BlueSelect Bronze 2139 ($0 Virtual Visits / $50 PCP Visit / $30 Generic Meds / Rewards $$$) – EPO
Network type: EPO
Coverage tier: Expanded Bronze
Primary care visit: No charge
Specialist visit: $20 copay
Urgent care visit: $85 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | No charge |
| Specialist visit | $20 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $85 copay |
| Emergency room | $1,000 copay |
| Ambulance | 50% coinsurance |
| Hospital stay (facility) | $3,000 copay per Day |
| Hospital stay (physician) | 50% coinsurance |
| Outpatient procedure (facility) | $1,500 copay |
| Outpatient procedure (physician) | 50% coinsurance |
| Physical rehabilitation | $85 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $3,000 copay |
Pharmacy, Drugs, and Medication
| Generic | Share |
| Brand | $200 copay |
| Non-preferred Brand | 50% coinsurance after deductible |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $175 copay |
| Imaging (CT/PET/MRI) | $20 copay |
| Blood work | $60 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $50 copay |
| Psychiatric hospital stay | $3,000 copay per Day |
Health Plan Provider Information
| Health Plan Benefits | https://www.bcbsfl.com/DocumentLibrary/sbc/2024/2139.pdf |
| Drug and medication plan formulary | https://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_FL_7T_CareChoices.pdf |
| Search doctor list | https://providersearch.floridablue.com/visitor/ffm/#/?ffmPlanCode=FFMBSC |
