myBlue Silver 24M06-76E ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Dental & Vision / Rewards) - 30252FL0200034 Health Insurance Plan

Health Options, Inc. health insurance plan with the Plan ID 30252FL0200034. The plan is called myBlue Silver 24M06-76E ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Dental & 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 30252FL0200034
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 30252FL0200034-00
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 57713 114189
PCP 11181 12203
Allergy 40 44
OB/GYN 733 823
Dentists 164 235
Available Variants of the Health Plan

Standard Off Exchange Plan - 30252FL0200034-00

Standard On Exchange Plan - 30252FL0200034-01

Open to Indians below 300% FPL - 30252FL0200034-02

Open to Indians above 300% FPL - 30252FL0200034-03

73% AV Silver Plan - 30252FL0200034-04

87% AV Silver Plan - 30252FL0200034-05

94% AV Silver Plan - 30252FL0200034-06

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

Benefits of myBlue Silver 24M06-76E ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Dental & Vision / Rewards) Health Insurance Plan, 30252FL0200034-00

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

See Policy for details

YES

50.00% Coinsurance after deductible

100.00%
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

Limit: 4.0 Treatment(s) per 2 Years

See Policy for details

YES

50.00% Coinsurance after deductible

100.00%
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)

Limit: 2.0 Exam(s) per Year

Exclusions: See Policy for details

exams, cleaning and x-rays

YES

No Charge

100.00%
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 24M06-76E ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Dental & Vision / Rewards) Health Insurance Plan Variant 30252FL0200034-00 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 0.9740000000000001
First Tier Utilization 1%
Formulary ID FLF017
Formulary URL URL
HIOS Product ID 30252FL020
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) 30252FL0200034-00
Plan Marketing Name myBlue Silver 24M06-76E ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Dental & Vision / Rewards)
Plan Type HMO
Plan Variant Marketing Name myBlue Silver 24M06-76E ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Dental & 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 30252FL0200034
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 24M06-76E ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Dental & Vision / Rewards) Health Insurance Plan, 30252FL0200034

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

Frequently Asked Questions(FAQ) about myBlue Silver 24M06-76E ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Dental & Vision / Rewards), 30252FL0200034 Health Insurance Plan, 30252FL0200034

  • Does myBlue Silver 24M06-76E ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Dental & Vision / Rewards) Health Insurance Plan, 30252FL0200034 support Mail Ordering?

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

  • Does (30252FL0200034) Health Insurance Plan, Variant (30252FL0200034-00) 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 (30252FL0200034) Health Insurance Plan, Variant (30252FL0200034-00) have Out Of Country Coverage?

    Yes. Details: Accident and emergency services.

    Does (30252FL0200034) Health Insurance Plan, Variant (30252FL0200034-00) have Out of Service Area Coverage?

    Yes. Details: Accident and emergency services.

    Does (30252FL0200034) Health Insurance Plan, Variant (30252FL0200034-00) 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 myBlue Silver 24M06-76E ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Dental & Vision / Rewards) Health Insurance Plan, Variant (30252FL0200034-00) offer Disease Management Programs for Asthma?

    Yes, the myBlue Silver 24M06-76E ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Dental & Vision / Rewards) Health Insurance Plan Variant 30252FL0200034-00 offers Disease Management Program for Asthma.

    Does myBlue Silver 24M06-76E ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Dental & Vision / Rewards) Health Insurance Plan, Variant (30252FL0200034-00) offer Disease Management Programs for Heart disease?

    Yes, the myBlue Silver 24M06-76E ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Dental & Vision / Rewards) Health Insurance Plan Variant 30252FL0200034-00 offers Disease Management Program for Heart disease.

    Does myBlue Silver 24M06-76E ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Dental & Vision / Rewards) Health Insurance Plan, Variant (30252FL0200034-00) offer Disease Management Programs for Depression?

    Yes, the myBlue Silver 24M06-76E ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Dental & Vision / Rewards) Health Insurance Plan Variant 30252FL0200034-00 offers Disease Management Program for Depression.

    Does myBlue Silver 24M06-76E ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Dental & Vision / Rewards) Health Insurance Plan, Variant (30252FL0200034-00) offer Disease Management Programs for Diabetes?

    Yes, the myBlue Silver 24M06-76E ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Dental & Vision / Rewards) Health Insurance Plan Variant 30252FL0200034-00 offers Disease Management Program for Diabetes.

    Does myBlue Silver 24M06-76E ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Dental & Vision / Rewards) Health Insurance Plan, Variant (30252FL0200034-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the myBlue Silver 24M06-76E ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Dental & Vision / Rewards) Health Insurance Plan Variant 30252FL0200034-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does myBlue Silver 24M06-76E ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Dental & Vision / Rewards) Health Insurance Plan, Variant (30252FL0200034-00) offer Disease Management Programs for Pregnancy?

    Yes, the myBlue Silver 24M06-76E ($0 Virtual PCP Visits / $50 PCP Visits / $10 Labs / Adult Dental & Vision / Rewards) Health Insurance Plan Variant 30252FL0200034-00 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