BlueSelect Silver Classic without Kid's Dental - 11269WY0170016 Health Insurance Plan

Blue Cross Blue Shield of Wyoming health insurance plan with the Plan ID 11269WY0170016. The plan is called BlueSelect Silver Classic without Kid's Dental.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 73.06% (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 26.94% 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 11269WY0170016
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 11269WY0170016-04
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, 10 Dec 2024 06:32 GMT).

Providers Wyoming All US States
All 359 87412
PCP N/A 273
Allergy N/A 5
OB/GYN N/A 13
Dentists 137 191
Available Variants of the Health Plan

Standard Off Exchange Plan - 11269WY0170016-00

Standard On Exchange Plan - 11269WY0170016-01

Open to Indians below 300% FPL - 11269WY0170016-02

Open to Indians above 300% FPL - 11269WY0170016-03

73% AV Silver Plan - 11269WY0170016-04

87% AV Silver Plan - 11269WY0170016-05

94% AV Silver Plan - 11269WY0170016-06

Last Plan Update Date Tue, 13 Aug 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of BlueSelect Silver Classic without Kid's Dental Health Insurance Plan, 11269WY0170016-04

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

40.00% 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

40.00% 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

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Chiropractic Care

Limit: 15.0 Visit(s) per Year

YES

40.00% 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

40.00% 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

40.00% 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

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Dialysis
YES

40.00% 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

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Room Services
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

40.00% 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

40.00% 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

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Generic Drugs
YES

$4.00

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

40.00% Coinsurance after deductible

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

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Hospice Services
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)
YES

40.00% 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

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Infusion Therapy

Prior approval is required.

YES

40.00% 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

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
YES

40.00% 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

40.00% 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

40.00% Coinsurance after deductible

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

40.00% Coinsurance after deductible

100.00%
Nutritional Counseling
NO
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

40.00% 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

40.00% 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

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services

Quantitative limit units apply, see specific service (e.g. colonoscopy)

YES

40.00% 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

$40.00

100.00%
Prenatal and Postnatal Care

Exclusions: Services related to surrogacy

Includes office visits, appropriate preventive services, and complications.

YES

40.00% 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

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness

The first 2 office visits are subject to copay. After 2 visits, subject to deductible and coinsurance.

YES

$40.00, 40.00% Coinsurance after deductible

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

40.00% 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

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Radiation
YES

40.00% 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

40.00% 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

40.00% Coinsurance after deductible

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

40.00% Coinsurance after deductible

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

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Routine Foot Care
NO
Skilled Nursing Facility

Prior approval is required.

YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Specialist Visit
YES

40.00% Coinsurance after deductible

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

40.00% Coinsurance after deductible

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

40.00% 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

40.00% Coinsurance after deductible

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

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities
YES

40.00% Coinsurance after deductible

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

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible

BlueSelect Silver Classic without Kid's Dental Health Insurance Plan Variant 11269WY0170016-04 Attributes

Plan Attribute Value
AV Calculator Output Number 0.7305814514231891
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 2
Business Year 2025
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type 73% AV Level Silver Plan
Dental Only Plan No
Design Type Not Applicable
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID WYF001
Formulary URL URL
HIOS Product ID 11269WY017
Import Date 2024-08-13 01:01:24
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 Silver
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) 11269WY0170016-04
Plan Marketing Name BlueSelect Silver Classic without Kid's Dental
Plan Type PPO
Plan Variant Marketing Name BlueSelect Silver Classic without Kid's Dental
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $3,800
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $2,750
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $700
SBC Scenario, Having Diabetes, Deductible $1,200
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $80
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,700
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID WYS001
Source Name HIOS
Plan ID 11269WY0170016
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 $45500 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $22750 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $22,750
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 40.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $5500 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $2750 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $2,750
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 $13300 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $6650 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $6,650
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 Silver Classic without Kid's Dental Health Insurance Plan, 11269WY0170016

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about BlueSelect Silver Classic without Kid's Dental, 11269WY0170016 Health Insurance Plan, 11269WY0170016

  • Does BlueSelect Silver Classic without Kid's Dental Health Insurance Plan, 11269WY0170016 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (11269WY0170016) Health Insurance Plan, Variant (11269WY0170016-04) have Out Of Country Coverage?

    Yes. Details: 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.

    Does (11269WY0170016) Health Insurance Plan, Variant (11269WY0170016-04) have Out of Service Area Coverage?

    Yes. Details: 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.

 

Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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