Blue Focus Gold POS℠ 207 - 30751MT0650014 Health Insurance Plan

Blue Cross and Blue Shield of Montana health insurance plan with the Plan ID 30751MT0650014. The plan is called Blue Focus Gold POS℠ 207.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 0.00% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.

Health Insurance Plan ID 30751MT0650014
Health Insurance Plan Year 2023
State Montana
Health Insurance Issuer Blue Cross and Blue Shield of Montana
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 30751MT0650014-02
Provider Network(s) ['MTN002']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT).

Providers Montana All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 30751MT0650014-00

Standard On Exchange Plan - 30751MT0650014-01

Open to Indians below 300% FPL - 30751MT0650014-02

Open to Indians above 300% FPL - 30751MT0650014-03

Last Plan Update Date Wed, 25 Jan 2023 00:00 GMT
Last Import Date Tue, 22 Oct 2024 06:47 GMT

Benefits of Blue Focus Gold POS℠ 207 Health Insurance Plan, 30751MT0650014-02

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Acupuncture

Limit: 12.0 Visit(s) per Benefit Period

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Allergy Testing
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Chiropractic Care

Limit: 10.0 Visit(s) per Benefit Period

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Cosmetic Surgery

Only for the correction of a condition resulting from an accident, a condition resulting from an injury or to treat a congenitial anomaly.

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Delivery and All Inpatient Services for Maternity Care

Childbirth/delivery professional services are subject to your Medical EHB Deductible/Maximum Out of Pocket for Medical EHB benefits, if applicable. Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Dental Check-Up for Children
NO
Diabetes Education

First $250 at 100% of allowable fee, then deductible, copayment, or coinsurance apply.

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Dialysis
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Durable Medical Equipment
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Emergency Room Services

Member will be responsible for copay per emergency room admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Emergency Transportation/Ambulance

Emergency Transportation/Ambulance is covered when your condition is such that an ambulance is necessary. Benefits will not be provided for long distance trips or for use of an ambulance because it is more convenient than other transportation when rendered in connection with a covered Inpatient admission or covered Emergency Accident Care or covered Emergency Medical Care or if it does not meet the definition of Medically Necessary for non-emergency medical situations. Benefits will not be provided for long distance trips. See benefit book for details.

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

One pair of glasses (frames and lenses) or one pair of contacts per Benefit Period.

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Gender Affirming Care
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Generic Drugs

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Certain generic drugs may have a higher cost share amount than is listed on this page. When prescription drugs are bought from an out of network pharmacy additional charges may apply. See benefit book for details.

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Habilitation Services
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Hearing Aids

Medically Necessary cochlear implants may be covered per Medical Policy. Max is 1 item per ear every 3 years only for 18 and under

NO
Home Health Care Services

Limit: 180.0 Visit(s) per Benefit Period

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Hospice Services
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Imaging (CT/PET Scans, MRIs)
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Infertility Treatment

Exclusions: Excludes invitro and prescription drugs for the treatment of infertility.

Covered for the diagnosis of infertility and artificial insemination.

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Infusion Therapy

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Inpatient Hospital Services (e.g., Hospital Stay)

Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Inpatient Physician and Surgical Services
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Laboratory Outpatient and Professional Services
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services

Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Mental/Behavioral Health Outpatient Services
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Non-Preferred Brand Drugs

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

When prescription drugs are bought from an out of network pharmacy additional charges may apply. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Nutritional Counseling

Covered under preventive health care.

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

Member will be responsible for copay per outpatient surgery admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Outpatient Rehabilitation Services
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Outpatient Surgery Physician/Surgical Services
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Preferred Brand Drugs

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

When prescription drugs are bought from an out of network pharmacy additional charges may apply. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Prenatal and Postnatal Care

First prenatal visit is subject to the Office Visit charge. All subsequent prenatal care is covered under delivery for maternity care.

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Preventive Care/Screening/Immunization
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Primary Care Visit to Treat an Injury or Illness
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Radiation
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Reconstructive Surgery
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Rehabilitative Speech Therapy
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Benefit Period

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Routine Foot Care

Covered when medically necessary.

NO
Skilled Nursing Facility

Limit: 60.0 Days per Benefit Period

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Specialist Visit
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Specialty Drugs

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Certain specialty drugs may have a higher cost share amount than is listed on this page. If prescription drugs are bought from an out of network pharmacy additional charges may apply. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Substance Abuse Disorder Inpatient Services

Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Substance Abuse Disorder Outpatient Services
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Transplant
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Treatment for Temporomandibular Joint Disorders

Surgical treatment is covered as any other surgery.

NO
Urgent Care Centers or Facilities
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
Weight Loss Programs

Covered for Preventive services only.

