North Dakota health plan · 2026

DakotaBlue Trinity Silver ($5 Value Based Drug List) · 37160ND2480010

Blue Cross Blue Shield of North Dakota offers this marketplace health insurance plan (Plan ID 37160ND2480010) so you can compare premiums, coverage levels, and provider access against other health plan insurance options. Use the modules below to decide whether this is the best health insurance plan for your household or if another insurance health plan fits better.

Metal level: Silver Plan type: PPO CSR: Standard Silver Off Exchange Plan Issuer: Blue Cross Blue Shield of North Dakota
Telehealth Data pending HSA eligible No Dental Child Vision Child
Pay / Manage Plan View issuer site

Issuer actuarial value: 71.19%. Expect to pay roughly 28.81% of covered costs out of pocket, based on issuer reporting.

CMS AV Calculator output: 70.17% (29.83% member share on average). Learn about AV methodology.

2026 cost summary

Key premiums & cost sharing

Rates mirror the latest CMS import (Tue, 02 Dec 2025 06:13 GMT). Personalize costs with your ZIP, age, and subsidies in the plan finder.

Monthly premium

$361 – $1417

Before subsidies

Estimate after subsidies

Deductible

$3,500

$7000 per group

See deductible details

Max out-of-pocket

$9,500

$19000 per group

Review MOOP rules

Office visits

Primary care $20.00
Specialist $80.00
HSA Not eligible

Drug tiers

Generic $20.00
Preferred brand $150.00

View formulary tiers

$495 / mo before subsidies

≈ $5942 per year before tax credits.

Start with this unsubsidized premium, then apply marketplace tax credits to see your final monthly payment.

  • Ideal for shoppers comparing Bronze vs. Silver budgets.
  • Update your Marketplace application to apply premium tax credits.

$1569 / mo before subsidies

≈ $18830 per year before tax credits.

Pre-subsidy rate for a couple with one dependent. Switch to Silver CSR plans if you qualify to reduce these numbers.

  • Compares well against PPO vs HMO networks when planning for childcare and telehealth needs.
  • This Silver tier qualifies for CSR if household income is ≤250% FPL.

$1900 / mo before subsidies

≈ $22804 per year before tax credits.

Pairs with cost-sharing reductions (CSR) when you select a Silver tier and qualify based on income.

  • Use this estimate before adding childcare, dental, or vision extras.
  • CSR Silver variants can lower deductibles dramatically for eligible incomes.
  • This Silver tier qualifies for CSR if household income is ≤250% FPL.

$1208 / mo before subsidies

≈ $14492 per year before tax credits.

Shows the combined pre-subsidy rate for two adults. Add dependents or subsidies in your application to refine it.

  • Great for households deciding between PPO and HMO networks.
  • Telehealth and HSA perks (when offered) apply to both members.
Issuer profile See benefits

Preventive Care/Screening/Immunization

No Charge, No Charge

Emergency Room Services

40.00% Coinsurance after deductible

Durable Medical Equipment

40.00% Coinsurance after deductible

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Enrollment guidance

Stay on top of 2026 ACA deadlines

Open Enrollment window

Marketplace enrollment for 2026 coverage typically runs Nov 1 – Jan 15 (dates may vary slightly in North Dakota). Submit changes before the deadline to avoid a coverage gap.

  • Enroll by Dec 15 for Jan 1 starts.
  • Finalize plan switches before the window closes.

Special Enrollment Periods

You can change plans mid-year if you experience a qualifying life event (move, childbirth, marriage, loss of other coverage).

  • Report the event within 60 days.
  • Keep documentation handy for Healthcare.gov or your state exchange.

CSR & subsidy reminders

Premium tax credits and cost-sharing reductions (CSR) update annually when you re-submit your marketplace application.

  • Enter accurate income to maximize Advanced Premium Tax Credits.
  • Standard Silver Off Exchange Plan plans like this one keep deductibles and copays lower if you qualify.

Thinking about switching?

Before you leave your current plan, compare networks, drug coverage, and total cost using the cards on this page.

