BlueSelect Platinum 1457 ($0 Virtual Visits / Rewards $$$) – EPO
Network type: EPO
Coverage tier: Platinum
Primary care visit: No charge
Specialist visit: $20 copay
Urgent care visit: $20 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $2,000 per person $4,000 per family |
| Metal tier | Platinum |
Visit Copay
| Primary care visit | No charge |
| Specialist visit | $20 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $20 copay |
| Emergency room | $75 copay |
| Ambulance | 20% coinsurance |
| Hospital stay (facility) | $350 copay per Day |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | $300 copay |
| Outpatient procedure (physician) | No charge |
| Physical rehabilitation | $20 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $350 copay |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | $40 copay |
| Non-preferred Brand | 30% coinsurance |
| Specialty | 50% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | $75 copay |
| Imaging (CT/PET/MRI) | $20 copay |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $10 copay |
| Psychiatric hospital stay | No charge |
Health Plan Provider Information
| Health Plan Benefits | https://www.bcbsfl.com/DocumentLibrary/sbc/2024/1457.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 |
