Common Contracts

FOR BCBSMT CUSTOMER SERVICE AND PRIOR AUTHORIZATION FOR CUSTOMER SERVICE

September 20th, 2023

• Filed
  September 20th, 2023

BLUE PREFERRED SILVER PPO 703 COST SHARING REDUCTION - 87% ACTUARIAL VALUE (AV) Annual and Lifetime Plan Maximum: None Benefit Period: Calendar Year The Benefits are subject to the Benefit Period unless otherwise specified. In-Network Out-of-Network Deductible: Individual $700 $2,800 Family $1,400 $5,600 The In-Network and Out-of-Network Deductibles are separate amounts and one does not accumulate to the other.Any Copayments (except insulin) and/or Coinsurance do not accumulate to the Deductible. Deductible Per Visit or Occurrence: Inpatient Admission No Copayment; Deductible and Coinsurance Apply $2,000* Outpatient Surgery – Facility No Copayment; Deductible and Coinsurance Apply $2,000* *The per visit or occurrence Deductible is in addition to The Plan Deductible and any Copayment and/or Coinsurance. Once the Out of Pocket Amount is satisfied, Plan Deductible, per visit or occurrence Deductible(s), Copayment and/or Coinsurance do not apply. Coinsurance: 30% 50% Copaymen