West Virginia health plan · 2026

my Blue Access WV PPO Gold 1700 HSA · 31274WV0580002

Highmark Blue Cross Blue Shield West Virginia offers this marketplace health insurance plan (Plan ID 31274WV0580002) so you can compare premiums, coverage levels, and provider access against other health plan insurance options. Use the modules below to decide whether this is the best health insurance plan for your household or if another insurance health plan fits better.

Metal level: Gold Plan type: PPO CSR: Standard Gold On Exchange Plan Issuer: Highmark Blue Cross Blue Shield West Virginia
Telehealth Data pending HSA eligible Yes Dental Child Vision Adult/Child
Pay / Manage Plan View issuer site

CMS AV Calculator output: 79.69% (20.31% member share on average). Learn about AV methodology.

2026 cost summary

Key premiums & cost sharing

Rates mirror the latest CMS import (Tue, 02 Dec 2025 06:13 GMT). Personalize costs with your ZIP, age, and subsidies in the plan finder.

Monthly premium

$530 – $2584

Before subsidies

Estimate after subsidies

Deductible

$1,700

$3400 per group

See deductible details

Max out-of-pocket

$7,100

$14200 per group

Review MOOP rules

Office visits

Primary care $15.00 Copay after deductible
Specialist $15.00 Copay after deductible
HSA Eligible

Drug tiers

Generic No Charge after deductible
Preferred brand $30.00 Copay after deductible

View formulary tiers

$841 / mo before subsidies

≈ $10087 per year before tax credits.

Start with this unsubsidized premium, then apply marketplace tax credits to see your final monthly payment.

  • Ideal for shoppers comparing Bronze vs. Silver budgets.
  • Update your Marketplace application to apply premium tax credits.

$2556 / mo before subsidies

≈ $30670 per year before tax credits.

Pre-subsidy rate for a couple with one dependent. Switch to Silver CSR plans if you qualify to reduce these numbers.

  • Compares well against PPO vs HMO networks when planning for childcare and telehealth needs.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$3226 / mo before subsidies

≈ $38712 per year before tax credits.

Pairs with cost-sharing reductions (CSR) when you select a Silver tier and qualify based on income.

  • Use this estimate before adding childcare, dental, or vision extras.
  • CSR Silver variants can lower deductibles dramatically for eligible incomes.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$1942 / mo before subsidies

≈ $23307 per year before tax credits.

Shows the combined pre-subsidy rate for two adults. Add dependents or subsidies in your application to refine it.

  • Great for households deciding between PPO and HMO networks.
  • Telehealth and HSA perks (when offered) apply to both members.
Issuer profile See benefits

Preventive Care/Screening/Immunization

No Charge

Emergency Room Services

$250.00 Copay after deductible

Durable Medical Equipment

20.00% Coinsurance after deductible

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Enrollment guidance

Stay on top of 2026 ACA deadlines

Open Enrollment window

Marketplace enrollment for 2026 coverage typically runs Nov 1 – Jan 15 (dates may vary slightly in West Virginia). Submit changes before the deadline to avoid a coverage gap.

  • Enroll by Dec 15 for Jan 1 starts.
  • Finalize plan switches before the window closes.

Special Enrollment Periods

You can change plans mid-year if you experience a qualifying life event (move, childbirth, marriage, loss of other coverage).

  • Report the event within 60 days.
  • Keep documentation handy for Healthcare.gov or your state exchange.

CSR & subsidy reminders

Premium tax credits and cost-sharing reductions (CSR) update annually when you re-submit your marketplace application.

  • Enter accurate income to maximize Advanced Premium Tax Credits.
  • Standard Gold On Exchange Plan plans like this one keep deductibles and copays lower if you qualify.

Thinking about switching?

Before you leave your current plan, compare networks, drug coverage, and total cost using the cards on this page.

  • Match provider networks so ongoing care isn’t disrupted.
  • Confirm prescriptions stay on-formulary or budget for tier changes.

Top covered benefits

How this plan handles key care scenarios

Preventive Care/Screening/Immunization

No Charge

Emergency Room Services

$250.00 Copay after deductible

Durable Medical Equipment

20.00% Coinsurance after deductible

Premium snapshot

Plan identifiers & filings

Track the official identifiers, documents, and filing dates tied to this plan. Open the marketing or formulary links whenever you need the latest PDF from the issuer.

