BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$) - 16842FL0120070 Health Insurance Plan

Blue Cross and Blue Shield of Florida health insurance plan with the Plan ID 16842FL0120070. The plan is called BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 91.50% (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 8.50% 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 16842FL0120070
Health Insurance Plan Year 2023
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 16842FL0120070-00
Provider Network(s) ['FLN002']
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 - 16842FL0120070-00

Standard On Exchange Plan - 16842FL0120070-01

Open to Indians below 300% FPL - 16842FL0120070-02

Open to Indians above 300% FPL - 16842FL0120070-03

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

Benefits of BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$) Health Insurance Plan, 16842FL0120070-00

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

$20.00

50.00% Coinsurance after deductible
Acupuncture
NO
Allergy Testing
YES

$20.00

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

In-Network Only: The cost share is applied for a max of 3 days per admission.

YES

$350.00

50.00% Coinsurance after deductible
Chemotherapy
YES

$300.00

50.00% Coinsurance after deductible
Chiropractic Care

Limit: 35.0 Procedure(s) per Benefit Period

Combined limit for all outpatient therapy plus chiropractic.

YES

$20.00

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

$300.00

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

In-Network Only: The cost share is applied for a max of 3 days per admission.

YES

$350.00

50.00% Coinsurance after deductible
Dental Anesthesia
YES

$20.00

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

$20.00

50.00% Coinsurance after deductible
Diabetes Education
YES

No Charge

50.00% Coinsurance after deductible
Dialysis
YES

$300.00

50.00% Coinsurance after deductible
Durable Medical Equipment
YES

No Charge

100.00%
Emergency Room Services

$75 Copay applies to first visit then $225 for remaining visits.

YES

$75.00

$75.00
Emergency Transportation/Ambulance
YES

20.00%

20.00%
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

$350.00

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

$10.00

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

$20.00

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

$150.00

50.00% Coinsurance after deductible
Infertility Treatment
NO
Infusion Therapy
YES

$300.00

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

In-Network Only: The cost share is applied for a max of 3 days per admission.

YES

$350.00 Copay per Day

50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

No Charge

No Charge
Laboratory Outpatient and Professional Services
YES

No Charge

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

No Charge
Mental/Behavioral Health Outpatient Services
YES

$20.00

50.00% Coinsurance after deductible
Non-Preferred Brand Drugs
YES

30.00%

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

Tier 1: $20.00

Tier 2: $20.00

50.00% Coinsurance after deductible
Nutrition/Formulas
YES

$20.00

50.00% Coinsurance after deductible
Off Label Prescription Drugs
YES

30.00%

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: $20.00

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

$20.00

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

$300.00

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

$20.00

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

No Charge

No Charge
Preferred Brand Drugs

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

YES

$40.00

100.00%
Prenatal and Postnatal Care
YES

$20.00

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.

YES

Tier 1: No Charge

Tier 2: $10.00

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

No Charge

100.00%
Radiation
YES

$300.00

50.00% Coinsurance after deductible
Reconstructive Surgery

Only for Breast reconstruction following a Mastectomy.

YES

$300.00

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

$20.00

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

$20.00

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: $20.00

50.00% Coinsurance after deductible
Skilled Nursing Facility

Limit: 60.0 Days per Benefit Period

YES

$500.00 Copay per Stay

50.00% Coinsurance after deductible
Specialist Visit

Lower out of pocket costs for virtual visits and reduced cost available at Value Choice Providers. Check your Online Provider Directory for providers in your area.

YES

Tier 1: $20.00

Tier 2: $20.00

50.00% Coinsurance after deductible
Specialty Drugs
YES

50.00%

100.00%
Substance Abuse Disorder Inpatient Services
YES

No Charge

No Charge
Substance Abuse Disorder Outpatient Services
YES

$20.00

50.00% Coinsurance after deductible
Transplant

In-Network Only: The cost share is applied for a max of 3 days per admission.

YES

$350.00

50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
YES

$20.00

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: $20.00

Tier 2: $20.00

$20.00 Copay after deductible
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

50.00%
X-rays and Diagnostic Imaging
YES

$75.00

50.00% Coinsurance after deductible

BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$) Health Insurance Plan Variant 16842FL0120070-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.914981916
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 Platinum 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 0%
Formulary ID FLF019
Formulary URL URL
HIOS Product ID 16842FL012
Import Date 2/28/2023 1:02
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 3
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 Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Platinum
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 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 16842FL0120070-00
Plan Marketing Name BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$)
Plan Type EPO
Plan Variant Marketing Name BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $400
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,300
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $200
SBC Scenario, Treatment of a Simple Fracture, Copayment $200
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 100%
Service Area ID FLS002
Source Name HIOS
Plan ID 16842FL0120070
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 20.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $0
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 20.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $0
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 $500 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $500
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $4000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $2000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $2,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $4000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $2000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $2,000
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 Platinum 1457 ($0 Virtual Visits / Rewards $$$) Health Insurance Plan, 16842FL0120070

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

Frequently Asked Questions(FAQ) about BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$), 16842FL0120070 Health Insurance Plan, 16842FL0120070

  • Does BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$) Health Insurance Plan, 16842FL0120070 support Mail Ordering?

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

  • Does (16842FL0120070) Health Insurance Plan, Variant (16842FL0120070-00) 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 (16842FL0120070) Health Insurance Plan, Variant (16842FL0120070-00) have Out Of Country Coverage?

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

    Does (16842FL0120070) Health Insurance Plan, Variant (16842FL0120070-00) have Out of Service Area Coverage?

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

    Does (16842FL0120070) Health Insurance Plan, Variant (16842FL0120070-00) 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 Platinum 1457 ($0 Virtual Visits / Rewards $$$) Health Insurance Plan, Variant (16842FL0120070-00) offer Disease Management Programs for Asthma?

    Yes, the BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$) Health Insurance Plan Variant 16842FL0120070-00 offers Disease Management Program for Asthma.

    Does BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$) Health Insurance Plan, Variant (16842FL0120070-00) offer Disease Management Programs for Heart disease?

    Yes, the BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$) Health Insurance Plan Variant 16842FL0120070-00 offers Disease Management Program for Heart disease.

    Does BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$) Health Insurance Plan, Variant (16842FL0120070-00) offer Disease Management Programs for Depression?

    Yes, the BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$) Health Insurance Plan Variant 16842FL0120070-00 offers Disease Management Program for Depression.

    Does BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$) Health Insurance Plan, Variant (16842FL0120070-00) offer Disease Management Programs for Diabetes?

    Yes, the BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$) Health Insurance Plan Variant 16842FL0120070-00 offers Disease Management Program for Diabetes.

    Does BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$) Health Insurance Plan, Variant (16842FL0120070-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$) Health Insurance Plan Variant 16842FL0120070-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$) Health Insurance Plan, Variant (16842FL0120070-00) offer Disease Management Programs for Pregnancy?

    Yes, the BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$) Health Insurance Plan Variant 16842FL0120070-00 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