2019 Blue Preferred Gold PPO 204 - Two $10 PCP Visits Plan Details - HealthPocket

Blue Preferred Gold PPO 204 - Two $10 PCP Visits

$647.98/mo

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Zip Code59102
Applicant10/15/1984 Male
Coverage Start10/16/2019
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameBlue Preferred Gold PPO 204 - Two $10 PCP Visits
Plan IDhhs-30751MT0550045
Plan Year2019
Insurance ProviderBlueCross BlueShield of Montana
Metal LevelGold
Plan TypePPO
Deductible$450
Out-of-Pocket Maximum$7,900
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$10 Copay, 30.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.
Specialist Visit30.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services30.00% Coinsurance after deductible
X-rays and Diagnostic Imaging30.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans30.00% Coinsurance after deductible
Deductible - Family$900 per group
Out-of-Pocket Maximum - Family$15800 per group

Prescription drug coverage

Generic Drugs$5 Copay
Preferred Brand Drugs$50 Copay
Non-Preferred Brand Drugs$100 Copay
Specialty Drugs$250 Copay

Access to doctors and hospitals

Provider directory URLhttps://www.bcbsmt.com/_layouts/BCBSMTPortal/FindProvider/ProviderSearchResults.aspx
Does this plan have access to a national provider network?Yes
Is a referral required to see a Specialist?Not Covered
Does this plan cover services outside plan service area?Yes - 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 this plan cover services outside the country?Yes - 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.

Hospital services

Emergency Room Services$1000 Copay with deductible, 30.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.
Inpatient Hospital Services (e.g., Hospital Stay)$850 Copay per Stay with deductible, 30.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.
Inpatient Physician and Surgical Services30.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service30.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care$10 Copay, 30.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.
Delivery and all inpatient services for maternity care$850 Copay with deductible, 30.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.

Mental Health

Mental/Behavioral Health Outpatient Services30.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services$850 Copay per Stay with deductible, 30.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.
Substance use disorder outpatient services30.00% Coinsurance after deductible
Substance use disorder inpatient services$850 Copay per Stay with deductible, 30.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
Does this plan offer a wellness program?Not Covered

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsNot Covered

Child Dental Coverage

Child Dental Coverage - Routine Dental CareNot Covered
Child Dental Coverage - Basic Dental CareNot Covered
Child Dental Coverage - OrthodontiaNot Covered
Child Dental Coverage - Major Dental CareNot Covered

Adult Dental Coverage

Adult Dental Coverage - Routine Dental CareNot Covered
Adult Dental Coverage - Basic Dental CareNot Covered
Adult Dental Coverage - OrthodontiaNot Covered
Adult Dental Coverage - Major Dental CareNot Covered

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
Preventive Care/Screening/Immunization
Cosmetic Surgery
Infertility Treatment
Imaging (CT/PET Scans, MRIs)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Outpatient Rehabilitation Services
Habilitation Services
Durable Medical Equipment
Hospice Services
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
Prosthetic Devices
Radiation
Reconstructive Surgery
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
Transplant
Well Baby Visits and Care
Prescription Drugs Other
More Limited BenefitsSkilled Nursing Facility
Acupuncture
Home Health Care Services
Chiropractic Care
More Excluded BenefitsBariatric Surgery
Hearing Aids
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Weight Loss Programs
Dental Check-Up for Children
Routine Foot Care
Abortion for Which Public Funding is Prohibited
Treatment for Temporomandibular Joint Disorders
PremiumPlan NameDeductible
from $241
Connected Care_Platinum
$350.00Select
from $252
Blue Cross Blue Shield Premier 2, a Multi-State Plan
$500.00Select
from $568
Blue Preferred Silver PPO 203
$650.00Select
from $577
Blue Preferred Gold PPO 204 - Two $10 PCP Visits
$450.00Select
from $635
Blue Preferred Silver PPO 203
$650.00Select
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  • Phone Number
    (406) 969-6310
  • Office Locations
    2110 Overland Ave Ste 102
    Billings, MT 59102
2110 Overland Ave Ste 102 Billings MT, 59102
  • What is the Gold Plan?

    ObamaCare’s Gold Plan is a type of Metal Plan on the Health Insurance Marketplace. Gold Plans qualify for Tax Credits, have high premiums, and good cost sharing. Gold plans mean higher premiums, less Tax Credits, but much better cost sharing on average than Silver or Bronze.

  • How are Gold Plans different than other Obamacare health plans?

    The fundamental difference among the new Obamacare health plans is the percentage of covered medical costs paid by the health plan. The Gold Plan typically pays 80% of covered medical costs.

  • How much does a Gold Plan cost?

    The monthly premium for a Gold Plan depends on the insurer from whom you purchase the plan, the number of people to be insured by the plan, your age, whether you smoke, and your geographic region. You can use HealthPocket’s comparison tool to compare Gold Plan premiums in your area.

  • When Can I Enroll in a Gold Plan?

    The Open Enrollment period for the 2018 Affordable Care Act health plans begins November 1, 2017 and ends December 15, 2017. See our Open Enrollment article for more information.

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HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Health Insurance Innovations, Inc. family of companies (NASDAQ: HIIQ).