Blue Preferred Gold PPO℠ 204 - 30751MT0550043 Health Insurance Plan
Blue Cross and Blue Shield of Montana health insurance plan with the Plan ID 30751MT0550043. The plan is called Blue Preferred Gold PPO℠ 204.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 80.25% (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 19.75% 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 | 30751MT0550043 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| 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 | 30751MT0550043-00 | ||||||||||||||||||
| Provider Network(s) | NON-PREFERRED BLUE-PREFERRED-PPO PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 17 Jun 2025 12:51 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 30751MT0550043-00 Standard On Exchange Plan - 30751MT0550043-01 |
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| Last Plan Update Date | Tue, 22 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 17 Jun 2025 12:51 GMT |
Blue Preferred Gold PPO℠ 204 Health Insurance Plan Variant 30751MT0550043-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.8024535874737171 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold Off Exchange Plan |
| 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, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 85% |
| Formulary ID | MTF018 |
| Formulary URL | URL |
| HIOS Product ID | 30751MT055 |
| Import Date | 2024-10-22 20:01:41 |
| 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 | No |
| Network ID | MTN009 |
| 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 | Emergency and Urgent Care services. Non-emergency services received outside the service area may be covered with an approved waiver from the Plan. |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 30751MT0550043-00 |
| 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 | $3,300 |
| SBC Scenario, Having a Baby, Copayment | $900 |
| SBC Scenario, Having a Baby, Deductible | $750 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $100 |
| SBC Scenario, Having Diabetes, Copayment | $500 |
| SBC Scenario, Having Diabetes, Deductible | $750 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $750 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 15% |
| Service Area ID | MTS029 |
| Source Name | SERFF |
| Plan ID | 30751MT0550043 |
| 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 | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,200 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $9,200 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $73600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $36800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $36,800 |
| 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, 30751MT0550043
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Blue Preferred Gold PPO℠ 204, 30751MT0550043 Health Insurance Plan, 30751MT0550043
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Does Blue Preferred Gold PPO℠ 204 Health Insurance Plan, 30751MT0550043 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (30751MT0550043) Health Insurance Plan, Variant (30751MT0550043-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
Does (30751MT0550043) Health Insurance Plan, Variant (30751MT0550043-00) 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 (30751MT0550043) Health Insurance Plan, Variant (30751MT0550043-00) have Out of Service Area Coverage?
Yes. Details: Emergency and Urgent Care services. Non-emergency services received outside the service area may be covered with an approved waiver from the Plan.
Does (30751MT0550043) Health Insurance Plan, Variant (30751MT0550043-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
Does Blue Preferred Gold PPO℠ 204 Health Insurance Plan, Variant (30751MT0550043-00) offer Disease Management Programs for Asthma?
Yes, the Blue Preferred Gold PPO℠ 204 Health Insurance Plan Variant
30751MT0550043-00 offers Disease
Management Program for Asthma.
Does Blue Preferred Gold PPO℠ 204 Health Insurance Plan, Variant (30751MT0550043-00) offer Disease Management Programs for Heart disease?
Yes, the Blue Preferred Gold PPO℠ 204 Health Insurance Plan Variant
30751MT0550043-00 offers Disease
Management Program for Heart disease.
Does Blue Preferred Gold PPO℠ 204 Health Insurance Plan, Variant (30751MT0550043-00) offer Disease Management Programs for Depression?
Yes, the Blue Preferred Gold PPO℠ 204 Health Insurance Plan Variant
30751MT0550043-00 offers Disease
Management Program for Depression.
Does Blue Preferred Gold PPO℠ 204 Health Insurance Plan, Variant (30751MT0550043-00) offer Disease Management Programs for Diabetes?
Yes, the Blue Preferred Gold PPO℠ 204 Health Insurance Plan Variant
30751MT0550043-00 offers Disease
Management Program for Diabetes.
Does Blue Preferred Gold PPO℠ 204 Health Insurance Plan, Variant (30751MT0550043-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the Blue Preferred Gold PPO℠ 204 Health Insurance Plan Variant
30751MT0550043-00 offers Disease
Management Program for High blood pressure & high cholesterol.
Does Blue Preferred Gold PPO℠ 204 Health Insurance Plan, Variant (30751MT0550043-00) offer Disease Management Programs for Low back pain?
Yes, the Blue Preferred Gold PPO℠ 204 Health Insurance Plan Variant
30751MT0550043-00 offers Disease
Management Program for Low back pain.
Does Blue Preferred Gold PPO℠ 204 Health Insurance Plan, Variant (30751MT0550043-00) offer Disease Management Programs for Pregnancy?
Yes, the Blue Preferred Gold PPO℠ 204 Health Insurance Plan Variant
30751MT0550043-00 offers Disease
Management Program for Pregnancy.
Disclaimer: This is based on the import(Date: Tue, 17 Jun 2025 12:51 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