BlueSelect Gold 1835 ($0 Virtual PCP Visits / $15 Labs / Rewards) - 16842FL0120086 Health Insurance Plan

Blue Cross and Blue Shield of Florida health insurance plan with the Plan ID 16842FL0120086. The plan is called BlueSelect Gold 1835 ($0 Virtual PCP Visits / $15 Labs / Rewards).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.45% (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 18.55% 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 16842FL0120086
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 16842FL0120086-00
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 - 16842FL0120086-00

Standard On Exchange Plan - 16842FL0120086-01

Open to Indians below 300% FPL - 16842FL0120086-02

Open to Indians above 300% FPL - 16842FL0120086-03

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

Benefits of BlueSelect Gold 1835 ($0 Virtual PCP Visits / $15 Labs / Rewards) Health Insurance Plan, 16842FL0120086-00

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

$75.00

50.00% Coinsurance after deductible
Acupuncture
NO
Allergy Testing
YES

$75.00

50.00% Coinsurance after deductible
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Bone Marrow Testing
YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Chemotherapy
YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Chiropractic Care

Limit: 35.0 Procedure(s) per Benefit Period

Combined limit for all outpatient therapy plus chiropractic.

YES

$75.00

50.00% Coinsurance after deductible
Congenital Anomaly, including Cleft Lip/Palate
YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Dental Anesthesia
YES

$75.00

50.00% Coinsurance after deductible
Dental Check-Up for Children
NO
Diabetes Care Management
YES

$75.00

50.00% Coinsurance after deductible
Diabetes Education
YES

No Charge

50.00% Coinsurance after deductible
Dialysis
YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Durable Medical Equipment
YES

No Charge

100.00%
Emergency Room Services
YES

$500.00

$500.00
Emergency Transportation/Ambulance
YES

20.00% Coinsurance after deductible

20.00% 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

20.00% Coinsurance after deductible

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

$20.00

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

$75.00

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: $325.00

50.00% Coinsurance after deductible
Infertility Treatment
NO
Infusion Therapy
YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

$10.00

$10.00
Laboratory Outpatient and Professional Services
YES

$15.00

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

20.00% Coinsurance after deductible

No Charge after deductible
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

$75.00

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: $75.00

50.00% Coinsurance after deductible
Nutrition/Formulas
YES

20.00% Coinsurance after deductible

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: $75.00

50.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$75.00

50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

20.00% Coinsurance after deductible

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

$75.00

50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
YES

$10.00

$10.00
Preferred Brand Drugs

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

YES

$65.00

100.00%
Prenatal and Postnatal Care
YES

$75.00

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: $40.00

50.00% Coinsurance after deductible
Private-Duty Nursing
NO
Prosthetic Devices
YES

No Charge

100.00%
Radiation
YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Reconstructive Surgery

Only for Breast reconstruction following a Mastectomy.

YES

20.00% Coinsurance after deductible

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

$75.00

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

$75.00

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: $75.00

50.00% Coinsurance after deductible
Skilled Nursing Facility

Limit: 60.0 Days per Benefit Period

YES

20.00% Coinsurance after deductible

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: $75.00

50.00% Coinsurance after deductible
Specialty Drugs
YES

50.00%

100.00%
Substance Abuse Disorder Inpatient Services
YES

20.00% Coinsurance after deductible

No Charge after deductible
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

$75.00

50.00% Coinsurance after deductible
Transplant
YES

20.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
YES

$75.00

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: $75.00

Tier 2: $75.00

$75.00 Copay after deductible
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

