BlueDirect Bronze 100 HSA Eligible ($8000 Deductible / $5 Preventive Drug List)

Blue Cross Blue Shield of North Dakota

Expanded BronzeHSA eligible

Ind. deductible: $8,000
Family deductible: $8,000
Ind. OOP max: $8,000
Family OOP max: $8,000

Other cost-sharing reduction variants for this plan:

Limited Cost Sharing Plan Variation Standard Bronze Off Exchange Plan Zero Cost Sharing Plan Variation

Monthly premiums by age

Age	Individual	Individual + tobacco
21	$360	—
30	$409	—
40	$461	—
50	$644	—
60	$978	—

Live premium estimate

Benefits & cost sharing

Primary Care

Benefit	In-network
Preventive Care/Screening/Immunization	$0.00
Primary Care Visit to Treat an Injury or Illness	No Charge after deductible

Specialist

Benefit	In-network
Specialist Visit	No Charge after deductible

Hospital

Benefit	In-network
Emergency Room Services	No Charge after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	No Charge after deductible
Outpatient Surgery Physician/Surgical Services	No Charge after deductible
Urgent Care Centers or Facilities	No Charge after deductible

Pharmacy

Benefit	In-network
Generic Drugs	$0.00
Non-Preferred Brand Drugs	No Charge after deductible
Preferred Brand Drugs	No Charge after deductible
Specialty Drugs	$0.00

Mental Health

Benefit	In-network
Mental/Behavioral Health Inpatient Services	No Charge after deductible
Mental/Behavioral Health Outpatient Services	No Charge after deductible

Other

Benefit	In-network
Cosmetic Surgery	Not covered
Abortion for Which Public Funding is Prohibited	Not covered
Accidental Dental	$0.00
Acupuncture	Not covered
Allergy Testing	$0.00
Bariatric Surgery	No Charge after deductible
Basic Dental Care - Adult	Not covered
Basic Dental Care - Child	$0.00
Chemotherapy	$0.00
Chiropractic Care	$0.00
Delivery and All Inpatient Services for Maternity Care	$0.00
Dental Check-Up for Children	$0.00
Diabetes Education	$0.00
Dialysis	$0.00
Durable Medical Equipment	No Charge after deductible
Emergency Transportation/Ambulance	$0.00
Eye Glasses for Children	No Charge after deductible
Habilitation Services	No Charge after deductible
Hearing Aids	No Charge after deductible
Home Health Care Services	No Charge after deductible
Hospice Services	No Charge after deductible
Imaging (CT/PET Scans, MRIs)	$0.00
Infertility Treatment	Not covered
Infusion Therapy	No Charge after deductible
Inpatient Physician and Surgical Services	$0.00
Laboratory Outpatient and Professional Services	No Charge after deductible
Long-Term/Custodial Nursing Home Care	Not covered
Major Dental Care - Adult	Not covered
Major Dental Care - Child	No Charge after deductible
Nutritional Counseling	No charge
Orthodontia - Adult	Not covered
Orthodontia - Child	No Charge after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)	$0.00
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	No Charge after deductible
Routine Foot Care	No Charge after deductible
Outpatient Rehabilitation Services	No Charge after deductible
Prenatal and Postnatal Care	No charge
Private-Duty Nursing	Not covered
Prosthetic Devices	$0.00
Radiation	No Charge after deductible
Reconstructive Surgery	No Charge after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy	No Charge after deductible
Rehabilitative Speech Therapy	No Charge after deductible
Routine Dental Services (Adult)	Not covered
Routine Eye Exam (Adult)	Not covered
Routine Eye Exam for Children	No Charge after deductible
Skilled Nursing Facility	$0.00
Substance Abuse Disorder Inpatient Services	$0.00
Substance Abuse Disorder Outpatient Services	No Charge after deductible
Transplant	No Charge after deductible
Treatment for Temporomandibular Joint Disorders	$0.00
Weight Loss Programs	Not covered
Well Baby Visits and Care	No charge
X-rays and Diagnostic Imaging	No Charge after deductible

Plan rules

Service area

This plan covers 1 geographic area.