my Blue Access WV PPO Standard Gold 2000

31274WV0620003
Gold
PPO

my Blue Access WV PPO Standard Gold 2000 is a Gold PPO plan by Highmark Blue Cross Blue Shield West Virginia.

IMPORTANT: You are viewing the 2023 version of my Blue Access WV PPO Standard Gold 2000 31274WV0620003. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

my Blue Access WV PPO Standard Gold 2000 is offered in the following counties.

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Plan Overview

This is a plan overview for 2023 version of my Blue Access WV PPO Standard Gold 2000 31274WV0620003.
Insurer: Highmark Blue Cross Blue Shield West Virginia
Network Type: PPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 31274WV0620003

Cost-Sharing Overview

my Blue Access WV PPO Standard Gold 2000 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 my Blue Access WV PPO Standard Gold 2000?

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

my Blue Access WV PPO Standard Gold 2000 offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
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 my Blue Access WV PPO Standard Gold 2000 covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Coverage is provided through the Blue Cross Blue Shield Global Core when a Member requires Emergency Care Services or Urgent Care Services while traveling or living outside the United States. All Emergency Care Services and Urgent Care Services are covered in accordance within the Member’s Agreement.
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: If a member receives non-emergency medically necessary and appropriate care from an out of area Blue Card provider, benefits will be paid in accordance with the contract.  If a member receives non-emergency care from a non-Blue Card provider, services will be covered at the lower, out-of-network level and the member will be financially responsible for the difference between the plan’s payment and the full amount of the Out-of-Area provider’s charge.
National Network: Yes

Additional Benefits and Cost-Sharing

my Blue Access WV PPO Standard Gold 2000 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
$30.00 50.00% Coinsurance after deductible
Specialist Visit
Covered
$60.00 50.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Hospice Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Life expectancy 6 months or less
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered depending on your group?s prescription drug program
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible35 Visit(s) per Benefit Period
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$45.00 $45.00
Home Health Care Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible100 Visit(s) per Benefit Period The following are Covered Services when you are Homebound and receive them from a Hospital or a Home Health Care Agency: Intermittent Skilled Care rendered by a registered or licensed practical nurse or nurse-midwife; Physical therapy, occupational therapy or speech therapy; Medical and surgical supplies; Prescription Drugs; Oxygen and its administration; Medical social Services; Home health aide visits when you are also receiving Skilled Care or Therapy Services; Laboratory tests; Home infusion therapy.
Emergency Room Services
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Bariatric Surgery
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Surgery determined to be Medically Necessary is covered.
Cosmetic Surgery
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Limited to reconstruction to restore body function or malformation caused by disease, trauma, birth defects, growth defects, prior therapeutic processes or as a result of an act of family violence
Skilled Nursing Facility
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Prenatal and Postnatal Care
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
Covered
$30.00 50.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
Covered
$30.00 50.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Generic Drugs
Covered
$15.00 100.00%
Preferred Brand Drugs
Covered
$30.00 100.00%
Non-Preferred Brand Drugs
Covered
$60.00 100.00% Your Prescription Drug benefits may include a Formulary … which is a list of Brand Name Prescription Drugs that are preferred by your Plan. We may remind your Physician or Professional Other Provider when a Formulary medication is available for a medication that is not on your Formulary. This may result in a change in your Prescription. However, your Physician or Professional Other Provider will always make the final decision on your medication.’
Specialty Drugs
Covered
$250.00 100.00%
Outpatient Rehabilitation Services
Covered
$30.00 50.00% Coinsurance after deductible
Habilitation Services
Covered
$30.00 50.00% Coinsurance after deductible30 Visit(s) per Benefit Period Limit does not apply to Habilitative services for the treatment of a Mental Health or Substance Abuse diagnosis.
Chiropractic Care
Covered
$30.00 50.00% Coinsurance after deductible30 Visit(s) per Benefit Period 30 visits per benefit period for other than chronic pain 20 visits per event for chronic pain (visit limits are combined for physical therapy, occupational therapy and spinal manipulations)
Durable Medical Equipment
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
Covered
No Charge 100.00%
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge 100.00%1 Exam(s) per Year
Eye Glasses for Children
Covered
No Charge 100.00%1 Item(s) per Year
Dental Check-Up for Children
Covered
No Charge 100.00%2 Visit(s) per Year
Rehabilitative Speech Therapy
Covered
$30.00 50.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 50.00% Coinsurance after deductible30 Visit(s) per Benefit Period 30 Rehab and 30 Habilitative/benefit period for other than chronic pain. Limit: 20 Rehab and 20 Habilitative/event for chronic pain (limits combined for PT, OT and spinal manipulations). Limit does not apply to Habilitative services for mental health or substance abuse.
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Basic Dental Care – Child
Covered
50.00% 100.00% Oral Evaluations (Exams), Prophylaxis (cleanings), Fluoride Treatments, Sealants, Consultations
Orthodontia – Child
Covered
50.00% 100.00% Medically Necessary Orthodontics, with prior approval and written plan of care
Major Dental Care – Child
Covered
50.00% 100.00% Radiographs (all x-rays), space maintainers, amalgam restorations (metal filings), resin based composite filings (white fillings), crowns, inlays, onlays, crown repair, endodontic therapy (root canals, etc.), other endodontic services, surgical periodontics, non-surgical periodontics, periodontal maintenance, prosthetics (complete or fixed partial dentures), adjustments and repair of prosthetics, other prosthetic services, implant services, simple extractions, surgical extractions, oral surgery, general anesthesia, nitrous oxide and/or IV sedation
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Accidental Dental
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Dialysis
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Allergy Testing
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Chemotherapy
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Radiation
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Diabetes Education
Covered
No Charge 100.00%
Prosthetic Devices
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Infusion Therapy
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Orthotics, splints and appliances are limited to one every 3 years
Nutritional Counseling
Covered
No Charge 100.00%
Reconstructive Surgery
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible (a) only those that restore a body function or which were caused by disease, trauma, birth defects, growth defects, prior therapeutic processes; or (b) reconstructive Surgery following Covered Services for a mastectomy, including reconstruction of the other breast for the purpose of restoring symmetry; or (c) reconstructive or cosmetic Surgery necessary as a result of an act of family violence.
Gender Affirming Care
Clinical Trials
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Diabetes Care Management
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Dental Anesthesia
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Mental Health Other
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible

Free Preventive Services

There is no copayment or coinsurance for any of the following my Blue Access WV PPO Standard Gold 2000 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 my Blue Access WV PPO Standard Gold 2000 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 my Blue Access WV PPO Standard Gold 2000?

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

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