myBlue Silver 24M06-76V ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Vision / Rewards) - 30252FL0190030 Health Insurance Plan
Health Options, Inc. health insurance plan with the Plan ID 30252FL0190030. The plan is called myBlue Silver 24M06-76V ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Vision / Rewards).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.08% (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 29.92% 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 | 30252FL0190030 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 30252FL0190030-00 | ||||||||||||||||||
| 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). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 30252FL0190030-00 Standard On Exchange Plan - 30252FL0190030-01 Open to Indians below 300% FPL - 30252FL0190030-02 Open to Indians above 300% FPL - 30252FL0190030-03 73% AV Silver Plan - 30252FL0190030-04 |
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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 myBlue Silver 24M06-76V ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Vision / Rewards) Health Insurance Plan, 30252FL0190030-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | $125.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $125.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Bone Marrow Transplant
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Chemotherapy
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 35.0 Procedure(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | $125.00 |
100.00% |
| Congenital Anomaly, including Cleft Lip/Palate
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Dental Anesthesia
|
YES | $125.00 |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
|
YES | $125.00 |
100.00% |
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | No Charge |
100.00% |
| Emergency Room Services
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance 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 | 50.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
In-Network Only: $0 preventive and low cost generics for certain drugs, plus Mail Order for these drugs is $0. |
YES | $40.00 Copay 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 | $125.00 |
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: 50.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $10.00 |
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 | 50.00% Coinsurance after deductible |
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 | $10.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 50.00% Coinsurance after deductible |
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: $125.00 |
100.00% |
| Nutrition/Formulas
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Off Label Prescription Drugs
|
YES | 50.00% Coinsurance after deductible |
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: $125.00 |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $125.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | $125.00 |
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 | $70.00 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | $125.00 |
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: $50.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | No Charge |
100.00% |
| Radiation
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Only for Breast reconstruction following a Mastectomy. |
YES | 50.00% Coinsurance after deductible |
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 | $125.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | $125.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year See Policy for details |
YES | No Charge |
100.00% |
| 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: $125.00 |
100.00% |
| Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period |
YES | $700.00 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: $125.00 |
100.00% |
| Specialty Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 50.00% Coinsurance after deductible |
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 | $10.00 |
100.00% |
| Transplant
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | $125.00 |
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: $125.00 Tier 2: $125.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $20.00 |
100.00% |
myBlue Silver 24M06-76V ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Vision / Rewards) Health Insurance Plan Variant 30252FL0190030-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.700761169014088 |
| 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 Silver Off 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 | 0.9927 |
| First Tier Utilization | 1% |
| Formulary ID | FLF017 |
| Formulary URL | URL |
| HIOS Product ID | 30252FL019 |
| Import Date | 2024-09-19 01:01:32 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | New |
| 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 | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| 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) | 30252FL0190030-00 |
| Plan Marketing Name | myBlue Silver 24M06-76V ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Vision / Rewards) |
| Plan Type | HMO |
| Plan Variant Marketing Name | myBlue Silver 24M06-76V ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Vision / Rewards) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $200 |
| SBC Scenario, Having a Baby, Deductible | $7,100 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,100 |
| SBC Scenario, Having Diabetes, Deductible | $3,600 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,200 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 99% |
| Service Area ID | FLS007 |
| 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 | 30252FL0190030 |
| 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 | 50.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $15200 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $7600 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $7,600 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 50.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $15200 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $7600 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $7,600 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,200 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $9,200 |
| 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 Silver 24M06-76V ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Vision / Rewards) Health Insurance Plan, 30252FL0190030
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about myBlue Silver 24M06-76V ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Vision / Rewards), 30252FL0190030 Health Insurance Plan, 30252FL0190030
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Does myBlue Silver 24M06-76V ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Vision / Rewards) Health Insurance Plan, 30252FL0190030 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (30252FL0190030) Health Insurance Plan, Variant (30252FL0190030-00) offer Disease Management Programs?
Does (30252FL0190030) Health Insurance Plan, Variant (30252FL0190030-00) have Out Of Country Coverage?
Does (30252FL0190030) Health Insurance Plan, Variant (30252FL0190030-00) have Out of Service Area Coverage?
Does (30252FL0190030) Health Insurance Plan, Variant (30252FL0190030-00) offer Disease Management Programs?
Does myBlue Silver 24M06-76V ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Vision / Rewards) Health Insurance Plan, Variant (30252FL0190030-00) offer Disease Management Programs for Asthma?
Does myBlue Silver 24M06-76V ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Vision / Rewards) Health Insurance Plan, Variant (30252FL0190030-00) offer Disease Management Programs for Heart disease?
Does myBlue Silver 24M06-76V ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Vision / Rewards) Health Insurance Plan, Variant (30252FL0190030-00) offer Disease Management Programs for Depression?
Does myBlue Silver 24M06-76V ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Vision / Rewards) Health Insurance Plan, Variant (30252FL0190030-00) offer Disease Management Programs for Diabetes?
Does myBlue Silver 24M06-76V ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Vision / Rewards) Health Insurance Plan, Variant (30252FL0190030-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does myBlue Silver 24M06-76V ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Vision / Rewards) Health Insurance Plan, Variant (30252FL0190030-00) 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