BlueSelect Silver Balance – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $40 copay, 25% coinsurance after deductible
Specialist visit: 25% coinsurance after deductible
Urgent care visit: 25% coinsurance after deductible
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $6,000 per person $6,000 per person |
| Out-of-pocket max | $9,100 per person $18,200 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $40 copay, 25% coinsurance after deductible |
| Specialist visit | 25% coinsurance after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 25% coinsurance after deductible |
| Emergency room | $1000 copay after deductible, 45% coinsurance after deductible |
| Ambulance | 25% coinsurance after deductible |
| Hospital stay (facility) | 45% coinsurance after deductible |
| Hospital stay (physician) | 25% coinsurance after deductible |
| Outpatient procedure (facility) | 45% coinsurance after deductible |
| Outpatient procedure (physician) | 25% coinsurance after deductible |
| Physical rehabilitation | 25% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 45% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $5 copay |
| Brand | $100 copay |
| Non-preferred Brand | 25% coinsurance after deductible |
| Specialty | 25% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 25% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 25% coinsurance after deductible |
| Blood work | 25% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 25% coinsurance after deductible |
| Psychiatric hospital stay | 45% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://shop.yourwyoblue.com/content/sbcs/2024/WY/Individual/BlueSelectSilverBalanceIX.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 |
