BlueSelect Gold Balance – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$2,000 per person $2,000 per person
Out-of-pocket max	$9,100 per person $18,200 per family
Metal tier	Gold

Visit Copay

Primary care visit	$30 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	$500 copay after deductible, 40% coinsurance after deductible
Ambulance	20% coinsurance after deductible
Hospital stay (facility)	40% coinsurance after deductible
Hospital stay (physician)	20% coinsurance after deductible
Outpatient procedure (facility)	40% 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	40% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$5 copay
Brand	$50 copay
Non-preferred Brand	20% coinsurance after deductible
Specialty	20% coinsurance after deductible

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	40% coinsurance after deductible

Health Plan Provider Information

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