BlueSelect Expanded Bronze Standard without Kid’s Dental
11269WY0170020
Expanded Bronze
PPO
BlueSelect Expanded Bronze Standard without Kid’s Dental is an Expanded Bronze PPO plan by Blue Cross Blue Shield of Wyoming.
IMPORTANT: You are viewing the 2024 version of BlueSelect Expanded Bronze Standard without Kid’s Dental 11269WY0170020. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.
Locations
BlueSelect Expanded Bronze Standard without Kid’s Dental is offered in the following counties.
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Plan Overview
This is a plan overview for 2024 version of BlueSelect Expanded Bronze Standard without Kid’s Dental 11269WY0170020.
| Insurer: | Blue Cross Blue Shield of Wyoming |
| Network Type: | PPO |
| Metal Type: | Expanded Bronze |
| HSA Eligible?: | No |
| Plan ID: | 11269WY0170020 |
Cost-Sharing Overview
BlueSelect Expanded Bronze Standard without Kid’s Dental offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for BlueSelect Expanded Bronze Standard without Kid’s Dental includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $9400 per person | $18800 per group |
| Deductible: | $7500 per person | $15000 per group |
| Coinsurance: | 50.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for BlueSelect Expanded Bronze Standard without Kid’s Dental will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | $20000 per person | $40000 per group |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $7,500.00 |
| Copayment: | $10.00 |
| Coinsurance: | $1,800.00 |
| Limit: | $60.00 |
| Deductible: | $1,200.00 |
| Copayment: | $800.00 |
| Coinsurance: | $0.00 |
| Limit: | $20.00 |
| Deductible: | $2,800.00 |
| Copayment: | $10.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
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 Expanded 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 Expanded 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 Expanded 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 Expanded 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 | $50.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Specialist Visit Covered | $100.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Quantitative limit units apply, see specific service (e.g. colonoscopy) |
| Outpatient Surgery Physician/Surgical Services Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Quantitative limit units apply, see specific service (e.g. colonoscopy) |
| Hospice Services Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Routine Dental Services (Adult) | |||
| Infertility Treatment Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 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 | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 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 | $75.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Home Health Care Services Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 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 | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 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 | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Bariatric Surgery Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 1.0 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 | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 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 | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Prior approval is required. |
| Prenatal and Postnatal Care Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 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 | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 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 | $50.00 Not Applicable | Not Applicable 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 | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 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 | $50.00 Not Applicable | Not Applicable 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 | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 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 | $25.00 Not Applicable | Not Applicable 100.00% | |
| Preferred Brand Drugs Covered | $50.00 Copay after deductible Not Applicable | Not Applicable 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 | $100.00 Copay after deductible Not Applicable | Not Applicable 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 | $500.00 Copay after deductible Not Applicable | Not Applicable 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 | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 60.0 Visit(s) per Year No coverage for hypnosis, biofeedback, or pain treatment/therapy. |
| Habilitation Services Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 20.0 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 | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 15.0 Visit(s) per Year |
| Durable Medical Equipment Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 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 | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Preventive Care/Screening/Immunization Covered | Not Applicable 0.00% | Not Applicable 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 | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 1.0 Visit(s) per Year Covers enrolled children through the end of the year in which they turn 19. |
| Eye Glasses for Children Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 1.0 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 | |||
| Rehabilitative Speech Therapy Covered | $50.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 60.0 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 | $50.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 60.0 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 Not Applicable | Not Applicable 100.00% | |
| Laboratory Outpatient and Professional Services Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| X-rays and Diagnostic Imaging Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 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 | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 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 | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 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 | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Allergy Testing Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 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 | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Radiation Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Diabetes Education Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 6.0 Visit(s) per Year Covered when billed by a participating provider. |
| Prosthetic Devices Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 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 | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Prior approval is required. |
| Treatment for Temporomandibular Joint Disorders | |||
| Nutritional Counseling | |||
| Reconstructive Surgery Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 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 | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 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 Expanded 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.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for BlueSelect Expanded 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 Expanded 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