2027 Medicare Advantage plan

WyoBlue Advantage Entrust PPO (PPO): 2027 benefits and costs

WyoBlue Advantage PPO

CMS plan ID: H9326-003-0 · Plan year: 2027

WyoBlue Advantage Entrust PPO (PPO) is a 2027 Medicare Advantage plan offered by WyoBlue Advantage. It is listed in Wyoming.

2027 plan costs at a glance

Monthly plan premium$0.00

In-network medical out-of-pocket maximum$6,750.00

Organization: WyoBlue Advantage
Plan organization: WYOBLUE ADVANTAGE INC
Parent company: Blue Cross Blue Shield of Michigan Mutual Ins. Co.
Plan type: PPO
Part C premium: $0.00
Prescription drug coverage: No
2027 CMS Star Rating: Plan too new to be measured

Standard monthly Medicare Part B premium: $209.50 (estimated)

You must continue to pay your Medicare Part B premium.

Annual medical deductible: None
In-network medical maximum: $6,750.00
Combined in/out-of-network medical maximum: $10,000.00
Out-of-network medical maximum: Not applicable

2027 benefit summary

Doctor visits and medical care

Common medical services and member costs
Service	In-network	Out-of-network	What to know
Primary care doctor	$0 Service-specific deductible No	$0 Deductible applies No
Specialist visit	$50.00 copay Service-specific deductible No	$50.00 copay Deductible applies No	Approval required No Referral required No
Telehealth	$0.00 to $50.00 copay Service-specific deductible No	Not summarized. Check coverage with the plan.	Approval required No Referral required No
Emergency care	$125.00 copay	Not summarized. Check coverage with the plan.
Urgent care	$50.00 copay	Not summarized. Check coverage with the plan.
Home health	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes Referral required No
Dialysis	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No
Part B chemotherapy and radiation drugs	0% to 20% coinsurance Deductible applies No	20% coinsurance Deductible applies No	Approval required Yes
Other Part B drugs	0% to 20% coinsurance Deductible applies No	35% coinsurance Deductible applies No	Approval required Yes
Kidney disease education services	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No
Medicare-covered chiropractic	$15.00 copay Service-specific deductible No	$15.00 copay Deductible applies No	Approval required No Referral required No
Medicare-covered foot care	$50.00 copay Service-specific deductible No	$50.00 copay Deductible applies No	Approval required No Referral required No
Other health professionals	$0.00 to $50.00 copay Service-specific deductible No	$0.00 to $50.00 copay Deductible applies No	Approval required No Referral required No

Hospital, outpatient surgery and observation care

Inpatient stays and skilled nursing care

In-network stays. Charges can depend on the number of days and the benefit period.
Care	Your share of the cost	What to know
Inpatient hospital stay	$0.00 copay per stay Days 1–4: $450.00 copay per day Days 5–90: $0.00 copay per day	Approval required Yes Referral required No Benefit period Original Medicare
Inpatient mental health care	$0.00 copay per stay Days 1–4: $450.00 copay per day Days 5–90: $0.00 copay per day	Approval required Yes Referral required No Benefit period Original Medicare
Skilled nursing facility	Days 1–20: $0.00 copay per day Days 21–100: $218.00 copay per day	Approval required Yes Referral required No Benefit period Original Medicare

See plan documents for out-of-network hospital and skilled nursing costs.

Hospital, outpatient surgery and observation care and member costs
Service	In-network	Out-of-network	What to know
Outpatient hospital care	$350.00 to $400.00 copay Service-specific deductible No	$350.00 to $400.00 copay Deductible applies No
Hospital observation services	$400.00 copay Service-specific deductible No	$400.00 copay Deductible applies No
Ambulatory surgical center	$200.00 copay Service-specific deductible No	$200.00 copay Deductible applies No	Approval required Yes Referral required No
Outpatient blood	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No

Tests, imaging and laboratory services

Tests, imaging and laboratory services and member costs
Service	In-network	Out-of-network	What to know
Diagnostic procedures and tests	$0.00 to $200.00 copay Service-specific deductible No	$0.00 to $200.00 copay Deductible applies No	Approval required Yes Referral required No
Laboratory services	$20.00 copay Service-specific deductible No	$20.00 copay Deductible applies No	Approval required Yes Referral required No
Diagnostic radiology (CT, MRI)	$0.00 to $500.00 copay Service-specific deductible No	$0.00 to $500.00 copay Deductible applies No	Approval required Yes Referral required No
Therapeutic radiology	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required Yes Referral required No
X-rays	$30.00 copay Service-specific deductible No	$30.00 copay Deductible applies No	Approval required Yes Referral required No

