West Virginia health plan · 2025

my Blue Access WV PPO Standard Silver 5000 + Adult Dental and Vision · 31274WV0570004

Highmark Blue Cross Blue Shield West Virginia offers this marketplace health insurance plan (Plan ID 31274WV0570004) 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: Silver Plan type: PPO CSR: 73% AV Level Silver Plan Issuer: Highmark Blue Cross Blue Shield West Virginia
Telehealth Data pending HSA eligible No Dental Adult/Child Vision Adult/Child
Pay / Manage Plan View issuer site

Issuer actuarial value: 73.09%. Expect to pay roughly 26.91% of covered costs out of pocket, based on issuer reporting.

CMS AV Calculator output: 75.35% (24.65% member share on average). Learn about AV methodology.

2025 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

$496 – $2418

Before subsidies

Estimate after subsidies

Deductible

$3,000

$6000 per group

See deductible details

Max out-of-pocket

$6,400

$12800 per group

Review MOOP rules

Office visits

Primary care $40.00
Specialist $80.00
HSA Not eligible

Drug tiers

Generic $20.00
Preferred brand $40.00

View formulary tiers

$787 / mo before subsidies

≈ $9441 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.

$2493 / mo before subsidies

≈ $29918 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.
  • This Silver tier qualifies for CSR if household income is ≤250% FPL.

$3019 / mo before subsidies

≈ $36233 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.
  • This Silver tier qualifies for CSR if household income is ≤250% FPL.

$1919 / mo before subsidies

≈ $23026 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

0.00%

Emergency Room Services

40.00% Coinsurance after deductible

Durable Medical Equipment

40.00% Coinsurance after deductible

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Enrollment guidance

Stay on top of 2025 ACA deadlines

Open Enrollment window

Marketplace enrollment for 2025 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.
  • 73% AV Level Silver 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

0.00%

Emergency Room Services

40.00% Coinsurance after deductible

Durable Medical Equipment

40.00% 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 31274WV0570004
Coverage year 2025
State West Virginia
Issuer Highmark Blue Cross Blue Shield West Virginia
Formulary document Download formulary
Marketing materials View marketing kit
Variant ID 31274WV0570004-04
Available variants

Standard Off Exchange Plan · 31274WV0570004-00

Standard On Exchange Plan · 31274WV0570004-01

Open to Indians below 300% FPL · 31274WV0570004-02

Open to Indians above 300% FPL · 31274WV0570004-03

73% AV Silver Plan · 31274WV0570004-04

87% AV Silver Plan · 31274WV0570004-05

94% AV Silver Plan · 31274WV0570004-06
Last plan update Tue, 13 Aug 2024 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 430
PCPs in West Virginia 7
Telehealth support Data pending
Nationwide providers 708
430 doctors statewide 7 PCPs

Provider network(s)

Providers West Virginia All US states
All 430 708
PCP 7 7
Allergy N/A N/A
OB/GYN N/A N/A
Dentists 276 298

Drug coverage overview

3,448 drugs tracked

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

Tier Covered drugs
GENERIC 3,214
PREVENTIVE-DRUGS 234
Prior authorization Drugs
Required 813
Not Required 2,635
Step therapy Drugs
Required 541
Not Required 2,907
Quantity limits Drugs
Has Limit 1,076
No Limit 2,372

Customer highlights

What stands out for members

  • Issuer: Highmark Blue Cross Blue Shield West Virginia · Plan ID 31274WV0570004 · 2025 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 31274WV0570004-04 (73% AV Silver Plan) currently displayed.
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Benefits

Covered services & limitations

Everyday care

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

Chiropractic Care

$40.00
Tier 1 in-network $40.00
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 20 visits per event for chronic pain (visit limits are combined for physical therapy, occupational therapy and spinal manipulations)

Exclusions: nan

Diabetes Care Management

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Diabetes Education

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

nan

Exclusions: nan

Home Health Care Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% 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: nan

Laboratory Outpatient and Professional Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance 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: nan

Other Practitioner Office Visit (Nurse, Physician Assistant)

$40.00
Tier 1 in-network $40.00
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Preventive Care/Screening/Immunization

0.00%
Tier 1 in-network 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

Primary Care Visit to Treat an Injury or Illness

$40.00
Tier 1 in-network $40.00
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Rehabilitative Occupational and Rehabilitative Physical Therapy

$40.00
Tier 1 in-network $40.00
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: nan

Rehabilitative Speech Therapy

$40.00
Tier 1 in-network $40.00
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Specialist Visit

$80.00
Tier 1 in-network $80.00
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Urgent Care Centers or Facilities

$60.00
Tier 1 in-network $60.00
Out-of-network $60.00

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

Exclusions: nan

X-rays and Diagnostic Imaging

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance 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: nan

Hospital & urgent

Emergency room, inpatient stays, ambulance, and surgeries.