  • Match provider networks so ongoing care isn’t disrupted.
  • Confirm prescriptions stay on-formulary or budget for tier changes.

Top covered benefits

How this plan handles key care scenarios

Preventive Care/Screening/Immunization

No Charge, No Charge

Emergency Room Services

40.00% Coinsurance after deductible

Durable Medical Equipment

40.00% Coinsurance after deductible

Premium snapshot

Plan identifiers & filings

Track the official identifiers, documents, and filing dates tied to this plan. Open the marketing or formulary links whenever you need the latest PDF from the issuer.

Plan ID 37160ND2480010
Coverage year 2026
State North Dakota
Issuer Blue Cross Blue Shield of North Dakota
Formulary document Download formulary
Marketing materials View marketing kit
Variant ID 37160ND2480010-00
Available variants

Standard Off Exchange Plan · 37160ND2480010-00

Standard On Exchange Plan · 37160ND2480010-01

Open to Indians below 300% FPL · 37160ND2480010-02

Open to Indians above 300% FPL · 37160ND2480010-03

73% AV Silver Plan · 37160ND2480010-04

87% AV Silver Plan · 37160ND2480010-05

94% AV Silver Plan · 37160ND2480010-06
Last plan update Wed, 29 Oct 2025 00:00 GMT
Last HealthPorta import Tue, 02 Dec 2025 06:13 GMT

Network stats

Provider access snapshot

Review the network branding plus the number of in-network clinicians we track from issuer filings. Counts update with each CMS import (Tue, 02 Dec 2025 06:13 GMT).

All providers in North Dakota 8849
PCPs in North Dakota 765
Telehealth support Data pending
Nationwide providers 11202
8,849 doctors statewide 765 PCPs 17 OB/GYN

Provider network(s)

Providers North Dakota All US states
All 8849 11202
PCP 765 1085
Allergy 2 4
OB/GYN 17 27
Dentists 216 256

Drug coverage overview

4,235 drugs tracked

Inspect tier distribution plus authorization, step therapy, and quantity-limit counts sourced from HealthPorta’s formulary import.

Tier Covered drugs
NON-PREFERRED-GENERIC 2,380
NON-PREFERRED-BRAND 958
NON-PREFERRED-SPECIALTY 897
Prior authorization Drugs
Required 884
Not Required 3,351
Step therapy Drugs
Required 46
Not Required 4,189
Quantity limits Drugs
Has Limit 1,263
No Limit 2,972

Customer highlights

What stands out for members

  • Issuer: Blue Cross Blue Shield of North Dakota · Plan ID 37160ND2480010 · 2026 filing.
  • Disease management programs available: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs.
  • Download the latest formulary directly from the issuer here.
  • Review marketing brochures and SBC PDFs via the issuer marketing repository.
  • Variant 37160ND2480010-00 (Standard Off Exchange Plan) currently displayed.
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Benefits

Covered services & limitations

Everyday care

Office visits, preventive care, labs, imaging, and home health.

Chiropractic Care

$20.00
Tier 1 in-network $20.00
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 20.0 Visit(s) per Benefit Period

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.

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.

Diabetes Education

40.00%
Tier 1 in-network 40.00%
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 100.00%

Diabetes Prevention Program

Home Health Care Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

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.

Laboratory Outpatient and Professional Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

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.

Other Practitioner Office Visit (Nurse, Physician Assistant)

$20.00
Tier 1 in-network $20.00
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Virtual Care and E-visits are $0 copay.

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.

Preventive Care/Screening/Immunization

No Charge, No Charge
Tier 1 in-network No Charge, No Charge
Tier 2 in-network No Charge, No Charge
Out-of-network 100.00%

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.

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.

Primary Care Visit to Treat an Injury or Illness

$20.00
Tier 1 in-network $20.00
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Virtual Care and E-visits are $0 copay.

Rehabilitative Occupational and Rehabilitative Physical Therapy

$20.00
Tier 1 in-network $20.00
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 30.0 Visit(s) per Year

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.

