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Blue Preferred Gold PPO℠ 204
Health Insurance Plan Details (2025 Plan)
by Blue Cross and Blue Shield of Montana
Monthly Premium
PPO
$ubsidy
Gold
- Deductible
- $750 /yr
- Max Out-of-Pocket
- $9,200 /yr
Details
| Deductible (per individual) | $750 /yr |
| Deductible (per family) | $1,500 /yr |
| Max Out-of-Pocket (per individual) | $9,200 /yr |
| Max Out-of-Pocket (per family) | $18,400 /yr |
| Drug Deductible (per individual) | $0 |
| Drug Deductible (per family) | $0 |
| Drug Max Out-of-Pocket (per individual) | Included in Medical |
| Drug Max Out-of-Pocket (per family) | Included in Medical |
| Plan Type | PPO |
| Includes Child Dental? | No |
| Includes Adult Dental? | No |
Out-of-Pocket Costs
| Preventive Care | No Charge |
| Primary Care Visit | $10 Copay |
| Specialist Visit | 30% Coinsurance after deductible |
| Emergency Room | $1000 Copay with deductible and 30% Coinsurance after deductible |
| Inpatient Facility | $850 Copay per Stay with deductible and 30% Coinsurance after deductible |
| Inpatient Physician | 30% Coinsurance after deductible |
| Generic Drugs | $5 Copay |
| Preferred Brand Drugs | $50 Copay |
| Non-preferred Brand Drugs | $100 Copay |
| Specialty Drugs | $250 Copay |
Plan Documents
| Summary of Benefits and Coverage | SBC doc |
| Provider Directory | Doctor lookup |
| Drug Formulary List | drug list |
Insurance Carrier Disclaimer
Blue Cross and Blue Shield of Montana, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
* Figures shown are only for in-network medical costs
** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible
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