BlueSelect Bronze Value – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$6,500 per person $6,500 per person
Out-of-pocket max	$9,100 per person $18,200 per family
Metal tier	Bronze

Visit Copay

Primary care visit	50% coinsurance after deductible
Specialist visit	50% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	50% coinsurance after deductible
Emergency room	50% coinsurance after deductible
Ambulance	50% coinsurance after deductible
Hospital stay (facility)	50% coinsurance after deductible
Hospital stay (physician)	50% coinsurance after deductible
Outpatient procedure (facility)	50% coinsurance after deductible
Outpatient procedure (physician)	50% coinsurance after deductible
Physical rehabilitation	50% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$20 copay after deductible
Brand	$150 copay after deductible
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance

Lab Tests and Diagnostic Procedures

X-rays	50% coinsurance after deductible
Imaging (CT/PET/MRI)	50% coinsurance after deductible
Blood work	50% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	50% coinsurance after deductible
Psychiatric hospital stay	50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://shop.yourwyoblue.com/content/sbcs/2024/WY/Individual/BlueSelectBronzeValueIX.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