Blue Cross Blue Shield of Wyoming health insurance plan with the Plan ID 11269WY0170016. The plan is called BlueSelect Silver Classic without Kid's Dental .
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.32% (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 28.68% 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 | 11269WY0170016 | ||||||||||||||||||
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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 | 11269WY0170016-03 | ||||||||||||||||||
Provider Network(s) | ['WYN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 01 Oct 2024 06:11 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 11269WY0170016-00 Standard On Exchange Plan - 11269WY0170016-01 Open to Indians below 300% FPL - 11269WY0170016-02 Open to Indians above 300% FPL - 11269WY0170016-03 73% AV Silver Plan - 11269WY0170016-04 |
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Last Plan Update Date | Fri, 13 Aug 2021 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 01 Oct 2024 06:11 GMT |
Plan Attribute | Value |
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AV Calculator Output Number | 0.713170906 |
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 2 |
Business Year | 2022 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | Limited Cost Sharing Plan Variation |
Dental Only Plan | No |
EHB Percent of Total Premium | 1 |
First Tier Utilization | 100% |
Formulary ID | WYF002 |
Formulary URL | URL |
HIOS Product ID | 11269WY017 |
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 | New |
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 | Silver |
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) | 11269WY0170016-03 |
Plan Marketing Name | BlueSelect Silver Classic without Kid's Dental |
Plan Type | PPO |
Plan Variant Marketing Name | BlueSelect Silver Classic without Kid's Dental |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $0 |
SBC Scenario, Having a Baby, Copayment | $0 |
SBC Scenario, Having a Baby, Deductible | $0 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $0 |
SBC Scenario, Having Diabetes, Deductible | $0 |
SBC Scenario, Having Diabetes, Limit | $20 |
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 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | WYS001 |
Source Name | HIOS |
Plan ID | 11269WY0170016 |
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 | $45000 per group |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $22500 per person |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $22,500 |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 40.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $5000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $2500 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $2,500 |
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 |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 01 Oct 2024 06:11 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