Mental health and substance use treatment

Mental health and substance use treatment and member costs
Service	In-network	Out-of-network	What to know
Partial hospitalization	$105.00 copay Service-specific deductible No	$105.00 copay Deductible applies No	Approval required Yes Referral required No
Intensive outpatient program	$105.00 copay Service-specific deductible No	$105.00 copay Deductible applies No	Approval required Yes Referral required No
Substance use treatment, individual sessions	$50.00 copay Service-specific deductible No	$50.00 copay Deductible applies No	Approval required No Referral required No
Substance use treatment, group sessions	$50.00 copay Service-specific deductible No	$50.00 copay Deductible applies No	Approval required No Referral required No
Opioid treatment program	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes Referral required No
Mental health, individual sessions	$50.00 copay Service-specific deductible No	$50.00 copay Deductible applies No	Approval required No Referral required No
Mental health, group sessions	$50.00 copay Service-specific deductible No	$50.00 copay Deductible applies No	Approval required No Referral required No
Psychiatry, individual sessions	$50.00 copay Service-specific deductible No	$50.00 copay Deductible applies No	Approval required No Referral required No
Psychiatry, group sessions	$50.00 copay Service-specific deductible No	$50.00 copay Deductible applies No	Approval required No Referral required No

Therapy and rehabilitation

Therapy and rehabilitation and member costs
Service	In-network	Out-of-network	What to know
Occupational therapy	$50.00 copay Service-specific deductible No	$50.00 copay Deductible applies No	Approval required No Referral required No
Physical and speech therapy	$50.00 copay Service-specific deductible No	$50.00 copay Deductible applies No	Approval required No Referral required No
Cardiac rehabilitation	$40.00 copay Service-specific deductible No	$40.00 copay Deductible applies No	Approval required No Referral required No
Intensive cardiac rehabilitation	$50.00 copay Service-specific deductible No	$50.00 copay Deductible applies No	Approval required No Referral required No
Pulmonary rehabilitation	$35.00 copay Service-specific deductible No	$35.00 copay Deductible applies No	Approval required No Referral required No
Supervised exercise for peripheral artery disease	$25.00 copay Service-specific deductible No	$25.00 copay Deductible applies No	Approval required No Referral required No

Ambulance, medical equipment and supplies

Ambulance, medical equipment and supplies and member costs
Service	In-network	Out-of-network	What to know
Ground ambulance	$400.00 copay Service-specific deductible No	$400.00 copay Deductible applies No	Approval required Yes
Air ambulance	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required Yes
Durable medical equipment	20% coinsurance Service-specific deductible No	35% coinsurance Deductible applies No	Approval required Yes
Prosthetic devices	20% coinsurance Service-specific deductible No	35% coinsurance Deductible applies No	Approval required Yes
Medical supplies	20% coinsurance Service-specific deductible No	50% coinsurance Deductible applies No	Approval required Yes
Diabetic supplies	$0 Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No
Diabetic shoes and inserts	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No
Diabetic monitors	$0 Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No

Dental benefits

Dental benefits and member costs
Service	In-network	Out-of-network
Medicare-covered dental	$50.00 copay	$50.00 copay Deductible applies No
Oral examsAdditional plan benefit	$0	$0 Deductible applies No
Dental X-raysAdditional plan benefit	$0	$0 Deductible applies No
Other diagnostic dentalAdditional plan benefit	$0	$0 Deductible applies No
Dental cleaningAdditional plan benefit	$0	$0 Deductible applies No
FluorideAdditional plan benefit	$0	$0 Deductible applies No
Other preventive dentalAdditional plan benefit	$0	$0 Deductible applies No
Restorative dental careAdditional plan benefit	$0	$0 Deductible applies No
Root canal treatment (endodontics)Additional plan benefit	$0	$0 Deductible applies No
Gum treatment (periodontics)Additional plan benefit	$0	$0 Deductible applies No
Removable dentures (prosthodontics)Additional plan benefit	$0	$0 Deductible applies No
Maxillofacial prostheticsAdditional plan benefit	$0	$0 Deductible applies No
Dental implantsAdditional plan benefit	$0	$0 Deductible applies No
Fixed dental restorations (prosthodontics)Additional plan benefit	$0	$0 Deductible applies No
Oral surgeryAdditional plan benefit	$0	$0 Deductible applies No
OrthodonticsAdditional plan benefit	$0	$0 Deductible applies No

Additional network details

These costs apply to the listed service categories and networks.

Dental benefits: additional out-of-network or point-of-service benefits
Service	Network	Your share of the cost	What to know
Diagnostic and preventive dental (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No
Comprehensive dental (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No

Vision benefits

Vision benefits and member costs
Service	In-network	Out-of-network	What to know
Medicare-covered eye exams	$0.00 to $50.00 copay Service-specific deductible No	$0.00 to $50.00 copay Deductible applies No	Approval required No Referral required No
Routine eye examsAdditional plan benefit	$0	50% coinsurance Deductible applies No	Approval required No Referral required No
Medicare-covered eyewear	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No
Contact lensesAdditional plan benefit	$0	$0 Deductible applies No	Approval required No Referral required No
Eyeglasses, lenses and framesAdditional plan benefit	$0	$0 Deductible applies No	Approval required No Referral required No
Eyeglass lensesAdditional plan benefit	$0	$0 Deductible applies No	Approval required No Referral required No
Eyeglass framesAdditional plan benefit	$0	$0 Deductible applies No	Approval required No Referral required No

Additional network details

These costs apply to the listed service categories and networks.

