BlueSelect Bronze (HSA) 1735 (Rewards $$$ / $4 Condition Care Rx) - 16842FL0120078 Health Insurance Plan
Blue Cross and Blue Shield of Florida health insurance plan with the Plan ID 16842FL0120078. The plan is called BlueSelect Bronze (HSA) 1735 (Rewards $$$ / $4 Condition Care Rx).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.94% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.06% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 16842FL0120078 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Florida | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross and Blue Shield of Florida | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 16842FL0120078-01 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 16842FL0120078-00 Standard On Exchange Plan - 16842FL0120078-01 |
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| Last Plan Update Date | Sat, 26 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of BlueSelect Bronze (HSA) 1735 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan, 16842FL0120078-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | No Charge after deductible |
No Charge after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge after deductible |
No Charge after deductible |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Bone Marrow Transplant
|
YES | No Charge after deductible |
No Charge after deductible |
| Chemotherapy
|
YES | No Charge after deductible |
No Charge after deductible |
| Chiropractic Care
Limit: 35.0 Procedure(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | No Charge after deductible |
No Charge after deductible |
| Congenital Anomaly, including Cleft Lip/Palate
|
YES | No Charge after deductible |
No Charge after deductible |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | No Charge after deductible |
No Charge after deductible |
| Dental Anesthesia
|
YES | No Charge after deductible |
No Charge after deductible |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
|
YES | No Charge after deductible |
No Charge after deductible |
| Diabetes Education
|
YES | No Charge after deductible |
No Charge after deductible |
| Dialysis
|
YES | No Charge after deductible |
No Charge after deductible |
| Durable Medical Equipment
|
YES | No Charge after deductible |
100.00% |
| Emergency Room Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
|
YES | No Charge after deductible |
No Charge after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge |
100.00% |
| Gender Affirming Care
Only covered when medically necessary. |
YES | No Charge after deductible |
No Charge after deductible |
| Generic Drugs
In-Network Only: $0 preventive and $4 generics for certain drugs, plus Mail Order for these drugs is $0. |
YES | No Charge after deductible |
100.00% |
| Habilitation Services
Limit: 35.0 Visit(s) per Benefit Period Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. |
YES | No Charge after deductible |
No Charge after deductible |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 60.0 Visit(s) per Benefit Period |
YES | No Charge after deductible |
100.00% |
| Hospice Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible |
No Charge after deductible |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | No Charge after deductible |
No Charge after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | No Charge after deductible |
No Charge after deductible |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Laboratory Outpatient and Professional Services
|
YES | No Charge after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health Outpatient Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Non-Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
| Nutritional Counseling
|
YES | No Charge after deductible |
No Charge after deductible |
| Nutrition/Formulas
|
YES | No Charge after deductible |
No Charge after deductible |
| Off Label Prescription Drugs
|
YES | No Charge after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Osteoporosis
|
YES | No Charge after deductible |
No Charge after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | No Charge after deductible |
No Charge after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
No Charge after deductible |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | No Charge after deductible |
No Charge after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Preferred Brand Drugs
In-Network Only: Certain drugs are available for a lower cost. |
YES | No Charge after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge after deductible |
No Charge after deductible |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
50.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | No Charge after deductible |
No Charge after deductible |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | No Charge after deductible |
100.00% |
| Radiation
|
YES | No Charge after deductible |
No Charge after deductible |
| Reconstructive Surgery
Only for Breast reconstruction following a Mastectomy. |
YES | No Charge after deductible |
No Charge after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | No Charge after deductible |
No Charge after deductible |
| Rehabilitative Speech Therapy
Limit: 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | No Charge after deductible |
No Charge after deductible |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
Only covered when medically necessary. |
YES | No Charge after deductible |
No Charge after deductible |
| Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period |
YES | No Charge after deductible |
No Charge after deductible |
| Specialist Visit
|
YES | No Charge after deductible |
No Charge after deductible |
| Specialty Drugs
|
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Transplant
|
YES | No Charge after deductible |
No Charge after deductible |
| Treatment for Temporomandibular Joint Disorders
|
YES | No Charge after deductible |
No Charge after deductible |
| Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
No Charge after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
50.00% |
| X-rays and Diagnostic Imaging
|
YES | No Charge after deductible |
No Charge after deductible |
BlueSelect Bronze (HSA) 1735 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan Variant 16842FL0120078-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.64941940468422 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Bronze On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | FLF022 |
| Formulary URL | URL |
| HIOS Product ID | 16842FL012 |
| Import Date | 2023-08-26 01:02:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | Yes |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 16842 |
| Issuer Marketplace Marketing Name | Florida Blue (BlueCross BlueShield FL) |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | FLN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Covered services as outlined in the member contract. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Covered services as outlined in the member contract. |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 16842FL0120078-01 |
| Plan Marketing Name | BlueSelect Bronze (HSA) 1735 (Rewards $$$ / $4 Condition Care Rx) |
| Plan Type | EPO |
| Plan Variant Marketing Name | BlueSelect Bronze (HSA) 1735 (Rewards $$$ / $4 Condition Care Rx) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $7,050 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $500 |
| SBC Scenario, Having Diabetes, Deductible | $4,700 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | FLS002 |
| Source Name | HIOS |
| Plan ID | 16842FL0120078 |
| State Code | FL |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $14100 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $7050 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $7,050 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $28200 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $14100 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $14,100 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $14100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7050 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,050 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $28200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $14100 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $14,100 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of BlueSelect Bronze (HSA) 1735 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan, 16842FL0120078
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about BlueSelect Bronze (HSA) 1735 (Rewards $$$ / $4 Condition Care Rx), 16842FL0120078 Health Insurance Plan, 16842FL0120078
-
Does BlueSelect Bronze (HSA) 1735 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan, 16842FL0120078 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (16842FL0120078) Health Insurance Plan, Variant (16842FL0120078-01) offer Disease Management Programs?
Does (16842FL0120078) Health Insurance Plan, Variant (16842FL0120078-01) have Out Of Country Coverage?
Does (16842FL0120078) Health Insurance Plan, Variant (16842FL0120078-01) have Out of Service Area Coverage?
Does (16842FL0120078) Health Insurance Plan, Variant (16842FL0120078-01) offer Disease Management Programs?
Does BlueSelect Bronze (HSA) 1735 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan, Variant (16842FL0120078-01) offer Disease Management Programs for Asthma?
Does BlueSelect Bronze (HSA) 1735 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan, Variant (16842FL0120078-01) offer Disease Management Programs for Heart disease?
Does BlueSelect Bronze (HSA) 1735 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan, Variant (16842FL0120078-01) offer Disease Management Programs for Depression?
Does BlueSelect Bronze (HSA) 1735 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan, Variant (16842FL0120078-01) offer Disease Management Programs for Diabetes?
Does BlueSelect Bronze (HSA) 1735 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan, Variant (16842FL0120078-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does BlueSelect Bronze (HSA) 1735 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan, Variant (16842FL0120078-01) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API