BlueSelect Gold Classic - 11269WY0070011 Health Insurance Plan

Blue Cross Blue Shield of Wyoming health insurance plan with the Plan ID 11269WY0070011. The plan is called BlueSelect Gold Classic.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.87% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.13% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.

Health Insurance Plan ID 11269WY0070011
Health Insurance Plan Year 2022
State Wyoming
Health Insurance Issuer Blue Cross Blue Shield of Wyoming
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 11269WY0070011-00
Provider Network(s) ['WYN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Wyoming All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 11269WY0070011-00

Standard On Exchange Plan - 11269WY0070011-01

Open to Indians below 300% FPL - 11269WY0070011-02

Open to Indians above 300% FPL - 11269WY0070011-03

Last Plan Update Date Fri, 13 Aug 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

BlueSelect Gold Classic Health Insurance Plan Variant 11269WY0070011-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.818721001
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 3
Business Year 2022
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Gold Off Exchange Plan
Dental Only Plan No
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID WYF008
Formulary URL URL
HIOS Product ID 11269WY007
Import Date 8/13/2021 1:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 11269
Issuer Marketplace Marketing Name Blue Cross Blue Shield of Wyoming
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Gold
Multiple In Network Tiers No
National Network Yes
Network ID WYN001
Out of Country Coverage Yes
Out of Country Coverage Description Blue Cross Blue Shield Global® Core – Have access to doctors and hospitals in more than 200 countries and territories around the world. Twenty four hours a day, seven days a week information can be obtained by calling 1-800-810-BLUE (2583) or on-line at www.bcbsglobalcore.com.
Out of Service Area Coverage Yes
Out of Service Area Coverage Description BlueCard Network - Provides access to our Out-of-Area Network Program, when they must seek health care out of state. This network includes discounts, negotiated reimbursement levels, and protection from balance billing.
Plan Brochure URL
Plan Effective Date 1/1/2022
Plan ID (Standard Component ID with Variant) 11269WY0070011-00
Plan Marketing Name BlueSelect Gold Classic
Plan Type PPO
Plan Variant Marketing Name BlueSelect Gold Classic
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $3,000
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $750
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $100
SBC Scenario, Having Diabetes, Copayment $500
SBC Scenario, Having Diabetes, Deductible $750
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $500
SBC Scenario, Treatment of a Simple Fracture, Copayment $100
SBC Scenario, Treatment of a Simple Fracture, Deductible $750
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID WYS001
Source Name HIOS
Plan ID 11269WY0070011
State Code WY
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, Combined In/Out of Network, Family Per Group $41500 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $20750 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $20,750
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 25.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $1500 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $750 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $750
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $40000 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $20000 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $20,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $17100 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8550 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,550
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual Not Applicable
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of BlueSelect Gold Classic Health Insurance Plan, 11269WY0070011

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about BlueSelect Gold Classic, 11269WY0070011 Health Insurance Plan, 11269WY0070011

  • Does BlueSelect Gold Classic Health Insurance Plan, 11269WY0070011 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (11269WY0070011) Health Insurance Plan, Variant (11269WY0070011-00) have Out Of Country Coverage?

    Yes. Details: Blue Cross Blue Shield Global® Core – Have access to doctors and hospitals in more than 200 countries and territories around the world. Twenty four hours a day, seven days a week information can be obtained by calling 1-800-810-BLUE (2583) or on-line at www.bcbsglobalcore.com.

    Does (11269WY0070011) Health Insurance Plan, Variant (11269WY0070011-00) have Out of Service Area Coverage?

    Yes. Details: BlueCard Network - Provides access to our Out-of-Area Network Program, when they must seek health care out of state. This network includes discounts, negotiated reimbursement levels, and protection from balance billing.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API