Important Note: BlueCare HMO coverage is offered by Florida Blue HMO

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BlueOptions Everyday Health Plus 1410P

PDF Summary Links
Mini-Benefit Summary View Details (PDF)
Summary of Benefits & Coverage (SBC) View Details (PDF)
In-Network Out-of-Network
Doctor Availability
Is My Doctor Covered? Yes Yes
Plan Benefits
Annual DeductibleIndividual: $5,750 / Family: $11,500Individual: $11,500 / Family: $23,000
Coinsurance (%)10%50%
Annual Out-of-Pocket Maximum (includes deductible, copays and coinsurance)Individual: $6,250 / Family: $12,500Individual: $23,000 / Family: $25,000
Physician Office Visits
Primary Care Physician$75 Copay50% after Deductible
Specialist10% after Deductible50% after Deductible
Preventive Services
Preventive and Wellness Care (e.g. physical, mammogram, immunizations)$0 50% (mammograms & colonoscopies are $0)
Emergency and Urgent Care
Emergency Room (waived if admitted to hospital)10% after Deductible10% after In-Network Deductible
Urgent Care Center10% after Deductible50% after Deductible
Hospital and Surgical Care
Ambulatory Surgical Center10% after Deductible50% after Deductible
Outpatient Hospital Facility10% after Deductible50% after Deductible
Inpatient Hospital Facility10% after Deductible50% after Deductible
Physician Services (all locations)$0 $0
Outpatient Diagnostic Services
Independent Clinical Lab (e.g. blood work)$0 50% after Deductible
Basic Imaging (e.g. x-ray, ultrasound)10% after Deductible50% after Deductible
Advanced Imaging (e.g. CT/CAT Scan, MRI, MRA)10% after Deductible50% after Deductible
Outpatient Rehabilitation and Habilitation
Physical, Speech, Occupational, Cardiac, and Massage Therapy10% after Deductible (35 visit annual max)50% after Deductible (35 visit annual max)
Mental Health and Substance Dependency
Specialist Office Visit10% after Deductible50% after Deductible
Inpatient Facility10% after Deductible50% after Deductible
Maternity Care
Prenatal and Postnatal - Office Visit10% after Deductible50% after Deductible
Labor and Delivery - Hospital Stay10% after Deductible50% after Deductible
Pediatric Vision and Dental (ages 18 and under)
Vision CareNot CoveredNot Covered
Dental CareNot CoveredNot Covered
Adult Vision and Dental (ages 19 and over)
Vision CareNot CoveredNot Covered
Dental CareNot CoveredNot Covered
Prescription Drugs
View Details (PDF)Medication GuideNot Covered
Generic Drugs - Tier 1 (Retail Pharmacy / Mail Order)
Preventive (e.g. oral contraceptives)$0 / $0 Not Covered / Not Covered
Condition Care Rx (e.g. asthma, cholesterol, diabetes, high blood pressure)$4 Copay / $0 Not Covered / Not Covered
All Other Generic$20 Copay / $50 CopayNot Covered / Not Covered
Brand Drugs - Tier 2 (Retail Pharmacy / Mail Order)
Condition Care Rx (e.g. asthma, cholesterol, diabetes, high blood pressure)$35 Copay / $88 CopayNot Covered / Not Covered
All Other Preferred Brand$70 Copay / $175 CopayNot Covered / Not Covered
Non-Preferred Brand Drugs - Tier 3 (Retail Pharmacy / Mail Order)
Non-Preferred Brand$100 Copay / $250 CopayNot Covered / Not Covered
Specialty Drugs - Tier 4 (Retail Pharmacy / Mail Order)
Specialty (purchased from specialty pharmacy)$150 Copay / Not CoveredNot Covered / Not Covered

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 122014