Blue Preferred Gold PPO℠ 204 - 30751MT0550044 Health Insurance Plan
Blue Cross and Blue Shield of Montana health insurance plan with the Plan ID 30751MT0550044. The plan is called Blue Preferred Gold PPO℠ 204.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 80.80% (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 19.20% 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 | 30751MT0550044 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 30751MT0550044-03 | ||||||||||||||||||
| 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). |
|
||||||||||||||||||
| Available Variants of the Health Plan | Standard Off Exchange Plan - 30751MT0550044-00 Standard On Exchange Plan - 30751MT0550044-01 |
||||||||||||||||||
| Last Plan Update Date | Wed, 25 Jan 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 22 Oct 2024 06:47 GMT |
Benefits of Blue Preferred Gold PPO℠ 204 Health Insurance Plan, 30751MT0550044-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Acupuncture
Limit: 12.0 Visit(s) per Benefit Period |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Allergy Testing
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Chiropractic Care
Limit: 10.0 Visit(s) per Benefit Period |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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 | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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 | $850.00 Copay with deductible, 30.00% Coinsurance after deductible |
$2000.00 Copay with deductible, 50.00% Coinsurance after deductible |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
First $250 at 100% of allowable fee, then deductible, copayment, or coinsurance apply. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dialysis
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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 | $1000.00 Copay with deductible, 30.00% Coinsurance after deductible |
$1000.00 Copay with deductible, 30.00% Coinsurance after deductible |
| 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 | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| 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 | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Gender Affirming Care
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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: $5.00 Tier 2: $10.00 |
$10.00 |
| Habilitation Services
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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 | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Hospice Services
|
YES | No Charge |
50.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Infertility Treatment
Exclusions: Excludes invitro and prescription drugs for the treatment of infertility. Covered for the diagnosis of infertility and artificial insemination. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Infusion Therapy
Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
YES | $100.00 |
50.00% Coinsurance after deductible |
| 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 | $850.00 Copay per Stay with deductible, 30.00% Coinsurance after deductible |
$2000.00 Copay per Stay with deductible, 50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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 | $850.00 Copay per Stay with deductible, 30.00% Coinsurance after deductible |
$2000.00 Copay per Stay with deductible, 50.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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: $100.00 Tier 2: $120.00 |
$120.00 |
| Nutritional Counseling
Covered under preventive health care. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 30.00% Coinsurance after deductible |
$2000.00 Copay with deductible, 50.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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: $50.00 Tier 2: $70.00 |
$70.00 |
| 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 | $10.00 |
50.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
50.00% Coinsurance after deductible |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $10.00 |
50.00% Coinsurance after deductible |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Radiation
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Reconstructive Surgery
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Benefit Period |
YES | No Charge |
No Charge |
| Routine Foot Care
Covered when medically necessary. |
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Specialist Visit
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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: $250.00 Tier 2: $250.00 |
$250.00 |
| Substance Abuse Disorder Inpatient Services
|
YES | $850.00 Copay per Stay with deductible, 30.00% Coinsurance after deductible |
$2000.00 Copay per Stay with deductible, 50.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Transplant
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
Surgical treatment is covered as any other surgery. |
NO | ||
| Urgent Care Centers or Facilities
|
YES | $15.00 |
$15.00 |
| Weight Loss Programs
Covered for Preventive services only. |
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
50.00% |
| X-rays and Diagnostic Imaging
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Blue Preferred Gold PPO℠ 204 Health Insurance Plan Variant 30751MT0550044-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.807953327 |
| 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 | Limited Cost Sharing Plan Variation |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 2), Family Per Group | $0 per group |
| Drug EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
| Drug EHB Deductible, In Network (Tier 2), Individual | $0 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| 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 | MTF026 |
| Formulary URL | URL |
| HIOS Product ID | 30751MT055 |
| 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 | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 30.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $1500 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $750 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $750 |
| Medical EHB Deductible, In Network (Tier 2), Default Coinsurance | 30.00% |
| Medical EHB Deductible, In Network (Tier 2), Family Per Group | $1500 per group |
| Medical EHB Deductible, In Network (Tier 2), Family Per Person | $750 per person |
| Medical EHB Deductible, In Network (Tier 2), Individual | $750 |
| Medical EHB Deductible, Out of Network, Family Per Group | $6000 per group |
| Medical EHB Deductible, Out of Network, Family Per Person | $3000 per person |
| Medical EHB Deductible, Out of Network, Individual | $3,000 |
| Metal Level | Gold |
| 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 Providersâ€) with the local Blue Cross and/or Blue Shield Licensee in that other geographic area (“Host Blueâ€). 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) | 30751MT0550044-03 |
| Plan Marketing Name | Blue Preferred Gold PPO℠ 204 |
| Plan Type | PPO |
| Plan Variant Marketing Name | Blue Preferred Gold PPO℠ 204 |
| 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 | MTS031 |
| Source Name | SERFF |
| Plan ID | 30751MT0550044 |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9100 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,100 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $18200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $9100 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $9,100 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $72800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $36400 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $36,400 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Blue Preferred Gold PPO℠ 204 Health Insurance Plan, 30751MT0550044
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Blue Preferred Gold PPO℠ 204, 30751MT0550044 Health Insurance Plan, 30751MT0550044
-
Does Blue Preferred Gold PPO℠ 204 Health Insurance Plan, 30751MT0550044 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (30751MT0550044) Health Insurance Plan, Variant (30751MT0550044-03) offer Disease Management Programs?
Does (30751MT0550044) Health Insurance Plan, Variant (30751MT0550044-03) have Out Of Country Coverage?
Does (30751MT0550044) Health Insurance Plan, Variant (30751MT0550044-03) have Out of Service Area Coverage?
Does (30751MT0550044) Health Insurance Plan, Variant (30751MT0550044-03) offer Disease Management Programs?
Does Blue Preferred Gold PPO℠ 204 Health Insurance Plan, Variant (30751MT0550044-03) offer Disease Management Programs for Asthma?
Does Blue Preferred Gold PPO℠ 204 Health Insurance Plan, Variant (30751MT0550044-03) offer Disease Management Programs for Heart disease?
Does Blue Preferred Gold PPO℠ 204 Health Insurance Plan, Variant (30751MT0550044-03) offer Disease Management Programs for Depression?
Does Blue Preferred Gold PPO℠ 204 Health Insurance Plan, Variant (30751MT0550044-03) offer Disease Management Programs for Diabetes?
Does Blue Preferred Gold PPO℠ 204 Health Insurance Plan, Variant (30751MT0550044-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Blue Preferred Gold PPO℠ 204 Health Insurance Plan, Variant (30751MT0550044-03) offer Disease Management Programs for Low back pain?
Does Blue Preferred Gold PPO℠ 204 Health Insurance Plan, Variant (30751MT0550044-03) offer Disease Management Programs 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