Blue Cross and Blue Shield of Montana health insurance plan with the Plan ID 30751MT0550049. The plan is called Blue Preferred Bronze PPO℠ 201.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 63.98% (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 36.02% 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 | 30751MT0550049 | ||||||||||||||||||
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Health Insurance Plan Year | 2022 | ||||||||||||||||||
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 | 30751MT0550049-03 | ||||||||||||||||||
Provider Network(s) | ['MTN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 30751MT0550049-00 Standard On Exchange Plan - 30751MT0550049-01 |
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Last Plan Update Date | Thu, 02 Dec 2021 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 22 Oct 2024 06:47 GMT |
Plan Attribute | Value |
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AV Calculator Output Number | 0.639833187 |
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2022 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | Limited Cost Sharing Plan Variation |
Dental Only Plan | No |
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 | 30751MT055 |
Import Date | 12/2/2021 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 | Expanded Bronze |
Multiple In Network Tiers | Yes |
National Network | Yes |
Network ID | MTN001 |
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 | 1/1/2022 |
Plan ID (Standard Component ID with Variant) | 30751MT0550049-03 |
Plan Marketing Name | Blue Preferred Bronze PPO℠ 201 |
Plan Type | PPO |
Plan Variant Marketing Name | Blue Preferred Bronze PPO℠ 201 |
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 | MTS021 |
Source Name | SERFF |
Plan ID | 30751MT0550049 |
State Code | MT |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $7000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $3500 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $3,500 |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 50.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $7000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $3500 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $3,500 |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $28000 per group |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $14000 per person |
Combined Medical and Drug EHB Deductible, Out of Network, Individual | $14,000 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $17400 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $17400 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $8700 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $8,700 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $69600 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $34800 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $34,800 |
Unique Plan Design | No |
URL for Enrollment Payment | URL |
URL for Summary of Benefits & Coverage | URL |
Wellness Program Offered | No |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
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