BlueValue Bronze

37160ND2410028
Expanded Bronze
PPO

BlueValue Bronze is an Expanded Bronze PPO plan by Blue Cross Blue Shield of North Dakota.

IMPORTANT: You are viewing the 2023 version of BlueValue Bronze 37160ND2410028. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

BlueValue Bronze is offered in the following counties.

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Plan Overview

This is a plan overview for 2023 version of BlueValue Bronze 37160ND2410028.
Insurer: Blue Cross Blue Shield of North Dakota
Network Type: PPO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 37160ND2410028

Cost-Sharing Overview

BlueValue Bronze offers the following cost-sharing.

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.
Ready to sign up for BlueValue Bronze?

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

Plan Features

BlueValue Bronze offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol
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 BlueValue Bronze 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

BlueValue Bronze includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Preventive Care/Screening/Immunization
Covered
0.00% 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
50.00% Coinsurance after deductible 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
$40.00 100.00%1 Exam(s) per Benefit Period
Eye Glasses for Children
Covered
50.00% Coinsurance after deductible 100.00%1 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 50.00% Coinsurance after deductible2 Exam(s) per Benefit Period
Rehabilitative Speech Therapy
Covered
$50.00 50.00% Coinsurance after deductible30 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
$50.00 50.00% Coinsurance after deductible30 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. Benefits are not available for Maintenance Care.
Primary Care Visit to Treat an Injury or Illness
Covered
$50.00 50.00% Coinsurance after deductible Office visits for pre and post-natal care waive all cost sharing amounts.
Specialist Visit
Covered
$100.00 50.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$100.00 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.
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
50.00% Coinsurance after deductible 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
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Hospice Services
Covered
50.00% Coinsurance after deductible 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
$75.00 50.00% Coinsurance after deductible
Home Health Care Services
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible40 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.
Emergency Room Services
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
50.00% Coinsurance after deductible 50.00% 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
50.00% Coinsurance after deductible 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
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Bariatric Surgery
Covered
50.00% Coinsurance after deductible 100.00%1 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. 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
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible30 Days per Benefit Period Precertification is required.
Prenatal and Postnatal Care
Covered
50.00% 50.00% Coinsurance after deductible Related prenatal or postnatal office visit covered at 100%.
Delivery and All Inpatient Services for Maternity Care
Covered
50.00% Coinsurance after deductible 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
$50.00 50.00% Coinsurance after deductible Special education, counseling or care for learning disorders or intellectual disability. Counseling or therapy services; Including bereavement, codependency, marital dysfunction, family dysfunction, sex or interpersonal relationship counseling services. 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, and partial hospitalization.
Mental/Behavioral Health Inpatient Services
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible For psychiatric services, precertification may be required for residential treatment, partial hospitalization, and out-of-network inpatient facitlites.
Substance Abuse Disorder Outpatient Services
Covered
$50.00 50.00% Coinsurance after deductible Ambulatory pharmacological detoxification management and social detoxification. Home and Office Visits Including assessment, counseling, case management services, treatment planning, coordination of care, psychotherapy and group therapy, Opioid Treatment Program and Peer Support; 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
50.00% Coinsurance after deductible 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 abuse, 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 Abuse Facility. Benefits available for residential treatment. Benefits available for partial hospitalization. Precertification is required. For SUD, Precertification is required for inpatient, residential, partial hospitalization, and intensive outpatient.
Generic Drugs
Covered
$25.00 100.00% 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. 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 Copay after deductible 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). 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.
Non-Preferred Brand Drugs
Covered
$100.00 Copay after deductible 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
$500.00 Copay after deductible 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.
Outpatient Rehabilitation Services
Covered
$50.00 50.00% Coinsurance after deductible30 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. Benefits are not available for Maintenance Care.
Habilitation Services
Covered
$50.00 50.00% Coinsurance after deductible30 Visit(s) per Benefit Period Therapy Maintenance Care and group speech therapy services. Communication aids or devices to create, replace or augment communication abilities, including speech processors, receivers, communication boards, or computer or electronic assisted communication. MAINTENANCE CARE – treatment provided to a Member whose condition/progress has ceased improvement or could reasonably be expected to be managed without the skills of a Health Care Provider. Exception: periodic reassessments are not considered Maintenance Care. 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. Precertification is required for Behavioral Modification Intervention for Autism Spectrum Disorder (Including Applied Behavior Analysis (ABA)).
Chiropractic Care
Covered
$50.00 50.00% Coinsurance after deductible20 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
50.00% Coinsurance after deductible 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
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible Benefits are available for hearing aids when provided as part of Habilitative Therapy.
Imaging (CT/PET Scans, MRIs)
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Well Baby Visits and Care
Covered
No Charge No Charge 100.00%11 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
50.00% Coinsurance after deductible 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
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Basic Dental Care – Child
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Orthodontia – Child
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible1 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
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
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
50.00% Coinsurance after deductible 100.00%1 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
50.00% Coinsurance after deductible 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
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Allergy Testing
Covered
50.00% Coinsurance after deductible 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
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Radiation
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Diabetes Education
Covered
50.00% 100.00%
Prosthetic Devices
Covered
50.00% Coinsurance after deductible 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
50.00% Coinsurance after deductible 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
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible2 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
No Charge 100.00%4 Visit(s) per Benefit Period 4 visits each per benefit period for hyperlipedemia, gestational diabetes, and diabetes mellitus.; 2 visits per benefit period for hypertension. Intensive Behavioral Interventions for Obesity allow 26 visits per Member per Benefit Period.
Reconstructive Surgery
Covered
50.00% Coinsurance after deductible 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
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible

Free Preventive Services

There is no copayment or coinsurance for any of the following BlueValue Bronze 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.

Additional Resources

Below are additional resources for BlueValue Bronze 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 BlueValue Bronze?

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

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