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 Speech Therapy

$20.00
Tier 1 in-network $20.00
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 30.0 Visit(s) per Year

Rehabilitative Services: therapies that are designed to restore function following a surgery or medical procedure, injury or illness.

Exclusions: Speech Therapy Maintenance Care and group speech therapy services.

Specialist Visit

$80.00
Tier 1 in-network $80.00
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Urgent Care Centers or Facilities

$20.00
Tier 1 in-network $20.00
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

X-rays and Diagnostic Imaging

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Hospital & urgent

Emergency room, inpatient stays, ambulance, and surgeries.

Chemotherapy

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Delivery and All Inpatient Services for Maternity Care

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Collection and storage of umbilical cord blood. Abortion except for those necessary to prevent the death of the woman.

Dialysis

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Durable Medical Equipment

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Out of state non-participating health care provider waiver may be required.

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.

Emergency Room Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Emergency Transportation/Ambulance

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

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.

Hospice Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

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.

Inpatient Hospital Services (e.g., Hospital Stay)

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Inpatient services performed primarily for diagnostic examinations, physical therapy, rest cure, convalescent care, custodial care, maintenance care or sanitaria care.

Inpatient Physician and Surgical Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Mental/Behavioral Health Inpatient Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

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.

Mental/Behavioral Health Outpatient Services

$20.00
Tier 1 in-network $20.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

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. Out of state non-participating health care provider waiver may be required. Please refer to the plan policy documents for detailed information.

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.

Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Includes dental anesthesia and hospitalization for dental care to members under age 9 who have a medical condition that requires hospitalization.

Outpatient Rehabilitation Services

$20.00
Tier 1 in-network $20.00
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 30.0 Visit(s) per Benefit Period

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.

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.

Outpatient Surgery Physician/Surgical Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Radiation

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Skilled Nursing Facility

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 30.0 Days per Benefit Period

Precertification is required. Psychiatric and substance use services are excluded from the Maximum Benefit Allowance.

Substance Abuse Disorder Inpatient Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

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.

Exclusions: Services by a vocational residential rehab center, a community reentry program, halfway house or group home.

Substance Abuse Disorder Outpatient Services

$20.00
Tier 1 in-network $20.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

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. Out of state non-participating health care provider waiver 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.

Transplant

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 1.0 Exam(s) per Transplant

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.

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.

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

50.00% Coinsurance after deductible
Tier 1 in-network 50.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 100.00%

Hearing Aids

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 1.0 Visit(s) per 3 Years

Subject to a Maximum Benefit Allowance per Member of 1 hearing aid per ear every 3 years.

Exclusions: No benefits are available for a tinnitus masker.

Major Dental Care - Child

50.00% Coinsurance after deductible
Tier 1 in-network 50.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 100.00%

Prenatal and Postnatal Care

No Charge
Tier 1 in-network No Charge
Tier 2 in-network No Charge
Out-of-network 50.00% Coinsurance after deductible

Office visits for pre and post-natal care waive all cost sharing amounts.

Routine Eye Exam for Children

$40.00
Tier 1 in-network $40.00
Tier 2 in-network $40.00
Out-of-network 100.00%

Limit: 1.0 Exam(s) per Benefit Period

Well Baby Visits and Care

No Charge, No Charge
Tier 1 in-network No Charge, No Charge
Tier 2 in-network No Charge, No Charge
Out-of-network 100.00%

Limit: 11.0 Visit(s) per 3 Years

Well Child Care through age 6, 100% of Allowed Charge. Deductible Amount is waived.

Pharmacy & drugs

Generic, brand, specialty, and mail order tiers.

Generic Drugs

$20.00
Tier 1 in-network $20.00
Tier 2 in-network $20.00
Out-of-network 100.00%

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.

Exclusions: Drugs for 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).

Non-Preferred Brand Drugs

$200.00
Tier 1 in-network $200.00
Tier 2 in-network $200.00
Out-of-network 100.00%

Exclusions: Drugs for 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 Brand Drugs

$150.00
Tier 1 in-network $150.00
Tier 2 in-network $150.00
Out-of-network 100.00%

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.

