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Our Limited Benefit Plan is a Preferred Provider Organization (PPO) plan with a $25,000 annual maximum per individual. Plan features include a low calendar year deductible of $250, office visit copayments, annual routine physical exams, and prescription drug coverage. The Limited Benefit Plan is not designed to be a comprehensive medical policy. The benefits provide a cost effective alternative for those who cannot afford traditional coverage.
This PPO plan gives you access to a nationwide network of preferred providers contracted by Mountain State Blue Cross Blue Shield. PPO providers agree to special pricing and utilization review arrangements to help contain the cost of care. By seeking care from Mountain State Blue Cross Blue Shield preferred providers, you can receive the highest level of benefits under your plan. Covered services received from non-network providers are reimbursed at a lower level of benefits.
Attractive features include:
- Lower monthly premium.
- 50/50 generic prescription drug card coverage with no annual deductible.
- Discounts available for brand name drugs.
- $15 copayment for Office Visits. $30 copayment for Specialist Office Visits.
- Annual Routine Physical Exam
- An extensive network of providers. Mountain State Blue Cross Blue Shield has nearly 5,000 Preferred Provider locations statewide.
- The Blue Card PPO program which allows members to travel outside the service area and still receive high level benefits when utilizing the services of more than 385,000 Preferred Providers nationwide.
- Guaranteed Renewal that automatically renews monthly as long as you pay premiums when due.
- Program of available discounts from major optical retailers.
- Maternity and Newborn Services are covered when purchasing optional Maternity Services Rider.
 Individual Product Enrollment Form
Limited Benefit Application Addendum
Limited Benefits is not designed to be a comprehensive medical policy.
The benefits provide a cost effective alternative for those who cannot
afford traditional coverage.
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