Blue Cross Blue Shield of Wyoming
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BlueSelect Gold Classic - PPO

Plan summary
Get our guide to the Essential Health Benefits covered by this plan and all other Marketplace plans.
Monthly premium
Your premium is the amount you pay for health insurance each month.
Deductible
$800 per person
$800 per person
Your deductible is the amount you pay for healthcare services before your insurance starts helping you cover the cost.
Depending on the plan, some basic services (like doctor visits and prescriptions) may be covered before your deductible is met.
Out-of-pocket max
$9,100 per person
$18,200 per family
This is the most you will have to pay for healthcare services during your coverage period (typically 12 months).
After you spend this amount on deductibles, copayments, and coinsurance, your health insurance plan will pay the rest.
Note: monthly premiums don’t count towards your out-of-pocket max.
Network type
PPO
The type of network you choose (HMO, PPO, POS, or EPO) will determine which providers (doctors, pharmacies, hospitals, and specialist) you can see.
• HMO plans usually limit coverage to providers who are within the plan’s network, and require a doctor’s referral to see specialists.
• PPO plans usually cover some of the cost of out-of-network providers (but not as much as for in-network providers), and don’t require a doctor’s referral to see specialists.
• EPO is a managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).
Metal tier
Gold
Metal levels (which include bronze, silver, gold, and platinum) determine how you will split the cost of your healthcare services with your insurance carrier.
• Bronze plans have the lowest monthly premiums and the highest costs when you need care
• Silver plans have moderate monthly premiums and moderate costs when you need care.
• Gold plans have high monthly premiums and low costs when you need care.
• Platinum plans have the highest monthly premiums and the lowest costs when you need care.
Doctor visits
This can include any visits to your doctors (outside of regular checkups) within your plan's network.
Primary care visit
$30 copay, 25% coinsurance after deductible
The first 3 office visits are subject to copay. After 3 visits, subject to deductible and coinsurance.
This is the amount you’re responsible for when receiving primary care services.
For example, this could be an appointment with your primary care provider for a routine checkup or screening.
Specialist visit
25% coinsurance after deductible
This is the amount you’re responsible for when visiting a specialist (a medical professional who specializes in different types of diseases or conditions).
For example, a dermatologist, cardiologist, or pathologist.
Preventive care visit
No charge
Preventive care benefits are covered as required under PPACA. Excludes: Only covered when services are rendered by a participating provider.
There are dozens of preventive care services available for free with every plan, including check-ups, counseling, screenings, and immunizations
To learn more, scroll down to the Free Preventive Care section below.
Emergency / Surgery
These are the costs you’re responsible for in the case of an emergency or surgery.
Urgent care
25% coinsurance after deductible
An urgent care center can be a convenient option if you have a non-life-threatening injury and your doctor is not available.
Urgent care is usually less expensive than going to the Emergency Room, and will usually have shorter wait times for non-life-threatening injuries.
Emergency room
25% coinsurance after deductible
This is the amount you’re responsible for when receiving emergency room services.
Ambulance
25% coinsurance after deductible
This is the amount you’re responsible for when receiving ambulatory services.
Hospital stay (facility)
25% coinsurance after deductible
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. Excludes: 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.
This is the amount you’re responsible for when using the facilities and equipment at a hospital.
Hospital stay (physician)
25% coinsurance after deductible
This is the amount you’re responsible for when receiving services provided by a physician, surgeon, medical doctor, or other specialist.
Outpatient procedure (facility)
25% coinsurance after deductible
Quantitative limit units apply, see specific service (e.g. colonoscopy)
This is the amount you’re responsible for when using the equipment and facilities at a hospital.
Specifically, during a procedure that does not require overnight hospitalization.
Outpatient procedure (physician)
25% coinsurance after deductible
Quantitative limit units apply, see specific service (e.g. colonoscopy)
This is the amount you’re responsible for when receiving services provided by a physician, surgeon, or other specialist.