50.00%
X-rays and Diagnostic Imaging
YES

$175.00

50.00% Coinsurance after deductible

BlueSelect Gold 1835 ($0 Virtual PCP Visits / $15 Labs / Rewards) Health Insurance Plan Variant 16842FL0120086-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.814490216518192
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 20.00%
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 20.00%
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 FLF025
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 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 20.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $3000 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $1500 per person
Medical EHB Deductible, In Network (Tier 1), Individual $1,500
Medical EHB Deductible, In Network (Tier 2), Default Coinsurance 20.00%
Medical EHB Deductible, In Network (Tier 2), Family Per Group $3000 per group
Medical EHB Deductible, In Network (Tier 2), Family Per Person $1500 per person
Medical EHB Deductible, In Network (Tier 2), Individual $1,500
Medical EHB Deductible, Out of Network, Family Per Group $6000 per group
Medical EHB Deductible, Out of Network, Family Per Person $3000 per person
Medical EHB Deductible, Out of Network, Individual $3,000
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) 16842FL0120086-00
Plan Marketing Name BlueSelect Gold 1835 ($0 Virtual PCP Visits / $15 Labs / Rewards)
Plan Type EPO
Plan Variant Marketing Name BlueSelect Gold 1835 ($0 Virtual PCP Visits / $15 Labs / Rewards)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,100
SBC Scenario, Having a Baby, Copayment $200
SBC Scenario, Having a Baby, Deductible $1,500
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $2,100
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $700
SBC Scenario, Treatment of a Simple Fracture, Deductible $900
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 100%
Service Area ID FLS002
Source Name HIOS
Plan ID 16842FL0120086
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 $11800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $5900 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $5,900
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $11800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $5900 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $5,900
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 1835 ($0 Virtual PCP Visits / $15 Labs / Rewards) Health Insurance Plan, 16842FL0120086

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about BlueSelect Gold 1835 ($0 Virtual PCP Visits / $15 Labs / Rewards), 16842FL0120086 Health Insurance Plan, 16842FL0120086

  • Does BlueSelect Gold 1835 ($0 Virtual PCP Visits / $15 Labs / Rewards) Health Insurance Plan, 16842FL0120086 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (16842FL0120086) Health Insurance Plan, Variant (16842FL0120086-00) 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 (16842FL0120086) Health Insurance Plan, Variant (16842FL0120086-00) have Out Of Country Coverage?

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

    Does (16842FL0120086) Health Insurance Plan, Variant (16842FL0120086-00) have Out of Service Area Coverage?

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

    Does (16842FL0120086) Health Insurance Plan, Variant (16842FL0120086-00) 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 Gold 1835 ($0 Virtual PCP Visits / $15 Labs / Rewards) Health Insurance Plan, Variant (16842FL0120086-00) offer Disease Management Programs for Asthma?

    Yes, the BlueSelect Gold 1835 ($0 Virtual PCP Visits / $15 Labs / Rewards) Health Insurance Plan Variant 16842FL0120086-00 offers Disease Management Program for Asthma.

    Does BlueSelect Gold 1835 ($0 Virtual PCP Visits / $15 Labs / Rewards) Health Insurance Plan, Variant (16842FL0120086-00) offer Disease Management Programs for Heart disease?

    Yes, the BlueSelect Gold 1835 ($0 Virtual PCP Visits / $15 Labs / Rewards) Health Insurance Plan Variant 16842FL0120086-00 offers Disease Management Program for Heart disease.

    Does BlueSelect Gold 1835 ($0 Virtual PCP Visits / $15 Labs / Rewards) Health Insurance Plan, Variant (16842FL0120086-00) offer Disease Management Programs for Depression?

    Yes, the BlueSelect Gold 1835 ($0 Virtual PCP Visits / $15 Labs / Rewards) Health Insurance Plan Variant 16842FL0120086-00 offers Disease Management Program for Depression.

    Does BlueSelect Gold 1835 ($0 Virtual PCP Visits / $15 Labs / Rewards) Health Insurance Plan, Variant (16842FL0120086-00) offer Disease Management Programs for Diabetes?

    Yes, the BlueSelect Gold 1835 ($0 Virtual PCP Visits / $15 Labs / Rewards) Health Insurance Plan Variant 16842FL0120086-00 offers Disease Management Program for Diabetes.

    Does BlueSelect Gold 1835 ($0 Virtual PCP Visits / $15 Labs / Rewards) Health Insurance Plan, Variant (16842FL0120086-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the BlueSelect Gold 1835 ($0 Virtual PCP Visits / $15 Labs / Rewards) Health Insurance Plan Variant 16842FL0120086-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does BlueSelect Gold 1835 ($0 Virtual PCP Visits / $15 Labs / Rewards) Health Insurance Plan, Variant (16842FL0120086-00) offer Disease Management Programs for Pregnancy?

    Yes, the BlueSelect Gold 1835 ($0 Virtual PCP Visits / $15 Labs / Rewards) Health Insurance Plan Variant 16842FL0120086-00 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