myBlue Gold 2011 ($0 Virtual Visits / $0 Labs / Rewards $$$) – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: No charge
Specialist visit: $20 copay
Urgent care visit: $120 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $940 per person $940 per person |
| Out-of-pocket max | $4,700 per person $9,400 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | No charge |
| Specialist visit | $20 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $120 copay |
| Emergency room | 20% coinsurance after deductible |
| Ambulance | 20% coinsurance after deductible |
| Hospital stay (facility) | 20% coinsurance after deductible |
| Hospital stay (physician) | 20% coinsurance after deductible |
| Outpatient procedure (facility) | 20% coinsurance after deductible |
| Outpatient procedure (physician) | 20% coinsurance after deductible |
| Physical rehabilitation | $120 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 20% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | 15% coinsurance after deductible |
| Non-preferred Brand | 50% coinsurance after deductible |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 20% coinsurance after deductible |
| Imaging (CT/PET/MRI) | $20 copay |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $60 copay |
| Psychiatric hospital stay | 20% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.bcbsfl.com/DocumentLibrary/sbc/2024/2011.pdf |
| Drug and medication plan formulary | https://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_FL_6T_ValueScript.pdf |
| Search doctor list | https://providersearch.floridablue.com/visitor/ffm/#/?ffmPlanCode=FFMMBI |
