BlueSelect Bronze Standard without Kid’s Dental

11269WY0170019
Bronze
PPO

BlueSelect Bronze Standard without Kid’s Dental is a Bronze PPO plan by Blue Cross Blue Shield of Wyoming.

IMPORTANT: You are viewing the 2023 version of BlueSelect Bronze Standard without Kid’s Dental 11269WY0170019. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

BlueSelect Bronze Standard without Kid’s Dental is offered in the following counties.

No data was found

Plan Overview

This is a plan overview for 2023 version of BlueSelect Bronze Standard without Kid’s Dental 11269WY0170019.
Insurer: Blue Cross Blue Shield of Wyoming
Network Type: PPO
Metal Type: Bronze
HSA Eligible?: No
Plan ID: 11269WY0170019

Cost-Sharing Overview

BlueSelect Bronze Standard without Kid’s Dental offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for BlueSelect Bronze Standard without Kid's Dental?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

BlueSelect Bronze Standard without Kid’s Dental offers the following features and referral requirements.

Wellness Program: No
Disease Program:
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what BlueSelect Bronze Standard without Kid’s Dental covers when you are out of the service area or out of the country.

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.
National Network: Yes

Additional Benefits and Cost-Sharing

BlueSelect Bronze Standard without Kid’s Dental includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Specialist Visit
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
No Charge after deductible 50.00% Coinsurance after deductible Quantitative limit units apply, see specific service (e.g. colonoscopy)
Outpatient Surgery Physician/Surgical Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible Quantitative limit units apply, see specific service (e.g. colonoscopy)
Hospice Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Routine Dental Services (Adult)
Infertility Treatment
Covered
No Charge after deductible 50.00% Coinsurance after deductible Benefits are not available for donor sperm for artificial insemination or extraordinary procedures to induce fertilization with technical assistance to include surrogate motherhood, gamete intrafallopian transfer, invitro fertilization, peritoneal oocyte and sperm transfer, tubal ovum transfer, artificial insemination, gestational carrier, and preimplantation genetic diagnosis testing. Covers surgical and medical services on an inpatient or outpatient basis when medically appropriate and necessary and provided by an eligible Professional or Institution to repair or correct the condition causing infertility.
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Covered
No Charge after deductible 50.00% Coinsurance after deductible Services rendered by a nurse who ordinarily resides in the Member’s home or is a member of the Member’s immediate family; Services that are provided on an inpatient basis and billed by a hospital; Services which are primarily non-medical in nature, such as bathing, personal grooming, exercising or the administration of medication which can usually be self-administered. Outpatient Private Duty Nursing.
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Home Health Care Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible Benefits are not available for services which are primarily non-medical in nature such as bathing, personal grooming, exercising or the administration of medications which can usually be self-administered. Benefits are not available for dietician services, homemaker services, maintenance therapy, food, home delivered meals.
Emergency Room Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
No Charge after deductible 50.00% Coinsurance after deductible 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. 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.
Inpatient Physician and Surgical Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Bariatric Surgery
Covered
No Charge after deductible 50.00% Coinsurance after deductible1 Procedure(s) per lifetime Benefits are NOT available for the Garren gastric bubble technique relating to morbid obesity. Prior approval is required.
Cosmetic Surgery
Covered
No Charge after deductible 50.00% Coinsurance after deductible No coverage for cosmetic surgery and related services intended primarily to improve appearance. Covers expenses related to cosmetic surgery only when restorative surgery is required as the result of a birth defect, accidental injury or a malignant disease process or its treatment. Prior approval is necessary.
Skilled Nursing Facility
Covered
No Charge after deductible 50.00% Coinsurance after deductible Prior approval is required.
Prenatal and Postnatal Care
Covered
No Charge after deductible 50.00% Coinsurance after deductible Services related to surrogacy Includes office visits, appropriate preventive services, and complications.
Delivery and All Inpatient Services for Maternity Care
Covered
No Charge after deductible 50.00% Coinsurance after deductible Services related to surrogacy 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.
Mental/Behavioral Health Outpatient Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible Benefits are NOT available for therapy or counseling services for marital dysfunction or family dysfunction. Benefits are NOT available for the treatment of codependency.
Mental/Behavioral Health Inpatient Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible Benefits are NOT available for therapy or counseling services for marital dysfunction or family dysfunction. Benefits are NOT available for the treatment of codependency.
Substance Abuse Disorder Outpatient Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible Benefits are NOT available for therapy or counseling services for marital dysfunction or family dysfunction. Benefits are NOT available for the treatment of codependency.
Substance Abuse Disorder Inpatient Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible Benefits are NOT available for therapy or counseling services for marital dysfunction or family dysfunction. Benefits are NOT available for the treatment of codependency.
Generic Drugs
Covered
No Charge after deductible 100.00%
Preferred Brand Drugs
Covered
No Charge after deductible 100.00% 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.
Non-Preferred Brand Drugs
Covered
No Charge after deductible 100.00% 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.
Specialty Drugs
Covered
No Charge after deductible 100.00% 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.
Outpatient Rehabilitation Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible60 Visit(s) per Year No coverage for hypnosis, biofeedback, or pain treatment/therapy.
