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 64.78% (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 35.22% 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 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 16842FL0120078-00
Provider Network(s) PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT).

Providers Florida All US States
All 57984 114406
PCP 12007 13041
Allergy 49 53
OB/GYN 687 770
Dentists 160 232
Available Variants of the Health Plan

Standard Off Exchange Plan - 16842FL0120078-00

Standard On Exchange Plan - 16842FL0120078-01

Open to Indians below 300% FPL - 16842FL0120078-02

Open to Indians above 300% FPL - 16842FL0120078-03

Last Plan Update Date Thu, 19 Sep 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of BlueSelect Bronze (HSA) 1735 (Rewards / $4 Condition Care Rx) Health Insurance Plan, 16842FL0120078-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

5.00% Coinsurance after deductible

No Charge after deductible
Acupuncture
NO
Allergy Testing
YES

5.00% Coinsurance after deductible

No Charge after deductible
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Bone Marrow Testing
YES

5.00% Coinsurance after deductible

No Charge after deductible
Chemotherapy
YES

5.00% Coinsurance 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

5.00% Coinsurance after deductible

No Charge after deductible
Congenital Anomaly, including Cleft Lip/Palate
YES

5.00% Coinsurance after deductible

No Charge after deductible
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

5.00% Coinsurance after deductible

No Charge after deductible
Dental Anesthesia
YES

5.00% Coinsurance after deductible

No Charge after deductible
Dental Check-Up for Children
NO
Diabetes Care Management
YES

5.00% Coinsurance after deductible

No Charge after deductible
Diabetes Education
YES

5.00% Coinsurance after deductible

No Charge after deductible
Dialysis
YES

5.00% Coinsurance after deductible

No Charge after deductible
Durable Medical Equipment
YES

5.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

5.00% Coinsurance after deductible

5.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

5.00% Coinsurance after deductible

5.00% 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

5.00% Coinsurance 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

5.00% Coinsurance after deductible

No Charge after deductible
Hearing Aids
NO
Home Health Care Services

Limit: 60.0 Visit(s) per Benefit Period

YES

5.00% Coinsurance after deductible

100.00%
Hospice Services
YES

5.00% Coinsurance after deductible

No Charge after deductible
Imaging (CT/PET Scans, MRIs)
YES

5.00% Coinsurance after deductible

No Charge after deductible
Infertility Treatment
NO
Infusion Therapy
YES

5.00% Coinsurance after deductible

No Charge after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
YES

5.00% Coinsurance after deductible

No Charge after deductible
Inpatient Physician and Surgical Services
YES

5.00% Coinsurance after deductible

5.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
YES

5.00% Coinsurance 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

5.00% Coinsurance after deductible

No Charge after deductible
Mental/Behavioral Health Outpatient Services
YES

5.00% Coinsurance after deductible

No Charge after deductible
Non-Preferred Brand Drugs
YES

7.00% Coinsurance after deductible

100.00%
Nutritional Counseling
YES

5.00% Coinsurance after deductible

No Charge after deductible
Nutrition/Formulas
YES

5.00% Coinsurance after deductible

No Charge after deductible
Off Label Prescription Drugs
YES

7.00% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Osteoporosis
YES

5.00% Coinsurance after deductible

No Charge after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

5.00% Coinsurance after deductible

No Charge after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

5.00% Coinsurance 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

5.00% Coinsurance after deductible

No Charge after deductible
Outpatient Surgery Physician/Surgical Services
YES

5.00% Coinsurance after deductible

5.00% Coinsurance after deductible
Preferred Brand Drugs

In-Network Only: Certain drugs are available for a lower cost.

YES

5.00% Coinsurance after deductible

100.00%
Prenatal and Postnatal Care
YES

5.00% Coinsurance 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

5.00% Coinsurance after deductible

No Charge after deductible
Private-Duty Nursing
NO
Prosthetic Devices
YES

5.00% Coinsurance after deductible

100.00%
Radiation
YES

5.00% Coinsurance after deductible

No Charge after deductible
Reconstructive Surgery

Only for Breast reconstruction following a Mastectomy.

