BlueSelect Gold Standard without Kid's Dental - 11269WY0170017 Health Insurance Plan
Blue Cross Blue Shield of Wyoming health insurance plan with the Plan ID 11269WY0170017. The plan is called BlueSelect Gold Standard without Kid's Dental.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.06% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.94% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 11269WY0170017 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Wyoming | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross Blue Shield of Wyoming | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 11269WY0170017-01 | ||||||||||||||||||
| Provider Network(s) | ALLOWED IN-NETWORK NON-PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 15 Apr 2025 06:06 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 11269WY0170017-00 Standard On Exchange Plan - 11269WY0170017-01 |
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| Last Plan Update Date | Fri, 15 Nov 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 15 Apr 2025 06:06 GMT |
Benefits of BlueSelect Gold Standard without Kid's Dental Health Insurance Plan, 11269WY0170017-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Dental services rendered by a dentist in an office setting which are required as a result of an accidental injury caused by an external force or blow to the jaw, sound natural teeth, mouth or face. Injury as a result of chewing or biting will not be considered an accidental injury. TMJ services would only be covered if accident related. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
Exclusions: Benefits are not available for clinical ecology, orthomolecular therapy, vitamins, dietary nutritional supplements, or related testing rendered on an outpatient basis. Benefits are not available for the following allergy testing modalities: nasal challenge testing, provocative/neutralization testing, leukocyte histamine release, Rebuck skin window test, passive transfer or Prausnitz- Kustner test, cytotoxic food testing, metabisulfite testing, candidiasis hypersensitivity syndrome testing, IgE level testing for food allergies, general volatile organic screening test and mauve urine test. Benefits are not available for the following methods of desensitization: provocation/neutralization therapy by sublingual (drops) intradermal and subcutaneous routes, urine autoinjections, repository emulsion therapy, candidiasis hypersensitivity syndrome treatment or IV vitamin C therapy. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Bariatric Surgery
Limit: 1.0 Procedure(s) per Lifetime Exclusions: Benefits are NOT available for the Garren gastric bubble technique relating to morbid obesity. Prior approval is required. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Chiropractic Care
Limit: 15.0 Visit(s) per Year |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Cosmetic Surgery
Exclusions: No coverage for cosmetic surgery and related services intended primarily to improve appearance. Covers expenses related to cosmetic surgery only when restorative surgery is required as the result of a birth defect, accidental injury or a malignant disease process or its treatment. Prior approval is necessary. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Delivery and All Inpatient Services for Maternity Care
Exclusions: Services related to surrogacy Includes vaginal delivery, caesarean section, miscarriage, complications of pregnancy, circumcisions. Benefits are available for midwives if delivery takes place in a licensed facility. Although, emergency and maternity admissions ARE NOT subject to a sanction,notification to BCBSWY is encouraged. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Limit: 6.0 Visit(s) per Year Covered when billed by a participating provider. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dialysis
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
Exclusions: Benefits are not available for support devices for the foot, including flat foot conditions. There are no benefits for shoe inserts. Benefits are not available for deluxe motorized equipment, electronic speech aids; robotization devices, robotic prosthetics, dental appliances and artificial organs. Benefits are not available for personal hygiene and convenience items such as air conditioner, humidifiers or physical fitness equipment. Benefits are not available for wigs or artificial hairpieces, or hair transplants or implants, regardless of whether or not there is a medical reason for hair loss. Includes but not limited to Diabetic supplies, therapeutic devices (e.g. hypodermic needles & syringes), oxygen, onsite and take-home medical/surgical supplies. Benefits are available for rental or purchase, initial fitting/adjustments, repair and replacement, used and refurbished equipment. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Room Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Covers enrolled children through the end of the year in which they turn 19. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Gender Affirming Care
Exclusions: Covered surgeries are limited to 1 per lifetime for each specified surgery except when medically necessary due to complications. Cosmetic procedures are not covered services. Covered services include psychotherapy, hormone therapy, puberty-suppressing medication, laboratory testing to monitor the safety of continues hormone therapy, surgeries as defined in the benefit booklet. Prior approval is required. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Generic Drugs
|
