Blue Preferred Silver PPO℠ 203 - 30751MT0550039 Health Insurance Plan
Blue Cross and Blue Shield of Montana health insurance plan with the Plan ID 30751MT0550039. The plan is called Blue Preferred Silver PPO℠ 203.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.72% (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 29.28% 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 | 30751MT0550039 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| 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 | 30751MT0550039-00 | ||||||||||||||||||
| 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, 03 Dec 2024 06:24 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 30751MT0550039-00 Standard On Exchange Plan - 30751MT0550039-01 Open to Indians below 300% FPL - 30751MT0550039-02 Open to Indians above 300% FPL - 30751MT0550039-03 73% AV Silver Plan - 30751MT0550039-04 |
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| Last Plan Update Date | Wed, 16 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Blue Preferred Silver PPO℠ 203 Health Insurance Plan, 30751MT0550039-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Acupuncture
Limit: 12.0 Visit(s) per Benefit Period |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Allergy Testing
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Chiropractic Care
Limit: 10.0 Visit(s) per Benefit Period |
YES | 50.00% 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 | 50.00% 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, 50.00% 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 | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dialysis
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
|
YES | 50.00% 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, 50.00% Coinsurance after deductible |
$1000.00 Copay with deductible, 50.00% 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 | 50.00% Coinsurance after deductible |
50.00% 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 | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Gender Affirming Care
|
YES | 50.00% 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: 20.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Habilitation Services
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years 1 hearing device every 3 years for dependents age 18 & younger. Medically Necessary cochlear implants may be covered per Medical Policy. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Home Health Care Services
Limit: 180.0 Visit(s) per Benefit Period |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Hospice Services
|
YES | No Charge |
50.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
|
YES | 50.00% 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 | 50.00% 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, 50.00% Coinsurance after deductible |
$2000.00 Copay per Stay with deductible, 50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | 50.00% 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, 50.00% Coinsurance after deductible |
$2000.00 Copay per Stay with deductible, 50.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
|
YES | 50.00% 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: 35.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Nutritional Counseling
Also covered under preventive health care. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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 | $600.00 Copay with deductible, 50.00% Coinsurance after deductible |
$2000.00 Copay with deductible, 50.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | 50.00% 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: 30.00% Coinsurance after deductible Tier 2: 35.00% Coinsurance after deductible |
35.00% Coinsurance after deductible |
| 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 | 40.00% Coinsurance after deductible |
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 | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Radiation
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Reconstructive Surgery
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
|
YES | 50.00% 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 | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Specialist Visit
|
YES | 50.00% 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: 45.00% Coinsurance after deductible Tier 2: 45.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
| 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 | $850.00 Copay per Stay with deductible, 50.00% Coinsurance after deductible |
$2000.00 Copay per Stay with deductible, 50.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Transplant
|
YES | 50.00% 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 | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Weight Loss Programs
Covered for Preventive services only. |
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
50.00% Coinsurance after deductible |
| X-rays and Diagnostic Imaging
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Blue Preferred Silver PPO℠ 203 Health Insurance Plan Variant 30751MT0550039-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.707194602083143 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Silver Off Exchange Plan |
| 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 | 1.0 |
| First Tier Utilization | 85% |
| Formulary ID | MTF030 |
| Formulary URL | URL |
| HIOS Product ID | 30751MT055 |
| Import Date | 2023-08-16 20:01:48 |
| 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 | Silver |
| 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 | 2024-01-01 |
| Plan ID (Standard Component ID with Variant) | 30751MT0550039-00 |
| Plan Marketing Name | Blue Preferred Silver PPO℠ 203 |
| Plan Type | PPO |
| Plan Variant Marketing Name | Blue Preferred Silver PPO℠ 203 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $5300 |
| SBC Scenario, Having a Baby, Copayment | $900 |
| SBC Scenario, Having a Baby, Deductible | $1200 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $1500 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $1200 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $600 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1200 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 15% |
| Service Area ID | MTS011 |
| Source Name | SERFF |
| Plan ID | 30751MT0550039 |
| 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 | $2400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1200 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,200 |
| 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 | $2400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $1200 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $1,200 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $9600 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $4800 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $4,800 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18900 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9450 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,450 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $18900 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $9450 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $9,450 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $75600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $37800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $37,800 |
| 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 Silver PPO℠ 203 Health Insurance Plan, 30751MT0550039
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Blue Preferred Silver PPO℠ 203, 30751MT0550039 Health Insurance Plan, 30751MT0550039
-
Does Blue Preferred Silver PPO℠ 203 Health Insurance Plan, 30751MT0550039 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (30751MT0550039) Health Insurance Plan, Variant (30751MT0550039-00) offer Disease Management Programs?
Does (30751MT0550039) Health Insurance Plan, Variant (30751MT0550039-00) have Out Of Country Coverage?
Does (30751MT0550039) Health Insurance Plan, Variant (30751MT0550039-00) have Out of Service Area Coverage?
Does (30751MT0550039) Health Insurance Plan, Variant (30751MT0550039-00) offer Disease Management Programs?
Does Blue Preferred Silver PPO℠ 203 Health Insurance Plan, Variant (30751MT0550039-00) offer Disease Management Programs for Asthma?
Does Blue Preferred Silver PPO℠ 203 Health Insurance Plan, Variant (30751MT0550039-00) offer Disease Management Programs for Heart disease?
Does Blue Preferred Silver PPO℠ 203 Health Insurance Plan, Variant (30751MT0550039-00) offer Disease Management Programs for Depression?
Does Blue Preferred Silver PPO℠ 203 Health Insurance Plan, Variant (30751MT0550039-00) offer Disease Management Programs for Diabetes?
Does Blue Preferred Silver PPO℠ 203 Health Insurance Plan, Variant (30751MT0550039-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Blue Preferred Silver PPO℠ 203 Health Insurance Plan, Variant (30751MT0550039-00) offer Disease Management Programs for Low back pain?
Does Blue Preferred Silver PPO℠ 203 Health Insurance Plan, Variant (30751MT0550039-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 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