BlueSelect for Individuals & Families - 2024 Archives - Page 2 of 2

Basic Plans – 2024

	Bronze Plan
HSA Eligible Learn More	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 »

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

Find important information on your prescriptions, including how to select a pharmacy, request prescription benefits, and more.

	Silver Plan	Bronze Plan
HSA Eligible Learn More	No	No
Participant deductible	$3,500	$6,000
Family deductible	$7,000	$12,000
Participant out-of-pocket	$7,900	$7,900
Family out-of-pocket	$15,800	$15,800
Coinsurance BCBSWY Pays Participant Pays	80% 20%	80% 20%
Preventive Care	Paid at 100% of maximum allowable amount at appropriate intervals.
Primary Care Copay	$40	Subject to the deductible & coinsurance
Prescription Drugs Tier 1: Generic DrugsTier 2: Preferred Brand drugs	$5 copay $50 copay	$10 copay $150 copay
Summary of Benefits and Coverage (SBC)	View SBC »	View SBC »

	Gold Plan	Silver Plan
HSA Eligible Learn More	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

	Bronze Plan
	Single Plan	Family Plan
HSA Eligible Learn More	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 »