BlueSelect Silver Value

Health Insurance Plan Details (2024 Plan)

by Blue Cross Blue Shield of Wyoming

Monthly Premium

PPO
$ubsidy
Silver
Deductible
$4,000 /yr
Max Out-of-Pocket
$9,100 /yr

Details

Deductible (per individual) $4,000 /yr
Deductible (per family) $8,000 /yr
Max Out-of-Pocket (per individual) $9,100 /yr
Max Out-of-Pocket (per family) $18,200 /yr
Drug Deductible (per individual) $1,000
Drug Deductible (per family) $2,000
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 $40 and 20% Coinsurance after deductible
Specialist Visit 20% Coinsurance after deductible
Emergency Room 20% Coinsurance after deductible
Inpatient Facility 20% Coinsurance after deductible
Inpatient Physician 20% Coinsurance after deductible
Drug Costs
Generic Drugs $5 Copay
Preferred Brand Drugs $50 Copay after deductible
Non-preferred Brand Drugs 20% Coinsurance after deductible
Specialty Drugs 20% Coinsurance

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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