NO
Well Baby Visits and Care
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%
X-rays and Diagnostic Imaging
YES

Tier 1: $0.00, 0.00%

Tier 2: $0.00, 0.00%

$0.00, 0.00%

Blue Focus Gold POS℠ 207 Health Insurance Plan Variant 30751MT0650014-02 Attributes

Plan Attribute Value
AV Calculator Output Number 1
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Zero Cost Sharing Plan Variation
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
EHB Percent of Total Premium 1
First Tier Utilization 85%
Formulary ID MTF020
Formulary URL URL
HIOS Product ID 30751MT065
Import Date 1/25/2023 20:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 30751
Issuer Marketplace Marketing Name Blue Cross and Blue Shield of Montana
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Gold
Multiple In Network Tiers Yes
National Network Yes
Network ID MTN002
Out of Country Coverage Yes
Out of Country Coverage Description This plan does not cover any services and/or supplies provided to a member outside of the United States, if the member traveled to the location for the purposes of receiving medical services, supplies, or drugs.
Out of Service Area Coverage Yes
Out of Service Area Coverage Description When accessing care outside our service area, you will obtain care from healthcare Providers that have a contractual agreement (i.e., are “Participating Providers”) with the local Blue Cross and/or Blue Shield Licensee in that other geographic area (“Host Blue”). In some instances, you may obtain care from Non-Participating Providers.
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan ID (Standard Component ID with Variant) 30751MT0650014-02
Plan Marketing Name Blue Focus Gold POS℠ 207
Plan Type HMO
Plan Variant Marketing Name Blue Focus Gold POS℠ 207
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 15%
Service Area ID MTS032
Source Name SERFF
Plan ID 30751MT0650014
State Code MT
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $0
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $0
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $0
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $0
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $0
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $0
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $0
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $0
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Blue Focus Gold POS℠ 207 Health Insurance Plan, 30751MT0650014

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Blue Focus Gold POS℠ 207, 30751MT0650014 Health Insurance Plan, 30751MT0650014

  • Does Blue Focus Gold POS℠ 207 Health Insurance Plan, 30751MT0650014 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (30751MT0650014) Health Insurance Plan, Variant (30751MT0650014-02) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does (30751MT0650014) Health Insurance Plan, Variant (30751MT0650014-02) have Out Of Country Coverage?

    Yes. Details: This plan does not cover any services and/or supplies provided to a member outside of the United States, if the member traveled to the location for the purposes of receiving medical services, supplies, or drugs.

    Does (30751MT0650014) Health Insurance Plan, Variant (30751MT0650014-02) have Out of Service Area Coverage?

    Yes. Details: When accessing care outside our service area, you will obtain care from healthcare Providers that have a contractual agreement (i.e., are “Participating Providers”) with the local Blue Cross and/or Blue Shield Licensee in that other geographic area (“Host Blue”). In some instances, you may obtain care from Non-Participating Providers.

    Does (30751MT0650014) Health Insurance Plan, Variant (30751MT0650014-02) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does Blue Focus Gold POS℠ 207 Health Insurance Plan, Variant (30751MT0650014-02) offer Disease Management Programs for Asthma?

    Yes, the Blue Focus Gold POS℠ 207 Health Insurance Plan Variant 30751MT0650014-02 offers Disease Management Program for Asthma.

    Does Blue Focus Gold POS℠ 207 Health Insurance Plan, Variant (30751MT0650014-02) offer Disease Management Programs for Heart disease?

    Yes, the Blue Focus Gold POS℠ 207 Health Insurance Plan Variant 30751MT0650014-02 offers Disease Management Program for Heart disease.

    Does Blue Focus Gold POS℠ 207 Health Insurance Plan, Variant (30751MT0650014-02) offer Disease Management Programs for Depression?

    Yes, the Blue Focus Gold POS℠ 207 Health Insurance Plan Variant 30751MT0650014-02 offers Disease Management Program for Depression.

    Does Blue Focus Gold POS℠ 207 Health Insurance Plan, Variant (30751MT0650014-02) offer Disease Management Programs for Diabetes?

    Yes, the Blue Focus Gold POS℠ 207 Health Insurance Plan Variant 30751MT0650014-02 offers Disease Management Program for Diabetes.

    Does Blue Focus Gold POS℠ 207 Health Insurance Plan, Variant (30751MT0650014-02) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Blue Focus Gold POS℠ 207 Health Insurance Plan Variant 30751MT0650014-02 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Blue Focus Gold POS℠ 207 Health Insurance Plan, Variant (30751MT0650014-02) offer Disease Management Programs for Low back pain?

    Yes, the Blue Focus Gold POS℠ 207 Health Insurance Plan Variant 30751MT0650014-02 offers Disease Management Program for Low back pain.

    Does Blue Focus Gold POS℠ 207 Health Insurance Plan, Variant (30751MT0650014-02) offer Disease Management Programs for Pregnancy?

    Yes, the Blue Focus Gold POS℠ 207 Health Insurance Plan Variant 30751MT0650014-02 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 22 Oct 2024 06:47 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API