Exclusions: Drugs for 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).

Specialty Drugs

50.00% Coinsurance after deductible
Tier 1 in-network 50.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 100.00%

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.

Exclusions: Drugs for 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).

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

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.

Basic Dental Care - Adult

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Dental Check-Up for Children

$40.00
Tier 1 in-network $40.00
Tier 2 in-network $40.00
Out-of-network 100.00%

Limit: 2.0 Exam(s) per Benefit Period

Infusion Therapy

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

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.

Major Dental Care - Adult

Coverage details pending

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.

Nutritional Counseling

No Charge
Tier 1 in-network No Charge
Tier 2 in-network No Charge
Out-of-network 100.00%

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. Psychiatric and substance use services are excluded from the Maximum Benefit Allowance.

Orthodontia - Adult

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Orthodontia - Child

50.00% Coinsurance after deductible
Tier 1 in-network 50.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 100.00%

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.'

Prosthetic Devices

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

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.

Routine Dental Services (Adult)

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Weight Loss Programs

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Additional benefits

Other plan-specific services and limitations.

Abortion for Which Public Funding is Prohibited

Coverage details pending

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.

Acupuncture

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Allergy Testing

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

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.

Bariatric Surgery

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

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.

Cosmetic Surgery

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Eye Glasses for Children

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

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.

Habilitation Services

$20.00
Tier 1 in-network $20.00
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

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.

Imaging (CT/PET Scans, MRIs)

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

PET Scan Benefits are available every six months per Member per Benefit Period with a Prostate Cancer Diagnosis.

Infertility Treatment

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Long-Term/Custodial Nursing Home Care

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Private-Duty Nursing

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Reconstructive Surgery

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Reconstructive surgery to restore bodily function or correct deformity resulting from disease, trauma, congenital or developmental anomalies or previous therapeutic processes.

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.

Routine Eye Exam (Adult)

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Routine Foot Care

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

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.

Treatment for Temporomandibular Joint Disorders

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: No benefits will be provided for orthodontic services or osseointegrated implant surgery.

Variant attributes

DakotaBlue Trinity Silver ($5 Value Based Drug List) · Variant 37160ND2480010-00

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2026

CSR Variation Type

Standard Silver Off Exchange Plan

HIOS Product ID

37160ND248

Metal Level

Silver

Plan ID (Standard Component ID with Variant)

37160ND2480010-00

Plan Marketing Name

DakotaBlue Trinity Silver ($5 Value Based Drug List)

Plan Variant Marketing Name

DakotaBlue Trinity Silver ($5 Value Based Drug List)

Issuer & service area

Issuer-provided metadata for this variant.

Issuer Actuarial Value

71.19%

Issuer ID

37160

Issuer Marketplace Marketing Name

Blue Cross Blue Shield of North Dakota

Market Coverage

Individual

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.

Service Area ID

NDS003

State Code

ND

URL for Summary of Benefits & Coverage

Open link

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

AV Calculator Output Number

0.7017144455721901

Begin Primary Care Deductible Coinsurance After Number Of Copays

0

Inpatient Copayment Maximum Days

0

Medical Drug Deductibles Integrated

Yes

Medical Drug Maximum Out of Pocket Integrated

Yes

SBC Scenario, Having a Baby, Coinsurance

$3,600

SBC Scenario, Having a Baby, Copayment

$60

SBC Scenario, Having a Baby, Deductible

$3,500

SBC Scenario, Having Diabetes, Coinsurance

$60

SBC Scenario, Having Diabetes, Copayment

$500

SBC Scenario, Having Diabetes, Deductible

$200

SBC Scenario, Treatment of a Simple Fracture, Coinsurance

$0

SBC Scenario, Treatment of a Simple Fracture, Copayment

$100

SBC Scenario, Treatment of a Simple Fracture, Deductible

$2,100

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group

$109500 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person

$54750 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual

$54,750

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance

40.00%

Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance

50.00%

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group

$19000 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person

$9500 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual

$9,500

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group

$20000 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person

$10000 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual

$10,000

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group

$70500 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person

$35250 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual

$35,250

Enrollment & documents

Issuer-provided metadata for this variant.