Specifically, during a procedure that does not require overnight hospitalization.
Physical rehabilitation
25% coinsurance after deductible
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.
This includes physical and occupational therapy, speech pathology, and psychiatric rehabilitation services.
Pregnancy
Every ACA health insurance plan covers healthcare services provided before and after your child is born. Here is a breakdown of the costs associated with your plan.
Well baby care
No charge
This is the amount you’re responsible for when receiving well baby care.
These services may include developmental screenings, counseling, behavioral assessments, plus more.
Labor, delivery, hospital stay
25% coinsurance after deductible
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. Excludes: Services related to surrogacy
This is the amount you will pay for your labor, delivery, and hospital stay.
Prescriptions
Prescription coverage and cost is usually based on a tiered structure. These tiers are determined by generic, brand, or speciality drugs.
Generic
$5 copay
This is the amount you will pay for a generic drug prescription.
Brand
$20 copay
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.
This is the amount you will pay for a brand name drug prescription.
Non-preferred Brand
25% coinsurance after deductible
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.
This is the amount you will pay for a non-preferred brand name drug prescription.
Specialty
25% coinsurance after deductible
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.
This is the amount you will pay for a speciality drug prescription.
Diagnostics / Labs / Imaging
This is the amount you're responsible for when receiving blood work, tests, or x-rays your doctor may need for diagnosing.
X-rays
25% coinsurance after deductible
Covers CT, MRI, PET scans. PET scans must be preauthorized. Excludes: Benefits are not available for all forms of thermography for all uses and indicators.
This is the amount you’re responsible for when having an x-ray.
Imaging (CT/PET/MRI)
25% coinsurance after deductible
This is the amount you’re responsible for when having an MRI, CET, PET scan.
Blood work
25% coinsurance after deductible
This is the amount you’re responsible for when receiving blood work.
Mental health
Under the Affordable Care Act, all Marketplace plans are required to cover behavioral health treatment, mental and behavioral health inpatient services, as well as substance use treatment.
Outpatient services
25% coinsurance after deductible
Excludes: Benefits are NOT available for therapy or counseling services for marital dysfunction or family dysfunction. Benefits are NOT available for the treatment of codependency.
This is the amount you’re responsible for when you have a procedure that does not require overnight hospitalization.
Psychiatric hospital stay
25% coinsurance after deductible
Excludes: Benefits are NOT available for therapy or counseling services for marital dysfunction or family dysfunction. Benefits are NOT available for the treatment of codependency.
This is the amount you’re responsible for when you’re admitted or receiving treatment at a psychiatric hospital.
The Affordable Care Act requires that all health insurance plans cover preventive care for free. Preventive care services focus on managing and maintaining your health before something becomes serious. This includes routine check-ups, counseling, screenings, and immunizations. Grab our free guide to preventive care to refer back to later.
Abdominal aortic aneurysm one-time screening
For men of specified ages who have ever smoked
Free
Alcohol misuse screening and counseling
To prevent cardiovascular disease for men and women of certain ages
Free
Free
Free
Cholesterol screening
For adults of certain ages or at higher risk
Free
Colorectal cancer screening
For adults over 50
Free
Free
Diabetes (Type 2) screening
For adults with high blood pressure
Free
Diet counseling
For adults at higher risk for chronic disease
Free
Hepatitis B screening
For people at high risk
Free
Hepatitis C screening
For adults at increased risk, and one time for everyone born 1945 – 1965
Free
HIV screening
For everyone ages 15 to 65, and other ages at increased risk
Free
Free
Free
Free
Free
Free
Free
Free
Free
Free
Free
Free
Free
Free
Free
Lung cancer screening
For adults 55 - 80 at high risk for lung cancer
Free
Free
Free
Syphilis screening
For adults at higher risk and all pregnant women
Free
Tobacco Use screening
For all adults and cessation interventions for tobacco users
Free
Official documents
If you'd like to see the official documents from the health insurance company, we've provided links to those here.
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