Plan ID 31274WV0580002
Coverage year 2026
State West Virginia
Issuer Highmark Blue Cross Blue Shield West Virginia
Formulary document Download formulary
Marketing materials View marketing kit
Variant ID 31274WV0580002-01
Available variants

Standard Off Exchange Plan · 31274WV0580002-00

Standard On Exchange Plan · 31274WV0580002-01

Open to Indians below 300% FPL · 31274WV0580002-02

Open to Indians above 300% FPL · 31274WV0580002-03
Last plan update Wed, 15 Oct 2025 00:00 GMT
Last HealthPorta import Tue, 02 Dec 2025 06:13 GMT

Network stats

Provider access snapshot

Review the network branding plus the number of in-network clinicians we track from issuer filings. Counts update with each CMS import (Tue, 02 Dec 2025 06:13 GMT).

All providers in West Virginia 9015
PCPs in West Virginia 1422
Telehealth support Data pending
Nationwide providers 21518
9,015 doctors statewide 1,422 PCPs 39 OB/GYN

Provider network(s)

Providers West Virginia All US states
All 9015 21518
PCP 1422 1808
Allergy 5 5
OB/GYN 39 52
Dentists 191 212

Drug coverage overview

3,432 drugs tracked

Inspect tier distribution plus authorization, step therapy, and quantity-limit counts sourced from HealthPorta’s formulary import.

Tier Covered drugs
GENERIC 3,175
PREVENTIVE-DRUGS 257
Prior authorization Drugs
Required 794
Not Required 2,638
Step therapy Drugs
Required 509
Not Required 2,923
Quantity limits Drugs
Has Limit 1,089
No Limit 2,343

Customer highlights

What stands out for members

  • Issuer: Highmark Blue Cross Blue Shield West Virginia · Plan ID 31274WV0580002 · 2026 filing.
  • Disease management programs available: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs.
  • Download the latest formulary directly from the issuer here.
  • Review marketing brochures and SBC PDFs via the issuer marketing repository.
  • Variant 31274WV0580002-01 (Standard On Exchange Plan) currently displayed.
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Benefits

Covered services & limitations

Everyday care

Office visits, preventive care, labs, imaging, and home health.

Chiropractic Care

$15.00 Copay after deductible
Tier 1 in-network $15.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 30.0 Visit(s) per Benefit Period

30 visits per benefit period for other than chronic pain\n20 visits per event for chronic pain (visit limits are combined for physical therapy, occupational therapy and spinal manipulations)

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Diabetes Care Management

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Diabetes Education

No Charge
Tier 1 in-network No Charge
Out-of-network 100.00%

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Home Health Care Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 100.0 Visit(s) per Benefit Period

The following are Covered Services when you are Homebound and receive them from a Hospital or a Home Health Care Agency: Intermittent Skilled Care rendered by a registered or licensed practical nurse or nurse-midwife; Physical therapy, occupational therapy or speech therapy; Medical and surgical supplies; Prescription Drugs; Oxygen and its administration; Medical social Services; Home health aide visits when you are also receiving Skilled Care or Therapy Services; Laboratory tests; Home infusion therapy.

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Laboratory Outpatient and Professional Services

$15.00 Copay after deductible
Tier 1 in-network $15.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Copayments, if any, do not apply to diagnostic services prescribed for the treatment of mental illness or substance use disorder.

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Other Practitioner Office Visit (Nurse, Physician Assistant)

$15.00 Copay after deductible
Tier 1 in-network $15.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Preventive Care/Screening/Immunization

No Charge
Tier 1 in-network No Charge
Out-of-network 100.00%

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Primary Care Visit to Treat an Injury or Illness

$15.00 Copay after deductible
Tier 1 in-network $15.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Rehabilitative Occupational and Rehabilitative Physical Therapy

$15.00 Copay after deductible
Tier 1 in-network $15.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 30.0 Visit(s) per Benefit Period

30 Rehab and 30 Habilitative/benefit period for other than chronic pain. Limit: 20 Rehab and 20 Habilitative/event for chronic pain (limits combined for PT, OT and spinal manipulations). Limit does not apply to therapy services for mental health or substance use disorder.

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Rehabilitative Speech Therapy

$15.00 Copay after deductible
Tier 1 in-network $15.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Specialist Visit

$15.00 Copay after deductible
Tier 1 in-network $15.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Urgent Care Centers or Facilities

$30.00 Copay after deductible
Tier 1 in-network $30.00 Copay after deductible
Out-of-network $30.00 Copay after deductible

The copayment, if any, does not apply to urgent care services prescribed for the treatment of mental illness or substance use disorder.

