Health Plan Details

 

In-Network

Out-of-Network

Plan Information

Description In-Network Out-of-Network
Annual Deductible Individual: $6,000 / Family: $12,000 Individual: $12,500 / Family: $25,000
Coinsurance (%) 0% 50%
Annual Out-of-Pocket Maximum (includes deductible, copays and coinsurance) Individual: $6,250 / Family: $12,500 Individual: $25,000 / Family: $25,000
 

In-Network

Out-of-Network

Prescription Drugs

Description In-Network Out-of-Network
Medication Guide Medication Guide

Generic Drugs - Tier 1 (Retail Pharmacy / Mail Order)

Description In-Network Out-of-Network
Preventive (e.g. oral contraceptives) (Retail Pharmacy) $0 Not Covered
Preventive (e.g. oral contraceptives) (Mail Order) $0 Not Covered
Condition Care Rx (e.g. asthma, cholesterol, diabetes, high blood pressure) (Retail Pharmacy) $4 Copay Not Covered
Condition Care Rx (e.g. asthma, cholesterol, diabetes, high blood pressure) (Mail Order) $0 Not Covered
All Other Generic (Retail Pharmacy) $10 Copay after Deductible Not Covered
All Other Generic (Mail Order) $25 Copay after Deductible Not Covered

Brand Drugs - Tier 2 (Retail Pharmacy / Mail Order)

Description In-Network Out-of-network
Condition Care Rx (e.g. asthma, cholesterol, diabetes, high blood pressure) (Retail Pharmacy) $30 Copay Not Covered
Condition Care Rx (e.g. asthma, cholesterol, diabetes, high blood pressure) (Mail Order) $75 Copay Not Covered
All Other Preferred Brand (Retail Pharmacy) $60 Copay after Deductible Not Covered
All Other Preferred Brand (Mail Order) $150 Copay after Deductible Not Covered

Non-Preferred Brand Drugs - Tier 3 (Retail Pharmacy / Mail Order)

Description In-Network Out-of-Network
Non-Preferred Brand (Retail Pharmacy) $100 Copay after Deductible Not Covered
Non-Preferred Brand (Mail Order) $250 Copay after Deductible Not Covered

Specialty Drugs - Tier 4 (Retail Pharmacy / Mail Order)

Description In-Network Out-of-Network
Specialty (purchased from specialty pharmacy) (Retail Pharmacy) $150 Copay after Deductible Not Covered
Specialty (purchased from specialty pharmacy) (Mail Order) Not Covered Not Covered

Physician Office Visits

Description In-Network Out-of-Network
Primary Care Physician $0 for first 3 visits, $40 Copay for all other visits 50% after Deductible
Specialist $60 Copay 50% after Deductible

Preventive Services

Description In-Network Out-of-Network
Preventive and Wellness Care (e.g. physical, mammogram, immunizations) $0 50% (mammograms & colonoscopies are $0)

Pediatric Vision and Dental (ages 18 and under)

Description In-Network Out-o-Network
Vision Care Covered - View Details (PDF) Not Covered
Dental Care Not Covered Not Covered

Adult Vision and Dental (ages 19 and over)

Description In-Network Out-of_network
Vision Care Not Covered Not Covered
Dental Care Not Covered Not Covered
 

In-Network

Out-of-Network

Emergency and Urgent Care

Description In-Network Out-of-Network
Emergency Room (waived if admitted to hospital) Deductible In-Network Deductible
Urgent Care Center $100 Copay 50% after Deductible

Hospital and Surgical Care

Description In-Network Out-of-Network
Ambulatory Surgical Center Deductible 50% after Deductible
Outpatient Hospital Facility Deductible 50% after Deductible
Inpatient Hospital Facility Deductible 50% after Deductible
Physician Services (all locations) Deductible In-Network Deductible

Outpatient Diagnostic Services

Description In-Network Out-of-Network
Independent Clinical Lab (e.g. blood work) $0 Not Covered
Basic Imaging (e.g. x-ray, ultrasound) Deductible 50% after Deductible
Advanced Imaging (e.g. CT/CAT Scan, MRI, MRA) Deductible 50% after Deductible

Mental Health and Substance Dependency

Description In-Network Out-of-Network
Specialist Office Visit $60 Copay 50% after Deductible
Inpatient Facility Deductible 50% after Deductible

Outpatient Rehabilitation and Habilitation

Description In-Network Out-of-Network
Physical, Speech, Occupational, Cardiac, and Massage Therapy Deductible (35 visit annual max) 50% after Deductible (35 visit annual max)

Maternity Care

Description In-Network Out-of-Network
Prenatal and Postnatal - Office Visit $60 Copay 50% after Deductible
Labor and Delivery - Hospital Stay Deductible 50% after Deductible

Please note these are estimated costs based on the responses you’ve provided. Actual costs are based on the answers provided on the application.

These policies have limitations and exclusions. The amount of benefits and premium provided may vary based on the plan selected.

BCRQ.IU.BB 0413 - BlueCare for Individuals Non-Group Contract
BOPQ.IU.BB 0413 - BlueOptions for Individuals Non-Group Contract
BSEQ.IU.BB 0413 - BlueSelect for Individuals Non-Group Contract

Health insurance is offered by Blue Cross and Blue Shield of Florida, Inc., D/B/A Florida Blue. HMO coverage is offered by Health Options, Inc., D/B/A Florida Blue HMO, an HMO subsidiary of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association. Florida Blue and Florida Blue HMO are Qualified Health Plan issuers in the Health Insurance Marketplace.

CWS SHP 004 NF 082015