Blue Preferred Bronze PPO℠ 301

30751MT0550075
Bronze
PPO

Blue Preferred Bronze PPO℠ 301 is a Bronze PPO plan by Blue Cross and Blue Shield of Montana.

IMPORTANT: You are viewing the 2024 version of Blue Preferred Bronze PPO℠ 301 30751MT0550075. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Blue Preferred Bronze PPO℠ 301 is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Blue Preferred Bronze PPO℠ 301 30751MT0550075.
Insurer: Blue Cross and Blue Shield of Montana
Network Type: PPO
Metal Type: Bronze
HSA Eligible?: No
Plan ID: 30751MT0550075

Cost-Sharing Overview

Blue Preferred Bronze PPO℠ 301 offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Blue Preferred Bronze PPO℠ 301?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Blue Preferred Bronze PPO℠ 301 offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Blue Preferred Bronze PPO℠ 301 covers when you are out of the service area or out of the country.

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.
National Network: Yes

Additional Benefits and Cost-Sharing

Blue Preferred Bronze PPO℠ 301 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Specialist Visit
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable No Charge after deductible$2000.00 Copay with deductible No Charge after deductible
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Hospice Services
Covered
No Charge Not ApplicableNot Applicable No Charge after deductible
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible Excludes invitro and prescription drugs for the treatment of infertility. Covered for the diagnosis of infertility and artificial insemination.
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Home Health Care Services
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible180.0 Visit(s) per Benefit Period
Emergency Room Services
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible 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.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable No Charge after deductible$2000.00 Copay per Stay with deductible No Charge after deductible
Inpatient Physician and Surgical Services
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Bariatric Surgery
Not Covered
Cosmetic Surgery
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible Only for the correction of a condition resulting from an accident, a condition resulting from an injury or to treat a congenitial anomaly.
Skilled Nursing Facility
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible60.0 Days per Benefit Period
Prenatal and Postnatal Care
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible First prenatal visit is subject to the Office Visit charge. All subsequent prenatal care is covered under delivery for maternity care.
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable No Charge after deductible$2000.00 Copay with deductible No Charge after deductible Childbirth/delivery professional services are subject to your Medical EHB Deductible/Maximum Out of Pocket for Medical EHB benefits, if applicable.
Mental/Behavioral Health Outpatient Services
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable No Charge after deductible$2000.00 Copay per Stay with deductible No Charge after deductible
Substance Abuse Disorder Outpatient Services
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable No Charge after deductible$2000.00 Copay per Stay with deductible No Charge after deductible
Generic Drugs
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible 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.
Preferred Brand Drugs
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible 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.
Non-Preferred Brand Drugs
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible 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.
Specialty Drugs
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible 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.
Outpatient Rehabilitation Services
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Habilitation Services
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Chiropractic Care
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible10.0 Visit(s) per Benefit Period
Durable Medical Equipment
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Hearing Aids
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible1.0 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.
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Preventive Care/Screening/Immunization
Covered
No Charge Not ApplicableNot Applicable No Charge after deductible
Routine Foot Care
Not Covered
Covered when medically necessary
Acupuncture
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible12.0 Visit(s) per Benefit Period
Weight Loss Programs
Not Covered
Covered for Preventive services only.
Routine Eye Exam for Children
Covered
No Charge Not ApplicableNo Charge Not Applicable1.0 Visit(s) per Benefit Period
Eye Glasses for Children
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible1.0 Item(s) per Benefit Period One pair of glasses (frames and lenses) or one pair of contacts per Benefit Period.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Well Baby Visits and Care
Covered
No Charge Not ApplicableNot Applicable 0.00%
Laboratory Outpatient and Professional Services
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
X-rays and Diagnostic Imaging
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Accidental Dental
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Dialysis
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Allergy Testing
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Chemotherapy
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Radiation
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Diabetes Education
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible First $250 at 100% of allowable fee, then deductible, copayment, or coinsurance apply.
Prosthetic Devices
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Infusion Therapy
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.
Treatment for Temporomandibular Joint Disorders
Not Covered
Surgical treatment is covered as any other surgery.
Nutritional Counseling
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible Also covered under preventive health care.
Reconstructive Surgery
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible
Gender Affirming Care
Covered
Not Applicable No Charge after deductibleNot Applicable No Charge after deductible

Free Preventive Services

There is no copayment or coinsurance for any of the following Blue Preferred Bronze PPO℠ 301 preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Blue Preferred Bronze PPO℠ 301 including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Blue Preferred Bronze PPO℠ 301?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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