BlueSelect Gold 1535 ($0 Virtual PCP Visits / $15 PCP Visits / Rewards) - 16842FL0120076 Health Insurance Plan
Blue Cross and Blue Shield of Florida health insurance plan with the Plan ID 16842FL0120076. The plan is called BlueSelect Gold 1535 ($0 Virtual PCP Visits / $15 PCP Visits / Rewards).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.62% (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 18.38% 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 | 16842FL0120076 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| 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 | 16842FL0120076-03 | ||||||||||||||||||
| 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 - 16842FL0120076-00 Standard On Exchange Plan - 16842FL0120076-01 |
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| Last Plan Update Date | Thu, 19 Sep 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of BlueSelect Gold 1535 ($0 Virtual PCP Visits / $15 PCP Visits / Rewards) Health Insurance Plan, 16842FL0120076-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | $60.00 |
50.00% Coinsurance after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $60.00 |
50.00% Coinsurance after deductible |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Bone Marrow Testing
In-Network Only: The cost share is applied for a max of 3 days per admission. |
YES | $600.00 |
50.00% Coinsurance after deductible |
| Chemotherapy
|
YES | $450.00 |
50.00% Coinsurance after deductible |
| Chiropractic Care
Limit: 35.0 Procedure(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | $60.00 |
50.00% Coinsurance after deductible |
| Congenital Anomaly, including Cleft Lip/Palate
|
YES | $450.00 |
50.00% Coinsurance after deductible |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
In-Network Only: The cost share is applied for a max of 3 days per admission. |
YES | $600.00 |
50.00% Coinsurance after deductible |
| Dental Anesthesia
|
YES | $60.00 |
50.00% Coinsurance after deductible |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
|
YES | $60.00 |
50.00% Coinsurance after deductible |
| Diabetes Education
|
YES | No Charge |
50.00% Coinsurance after deductible |
| Dialysis
|
YES | $450.00 |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
|
YES | No Charge |
100.00% |
| Emergency Room Services
|
YES | $350.00 |
$350.00 |
| Emergency Transportation/Ambulance
|
YES | 40.00% |
40.00% |
| 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 | $600.00 |
50.00% Coinsurance after deductible |
| Generic Drugs
In-Network Only: $0 preventive and $4 generics for certain drugs, plus Mail Order for these drugs is $0. |
YES | $15.00 |
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 | $60.00 |
50.00% Coinsurance after deductible |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 60.0 Visit(s) per Benefit Period |
YES | No Charge |
100.00% |
| Hospice Services
|
YES | No Charge |
50.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
|
YES | Tier 1: $20.00 Tier 2: $250.00 |
50.00% Coinsurance after deductible |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | $450.00 |
50.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
In-Network Only: The cost share is applied for a max of 3 days per admission. |
YES | $600.00 Copay per Day |
50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | No Charge |
No Charge |
| Laboratory Outpatient and Professional Services
|
YES | $20.00 |
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 |
No Charge |
| Mental/Behavioral Health Outpatient Services
Virtual Visits are available and some may be at a reduced or $0 cost share. Please refer to your Summary of Benefits and Coverage for more detail. |
YES | $60.00 |
50.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
|
YES | 47.00% |
100.00% |
| Nutritional Counseling
Reduced cost available at Value Choice Providers. Check your Online Provider Directory for providers in your area. |
YES | Tier 1: $20.00 Tier 2: $60.00 |
50.00% Coinsurance after deductible |
| Nutrition/Formulas
|
YES | $60.00 |
50.00% Coinsurance after deductible |
| Off Label Prescription Drugs
|
YES | 47.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Osteoporosis
Reduced cost available at Value Choice Providers. Check your Online Provider Directory for providers in your area. |
YES | Tier 1: $20.00 Tier 2: $60.00 |
50.00% Coinsurance after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $60.00 |
50.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $450.00 |
50.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | $60.00 |
50.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge |
No Charge |
| Preferred Brand Drugs
In-Network Only: Certain drugs are available for a lower cost. |
YES | $50.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $60.00 |
50.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
50.00% |
| Primary Care Visit to Treat an Injury or Illness
No charge for unlimited visits rendered by Value Choice Providers. Check your Online Provider Directory for providers in your area. Virtual Visits are available and some may be at a reduced or $0 cost share. Please refer to your Summary of Benefits and Coverage for more detail. |
YES | Tier 1: No Charge Tier 2: $15.00 |
50.00% Coinsurance after deductible |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | No Charge |
100.00% |
| Radiation
|
YES | $450.00 |
50.00% Coinsurance after deductible |
| Reconstructive Surgery
Only for Breast reconstruction following a Mastectomy. |
YES | $450.00 |
50.00% Coinsurance 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 | $60.00 |
50.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
Limit: 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | $60.00 |
50.00% Coinsurance 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. Reduced cost available at Value Choice Providers. Check your Online Provider Directory for providers in your area. |
YES | Tier 1: $20.00 Tier 2: $60.00 |
50.00% Coinsurance after deductible |
| Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period |
