BlueSelect Silver Value – PPO

Description

This plan has 94% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	PPO
Deductible	$150 per person $150 per person
Out-of-pocket max	$900 per person $1,800 per family
Metal tier	Silver

Visit Copay

Primary care visit	$5 copay, 20% coinsurance after deductible
Specialist visit	20% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	20% coinsurance after deductible
Emergency room	20% coinsurance after deductible
Ambulance	20% coinsurance after deductible
Hospital stay (facility)	20% coinsurance after deductible
Hospital stay (physician)	20% coinsurance after deductible
Outpatient procedure (facility)	20% coinsurance after deductible
Outpatient procedure (physician)	20% coinsurance after deductible
Physical rehabilitation	20% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	20% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$2 copay
Brand	$25 copay after deductible
Non-preferred Brand	20% coinsurance after deductible
Specialty	20% coinsurance

Lab Tests and Diagnostic Procedures

X-rays	20% coinsurance after deductible
Imaging (CT/PET/MRI)	20% coinsurance after deductible
Blood work	20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	20% coinsurance after deductible
Psychiatric hospital stay	20% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://shop.yourwyoblue.com/content/sbcs/2024/WY/Individual/BlueSelectSilverValue94.pdf
Drug and medication plan formulary	https://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_WY_4T_HealthInsuranceMarketplaceBlueSelect.pdf
Search doctor list	https://bcbswy.sapphirecareselect.com