BlueCare Gold $25 PCP Copay ($5 Value Based Drug List)
37160ND2410005
Gold
PPO
BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) is a Gold PPO plan by Blue Cross Blue Shield of North Dakota.
Locations
BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) is offered in the following counties.
Plan Overview
This is a plan overview for 2025 version of BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) 37160ND2410005.
| Insurer: | Blue Cross Blue Shield of North Dakota |
| Network Type: | PPO |
| Metal Type: | Gold |
| HSA Eligible?: | No |
| Plan ID: | 37160ND2410005 |
Cost-Sharing Overview
BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $7500 per person | $15000 per group |
| Deductible: | $2000 per person | $4000 per group |
| Coinsurance: | 30.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | $15000 per person | $30000 per group |
| Out-of-Network Deductible: | $4000 per person | $8000 per group |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $2,000 |
| Copayment: | $30 |
| Coinsurance: | $3,200 |
| Limit: | $20 |
| Deductible: | $200 |
| Copayment: | $500 |
| Coinsurance: | $50 |
| Limit: | $0 |
| Deductible: | $2,000 |
| Copayment: | $100 |
| Coinsurance: | $20 |
| Limit: | $0 |
Notes:
- Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
- You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
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Plan Features
BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) offers the following features and referral requirements.
| Wellness Program: | Yes |
| Disease Program: | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| Notice Pregnancy: | No |
| Referral Specialist: | No |
| Specialist Requiring Referral: | |
| Plan Exclusions: | |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) covers when you are out of the service area or out of the country.
| 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. |
| National Network: | Yes |
Additional Benefits and Cost-Sharing
BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) includes the following benefits at the cost sharing rates listed below.
| Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
|---|---|---|---|
| Primary Care Visit to Treat an Injury or Illness Covered | $25.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | Virtual Care and E-visits are $0 copay. |
| Specialist Visit Covered | $45.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $25.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 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. |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 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 Surgery Physician/Surgical Services Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Hospice Services Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 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. |
| Routine Dental Services (Adult) Not Covered | |||
| Infertility Treatment Not Covered | |||
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Not Covered | |||
| Routine Eye Exam (Adult) Not Covered | |||
| Urgent Care Centers or Facilities Covered | $25.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Home Health Care Services Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 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. |
| Emergency Room Services Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 30.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 30.00% 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. |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 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 Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Bariatric Surgery Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | 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 Not Covered | |||
| Skilled Nursing Facility Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 30.0 Days per Benefit Period Precertification is required. Psychiatric and substance use services are excluded from the Maximum Benefit Allowance. |
| Prenatal and Postnatal Care Covered | Not Applicable No Charge | Not Applicable 50.00% Coinsurance after deductible | Office visits for pre and post-natal care waive all cost sharing amounts. |
| Delivery and All Inpatient Services for Maternity Care Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Collection and storage of umbilical cord blood. Abortion except for those necessary to prevent the death of the woman. |
| Mental/Behavioral Health Outpatient Services Covered | $25.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 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. |
| Mental/Behavioral Health Inpatient Services Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 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. |
| Substance Abuse Disorder Outpatient Services Covered | $25.00 Not Applicable | Not Applicable 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. 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. |
| Substance Abuse Disorder Inpatient Services Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 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. |
| Generic Drugs Covered | $5.00 Not Applicable | Not Applicable 100.00% | 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. |
| Preferred Brand Drugs Covered | $50.00 Not Applicable | Not Applicable 100.00% | 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. |
| Non-Preferred Brand Drugs Covered | $100.00 Not Applicable | Not Applicable 100.00% | 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). |
| Specialty Drugs Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | 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. |
| Outpatient Rehabilitation Services Covered | $25.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 30.0 Visit(s) per Benefit Period 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. |
| Habilitation Services Covered | $25.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 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. |
| Chiropractic Care Covered | $25.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 20.0 Visit(s) per Benefit Period 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. |
| Durable Medical Equipment Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 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. |
| Hearing Aids Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 1.0 Visit(s) per 3 Years 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. |
| Imaging (CT/PET Scans, MRIs) Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | PET Scan Benefits are available every six months per Member per Benefit Period with a Prostate Cancer Diagnosis. |
| Preventive Care/Screening/Immunization Covered | No Charge No Charge | Not Applicable 100.00% | 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. |
| Routine Foot Care Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 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. |
| Acupuncture Not Covered | |||
| Weight Loss Programs Not Covered | |||
| Routine Eye Exam for Children Covered | $40.00 Not Applicable | Not Applicable 100.00% | 1.0 Exam(s) per Benefit Period |
| Eye Glasses for Children Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | 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. |
| Dental Check-Up for Children Covered | $40.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 2.0 Exam(s) per Benefit Period |
| Rehabilitative Speech Therapy Covered | $25.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 30.0 Visit(s) per Year 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. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $25.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 30.0 Visit(s) per Year 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. |
| Well Baby Visits and Care Covered | No Charge No Charge | Not Applicable 100.00% | 11.0 Visit(s) per 3 Years Well Child Care through age 6, 100% of Allowed Charge. Deductible Amount is waived. |
| Laboratory Outpatient and Professional Services Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 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. |
| X-rays and Diagnostic Imaging Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Basic Dental Care – Child Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Orthodontia – Child Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 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.’ |
| Major Dental Care – Child Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Basic Dental Care – Adult Not Covered | |||
| Orthodontia – Adult Not Covered | |||
| Major Dental Care – Adult Not Covered | 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. | ||
| Abortion for Which Public Funding is Prohibited Not Covered | 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. | ||
| Transplant Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 100.00% | 1.0 Exam(s) per Transplant 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. |
| Accidental Dental Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 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. |
| Dialysis Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Allergy Testing Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 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. |
| Chemotherapy Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Radiation Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Diabetes Education Covered | Not Applicable 30.00% | Not Applicable 100.00% | Diabetes Prevention Program for Members age 18 and older |
| Prosthetic Devices Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 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. |
| Infusion Therapy Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 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. |
| Treatment for Temporomandibular Joint Disorders Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 2.0 Treatment(s) per Lifetime 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. |
| Nutritional Counseling Covered | Not Applicable No Charge | Not Applicable 100.00% | 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. |
| Reconstructive Surgery Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 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. |
| Gender Affirming Care Covered | Not Applicable 30.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible |
Free Preventive Services
There is no copayment or coinsurance for any of the following BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) preventive services. This is true even if you haven’t met your yearly deductible.
Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for BlueCare Gold $25 PCP Copay ($5 Value Based Drug List) including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.
| Summary of Benefits: | Summary of Benefits Link |
| Plan Brochure: | Plan Brochure Link |
| Formulary: | Formulary Link |
| Premium Payment Website: | Premium Payment Link |
Ready to sign up for BlueCare Gold $25 PCP Copay ($5 Value Based Drug List)?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904