BlueSelect Gold Classic

Health Insurance Plan Details (2024 Plan)

by Blue Cross Blue Shield of Wyoming

Monthly Premium

PPO
$ubsidy
Gold
Deductible
$800 /yr
Max Out-of-Pocket
$9,100 /yr

Details

Deductible (per individual) $800 /yr
Deductible (per family) $1,600 /yr
Max Out-of-Pocket (per individual) $9,100 /yr
Max Out-of-Pocket (per family) $18,200 /yr
Drug Deductible (per individual) Included in Medical
Drug Deductible (per family) Included in Medical
Drug Max Out-of-Pocket (per individual) Included in Medical
Drug Max Out-of-Pocket (per family) Included in Medical
Plan Type PPO
Includes Child Dental? Yes
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit $30 and 25% Coinsurance after deductible
Specialist Visit 25% Coinsurance after deductible
Emergency Room 25% Coinsurance after deductible
Inpatient Facility 25% Coinsurance after deductible
Inpatient Physician 25% Coinsurance after deductible
Drug Costs
Generic Drugs $5 Copay
Preferred Brand Drugs $20 Copay
Non-preferred Brand Drugs 25% Coinsurance after deductible
Specialty Drugs 25% Coinsurance after deductible

Plan Documents

Summary of Benefits and Coverage SBC doc
Provider Directory Doctor lookup
Drug Formulary List drug list

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible


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