X-rays and Diagnostic Imaging

$15.00 Copay after deductible
Tier 1 in-network $15.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Copayments, if any, do not apply to diagnostic services prescribed for the treatment of mental illness or substance use disorder.

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Hospital & urgent

Emergency room, inpatient stays, ambulance, and surgeries.

Chemotherapy

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Delivery and All Inpatient Services for Maternity Care

$450.00 Copay after deductible
Tier 1 in-network $450.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Dialysis

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Durable Medical Equipment

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Emergency Room Services

$250.00 Copay after deductible
Tier 1 in-network $250.00 Copay after deductible
Out-of-network $250.00 Copay after deductible

Emergency Transportation/Ambulance

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Hospice Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Life expectancy 6 months or less

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Inpatient Hospital Services (e.g., Hospital Stay)

$450.00 Copay per Stay after deductible
Tier 1 in-network $450.00 Copay per Stay after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Inpatient Physician and Surgical Services

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Mental/Behavioral Health Inpatient Services

$450.00 Copay per Stay after deductible
Tier 1 in-network $450.00 Copay per Stay after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Mental/Behavioral Health Outpatient Services

$15.00 Copay after deductible
Tier 1 in-network $15.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

$130.00 Copay after deductible
Tier 1 in-network $130.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Outpatient Rehabilitation Services

$15.00 Copay after deductible
Tier 1 in-network $15.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Outpatient Surgery Physician/Surgical Services

$130.00 Copay after deductible
Tier 1 in-network $130.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Radiation

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Skilled Nursing Facility

$450.00 Copay per Stay after deductible
Tier 1 in-network $450.00 Copay per Stay after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Substance Abuse Disorder Inpatient Services

$450.00 Copay per Stay after deductible
Tier 1 in-network $450.00 Copay per Stay after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Substance Abuse Disorder Outpatient Services

$15.00 Copay after deductible
Tier 1 in-network $15.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Transplant

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Mental health & substance use

Behavioral health visits and substance use treatment.

Mental Health Other

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Oral Evaluations (Exams), Prophylaxis (cleanings), Fluoride Treatments, Sealants, Consultations

Hearing Aids

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Major Dental Care - Child

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Radiographs (all x-rays), space maintainers, amalgam restorations (metal filings), resin based composite filings (white fillings), crowns, inlays, onlays, crown repair, endodontic therapy (root canals, etc.), other endodontic services, surgical periodontics, non-surgical periodontics, periodontal maintenance, prosthetics (complete or fixed partial dentures), adjustments and repair of prosthetics, other prosthetic services, implant services, simple extractions, surgical extractions, oral surgery, general anesthesia, nitrous oxide and/or IV sedation

Prenatal and Postnatal Care

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Routine Eye Exam for Children

No Charge
Tier 1 in-network No Charge
Out-of-network 100.00%

Limit: 1.0 Exam(s) per Year

Well Baby Visits and Care

No Charge
Tier 1 in-network No Charge
Out-of-network 100.00%

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Pharmacy & drugs

Generic, brand, specialty, and mail order tiers.

Generic Drugs

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Non-Preferred Brand Drugs

$150.00 Copay after deductible
Tier 1 in-network $150.00 Copay after deductible
Out-of-network 100.00%

Your Prescription Drug benefits may include a Formulary ... which is a list of Brand Name Prescription Drugs that are preferred by your Plan. We may remind your Physician or Professional Other Provider when a Formulary medication is available for a medication that is not on your Formulary. This may result in a change in your Prescription. However, your Physician or Professional Other Provider will always make the final decision on your medication.

Preferred Brand Drugs

$30.00 Copay after deductible
Tier 1 in-network $30.00 Copay after deductible
Out-of-network 100.00%

Specialty Drugs

50.00% Coinsurance after deductible
Tier 1 in-network 50.00% Coinsurance after deductible
Out-of-network 100.00%

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Basic Dental Care - Adult

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Dental Anesthesia

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Dental Check-Up for Children

No Charge
Tier 1 in-network No Charge
Out-of-network 100.00%

Limit: 1.0 Exam(s) per 6 Months

Infusion Therapy

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Major Dental Care - Adult

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Nutritional Counseling

No Charge
Tier 1 in-network No Charge
Out-of-network 100.00%

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Orthodontia - Adult

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Orthodontia - Child

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 100.00%

Medically Necessary Orthodontics, with prior approval and written plan of care

Prosthetic Devices

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Routine Dental Services (Adult)

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Weight Loss Programs

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Additional benefits

Other plan-specific services and limitations.

