Medical Plan (mandatory)
FY2022
Administered by BlueCross BlueShield of Montana 1-800-820-1674 or 447-8747, www.bcbsmt.com
Choices offers a Medical Plan for Employees and their eligible dependents. Medical Plan Monthly Employee/Survivor Only
$748
Employee & Spouse Employee & Child(ren)/ Survivor & Childr(ren
$1,075
Employee & Family
$1,327
Sample Medical card
$994
The employer contribution for FY2022 is $1,054 per month for eligible active employees (applies to pre-tax benefits only).
Medical Plan Costs
FY2022 Medical Plan Costs
Annual Deductible
Applies to all covered services, unless otherwise noted or copayment is indicated.
Copayment (outpatient office visits) Primary Care Physician Visit (PCP) Specialty Provider Visit
Medical Plan In-Network
Medical Plan Out-of-Network *
$750/Person $1,500/Family
Separate $750/Person Separate $1,750/Family
$25 copay $40 copay
N/A N/A
25%
35%
$4,000/Person $8,000/Family
Separate $6,000/Person Separate $12,000/Family
Coinsurance Percentages
(% of allowed charges member pays)
Annual Out-of-Pocket Maximum
(Maximum paid by member in a benefit plan year for covered services; includes deductibles, copays and coinsurance)
from an Out-of-Network provider have separate deductibles, % coinsurance, and Out-of-Pocket maximums. An Out-of* Services Network provider can balance bill the difference between the allowed amount and the billed charge.
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