Blue Preferred Silver PPO℠ 308 - 30751MT0550071 Health Insurance Plan
Blue Cross and Blue Shield of Montana health insurance plan with the Plan ID 30751MT0550071. The plan is called Blue Preferred Silver PPO℠ 308.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 73.19% (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 26.81% 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 | 30751MT0550071 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 30751MT0550071-04 | ||||||||||||||||||
| 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 - 30751MT0550071-00 Standard On Exchange Plan - 30751MT0550071-01 Open to Indians below 300% FPL - 30751MT0550071-02 Open to Indians above 300% FPL - 30751MT0550071-03 73% AV Silver Plan - 30751MT0550071-04 |
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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℠ 308 Health Insurance Plan, 30751MT0550071-04
| 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 30751MT0550071-04 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7318740059384692 |
| 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 | 73% AV Level Silver 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 | $12500 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $6250 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $6,250 |
| Medical EHB Deductible, In Network (Tier 2), Default Coinsurance | 0.00% |
| Medical EHB Deductible, In Network (Tier 2), Family Per Group | $12500 per group |
| Medical EHB Deductible, In Network (Tier 2), Family Per Person | $6250 per person |
| Medical EHB Deductible, In Network (Tier 2), Individual | $6,250 |
| Medical EHB Deductible, Out of Network, Family Per Group | $50000 per group |
| Medical EHB Deductible, Out of Network, Family Per Person | $25000 per person |
| Medical EHB Deductible, Out of Network, Individual | $25,000 |
| 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) | 30751MT0550071-04 |
| 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 | $6250 |
| 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 | MTS021 |
| Source Name | SERFF |
| Plan ID | 30751MT0550071 |
| 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 | $12500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6250 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,250 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $12500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $6250 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $6,250 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $50000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $25000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $25,000 |
| 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, 30751MT0550071
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Blue Preferred Silver PPO℠ 308, 30751MT0550071 Health Insurance Plan, 30751MT0550071
-
Does Blue Preferred Silver PPO℠ 308 Health Insurance Plan, 30751MT0550071 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (30751MT0550071) Health Insurance Plan, Variant (30751MT0550071-04) offer Disease Management Programs?
Does (30751MT0550071) Health Insurance Plan, Variant (30751MT0550071-04) have Out Of Country Coverage?
Does (30751MT0550071) Health Insurance Plan, Variant (30751MT0550071-04) have Out of Service Area Coverage?
Does (30751MT0550071) Health Insurance Plan, Variant (30751MT0550071-04) offer Disease Management Programs?
Does Blue Preferred Silver PPO℠ 308 Health Insurance Plan, Variant (30751MT0550071-04) offer Disease Management Programs for Asthma?
Does Blue Preferred Silver PPO℠ 308 Health Insurance Plan, Variant (30751MT0550071-04) offer Disease Management Programs for Heart disease?
Does Blue Preferred Silver PPO℠ 308 Health Insurance Plan, Variant (30751MT0550071-04) offer Disease Management Programs for Depression?
Does Blue Preferred Silver PPO℠ 308 Health Insurance Plan, Variant (30751MT0550071-04) offer Disease Management Programs for Diabetes?
Does Blue Preferred Silver PPO℠ 308 Health Insurance Plan, Variant (30751MT0550071-04) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Blue Preferred Silver PPO℠ 308 Health Insurance Plan, Variant (30751MT0550071-04) offer Disease Management Programs for Low back pain?
Does Blue Preferred Silver PPO℠ 308 Health Insurance Plan, Variant (30751MT0550071-04) 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