myBlue Silver 2204 ($0 Virtual Visits / Rewards $$$) – HMO

Network type: HMO
Coverage tier: Silver
Primary care visit: No charge
Specialist visit: $20 copay
Urgent care visit: $100 copay after deductible

Description

Health Care Plan Details

Network type HMO
Deductible $4,750 per person $4,750 per person
Out-of-pocket max $7,800 per person $15,600 per family
Metal tier Silver

Visit Copay

Primary care visit No charge
Specialist visit $20 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $100 copay after deductible
Emergency room $650 copay after deductible
Ambulance 40% coinsurance after deductible
Hospital stay (facility) 40% coinsurance after deductible
Hospital stay (physician) No charge
Outpatient procedure (facility) 40% coinsurance after deductible
Outpatient procedure (physician) No charge
Physical rehabilitation $100 copay after deductible

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 40% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic $25 copay
Brand $55 copay after deductible
Non-preferred Brand 50% coinsurance after deductible
Specialty 50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays $85 copay
Imaging (CT/PET/MRI) $20 copay
Blood work $20 copay

Mental and Psychiatric Health Care

Mental Health outpatient services $55 copay
Psychiatric hospital stay 40% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://www.bcbsfl.com/DocumentLibrary/sbc/2024/2204.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