Terms and Definitions
Here you will find brief definitions of some frequently used BCBSWY terms. For a more complete listing, please refer to your benefit document and the Explanation of Benefits Guide.
The maximum amount allowed for covered services. When services are performed by a BCBSWY participating provider, the allowable charges (and any cost sharing amounts) are accepted as payment-in-full. Allowable charges do not include charges in excess of the BCBSWY allowance and may be your responsibility if services are provided by a non-participating provider.
All hospital services for a patient other than room and board and nursing services. Laboratory tests and X-rays are examples of ancillary services.
The book provided to every BCBSWY subscriber outlining benefits, eligibility regulations, how to change or end membership, benefit limitations, and further details regarding BCBSWY coverage. This may also be called a Subscription Agreement.
A benefit period is one calendar year beginning on January 1 each year and ending on December 31 of the same year. Refer to your benefit document for additional details since the benefit period may differ for some programs.
A program that allows BCBSWY members the freedom to choose a Blue Cross Blue Shield provider anywhere in the United States and in many foreign countries—an important advantage if you receive services outside of Wyoming. Just show your BCBSWY identification card to any Blue Cross Blue Shield participating provider.
COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985)
The law that gives employees and their dependents, who are participating in employer sponsored plans with 20 or more full time employees, the right to continue their employer group health coverage for a specified amount of time if they lose coverage because of a qualifying event.
A percentage of the health benefit cost you pay after you have met your deductible.
The limit set on the total coinsurance amount you must pay during the benefit period. The coinsurance maximum does not include the deductible, copayment, non-covered amount, or charges in excess of the BCBSWY allowance. Note: Pharmacy expenses may be subject to separate coinsurance requirements.
The amount you pay each time a specific service is received regardless of deductible and coinsurance. Note: Pharmacy expenses may be subject to separate copayment requirements.
The dollars you spend for covered services. Cost sharing amounts include the deductible, coinsurance and copayment amounts.
The services or supplies for which benefits will be provided according to your benefit document.
A specific dollar amount you must pay within the benefit period before BCBSWY begins paying for covered services.
A continually updated list of medications and related information representing the clinical judgment of physicians, pharmacists and other experts. This may also be called a prescription drug list or a preferred drug list. Your cost to purchase a prescription drug is determined by the formulary and your benefit document.
The charges for services or supplies that are not covered according to the terms of your benefit document. In addition, any amounts considered over the BCBSWY allowance are non-covered amounts.
A set amount that equals the deductible plus the coinsurance maximum. Once you have met the out-of-pocket maximum, covered services are paid at 100% of allowable charges for the rest of the benefit period. Copayment amounts may continue to apply.
A healthcare provider who has entered into an agreement with BCBSWY to send the bill directly to BCBSWY and to accept the allowable charges as payment-in-full for covered services. Payment for covered services will be made directly to the provider. Note: A non-participating provider has not entered into an agreement with BCBSWY and may bill you directly. In this case, the payment for covered services from BCBSWY will be made directly to you.
If your physician recommends that you be hospitalized for any non-maternity or non-emergency condition, services must be submitted in advance to BCBSWY for review. Benefits may be reduced if pre-admission review is not obtained according to your benefit document.
A condition (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the six (6) month period immediately preceding the enrollment date.
The policyholder whose name appears on the identification card. May also be referred to as the member or the participant.