Formulary ID

NDF004

Formulary URL

Open link

Plan Brochure

Open link

SBC Scenario, Having a Baby, Limit

$20

SBC Scenario, Having Diabetes, Limit

$0

SBC Scenario, Treatment of a Simple Fracture, Limit

$0

URL for Enrollment Payment

Open link

Additional attributes

Issuer-provided metadata for this variant.

Begin Primary Care Cost-Sharing After Number Of Visits

0

Child-Only Offering

Allows Adult and Child-Only

Composite Rating Offered

No

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

First Tier Utilization

90%

Import Date

10/29/2025

Limited Cost Sharing Plan Variation - Estimated Advanced Payment

$0.00

HSA Eligible

No

New/Existing Plan

Existing

Notice Required for Pregnancy

No

Is a Referral Required for Specialist?

No

Plan Effective Date

1/1/2026

Plan Type

PPO

QHP/Non QHP

Both

Second Tier Utilization

10%

Source Name

HIOS

Plan ID

37160ND2480010

Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group

$41500 per group

Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person

$20750 per person

Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual

$20,750

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group

$7000 per group

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person

$3500 per person

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual

$3,500

Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group

$12000 per group

Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person

$6000 per person

Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual

$6,000

Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group

$22500 per group

Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person

$11250 per person

Combined Medical and Drug EHB Deductible, Out of Network, Individual

$11,250

Unique Plan Design

Yes

Wellness Program Offered

Yes

Copay & coinsurance

Pharmacy cost sharing by tier

Drug tier Pharmacy type Copay amount Copay option Coinsurance rate Coinsurance option Mail order

Questions & answers

Frequently asked questions

How do I choose the right ACA plan in North Dakota?

DakotaBlue Trinity Silver ($5 Value Based Drug List) (37160ND2480010) is a Silver PPO from Blue Cross Blue Shield of North Dakota in North Dakota for the 2026 coverage year.

Compare it against other options with the HealthPorta plan finder to confirm premiums, deductibles, and network access fit your household.

Does DakotaBlue Trinity Silver ($5 Value Based Drug List) support telehealth or virtual urgent care?

The issuer has not published telehealth details yet. Review the Summary of Benefits and Coverage to confirm if virtual visits are included.

Is DakotaBlue Trinity Silver ($5 Value Based Drug List) HSA-eligible and does it include dental or vision coverage?

It is not marked as HSA-eligible, so confirm with the issuer before relying on tax-advantaged savings.

Dental add-ons: Child.

Vision add-ons: Child.

Does DakotaBlue Trinity Silver ($5 Value Based Drug List) support mail-order prescriptions?

Mail order coverage is not listed for this plan, so confirm with the issuer before relying on home delivery.

Which disease management programs come with DakotaBlue Trinity Silver ($5 Value Based Drug List)?

The issuer lists disease management resources for: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs.

Is there out-of-country coverage for DakotaBlue Trinity Silver ($5 Value Based Drug List)?

Yes, limited out-of-country coverage is available. Review the Summary of Benefits for reimbursement steps. 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 DakotaBlue Trinity Silver ($5 Value Based Drug List) cover care outside the service area?

Yes, you have limited out-of-area coverage. See the plan documents for referral and prior authorization rules. 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.

How do I enroll in or manage payments for DakotaBlue Trinity Silver ($5 Value Based Drug List)?

Use the issuer portal https://cdsso.highmark.com/oam/server/fed/sp/sso to pay premiums or start enrollment, then return to HealthPorta for benefit comparisons.

Disclaimer: Based on the Tue, 02 Dec 2025 06:13 GMT HealthPorta import from CMS issuer filings. Data is best-effort and should be validated with the issuer directly. Sources: CMS.gov and the HealthPorta Healthcare MRF API.
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