Chemotherapy

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Delivery and All Inpatient Services for Maternity Care

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Dialysis

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Durable Medical Equipment

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Emergency Room Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

nan

Exclusions: nan

Emergency Transportation/Ambulance

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

nan

Exclusions: nan

Hospice Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Life expectancy 6 months or less

Exclusions: nan

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

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Inpatient Physician and Surgical Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Mental/Behavioral Health Inpatient Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Mental/Behavioral Health Outpatient Services

$40.00
Tier 1 in-network $40.00
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

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

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Outpatient Rehabilitation Services

$40.00
Tier 1 in-network $40.00
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Outpatient Surgery Physician/Surgical Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Radiation

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Skilled Nursing Facility

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Substance Abuse Disorder Inpatient Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Substance Abuse Disorder Outpatient Services

$40.00
Tier 1 in-network $40.00
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Transplant

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Mental health & substance use

Behavioral health visits and substance use treatment.

Mental Health Other

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

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

Exclusions: nan

Hearing Aids

Coverage details pending

nan

Exclusions: nan

Major Dental Care - Child

50.00%
Tier 1 in-network 50.00%
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

Exclusions: nan

Prenatal and Postnatal Care

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

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

nan

Exclusions: nan

Well Baby Visits and Care

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

nan

Exclusions: nan

Pharmacy & drugs

Generic, brand, specialty, and mail order tiers.

Generic Drugs

$20.00
Tier 1 in-network $20.00
Out-of-network 100.00%

nan

Exclusions: nan

Non-Preferred Brand Drugs

$80.00 Copay after deductible
Tier 1 in-network $80.00 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.

Exclusions: nan

Preferred Brand Drugs

$40.00
Tier 1 in-network $40.00
Out-of-network 100.00%

nan

Exclusions: nan

Specialty Drugs

$350.00 Copay after deductible
Tier 1 in-network $350.00 Copay after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Basic Dental Care - Adult

20.00%
Tier 1 in-network 20.00%
Out-of-network 100.00%

Adult dental services have a separate $50 deductible and $1,250 annual maximum per person.

Exclusions: nan

Dental Anesthesia

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

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

nan

Exclusions: nan

Infusion Therapy

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Major Dental Care - Adult

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

Adult dental services have a separate $50 deductible and $1,250 annual maximum per person.

Exclusions: nan

Nutritional Counseling

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

nan

Exclusions: nan

Orthodontia - Adult

Coverage details pending

nan

Exclusions: nan

Orthodontia - Child

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

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

Exclusions: nan

Prosthetic Devices

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Routine Dental Services (Adult)

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

Adult dental services have a separate $50 deductible and $1,250 annual maximum per person.

Exclusions: nan

Weight Loss Programs

Coverage details pending

nan

Exclusions: nan

Additional benefits

Other plan-specific services and limitations.

Abortion for Which Public Funding is Prohibited

Coverage details pending

nan

Exclusions: nan

Acupuncture

Coverage details pending

nan

Exclusions: nan

Allergy Testing

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Bariatric Surgery

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Surgery determined to be Medically Necessary is covered.

Exclusions: nan

Clinical Trials

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Cosmetic Surgery

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% 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: nan

Eye Glasses for Children

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

Limit: 1.0 Item(s) per Year

nan

Exclusions: nan

Gender Affirming Care

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Habilitation Services

$40.00
Tier 1 in-network $40.00
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: nan

Imaging (CT/PET Scans, MRIs)

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance 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: nan

Infertility Treatment

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% 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. Infertility drug therapy may or may not be covered depending on your groups prescription drug program

Exclusions: nan

Long-Term/Custodial Nursing Home Care

Coverage details pending

nan

Exclusions: nan

Private-Duty Nursing

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 35.0 Visit(s) per Benefit Period

nan

Exclusions: nan

Reconstructive Surgery

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% 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: nan

