Blue Preferred Silver PPO℠ 308 - 30751MT0550061 Health Insurance Plan

Blue Cross and Blue Shield of Montana health insurance plan with the Plan ID 30751MT0550061. The plan is called Blue Preferred Silver PPO℠ 308.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.08% (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 29.92% 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 30751MT0550061
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 30751MT0550061-01
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).

Providers Montana All US States
All 9648 107485
PCP 979 1736
Allergy 2 3
OB/GYN 24 90
Dentists 80 278
Available Variants of the Health Plan

Standard Off Exchange Plan - 30751MT0550061-00

Standard On Exchange Plan - 30751MT0550061-01

Open to Indians below 300% FPL - 30751MT0550061-02

Open to Indians above 300% FPL - 30751MT0550061-03

73% AV Silver Plan - 30751MT0550061-04

87% AV Silver Plan - 30751MT0550061-05

94% AV Silver Plan - 30751MT0550061-06

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℠ 308 Health Insurance Plan, 30751MT0550061-01

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

No Charge after deductible

No Charge after deductible
Acupuncture

Limit: 12.0 Visit(s) per Benefit Period

YES

No Charge after deductible

No Charge after deductible
Allergy Testing
YES

No Charge after deductible

No Charge after deductible
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

No Charge after deductible

No Charge after deductible
Chiropractic Care

Limit: 10.0 Visit(s) per Benefit Period

YES

No Charge after deductible

No Charge 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

No Charge after deductible

No Charge 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.

YES

No Charge after deductible

$2000.00 Copay with deductible, No Charge after deductible
Dental Check-Up for Children
NO
Diabetes Education

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

YES

No Charge after deductible

No Charge after deductible
Dialysis
YES

No Charge after deductible

No Charge after deductible
Durable Medical Equipment
YES

No Charge after deductible

No Charge after deductible
Emergency Room Services
YES

No Charge after deductible

No Charge 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

No Charge after deductible

No Charge 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

No Charge after deductible

No Charge after deductible
Gender Affirming Care
YES

No Charge after deductible

No Charge 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: $10.00

Tier 2: $20.00

$20.00
Habilitation Services
YES

No Charge after deductible

No Charge 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

No Charge after deductible

No Charge after deductible
Home Health Care Services

Limit: 180.0 Visit(s) per Benefit Period

YES

No Charge after deductible

No Charge after deductible
Hospice Services
YES

No Charge

No Charge after deductible
Imaging (CT/PET Scans, MRIs)
YES

No Charge after deductible

No Charge 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

No Charge after deductible

No Charge 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

No Charge after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
YES

No Charge after deductible

$2000.00 Copay per Stay with deductible, No Charge after deductible
Inpatient Physician and Surgical Services
YES

No Charge after deductible

No Charge after deductible
Laboratory Outpatient and Professional Services
YES

No Charge after deductible

No Charge after deductible
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

No Charge after deductible

$2000.00 Copay per Stay with deductible, No Charge after deductible
Mental/Behavioral Health Outpatient Services
YES

No Charge after deductible

No Charge 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: $150.00

$150.00
Nutritional Counseling

Also covered under preventive health care.

YES

No Charge after deductible

No Charge after deductible
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

No Charge after deductible

No Charge after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

No Charge after deductible

$2000.00 Copay with deductible, No Charge after deductible
Outpatient Rehabilitation Services
YES

No Charge after deductible

No Charge after deductible
Outpatient Surgery Physician/Surgical Services
YES

No Charge after deductible

No Charge 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: $100.00

$100.00
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

No Charge after deductible

No Charge after deductible
Preventive Care/Screening/Immunization
YES

No Charge

No Charge after deductible
Primary Care Visit to Treat an Injury or Illness
YES

No Charge after deductible

No Charge after deductible
Private-Duty Nursing
NO
Prosthetic Devices
YES

No Charge after deductible

No Charge after deductible
Radiation
YES

No Charge after deductible

No Charge after deductible
Reconstructive Surgery
YES

No Charge after deductible

No Charge after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy
YES

No Charge after deductible

No Charge after deductible
Rehabilitative Speech Therapy
YES

No Charge after deductible

No Charge 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

No Charge after deductible

No Charge after deductible
Specialist Visit
YES

No Charge after deductible

No Charge 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

No Charge after deductible

$2000.00 Copay per Stay with deductible, No Charge after deductible
Substance Abuse Disorder Outpatient Services
YES

No Charge after deductible

No Charge after deductible
Transplant
YES

No Charge after deductible

No Charge after deductible
Treatment for Temporomandibular Joint Disorders

Surgical treatment is covered as any other surgery.

