BlueCare Bronze (HSA) 1765 (Rewards $$$ / $4 Condition Care Rx) - 30252FL0020076 Health Insurance Plan

Health Options, Inc. health insurance plan with the Plan ID 30252FL0020076. The plan is called BlueCare Bronze (HSA) 1765 (Rewards $$$ / $4 Condition Care Rx).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.51% (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 35.49% 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 30252FL0020076
Health Insurance Plan Year 2023
State Florida
Health Insurance Issuer Health Options, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 30252FL0020076-00
Provider Network(s) ['FLN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Florida All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 30252FL0020076-00

Standard On Exchange Plan - 30252FL0020076-01

Open to Indians below 300% FPL - 30252FL0020076-02

Open to Indians above 300% FPL - 30252FL0020076-03

Last Plan Update Date Tue, 28 Feb 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of BlueCare Bronze (HSA) 1765 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan, 30252FL0020076-00

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

No Charge after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

No Charge after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Bone Marrow Transplant
YES

No Charge after deductible

100.00%
Chemotherapy
YES

No Charge after deductible

100.00%
Chiropractic Care

Limit: 35.0 Procedure(s) per Benefit Period

Combined limit for all outpatient therapy plus chiropractic.

YES

No Charge after deductible

100.00%
Congenital Anomaly, including Cleft Lip/Palate
YES

No Charge after deductible

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

No Charge after deductible

100.00%
Dental Anesthesia
YES

No Charge after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Care Management
YES

No Charge after deductible

100.00%
Diabetes Education
YES

No Charge after deductible

100.00%
Dialysis
YES

No Charge after deductible

100.00%
Durable Medical Equipment
YES

No Charge after deductible

100.00%
Emergency Room Services
YES

No Charge after deductible

No Charge after deductible
Emergency Transportation/Ambulance
YES

No Charge after deductible

No Charge 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

No Charge after deductible

100.00%
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

No Charge after deductible

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 60.0 Visit(s) per Benefit Period

YES

No Charge after deductible

100.00%
Hospice Services
YES

No Charge after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

No Charge after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

No Charge after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

No Charge after deductible

100.00%
Inpatient Physician and Surgical Services
YES

No Charge after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

No Charge 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

No Charge after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

No Charge after deductible

100.00%
Non-Preferred Brand Drugs
YES

No Charge after deductible

100.00%
Nutritional Counseling

Reduced cost available at Value Choice Providers. Check your Online Provider Directory for providers in your area. Diabetes coverage includes 'nutrition counseling'; home health services include 'nutritional guidance'.

YES

No Charge after deductible

100.00%
Nutrition/Formulas
YES

No Charge after deductible

100.00%
Off Label Prescription Drugs
YES

No Charge 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

No Charge after deductible

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

No Charge after deductible

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

No Charge after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 35.0 Visit(s) per Benefit Period

Combined limit for all outpatient therapy plus chiropractic.

YES

No Charge after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

No Charge after deductible

100.00%
Preferred Brand Drugs

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

YES

No Charge after deductible

100.00%
Prenatal and Postnatal Care
YES

No Charge after deductible

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

No Charge after deductible

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

No Charge after deductible

100.00%
Radiation
YES

No Charge after deductible

100.00%
Reconstructive Surgery

Only for Breast reconstruction following a Mastectomy.

YES

No Charge 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

No Charge after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 35.0 Visit(s) per Benefit Period

Combined limit for all outpatient therapy plus chiropractic.

YES

No Charge after deductible

100.00%
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

No Charge after deductible

100.00%
Skilled Nursing Facility

Limit: 60.0 Days per Benefit Period

YES

No Charge after deductible

100.00%
Specialist Visit
YES

No Charge after deductible

100.00%
Specialty Drugs
YES

No Charge after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

No Charge after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

No Charge after deductible

100.00%
Transplant
YES

No Charge after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

No Charge after deductible

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

No Charge after deductible

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

No Charge after deductible

100.00%

BlueCare Bronze (HSA) 1765 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan Variant 30252FL0020076-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.645120129
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
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
First Tier Utilization 100%
Formulary ID FLF009
Formulary URL URL
HIOS Product ID 30252FL002
Import Date 2/28/2023 1:02
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 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 Expanded Bronze
Multiple In Network Tiers No
National Network No
Network ID FLN001
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 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 30252FL0020076-00
Plan Marketing Name BlueCare Bronze (HSA) 1765 (Rewards $$$ / $4 Condition Care Rx)
Plan Type HMO
Plan Variant Marketing Name BlueCare Bronze (HSA) 1765 (Rewards $$$ / $4 Condition Care Rx)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $6,850
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 $20
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 FLS001
Source Name HIOS
Plan ID 30252FL0020076
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 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $13700 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $6850 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $6,850
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 $13700 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $6850 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $6,850
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 BlueCare Bronze (HSA) 1765 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan, 30252FL0020076

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

Frequently Asked Questions(FAQ) about BlueCare Bronze (HSA) 1765 (Rewards $$$ / $4 Condition Care Rx), 30252FL0020076 Health Insurance Plan, 30252FL0020076

  • Does BlueCare Bronze (HSA) 1765 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan, 30252FL0020076 support Mail Ordering?

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

  • Does (30252FL0020076) Health Insurance Plan, Variant (30252FL0020076-00) 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 (30252FL0020076) Health Insurance Plan, Variant (30252FL0020076-00) have Out Of Country Coverage?

    Yes. Details: Accident and emergency services.

    Does (30252FL0020076) Health Insurance Plan, Variant (30252FL0020076-00) have Out of Service Area Coverage?

    Yes. Details: Accident and emergency services.

    Does (30252FL0020076) Health Insurance Plan, Variant (30252FL0020076-00) 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 BlueCare Bronze (HSA) 1765 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan, Variant (30252FL0020076-00) offer Disease Management Programs for Asthma?

    Yes, the BlueCare Bronze (HSA) 1765 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan Variant 30252FL0020076-00 offers Disease Management Program for Asthma.

    Does BlueCare Bronze (HSA) 1765 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan, Variant (30252FL0020076-00) offer Disease Management Programs for Heart disease?

    Yes, the BlueCare Bronze (HSA) 1765 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan Variant 30252FL0020076-00 offers Disease Management Program for Heart disease.

    Does BlueCare Bronze (HSA) 1765 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan, Variant (30252FL0020076-00) offer Disease Management Programs for Depression?

    Yes, the BlueCare Bronze (HSA) 1765 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan Variant 30252FL0020076-00 offers Disease Management Program for Depression.

    Does BlueCare Bronze (HSA) 1765 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan, Variant (30252FL0020076-00) offer Disease Management Programs for Diabetes?

    Yes, the BlueCare Bronze (HSA) 1765 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan Variant 30252FL0020076-00 offers Disease Management Program for Diabetes.

    Does BlueCare Bronze (HSA) 1765 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan, Variant (30252FL0020076-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the BlueCare Bronze (HSA) 1765 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan Variant 30252FL0020076-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does BlueCare Bronze (HSA) 1765 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan, Variant (30252FL0020076-00) offer Disease Management Programs for Pregnancy?

    Yes, the BlueCare Bronze (HSA) 1765 (Rewards $$$ / $4 Condition Care Rx) Health Insurance Plan Variant 30252FL0020076-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 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