YES | $15.00 |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Year Speech, occupational, and physical therapy for habilitation are limited to combined maximums of 20 visits per calendar year for outpatient services and 45 days per calendar year for inpatient services. Non-habilitation physical therapy is limited to 40 visits per calendar year. |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Exclusions: Benefits are not available for services which are primarily non-medical in nature such as bathing, personal grooming, exercising or the administration of medications which can usually be self-administered. Benefits are not available for dietician services, homemaker services, maintenance therapy, food, home delivered meals. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Hospice Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Infertility Treatment
Exclusions: Benefits are not available for donor sperm for artificial insemination or extraordinary procedures to induce fertilization with technical assistance to include surrogate motherhood, gamete intrafallopian transfer, invitro fertilization, peritoneal oocyte and sperm transfer, tubal ovum transfer, artificial insemination, gestational carrier, and preimplantation genetic diagnosis testing. Covers surgical and medical services on an inpatient or outpatient basis when medically appropriate and necessary and provided by an eligible Professional or Institution to repair or correct the condition causing infertility. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Infusion Therapy
Prior approval is required. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: Benefits are NOT available for inpatient services rendered primarily for diagnostic examinations, physical therapy, rest cure, convalescent care, custodial or sanitaria care. Benefits are NOT available for inpatient care rendered primarily for the purpose of administering allergy, sensitivity, food challenge, or related testing, clinical ecology and vitamins or dietary nutritional supplements. Covers semi private room only and special care unit. When an eligible Professional recommends an inpatient admission, notification to BCBSWY is required prior to services being rendered. Although notices for emergency and maternity admissions ARE NOT required, notification to BCBSWY is encouraged. The preadmission authorization and admission notification provisions do not apply when secondary to Medicare, other health insurance or 3rd party coverage. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Exclusions: Benefits are NOT available for therapy or counseling services for marital dysfunction or family dysfunction. Benefits are NOT available for the treatment of codependency. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
Exclusions: Benefits are NOT available for therapy or counseling services for marital dysfunction or family dysfunction. Benefits are NOT available for the treatment of codependency. |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
If the member chooses a drug from tiers 2-4 when a tier 1 (generic) drug is available, the member must pay the difference in cost between the selected drug and the tier 1 (generic) drug. |
YES | $60.00 |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Quantitative limit units apply, see specific service (e.g. colonoscopy) |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Year Exclusions: No coverage for hypnosis, biofeedback, or pain treatment/therapy. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
Quantitative limit units apply, see specific service (e.g. colonoscopy) |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Preferred Brand Drugs
If the member chooses a drug from tiers 2-4 when a tier 1 (generic) drug is available, the member must pay the copay and the difference in cost between the selected drug and the tier 1 (generic) drug. |
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
Exclusions: Services related to surrogacy Includes office visits, appropriate preventive services, and complications. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
Exclusions: Only covered when services are rendered by a participating provider. Preventive care benefits are covered as required under PPACA. |
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 |
50.00% Coinsurance after deductible |
| Private-Duty Nursing
Exclusions: Services rendered by a nurse who ordinarily resides in the Member's home or is a member of the Member's immediate family; Services that are provided on an inpatient basis and billed by a hospital; Services which are primarily non-medical in nature, such as bathing, personal grooming, exercising or the administration of medication which can usually be self-administered. Outpatient Private Duty Nursing. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Prosthetic Devices
Exclusions: Benefits are not available for deluxe motorized equipment, electronic speech aids; robotization devices, robotic prosthetics, dental appliances and artificial organs. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Radiation
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Reconstructive Surgery
Exclusions: No coverage for cosmetic surgery and related services intended primarily to improve appearance. Covers expenses related to cosmetic surgery only when restorative surgery is required as the result of a birth defect, accidental injury or a malignant disease process or its treatment. Prior approval is necessary. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 60.0 Visit(s) per Year Speech, occupational, and physical therapy for rehabilitation are limited to combined maximums of 60 visits per calendar year for outpatient services and 45 days per calendar year for inpatient services. Non-rehabiliation physical therapy is limited to 40 visits per calendar year. |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
