If you plan to get care from a provider outside North Dakota and that is not in the BCBSND network, you may need a waiver before services are covered. 

This helps make sure care is provided by qualified facilities and protects members from billing fraud. 

This form is for Marketplace (ACA) members getting non‑urgent care from an out‑of‑state provider who isn’t in another Blue Cross Blue Shield network. If you’re on an employer/group plan, you do not need to fill out this form.

Find a Doctor to see if you can get care from participating (non-urgent & non-emergency) providers to lower your cost.

Submit this waiver if:

• You are getting certain mental health or substance use services, like intensive outpatient or partial hospitalization programs.
• You need specialized services such as durable medical equipment, lab testing, radiology, or wound grafting.
• You’re seeking non-emergency services from a provider who is not part of the Blue Cross Blue Shield network.
• You are a Marketplace (ACA) member. If you’re on an employer/group plan, you do not need to fill out this form.