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Blue Cross Blue Shields of Wyoming

Plan Type: BlueSelect for Individuals & Families - 2024

Coverage for you and those you love

Basic Plans – 2025

Bronze Plan
HSA Eligible

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 No
Participant deductible $8,550
Family deductible $17,100
Participant out-of-pocket $8,550
Family out-of-pocket $17,100
Coinsurance

BCBSWY Pays

Participant Pays

 100%

0%
Preventive Care Paid at 100% of maximum allowable amount at appropriate intervals.
Primary Care

Copay

 Subject to the deductible & coinsurance

Prescription Drugs
Tier 1: Generic Drugs
Tier 2: Preferred Brand drugs		  

Subject to the deductible & coinsurance

Subject to the deductible & coinsurance
Summary of Benefits and Coverage (SBC) View SBC »

Cost Assistance

Based on certain income requirements, you may qualify for assistance, through government subsidies, with your monthly premiums.


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Classic Plans – 2025

Gold Plan Silver Plan
HSA Eligible

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 No No
Participant deductible $750 $2,500
Family deductible $1,500 $5,000
Participant out-of-pocket $7,900 $7,900
Family out-of-pocket $15,800 $15,800
Coinsurance

BCBSWY Pays

Participant Pays

 75%

25%

 60%

40%
Preventive Care Paid at 100% of maximum allowable amount at appropriate intervals.
Primary Care

Copay		 $30 $45
Prescription Drugs
Tier 1: Generic Drugs  $5 copay $5 copay
 Tier 2: Preferred Brand drugs $20 copay $50 copay
Summary of Benefits and Coverage (SBC)
View SBC
View SBC

HealthPlus Plans – 2025

Gold Plan Silver Plan
HSA Eligible

Learn More

 No No
Participant deductible $1,000 $4,000
Family deductible $2,000 $8,000
Participant out-of-pocket $7,900 $7,900
Family out-of-pocket $15,800 $15,800
Coinsurance

BCBSWY Pays

Participant Pays

 80%

20%

 75%

25%
Preventive Care Paid at 100% of maximum allowable amount at appropriate intervals.
Primary Care

Copay

 $30 $45
Prescription Drugs

Tier 1: Generic Drugs

Tier 2: Preferred Brand drugs

 $5/$0 copay

$20/$10 copay

 $5/$0 copay

$50/$25 copay
Summary of Benefits and Coverage (SBC) View SBC  View SBC 

Core Plans – 2025

Bronze Plan
Single Plan Family Plan
HSA Eligible

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 Yes Yes
Participant deductible $4,500 NA
Family deductible NA $9,000
Participant out-of-pocket $6,750 $6,750
Family out-of-pocket NA $13,500
Coinsurance

BCBSWY Pays

Participant Pays

 50%

50%

 50%

50%
Preventive Care Paid at 100% of maximum allowable amount at appropriate intervals.
Primary Care

Copay

 Subject to the deductible

& coinsurance

 Subject to the deductible

& coinsurance
Prescription Drugs

Tier 1: Generic Drugs

Tier 2: Preferred Brand drugs

 Subject to the deductible

& coinsurance

 Subject to the deductible

& coinsurance
Summary of Benefits and Coverage (SBC) View SBC » View SBC »

Balance Plans – 2024

 Gold PlanSilver PlanBronze Plan
 Professional
Services		Hospital
Services		Professional
Services		Hospital
Services		Professional
Services		Hospital
Services

HSA Eligible

Learn More

NoNoNo
Participant deductible$500$1,500$1,500$4,500$3,500$7,000
Family deductible$1,000$3,000$3,000$9,000$7,000$14,000
Participant out-of-pocket$7,900$7,900$7,900
Family out-of-pocket$15,800$15,800$15,800
Coinsurance
BCBSWY Pays80%60%75%55%70%50%
Participant Pays20%40%25%45%30%50%
Preventive CarePaid at 100% of maximum allowable amount at appropriate intervals.
Primary Care
Copay$30N/A$40N/ASubject to the deductible & coinsuranceN/A
Prescription Drugs

Tier 1: Generic Drugs

Tier 2: Preferred Brand drugs

$5 copay

$50 copay

$5 copay

$100 copay

Subject to the professional services deductible & coinsurance
Summary of Benefits and Coverage (SBC)
View SBC

View SBC

View SBC

HealthPlus Plans – 2024

Gold Plan Silver Plan
HSA Eligible

Learn More

 No No
Participant deductible $1,000 $4,000
Family deductible $2,000 $8,000
Participant out-of-pocket $7,900 $7,900
Family out-of-pocket $15,800 $15,800
Coinsurance

BCBSWY Pays

Participant Pays

 80%

20%

 75%

25%
Preventive Care Paid at 100% of maximum allowable amount at appropriate intervals.
Primary Care

Copay

 $30 $45
Prescription Drugs

Tier 1: Generic Drugs

Tier 2: Preferred Brand drugs

 $5/$0 copay

$20/$10 copay

 $5/$0 copay

$50/$25 copay
Summary of Benefits and Coverage (SBC) View SBC  View SBC 
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