Limit: 60.0 Visit(s) per Year Speech, occupational, and physical therapy for rehabilitation are limited to combined maximums of 60 visits per calendar year for outpatient services and 45 days per calendar year for inpatient services. Non-rehabiliation physical therapy is limited to 40 visits per calendar year. |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year Covers enrolled children through the end of the year in which they turn 19. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Prior approval is required. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Specialist Visit
|
YES | $60.00 |
50.00% Coinsurance after deductible |
| Specialty Drugs
Precertification required. If the member chooses a drug from tiers 2-4 when a tier 1 (generic) drug is available, the member must pay the difference in cost between the selected drug and the tier 1 (generic) drug. |
YES | $250.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: Benefits are NOT available for therapy or counseling services for marital dysfunction or family dysfunction. Benefits are NOT available for the treatment of codependency. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
Exclusions: Benefits are NOT available for therapy or counseling services for marital dysfunction or family dysfunction. Benefits are NOT available for the treatment of codependency. |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Transplant
Exclusions: Transportation of the recipient to the location of the transplant surgery. Benefits are NOT available for small intestine, spleen transplantation or donor organs or tissue other than human donor organ or tissue. Covered but not limited to the following: liver, heart, heart-lung, kidney, pancreas, bone marrow and cornea transplant. Includes evaluation, preparation & delivery of the donor organ; removal of the donor organ; transportation of the donor organ to the location of the transplant surgery; donor search costs. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | $45.00 |
50.00% Coinsurance after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Exclusions: Benefits are not available for all forms of thermography for all uses and indicators. Covers CT, MRI, PET scans. PET scans must be preauthorized. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
BlueSelect Gold Standard without Kid's Dental Health Insurance Plan Variant 11269WY0170017-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7806125763529309 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | WYF009 |
| Formulary URL | URL |
| HIOS Product ID | 11269WY017 |
| Import Date | 2024-11-15 00:01:36 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 11269 |
| Issuer Marketplace Marketing Name | Blue Cross Blue Shield of Wyoming |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | WYN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Blue Cross Blue Shield Global® Core – Have access to doctors and hospitals in more than 200 countries and territories around the world. Twenty four hours a day, seven days a week information can be obtained by calling 1-800-810-BLUE (2583) or on-line at www.bcbsglobalcore.com. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | BlueCard Network - Provides access to our Out-of-Area Network Program, when they must seek health care out of state. This network includes discounts, negotiated reimbursement levels, and protection from balance billing. |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 11269WY0170017-01 |
| Plan Marketing Name | BlueSelect Gold Standard without Kid's Dental |
| Plan Type | PPO |
| Plan Variant Marketing Name | BlueSelect Gold Standard without Kid's Dental |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,800 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $500 |
| SBC Scenario, Having Diabetes, Deductible | $1,200 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $10 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WYS001 |
| Source Name | HIOS |
| Plan ID | 11269WY0170017 |
| State Code | WY |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $43000 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $21500 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $21,500 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $40000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $20000 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $20,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $15600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,800 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of BlueSelect Gold Standard without Kid's Dental Health Insurance Plan, 11269WY0170017
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about BlueSelect Gold Standard without Kid's Dental, 11269WY0170017 Health Insurance Plan, 11269WY0170017
-
Does BlueSelect Gold Standard without Kid's Dental Health Insurance Plan, 11269WY0170017 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (11269WY0170017) Health Insurance Plan, Variant (11269WY0170017-01) have Out Of Country Coverage?
Does (11269WY0170017) Health Insurance Plan, Variant (11269WY0170017-01) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Tue, 15 Apr 2025 06:06 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API