Abortion for Which Public Funding is Prohibited

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Acupuncture

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Allergy Testing

$15.00 Copay after deductible
Tier 1 in-network $15.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Bariatric Surgery

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Surgery determined to be Medically Necessary is covered.

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Clinical Trials

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Cosmetic Surgery

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Limited to reconstruction to restore body function or malformation caused by disease, trauma, birth defects, growth defects, prior therapeutic processes or as a result of an act of family violence

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Eye Glasses for Children

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 100.00%

Limit: 1.0 Item(s) per Year

Habilitation Services

$15.00 Copay after deductible
Tier 1 in-network $15.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 30.0 Visit(s) per Benefit Period

Limit does not apply to Habilitative services for the treatment of a Mental Health or Substance Abuse diagnosis.

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Imaging (CT/PET Scans, MRIs)

$175.00 Copay after deductible
Tier 1 in-network $175.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Copayments, if any, do not apply to diagnostic services prescribed for the treatment of mental illness or substance use disorder.

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Infertility Treatment

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Treatment includes coverage for the correction of a physical or medical problem associated with infertility.

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Long-Term/Custodial Nursing Home Care

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Private-Duty Nursing

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 35.0 Visit(s) per Benefit Period

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Reconstructive Surgery

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

(a) only those that restore a body function or which were caused by disease, trauma, birth defects, growth defects, prior therapeutic processes; or (b) reconstructive Surgery following Covered Services for a mastectomy, including reconstruction of the other breast for the purpose of restoring symmetry; or (c) reconstructive or cosmetic Surgery necessary as a result of an act of family violence.

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Routine Eye Exam (Adult)

No Charge
Tier 1 in-network No Charge
Out-of-network 100.00%

Limit: 1.0 Exam(s) per Year

Routine Foot Care

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Treatment for Temporomandibular Joint Disorders

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Orthotics, splints and appliances are limited to one every 3 years

Exclusions: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan. Please refer to Plan Documents for full details.

Variant attributes

my Blue Access WV PPO Gold 1700 HSA · Variant 31274WV0580002-01

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2026

CSR Variation Type

Standard Gold On Exchange Plan

HIOS Product ID

31274WV058

Metal Level

Gold

Plan ID (Standard Component ID with Variant)

31274WV0580002-01

Plan Marketing Name

my Blue Access WV PPO Gold 1700 HSA

Plan Variant Marketing Name

my Blue Access WV PPO Gold 1700 HSA

Issuer & service area

Issuer-provided metadata for this variant.

Issuer ID

31274

Issuer Marketplace Marketing Name

Highmark Blue Cross Blue Shield West Virginia

Market Coverage

Individual

Multiple In Network Tiers

No

National Network

Yes

Network ID

WVN001

Out of Country Coverage

Yes

Out of Country Coverage Description

Coverage is provided through the Blue Cross Blue Shield Global Core when a Member requires Emergency Care Services or Urgent Care Services while traveling or living outside the United States. All Emergency Care Services and Urgent Care Services are covered in accordance within the Member's Agreement.

Out of Service Area Coverage

Yes

Out of Service Area Coverage Description

Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan.

Service Area ID

WVS001

State Code

WV

URL for Summary of Benefits & Coverage

Open link

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

AV Calculator Output Number

0.7969200538163309

Begin Primary Care Deductible Coinsurance After Number Of Copays

0

Inpatient Copayment Maximum Days

0

Medical Drug Deductibles Integrated

Yes

Medical Drug Maximum Out of Pocket Integrated

Yes

SBC Scenario, Having a Baby, Coinsurance

$0

SBC Scenario, Having a Baby, Copayment

$700

SBC Scenario, Having a Baby, Deductible

$1,700

SBC Scenario, Having Diabetes, Coinsurance

$100

SBC Scenario, Having Diabetes, Copayment

$400

SBC Scenario, Having Diabetes, Deductible

$1,700

SBC Scenario, Treatment of a Simple Fracture, Coinsurance

$60

SBC Scenario, Treatment of a Simple Fracture, Copayment

$100

SBC Scenario, Treatment of a Simple Fracture, Deductible

$1,700

Specialty Drug Maximum Coinsurance

$1,000

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, In Network (Tier 1), Default Coinsurance

20.00%

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group

$14200 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person

$7100 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual

$7,100

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group

$28400 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person

$14200 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual

$14,200

Enrollment & documents

Issuer-provided metadata for this variant.