Vision benefits: additional out-of-network or point-of-service benefits
Service	Network	Your share of the cost	What to know
Eye exams (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No
Eyewear (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No
UpgradesAdditional plan benefit	Out-of-network	$0 Deductible applies No

Hearing benefits

Hearing benefits and member costs
Service	In-network	Out-of-network	What to know
Medicare-covered hearing exams	$0.00 to $50.00 copay Service-specific deductible No	$0.00 to $50.00 copay Deductible applies No	Approval required No Referral required No
Routine hearing examsAdditional plan benefit	$0	$0 Deductible applies No	Approval required No Referral required No
Hearing aid fitting and evaluationAdditional plan benefit	$0	$0 Deductible applies No	Approval required No Referral required No
Prescription hearing aids (all types)Additional plan benefit	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No
Over-the-counter hearing aidsAdditional plan benefit	$0 Service-specific deductible No	$0 Deductible applies No Dollar benefit limit applies Yes Benefit allowance $50.00 How often this limit applies Every three months	Approval required No Referral required No

Additional network details

These costs apply to the listed service categories and networks.

Hearing benefits: additional out-of-network or point-of-service benefits
Service	Network	Your share of the cost	What to know
Hearing exams (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No
Prescription hearing aids (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No

Extra benefits

Extra benefits and member costs
Service	In-network	Out-of-network	What to know
Over-the-counter health itemsAdditional plan benefit	$0 Service-specific deductible No	$0 Deductible applies No Dollar benefit limit applies Yes Benefit allowance $50.00 How often this limit applies Every three months
Annual physical examAdditional plan benefit	$0 Service-specific deductible No	$0 Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Fitness benefitAdditional plan benefit	$0 Service-specific deductible No	$0 Deductible applies No Dollar benefit limit applies Yes Benefit allowance $100.00 How often this limit applies Every year	Approval required No Referral required No

Additional services and network costs

Additional network details

These costs apply to the listed service categories and networks.

Additional medical services: additional out-of-network or point-of-service benefits
Service	Network	Your share of the cost	What to know
Chiropractic ServicesAdditional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No
Routine Chiropractic CareAdditional plan benefit	Out-of-network	$45.00 copay Deductible applies No
Other Chiropractic ServicesAdditional plan benefit	Out-of-network	$0 Deductible applies No
Medicare-covered preventive servicesMedicare-covered care	Out-of-network	$0 Deductible applies No
Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline)Additional plan benefit	Out-of-network	$0 Deductible applies No	Dollar benefit limit applies No
Personal emergency alert systemAdditional plan benefit	Out-of-network	$0 Deductible applies No	Dollar benefit limit applies No
Glaucoma ScreeningMedicare-covered care	Out-of-network	$0 Deductible applies No
Diabetes Self-Management TrainingMedicare-covered care	Out-of-network	$0 Deductible applies No
Digital Rectal ExamsMedicare-covered care	Out-of-network	$0 Deductible applies No
EKG after a Welcome to Medicare visitMedicare-covered care	Out-of-network	$0 Deductible applies No
Medicare Part B insulinMedicare-covered care	Out-of-network	$35.00 copay Deductible applies No

Allowances and optional benefits

Combined Supplemental Benefits

One shared limit covers the listed services, not a separate allowance for each service.

Services sharing this allowance: Oral Exams; Dental X-Rays; Other Diagnostic Dental Services; Dental cleaning; Fluoride Treatment; Other Preventive Dental Services; Restorative dental care; Root canal treatment (endodontics); Gum treatment (periodontics); Removable dentures (prosthodontics); Maxillofacial Prosthetics; Implant Services; Fixed dental restorations (prosthodontics); Oral and Maxillofacial Surgery; Orthodontics; Contact Lenses; Eyeglasses (lenses and frames); Eyeglass lenses; Eyeglass frames; Upgrades; Hearing aid fitting and evaluation; Prescription Hearing Aids (all types)
How benefits are provided: Debit Card
Advance choice of benefits required: No
Shared benefit limit: $650.00
How often this limit applies: Every year
Shared limit on visits or trips: No

Prescription drug coverage

This plan does not include a Part D prescription drug benefit.

Where this plan is offered

CMS lists this plan in 1 state or territory. Availability can vary by county and ZIP code.

View all locations 23 county listings across 1 state or territory