Habilitation Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible20 Visit(s) per Year Speech, occupational, and physical therapy for habilitation are limited to combined maximums of 20 visits per calendar year for outpatient services and 45 days per calendar year for inpatient services. Non-habilitation physical therapy is limited to 40 visits per calendar year.
Chiropractic Care
Covered
No Charge after deductible 50.00% Coinsurance after deductible15 Visit(s) per Year
Durable Medical Equipment
Covered
No Charge after deductible 50.00% Coinsurance after deductible Benefits are not available for support devices for the foot, including flat foot conditions. There are no benefits for shoe inserts. Benefits are not available for deluxe motorized equipment, electronic speech aids; robotization devices, robotic prosthetics, dental appliances and artificial organs. Benefits are not available for personal hygiene and convenience items such as air conditioner, humidifiers or physical fitness equipment. Benefits are not available for wigs or artificial hairpieces, or hair transplants or implants, regardless of whether or not there is a medical reason for hair loss. Includes but not limited to Diabetic supplies, therapeutic devices (e.g. hypodermic needles & syringes), oxygen, onsite and take-home medical/surgical supplies. Benefits are available for rental or purchase, initial fitting/adjustments, repair and replacement, used and refurbished equipment.
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
Covered
0.00% 100.00% Only covered when services are rendered by a participating provider. Preventive care benefits are covered as required under PPACA.
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Covered
No Charge after deductible 50.00% Coinsurance after deductible1 Visit(s) per Year Covers enrolled children through the end of the year in which they turn 19.
Eye Glasses for Children
Covered
No Charge after deductible No Charge after deductible 50.00% Coinsurance after deductible1 Item(s) per Year Covers enrolled children through the end of the year in which they turn 19.
Dental Check-Up for Children
Not Covered
Visit(s) per 6 Months
Rehabilitative Speech Therapy
Covered
No Charge after deductible 50.00% Coinsurance after deductible60 Visit(s) per Year 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.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
No Charge after deductible 50.00% Coinsurance after deductible60 Visit(s) per Year 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.
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
Covered
No Charge after deductible 50.00% Coinsurance after deductible Benefits are not available for all forms of thermography for all uses and indicators. Covers CT, MRI, PET scans. PET scans must be preauthorized.
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Orthodontia – Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Transplant
Covered
No Charge after deductible 50.00% Coinsurance after deductible Transportation of the recipient to the location of the transplant surgery. Benefits are NOT available for small intestine, spleen transplantation or donor organs or tissue other than human donor organ or tissue. Covered but not limited to the following: liver, heart, heart-lung, kidney, pancreas, bone marrow and cornea transplant. Includes evaluation, preparation & delivery of the donor organ; removal of the donor organ; transportation of the donor organ to the location of the transplant surgery; donor search costs.
Accidental Dental
Covered
No Charge after deductible 50.00% Coinsurance after deductible Dental services rendered by a dentist in an office setting which are required as a result of an accidental injury caused by an external force or blow to the jaw, sound natural teeth, mouth or face. Injury as a result of chewing or biting will not be considered an accidental injury. TMJ services would only be covered if accident related.
Dialysis
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Allergy Testing
Covered
No Charge after deductible 50.00% Coinsurance after deductible Benefits are not available for clinical ecology, orthomolecular therapy, vitamins, dietary nutritional supplements, or related testing rendered on an outpatient basis. Benefits are not available for the following allergy testing modalities: nasal challenge testing, provocative/neutralization testing, leukocyte histamine release, Rebuck skin window test, passive transfer or Prausnitz- Kustner test, cytotoxic food testing, metabisulfite testing, candidiasis hypersensitivity syndrome testing, IgE level testing for food allergies, general volatile organic screening test and mauve urine test. Benefits are not available for the following methods of desensitization: provocation/neutralization therapy by sublingual (drops) intradermal and subcutaneous routes, urine autoinjections, repository emulsion therapy, candidiasis hypersensitivity syndrome treatment or IV vitamin C therapy.
Chemotherapy
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Radiation
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Diabetes Education
Covered
No Charge after deductible 50.00% Coinsurance after deductible6 Visit(s) per Year Covered when billed by a participating provider.
Prosthetic Devices
Covered
No Charge after deductible 50.00% Coinsurance after deductible Benefits are not available for deluxe motorized equipment, electronic speech aids; robotization devices, robotic prosthetics, dental appliances and artificial organs.
Infusion Therapy
Covered
No Charge after deductible 50.00% Coinsurance after deductible Prior approval is required.
Treatment for Temporomandibular Joint Disorders
Nutritional Counseling
Reconstructive Surgery
Covered
No Charge after deductible 50.00% Coinsurance after deductible No coverage for cosmetic surgery and related services intended primarily to improve appearance. Covers expenses related to cosmetic surgery only when restorative surgery is required as the result of a birth defect, accidental injury or a malignant disease process or its treatment. Prior approval is necessary.
Gender Affirming Care
Covered
No Charge after deductible 50.00% Coinsurance after deductible Covered surgeries are limited to 1 per lifetime for each specified surgery except when medically necessary due to complications. Cosmetic procedures are not covered services. Covered services include psychotherapy, hormone therapy, puberty-suppressing medication, laboratory testing to monitor the safety of continues hormone therapy, surgeries as defined in the benefit booklet. Prior approval is required.

Free Preventive Services

There is no copayment or coinsurance for any of the following BlueSelect Bronze Standard without Kid’s Dental preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for BlueSelect Bronze Standard without Kid’s Dental including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for BlueSelect Bronze Standard without Kid's Dental?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Table of Contents