NO
Urgent Care Centers or Facilities
YES

No Charge after deductible

No Charge after deductible
Weight Loss Programs

Covered for Preventive services only.

NO
Well Baby Visits and Care
YES

No Charge

0.00%
X-rays and Diagnostic Imaging
YES

No Charge after deductible

No Charge after deductible

Blue Preferred Silver PPO℠ 308 Health Insurance Plan Variant 30751MT0550061-01 Attributes

Plan Attribute Value
AV Calculator Output Number 0.700830557678162
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 On 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, 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 MTF023
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 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 0.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $16300 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $8150 per person
Medical EHB Deductible, In Network (Tier 1), Individual $8,150
Medical EHB Deductible, In Network (Tier 2), Default Coinsurance 0.00%
Medical EHB Deductible, In Network (Tier 2), Family Per Group $16300 per group
Medical EHB Deductible, In Network (Tier 2), Family Per Person $8150 per person
Medical EHB Deductible, In Network (Tier 2), Individual $8,150
Medical EHB Deductible, Out of Network, Family Per Group $65200 per group
Medical EHB Deductible, Out of Network, Family Per Person $32600 per person
Medical EHB Deductible, Out of Network, Individual $32,600
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) 30751MT0550061-01
Plan Marketing Name Blue Preferred Silver PPO℠ 308
Plan Type PPO
Plan Variant Marketing Name Blue Preferred Silver PPO℠ 308
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $8150
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $800
SBC Scenario, Having Diabetes, Deductible $1900
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $10
SBC Scenario, Treatment of a Simple Fracture, Deductible $2800
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 15%
Service Area ID MTS011
Source Name SERFF
Plan ID 30751MT0550061
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 $16300 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8150 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,150
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $16300 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $8150 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $8,150
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $65200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $32600 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $32,600
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℠ 308 Health Insurance Plan, 30751MT0550061

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

Frequently Asked Questions(FAQ) about Blue Preferred Silver PPO℠ 308, 30751MT0550061 Health Insurance Plan, 30751MT0550061

  • Does Blue Preferred Silver PPO℠ 308 Health Insurance Plan, 30751MT0550061 support Mail Ordering?

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

  • Does (30751MT0550061) Health Insurance Plan, Variant (30751MT0550061-01) 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 (30751MT0550061) Health Insurance Plan, Variant (30751MT0550061-01) 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 (30751MT0550061) Health Insurance Plan, Variant (30751MT0550061-01) 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 (30751MT0550061) Health Insurance Plan, Variant (30751MT0550061-01) 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 Preferred Silver PPO℠ 308 Health Insurance Plan, Variant (30751MT0550061-01) offer Disease Management Programs for Asthma?

    Yes, the Blue Preferred Silver PPO℠ 308 Health Insurance Plan Variant 30751MT0550061-01 offers Disease Management Program for Asthma.

    Does Blue Preferred Silver PPO℠ 308 Health Insurance Plan, Variant (30751MT0550061-01) offer Disease Management Programs for Heart disease?

    Yes, the Blue Preferred Silver PPO℠ 308 Health Insurance Plan Variant 30751MT0550061-01 offers Disease Management Program for Heart disease.

    Does Blue Preferred Silver PPO℠ 308 Health Insurance Plan, Variant (30751MT0550061-01) offer Disease Management Programs for Depression?

    Yes, the Blue Preferred Silver PPO℠ 308 Health Insurance Plan Variant 30751MT0550061-01 offers Disease Management Program for Depression.

    Does Blue Preferred Silver PPO℠ 308 Health Insurance Plan, Variant (30751MT0550061-01) offer Disease Management Programs for Diabetes?

    Yes, the Blue Preferred Silver PPO℠ 308 Health Insurance Plan Variant 30751MT0550061-01 offers Disease Management Program for Diabetes.

    Does Blue Preferred Silver PPO℠ 308 Health Insurance Plan, Variant (30751MT0550061-01) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Blue Preferred Silver PPO℠ 308 Health Insurance Plan Variant 30751MT0550061-01 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Blue Preferred Silver PPO℠ 308 Health Insurance Plan, Variant (30751MT0550061-01) offer Disease Management Programs for Low back pain?

    Yes, the Blue Preferred Silver PPO℠ 308 Health Insurance Plan Variant 30751MT0550061-01 offers Disease Management Program for Low back pain.

    Does Blue Preferred Silver PPO℠ 308 Health Insurance Plan, Variant (30751MT0550061-01) offer Disease Management Programs for Pregnancy?

    Yes, the Blue Preferred Silver PPO℠ 308 Health Insurance Plan Variant 30751MT0550061-01 offers Disease Management Program 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