myBlue Gold 2016 ($0 Deductible / $0 Virtual PCP Visits / Rewards) - 30252FL0070028 Health Insurance Plan
Health Options, Inc. health insurance plan with the Plan ID 30252FL0070028. The plan is called myBlue Gold 2016 ($0 Deductible / $0 Virtual PCP Visits / Rewards).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.97% (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 18.03% 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 | 30252FL0070028 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Florida | ||||||||||||||||||
| Health Insurance Issuer | Health Options, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 30252FL0070028-00 | ||||||||||||||||||
| 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). |
|
||||||||||||||||||
| Available Variants of the Health Plan | Standard Off Exchange Plan - 30252FL0070028-00 Standard On Exchange Plan - 30252FL0070028-01 |
||||||||||||||||||
| Last Plan Update Date | Thu, 19 Sep 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of myBlue Gold 2016 ($0 Deductible / $0 Virtual PCP Visits / Rewards) Health Insurance Plan, 30252FL0070028-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | $60.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $60.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Bone Marrow Transplant
In-Network Only: The cost share is applied for a max of 3 days per admission. |
YES | $600.00 |
100.00% |
| Chemotherapy
|
YES | $450.00 |
100.00% |
| Chiropractic Care
Limit: 35.0 Procedure(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | $60.00 |
100.00% |
| Congenital Anomaly, including Cleft Lip/Palate
|
YES | $450.00 |
100.00% |
| 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 |
100.00% |
| Dental Anesthesia
|
YES | $60.00 |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
|
YES | $60.00 |
100.00% |
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | $450.00 |
100.00% |
| 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 |
100.00% |
| Generic Drugs
In-Network Only: $0 preventive and $4 generics for certain drugs, plus Mail Order for these drugs is $0. |
YES | $10.00 |
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 |
100.00% |
| 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 |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | Tier 1: $20.00 Tier 2: $250.00 |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | $450.00 |
100.00% |
| 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 |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $25.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
In-Network Only: The cost share is applied for a max of 3 days per admission. |
YES | $600.00 Copay per Day |
100.00% |
| 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 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 50.00% |
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 |
100.00% |
| Nutrition/Formulas
|
YES | $60.00 |
100.00% |
| Off Label Prescription Drugs
|
YES | 50.00% |
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 |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $60.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $450.00 |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | $60.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge |
100.00% |
| 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 |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| 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: $25.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | No Charge |
100.00% |
| Radiation
|
YES | $450.00 |
100.00% |
| Reconstructive Surgery
Only for Breast reconstruction following a Mastectomy. |
YES | $450.00 |
100.00% |
| 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 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | $60.00 |
100.00% |
| 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 |
100.00% |
| Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period |
YES | $500.00 Copay per Stay |
100.00% |
| 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 |
100.00% |
| Specialty Drugs
|
YES | 50.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
In-Network Only: The cost share is applied for a max of 3 days per admission. |
YES | $600.00 Copay per Day |
100.00% |
| 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 |
100.00% |
| Transplant
In-Network Only: The cost share is applied for a max of 3 days per admission. |
YES | $600.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | $60.00 |
100.00% |
| 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 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $135.00 |
100.00% |
myBlue Gold 2016 ($0 Deductible / $0 Virtual PCP Visits / Rewards) Health Insurance Plan Variant 30252FL0070028-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.8197241874791801 |
| 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 | Standard Gold Off Exchange Plan |
| 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 | FLF024 |
| Formulary URL | URL |
| HIOS Product ID | 30252FL007 |
| 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? | Yes |
| Issuer ID | 30252 |
| Issuer Marketplace Marketing Name | Florida Blue HMO (a BlueCross BlueShield FL company) |
| 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 | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Gold |
| Multiple In Network Tiers | Yes |
| National Network | No |
| Network ID | FLN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Accident and emergency services. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Accident and emergency services. |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 30252FL0070028-00 |
| Plan Marketing Name | myBlue Gold 2016 ($0 Deductible / $0 Virtual PCP Visits / Rewards) |
| Plan Type | HMO |
| Plan Variant Marketing Name | myBlue Gold 2016 ($0 Deductible / $0 Virtual 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 | FLS004 |
| Source Name | HIOS |
| Specialist Requiring a Referral | All Specialists require a referral with the exception of Chiropractors, Podiatrists, Dermatologists, Obstetric/Gynecologists, Behavioral Health Services, Physical Therapy, Occupational Therapy, and Speech Therapy. |
| Plan ID | 30252FL0070028 |
| 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 | $11900 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $5950 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,950 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $11900 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $5950 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $5,950 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of myBlue Gold 2016 ($0 Deductible / $0 Virtual PCP Visits / Rewards) Health Insurance Plan, 30252FL0070028
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about myBlue Gold 2016 ($0 Deductible / $0 Virtual PCP Visits / Rewards), 30252FL0070028 Health Insurance Plan, 30252FL0070028
-
Does myBlue Gold 2016 ($0 Deductible / $0 Virtual PCP Visits / Rewards) Health Insurance Plan, 30252FL0070028 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (30252FL0070028) Health Insurance Plan, Variant (30252FL0070028-00) offer Disease Management Programs?
Does (30252FL0070028) Health Insurance Plan, Variant (30252FL0070028-00) have Out Of Country Coverage?
Does (30252FL0070028) Health Insurance Plan, Variant (30252FL0070028-00) have Out of Service Area Coverage?
Does (30252FL0070028) Health Insurance Plan, Variant (30252FL0070028-00) offer Disease Management Programs?
Does myBlue Gold 2016 ($0 Deductible / $0 Virtual PCP Visits / Rewards) Health Insurance Plan, Variant (30252FL0070028-00) offer Disease Management Programs for Asthma?
Does myBlue Gold 2016 ($0 Deductible / $0 Virtual PCP Visits / Rewards) Health Insurance Plan, Variant (30252FL0070028-00) offer Disease Management Programs for Heart disease?
Does myBlue Gold 2016 ($0 Deductible / $0 Virtual PCP Visits / Rewards) Health Insurance Plan, Variant (30252FL0070028-00) offer Disease Management Programs for Depression?
Does myBlue Gold 2016 ($0 Deductible / $0 Virtual PCP Visits / Rewards) Health Insurance Plan, Variant (30252FL0070028-00) offer Disease Management Programs for Diabetes?
Does myBlue Gold 2016 ($0 Deductible / $0 Virtual PCP Visits / Rewards) Health Insurance Plan, Variant (30252FL0070028-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does myBlue Gold 2016 ($0 Deductible / $0 Virtual PCP Visits / Rewards) Health Insurance Plan, Variant (30252FL0070028-00) 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