BlueSelect Silver Balance without Kid’s Dental – PPO
87% cost sharing reduction [Popular Plan]
Network type: PPO
Coverage tier: Silver
Primary care visit: $20 copay, 15% coinsurance after deductible
Specialist visit: 15% coinsurance after deductible
Urgent care visit: 15% coinsurance after deductible
Description
This plan has 87% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | PPO |
| Deductible | $1,400 per person $1,400 per person |
| Out-of-pocket max | $2,500 per person $5,000 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $20 copay, 15% coinsurance after deductible |
| Specialist visit | 15% coinsurance after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 15% coinsurance after deductible |
| Emergency room | $500 copay after deductible, 35% coinsurance after deductible |
| Ambulance | 15% coinsurance after deductible |
| Hospital stay (facility) | 35% coinsurance after deductible |
| Hospital stay (physician) | 15% coinsurance after deductible |
| Outpatient procedure (facility) | 35% coinsurance after deductible |
| Outpatient procedure (physician) | 15% coinsurance after deductible |
| Physical rehabilitation | 15% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 35% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $4 copay |
| Brand | $75 copay |
| Non-preferred Brand | 15% coinsurance after deductible |
| Specialty | 15% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 15% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 15% coinsurance after deductible |
| Blood work | 15% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 15% coinsurance after deductible |
| Psychiatric hospital stay | 35% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://shop.yourwyoblue.com/content/sbcs/2024/WY/Individual/BlueSelectSilverBalance87ND.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 |