YES

5.00% Coinsurance 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

5.00% Coinsurance 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

5.00% Coinsurance 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

5.00% Coinsurance after deductible

No Charge after deductible
Skilled Nursing Facility

Limit: 60.0 Days per Benefit Period

YES

5.00% Coinsurance after deductible

No Charge after deductible
Specialist Visit
YES

5.00% Coinsurance after deductible

No Charge after deductible
Specialty Drugs
YES

10.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

5.00% Coinsurance after deductible

No Charge after deductible
Substance Abuse Disorder Outpatient Services
YES

5.00% Coinsurance after deductible

No Charge after deductible
Transplant
YES

5.00% Coinsurance after deductible

No Charge after deductible
Treatment for Temporomandibular Joint Disorders
YES

5.00% Coinsurance after deductible

No Charge after deductible
Urgent Care Centers or Facilities
YES

5.00% Coinsurance after deductible

5.00% Coinsurance after deductible
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

50.00%
X-rays and Diagnostic Imaging
YES

5.00% Coinsurance after deductible

No Charge after deductible

BlueSelect Bronze (HSA) 1735 (Rewards / $4 Condition Care Rx) Health Insurance Plan Variant 16842FL0120078-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.6477753521442929
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 Bronze 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 1.0
First Tier Utilization 100%
Formulary ID FLF022
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 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 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 16842FL0120078-00
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 $50
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $6,650
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 $0
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 5.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $13300 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $6650 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $6,650
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $26600 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $13300 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $13,300
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $13400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $6700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $6,700
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $26800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $13400 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $13,400
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 (16842FL0120078-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy

    Does (16842FL0120078) Health Insurance Plan, Variant (16842FL0120078-00) have Out Of Country Coverage?

    Yes. Details: Covered services as outlined in the member contract.

    Does (16842FL0120078) Health Insurance Plan, Variant (16842FL0120078-00) have Out of Service Area Coverage?

    Yes. Details: Covered services as outlined in the member contract.

    Does (16842FL0120078) Health Insurance Plan, Variant (16842FL0120078-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy

    Does BlueSelect Bronze (HSA) 1735 (Rewards / $4 Condition Care Rx) Health Insurance Plan, Variant (16842FL0120078-00) offer Disease Management Programs for Asthma?

    Yes, the BlueSelect Bronze (HSA) 1735 (Rewards / $4 Condition Care Rx) Health Insurance Plan Variant 16842FL0120078-00 offers Disease Management Program for Asthma.

    Does BlueSelect Bronze (HSA) 1735 (Rewards / $4 Condition Care Rx) Health Insurance Plan, Variant (16842FL0120078-00) offer Disease Management Programs for Heart disease?

    Yes, the BlueSelect Bronze (HSA) 1735 (Rewards / $4 Condition Care Rx) Health Insurance Plan Variant 16842FL0120078-00 offers Disease Management Program for Heart disease.

    Does BlueSelect Bronze (HSA) 1735 (Rewards / $4 Condition Care Rx) Health Insurance Plan, Variant (16842FL0120078-00) offer Disease Management Programs for Depression?

    Yes, the BlueSelect Bronze (HSA) 1735 (Rewards / $4 Condition Care Rx) Health Insurance Plan Variant 16842FL0120078-00 offers Disease Management Program for Depression.

    Does BlueSelect Bronze (HSA) 1735 (Rewards / $4 Condition Care Rx) Health Insurance Plan, Variant (16842FL0120078-00) offer Disease Management Programs for Diabetes?

    Yes, the BlueSelect Bronze (HSA) 1735 (Rewards / $4 Condition Care Rx) Health Insurance Plan Variant 16842FL0120078-00 offers Disease Management Program for Diabetes.

    Does BlueSelect Bronze (HSA) 1735 (Rewards / $4 Condition Care Rx) Health Insurance Plan, Variant (16842FL0120078-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the BlueSelect Bronze (HSA) 1735 (Rewards / $4 Condition Care Rx) Health Insurance Plan Variant 16842FL0120078-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does BlueSelect Bronze (HSA) 1735 (Rewards / $4 Condition Care Rx) Health Insurance Plan, Variant (16842FL0120078-00) offer Disease Management Programs for Pregnancy?

    Yes, the BlueSelect Bronze (HSA) 1735 (Rewards / $4 Condition Care Rx) Health Insurance Plan Variant 16842FL0120078-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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