DakotaBlue Trinity Gold ($5 Value Based Drug List) - 37160ND2480009 Health Insurance Plan
Blue Cross Blue Shield of North Dakota health insurance plan with the Plan ID 37160ND2480009. The plan is called DakotaBlue Trinity Gold ($5 Value Based Drug List).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 80.27% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 19.73% 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 80.09% (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 19.91% 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 | 37160ND2480009 | ||||||||||||||||||
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| 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 | 37160ND2480009-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED IN-NETWORK | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 17 Jun 2025 12:51 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 37160ND2480009-00 Standard On Exchange Plan - 37160ND2480009-01 |
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| Last Plan Update Date | Fri, 15 Nov 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 17 Jun 2025 12:51 GMT |
DakotaBlue Trinity Gold ($5 Value Based Drug List) Health Insurance Plan Variant 37160ND2480009-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.8008550287204019 |
| 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, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 90% |
| Formulary ID | NDF005 |
| Formulary URL | URL |
| HIOS Product ID | 37160ND248 |
| Import Date | 2024-11-15 00:01:36 |
| 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 | 80.27% |
| 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 | Yes |
| National Network | Yes |
| Network ID | NDN002 |
| 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) | 37160ND2480009-00 |
| Plan Marketing Name | DakotaBlue Trinity Gold ($5 Value Based Drug List) |
| Plan Type | PPO |
| Plan Variant Marketing Name | DakotaBlue Trinity Gold ($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 | $300 |
| 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 | $30 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,000 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 10% |
| Service Area ID | NDS003 |
| Source Name | HIOS |
| Plan ID | 37160ND2480009 |
| State Code | ND |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $55250 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $32625 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $32,625 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $29500 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $14750 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $14,750 |
| 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, In Network (Tier 2), Default Coinsurance | 50.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $6000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $3000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $3,000 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $19500 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $9750 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $9,750 |
| 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), In Network (Tier 2), Family Per Group | $18000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $9000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $9,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $32250 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $16125 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $16,125 |
| Unique Plan Design | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of DakotaBlue Trinity Gold ($5 Value Based Drug List) Health Insurance Plan, 37160ND2480009
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about DakotaBlue Trinity Gold ($5 Value Based Drug List), 37160ND2480009 Health Insurance Plan, 37160ND2480009
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Does DakotaBlue Trinity Gold ($5 Value Based Drug List) Health Insurance Plan, 37160ND2480009 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (37160ND2480009) Health Insurance Plan, Variant (37160ND2480009-00) offer Disease Management Programs?
Does (37160ND2480009) Health Insurance Plan, Variant (37160ND2480009-00) have Out Of Country Coverage?
Does (37160ND2480009) Health Insurance Plan, Variant (37160ND2480009-00) have Out of Service Area Coverage?
Does (37160ND2480009) Health Insurance Plan, Variant (37160ND2480009-00) offer Disease Management Programs?
Does DakotaBlue Trinity Gold ($5 Value Based Drug List) Health Insurance Plan, Variant (37160ND2480009-00) offer Disease Management Programs for Asthma?
Does DakotaBlue Trinity Gold ($5 Value Based Drug List) Health Insurance Plan, Variant (37160ND2480009-00) offer Disease Management Programs for Heart disease?
Does DakotaBlue Trinity Gold ($5 Value Based Drug List) Health Insurance Plan, Variant (37160ND2480009-00) offer Disease Management Programs for Depression?
Does DakotaBlue Trinity Gold ($5 Value Based Drug List) Health Insurance Plan, Variant (37160ND2480009-00) offer Disease Management Programs for Diabetes?
Does DakotaBlue Trinity Gold ($5 Value Based Drug List) Health Insurance Plan, Variant (37160ND2480009-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does DakotaBlue Trinity Gold ($5 Value Based Drug List) Health Insurance Plan, Variant (37160ND2480009-00) offer Disease Management Programs for Low back pain?
Does DakotaBlue Trinity Gold ($5 Value Based Drug List) Health Insurance Plan, Variant (37160ND2480009-00) offer Disease Management Programs for Pregnancy?
Does DakotaBlue Trinity Gold ($5 Value Based Drug List) Health Insurance Plan, Variant (37160ND2480009-00) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 17 Jun 2025 12:51 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