YES | $500.00 Copay per Stay |
50.00% Coinsurance after deductible |
| Specialist Visit
Lower out of pocket costs for virtual visits and reduced cost may be available at Value Choice Providers. Check your Online Provider Directory for providers in your area. Virtual Visits are available and some may be at a reduced or $0 cost share. Please refer to your Summary of Benefits and Coverage for more detail. |
YES | Tier 1: $20.00 Tier 2: $60.00 |
50.00% Coinsurance after deductible |
| Specialty Drugs
|
YES | 50.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | No Charge |
No Charge |
| Substance Abuse Disorder Outpatient Services
Virtual Visits are available and some may be at a reduced or $0 cost share. Please refer to your Summary of Benefits and Coverage for more detail. |
YES | $60.00 |
50.00% Coinsurance after deductible |
| Transplant
In-Network Only: The cost share is applied for a max of 3 days per admission. |
YES | $600.00 |
50.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
|
YES | $60.00 |
50.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities
Reduced cost available at Value Choice Providers. Check your Online Provider Directory for providers in your area. |
YES | Tier 1: $60.00 Tier 2: $60.00 |
$60.00 Copay after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
50.00% |
| X-rays and Diagnostic Imaging
|
YES | $135.00 |
50.00% Coinsurance after deductible |
BlueSelect Gold 1535O ($0 Virtual PCP Visits / $15 PCP Visits / Rewards) Health Insurance Plan Variant 16842FL0120076-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.816178520236043 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 40.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 40.00% |
| Drug EHB Deductible, In Network (Tier 2), Family Per Group | $0 per group |
| Drug EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
| Drug EHB Deductible, In Network (Tier 2), Individual | $0 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| 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 | 0% |
| Formulary ID | FLF021 |
| Formulary URL | URL |
| HIOS Product ID | 16842FL012 |
| Import Date | 2024-09-19 01:01:32 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 3 |
| HSA Eligible | No |
| 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 | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 40.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| Medical EHB Deductible, In Network (Tier 2), Default Coinsurance | 40.00% |
| Medical EHB Deductible, In Network (Tier 2), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 2), Individual | $0 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | $500 per person |
| Medical EHB Deductible, Out of Network, Individual | $500 |
| Metal Level | Gold |
| Multiple In Network Tiers | Yes |
| 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 | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 16842FL0120076-03 |
| Plan Marketing Name | BlueSelect Gold 1535 ($0 Virtual PCP Visits / $15 PCP Visits / Rewards) |
| Plan Type | EPO |
| Plan Variant Marketing Name | BlueSelect Gold 1535O ($0 Virtual PCP Visits / $15 PCP Visits / Rewards) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $800 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,700 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $600 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 100% |
| Service Area ID | FLS002 |
| Source Name | HIOS |
| Plan ID | 16842FL0120076 |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $12500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6250 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,250 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $12500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $6250 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $6,250 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $25000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $12500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $12,500 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of BlueSelect Gold 1535 ($0 Virtual PCP Visits / $15 PCP Visits / Rewards) Health Insurance Plan, 16842FL0120076
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about BlueSelect Gold 1535 ($0 Virtual PCP Visits / $15 PCP Visits / Rewards), 16842FL0120076 Health Insurance Plan, 16842FL0120076
-
Does BlueSelect Gold 1535 ($0 Virtual PCP Visits / $15 PCP Visits / Rewards) Health Insurance Plan, 16842FL0120076 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (16842FL0120076) Health Insurance Plan, Variant (16842FL0120076-03) offer Disease Management Programs?
Does (16842FL0120076) Health Insurance Plan, Variant (16842FL0120076-03) have Out Of Country Coverage?
Does (16842FL0120076) Health Insurance Plan, Variant (16842FL0120076-03) have Out of Service Area Coverage?
Does (16842FL0120076) Health Insurance Plan, Variant (16842FL0120076-03) offer Disease Management Programs?
Does BlueSelect Gold 1535O ($0 Virtual PCP Visits / $15 PCP Visits / Rewards) Health Insurance Plan, Variant (16842FL0120076-03) offer Disease Management Programs for Asthma?
Does BlueSelect Gold 1535O ($0 Virtual PCP Visits / $15 PCP Visits / Rewards) Health Insurance Plan, Variant (16842FL0120076-03) offer Disease Management Programs for Heart disease?
Does BlueSelect Gold 1535O ($0 Virtual PCP Visits / $15 PCP Visits / Rewards) Health Insurance Plan, Variant (16842FL0120076-03) offer Disease Management Programs for Depression?
Does BlueSelect Gold 1535O ($0 Virtual PCP Visits / $15 PCP Visits / Rewards) Health Insurance Plan, Variant (16842FL0120076-03) offer Disease Management Programs for Diabetes?
Does BlueSelect Gold 1535O ($0 Virtual PCP Visits / $15 PCP Visits / Rewards) Health Insurance Plan, Variant (16842FL0120076-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does BlueSelect Gold 1535O ($0 Virtual PCP Visits / $15 PCP Visits / Rewards) Health Insurance Plan, Variant (16842FL0120076-03) 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