Formulary ID

WVF004

Formulary URL

Open link

Plan Brochure

Open link

SBC Scenario, Having a Baby, Limit

$60

SBC Scenario, Having Diabetes, Limit

$20

SBC Scenario, Treatment of a Simple Fracture, Limit

$0

URL for Enrollment Payment

Open link

Additional attributes

Issuer-provided metadata for this variant.

Begin Primary Care Cost-Sharing After Number Of Visits

0

Child-Only Offering

Allows Adult and Child-Only

Composite Rating Offered

No

Dental Only Plan

No

Design Type

Not Applicable

Disease Management Programs Offered

Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

EHB Percent of Total Premium

0.9991

First Tier Utilization

100%

Import Date

10/15/2025

Limited Cost Sharing Plan Variation - Estimated Advanced Payment

$0.00

HSA Eligible

Yes

New/Existing Plan

Existing

Notice Required for Pregnancy

No

Is a Referral Required for Specialist?

No

Plan Effective Date

1/1/2026

Plan Type

PPO

QHP/Non QHP

Both

Source Name

SERFF

Plan ID

31274WV0580002

Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group

per group not applicable

Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person

per person not applicable

Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual

Not Applicable

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group

$3400 per group

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person

$3400 per person

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual

$1,700

Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group

$6800 per group

Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person

$3400 per person

Combined Medical and Drug EHB Deductible, Out of Network, Individual

$3,400

Unique Plan Design

No

Wellness Program Offered

Yes

Copay & coinsurance

Pharmacy cost sharing by tier

Drug tier Pharmacy type Copay amount Copay option Coinsurance rate Coinsurance option Mail order

Questions & answers

Frequently asked questions

How do I choose the right ACA plan in West Virginia?

my Blue Access WV PPO Gold 1700 HSA (31274WV0580002) is a Gold PPO from Highmark Blue Cross Blue Shield West Virginia in West Virginia for the 2026 coverage year.

Compare it against other options with the HealthPorta plan finder to confirm premiums, deductibles, and network access fit your household.

Does my Blue Access WV PPO Gold 1700 HSA support telehealth or virtual urgent care?

The issuer has not published telehealth details yet. Review the Summary of Benefits and Coverage to confirm if virtual visits are included.

Is my Blue Access WV PPO Gold 1700 HSA HSA-eligible and does it include dental or vision coverage?

It is HSA-eligible, so you can pair it with a Health Savings Account to lower taxes.

Dental add-ons: Child.

Vision add-ons: Adult, Child.

Does my Blue Access WV PPO Gold 1700 HSA support mail-order prescriptions?

Mail order coverage is not listed for this plan, so confirm with the issuer before relying on home delivery.

Which disease management programs come with my Blue Access WV PPO Gold 1700 HSA?

The issuer lists disease management resources for: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs.

Is there out-of-country coverage for my Blue Access WV PPO Gold 1700 HSA?

Yes, limited out-of-country coverage is available. Review the Summary of Benefits for reimbursement steps. Details: Coverage is provided through the Blue Cross Blue Shield Global Core when a Member requires Emergency Care Services or Urgent Care Services while traveling or living outside the United States. All Emergency Care Services and Urgent Care Services are covered in accordance within the Member's Agreement.

Does my Blue Access WV PPO Gold 1700 HSA cover care outside the service area?

Yes, you have limited out-of-area coverage. See the plan documents for referral and prior authorization rules. Details: Non-emergency and non-urgent care received from out-of-network providers located in West Virginia will be covered at the out-of-network benefit level shown. Non-emergency and non-urgent care received from out-of-network providers located outside of West Virginia is not covered, unless pre-authorized by the plan.

How do I enroll in or manage payments for my Blue Access WV PPO Gold 1700 HSA?

Use the issuer portal https://cdsso.highmark.com/oam/server/fed/sp/sso to pay premiums or start enrollment, then return to HealthPorta for benefit comparisons.

Disclaimer: Based on the Tue, 02 Dec 2025 06:13 GMT HealthPorta import from CMS issuer filings. Data is best-effort and should be validated with the issuer directly. Sources: CMS.gov and the HealthPorta Healthcare MRF API.
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