Routine Eye Exam (Adult)

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

Limit: 1.0 Exam(s) per Year

nan

Exclusions: nan

Routine Foot Care

Coverage details pending

nan

Exclusions: nan

Treatment for Temporomandibular Joint Disorders

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

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

Exclusions: nan

Variant attributes

my Blue Access WV PPO Standard Silver 5000 + Adult Dental and Vision · Variant 31274WV0570004-04

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2025

CSR Variation Type

73% AV Level Silver Plan

HIOS Product ID

31274WV057

Metal Level

Silver

Plan ID (Standard Component ID with Variant)

31274WV0570004-04

Plan Marketing Name

my Blue Access WV PPO Standard Silver 5000 + Adult Dental and Vision

Plan Variant Marketing Name

my Blue Access WV PPO Standard Extra Savings Silver 3000 + Adult Dental and Vision

Issuer & service area

Issuer-provided metadata for this variant.

Issuer Actuarial Value

73.09%

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

If a member receives non-emergency medically necessary and appropriate care from an out-of-area Blue Card provider, benefits will be paid in accordance with the contract. If a member receives non-emergency care from a non-Blue Card provider, services will be covered at the lower, out-of-network level and the member will be financially responsible for the difference between the plan's payment and the full amount of the out-of-area provider's charge.

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

0.753490779285578

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

$0

SBC Scenario, Having a Baby, Deductible

$0

SBC Scenario, Having Diabetes, Coinsurance

$0

SBC Scenario, Having Diabetes, Copayment

$0

SBC Scenario, Having Diabetes, Deductible

$0

SBC Scenario, Treatment of a Simple Fracture, Coinsurance

$0

SBC Scenario, Treatment of a Simple Fracture, Copayment

$0

SBC Scenario, Treatment of a Simple Fracture, Deductible

$0

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

40.00%

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

$12800 per group

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

$6400 per person

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

$6,400

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

$25600 per group

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

$12800 per person

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

$12,800

Enrollment & documents

Issuer-provided metadata for this variant.

Formulary ID

WVF009

Formulary URL

Open link

Plan Brochure

Open link

SBC Scenario, Having a Baby, Limit

$3,900

SBC Scenario, Having Diabetes, Limit

$7,400

SBC Scenario, Treatment of a Simple Fracture, Limit

$1,900

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

Design 1

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

0.977

First Tier Utilization

100%

Import Date

2024-08-13 20:01:38

Limited Cost Sharing Plan Variation - Estimated Advanced Payment

$0.00

HSA Eligible

No

New/Existing Plan

Existing

Notice Required for Pregnancy

No

Is a Referral Required for Specialist?

No

Plan Effective Date

2025-01-01

Plan Type

PPO

QHP/Non QHP

Both

Source Name

SERFF

Plan ID

31274WV0570004

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

$6000 per group

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

$3000 per person

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

$3,000

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

$12000 per group

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

$6000 per person

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

$6,000

Unique Plan Design

Yes

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 Standard Silver 5000 + Adult Dental and Vision (31274WV0570004) is a Silver PPO from Highmark Blue Cross Blue Shield West Virginia in West Virginia for the 2025 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 Standard Silver 5000 + Adult Dental and Vision 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 Standard Silver 5000 + Adult Dental and Vision HSA-eligible and does it include dental or vision coverage?

It is not marked as HSA-eligible, so confirm with the issuer before relying on tax-advantaged savings.

Dental add-ons: Adult, Child.

Vision add-ons: Adult, Child.

Does my Blue Access WV PPO Standard Silver 5000 + Adult Dental and Vision 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 Standard Silver 5000 + Adult Dental and Vision?

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 Standard Silver 5000 + Adult Dental and Vision?

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 Standard Silver 5000 + Adult Dental and Vision 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: If a member receives non-emergency medically necessary and appropriate care from an out-of-area Blue Card provider, benefits will be paid in accordance with the contract. If a member receives non-emergency care from a non-Blue Card provider, services will be covered at the lower, out-of-network level and the member will be financially responsible for the difference between the plan's payment and the full amount of the out-of-area provider's charge.

How do I enroll in or manage payments for my Blue Access WV PPO Standard Silver 5000 + Adult Dental and Vision?

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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