160ND2410005-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) Health Insurance Plan, Variant (37160ND2410005-00) offer Disease Management Programs for Asthma?

    Yes, the BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) Health Insurance Plan Variant 37160ND2410005-00 offers Disease Management Program for Asthma.

    Does BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) Health Insurance Plan, Variant (37160ND2410005-00) offer Disease Management Programs for Heart disease?

    Yes, the BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) Health Insurance Plan Variant 37160ND2410005-00 offers Disease Management Program for Heart disease.

    Does BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) Health Insurance Plan, Variant (37160ND2410005-00) offer Disease Management Programs for Depression?

    Yes, the BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) Health Insurance Plan Variant 37160ND2410005-00 offers Disease Management Program for Depression.

    Does BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) Health Insurance Plan, Variant (37160ND2410005-00) offer Disease Management Programs for Diabetes?

    Yes, the BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) Health Insurance Plan Variant 37160ND2410005-00 offers Disease Management Program for Diabetes.

    Does BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) Health Insurance Plan, Variant (37160ND2410005-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) Health Insurance Plan Variant 37160ND2410005-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) Health Insurance Plan, Variant (37160ND2410005-00) offer Disease Management Programs for Low back pain?

    Yes, the BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) Health Insurance Plan Variant 37160ND2410005-00 offers Disease Management Program for Low back pain.

    Does BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) Health Insurance Plan, Variant (37160ND2410005-00) offer Disease Management Programs for Pregnancy?

    Yes, the BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) Health Insurance Plan Variant 37160ND2410005-00 offers Disease Management Program for Pregnancy.

    Does BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) Health Insurance Plan, Variant (37160ND2410005-00) offer Disease Management Programs for Weight loss programs?

    Yes, the BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) Health Insurance Plan Variant 37160ND2410005-00 offers Disease Management Program for Weight loss programs.

 

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