BlueValue

Affordable Care Act Standard Plan Offering

Special Enrollment

Consider this plan if:

You like predictability in costs. With set co-pays, you'll know beforehand what you'll spend in heath care. Also, if you qualify for health insurance premium tax credits, this plan is eligible on the exchange.

Coverage available for:

Individual
Families

Plan features

You pay the same copayment (copay) each time you visit the doctor or pharmacy.
Preventive care, screenings and immunization at no cost if received in network
Low copay for generic drugs
Mental health and substance abuse disorder services
Includes HealthyBlue online wellness and rewards for managing your health

Plan highlights

Plan has a lower monthly premium in return for using the Preferred Blue PPO network
Network includes most ND doctors
Easy-to-use coverage, plus help when you need it--online, by phone or in-person
Coverage when you travel around the country or outside the U.S.

Gold Plan

Silver Plans

Bronze Plans

BlueValue Gold 75 2000

BlueValue Silver 60 5800

BlueValue Bronze 50 7500

All cost sharing amounts apply to covered services you receive within the Preferred Blue PPO network. Covered services received out-of-network are paid at a lesser benefit or no benefit amount.
For a gold family plan, the entire family deductible must be met before coinsurance begins. The deductible can be met by one family member or all members.
For a silver or bronze family plan, an individual on the plan must meet the individual deductible before coinsurance begins.
Drug formularies and drug listings are reviewed on an ongoing basis and subject to change.
*After deductible is met

Deductible

Individual: $2,000
Family: $4,000

Individual: $5,800
Family: $11,600

Individual: $7,500
Family: $15,000

Coinsurance

25% of total cost*

40% of total cost*

50% of total cost*

Out-of-Pocket Maximums

Individual: $8,700
Family: $17,400

Individual: $8,900
Family: $17,800

Individual: $9,000
Family: $18,000

Preventive Visits

HealthyBlue Online Wellness

Doctor Visits

$30

$40

$50

Chiropractic Care, Physical, Speech and Occupational Therapy

$30

$40

$50

Prescription Drugs

Value Drug: $5
Preferred Generic: $15
Non-Preferred Generic: $15
Preferred Brand: $30
Non-Preferred Brand: $60
Preferred Specialty: $250
Non-Preferred Specialty: $250

Value Drug: $5
Preferred Generic: $20
Non-Preferred Generic: $20
Preferred Brand: $40
Non-Preferred Brand: $80*
Preferred Specialty: $350*
Non-Preferred Specialty: $350*

Value Drug: $5
Preferred Generic: $25
Non-Preferred Generic: $25
Preferred Brand: $50*
Non-Preferred Brand: $100*
Preferred Specialty: $500*
Non-Preferred Specialty: $500*

Emergency Room Visit

25% of total cost*

40% of total cost*

50% of total cost*

Hospitalization

25% of total cost*

40% of total cost*

50% of total cost*

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