BlueOptions Gold 1505 ($0 Virtual Visits / $20 PCP Visits / $15 Generic Meds / Rewards $$$)

16842FL0070120
Gold
EPO

BlueOptions Gold 1505 ($0 Virtual Visits / $20 PCP Visits / $15 Generic Meds / Rewards $$$) is a Gold EPO plan by Florida Blue (BlueCross BlueShield FL).

IMPORTANT: You are viewing the 2023 version of BlueOptions Gold 1505 ($0 Virtual Visits / $20 PCP Visits / $15 Generic Meds / Rewards $$$) 16842FL0070120. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

BlueOptions Gold 1505 ($0 Virtual Visits / $20 PCP Visits / $15 Generic Meds / Rewards $$$) is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of BlueOptions Gold 1505 ($0 Virtual Visits / $20 PCP Visits / $15 Generic Meds / Rewards $$$) 16842FL0070120.
Insurer: Florida Blue (BlueCross BlueShield FL)
Network Type: EPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 16842FL0070120

Cost-Sharing Overview

BlueOptions Gold 1505 ($0 Virtual Visits / $20 PCP Visits / $15 Generic Meds / Rewards $$$) offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for BlueOptions Gold 1505 ($0 Virtual Visits / $20 PCP Visits / $15 Generic Meds / Rewards $$$)?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

BlueOptions Gold 1505 ($0 Virtual Visits / $20 PCP Visits / $15 Generic Meds / Rewards $$$) offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what BlueOptions Gold 1505 ($0 Virtual Visits / $20 PCP Visits / $15 Generic Meds / Rewards $$$) covers when you are out of the service area or out of the country.

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.
National Network: Yes

Additional Benefits and Cost-Sharing

BlueOptions Gold 1505 ($0 Virtual Visits / $20 PCP Visits / $15 Generic Meds / Rewards $$$) includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Gender Affirming Care
Covered
$600.00 50.00% Coinsurance after deductible Only covered when medically necessary.
Diabetes Care Management
Covered
$60.00 50.00% Coinsurance after deductible
Off Label Prescription Drugs
Covered
50.00% 100.00%
Dental Anesthesia
Covered
$60.00 50.00% Coinsurance after deductible
Congenital Anomaly, including Cleft Lip/Palate
Covered
$450.00 50.00% Coinsurance after deductible
Bone Marrow Transplant
Covered
$600.00 50.00% Coinsurance after deductible In-Network Only: The cost share is applied for a max of 3 days per admission.
Nutrition/Formulas
Covered
$60.00 50.00% Coinsurance after deductible
Osteoporosis
Covered
$20.00 50.00% Coinsurance after deductible Reduced cost available at Value Choice Providers. Check your Online Provider Directory for providers in your area.
Primary Care Visit to Treat an Injury or Illness
Covered
No Charge 50.00% Coinsurance after deductible No charge for unlimited visits rendered by Value Choice Providers. Check your Online Provider Directory for providers in your area.
Specialist Visit
Covered
$20.00 50.00% Coinsurance after deductible 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.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$60.00 50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
$450.00 50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
Covered
No Charge No Charge
Hospice Services
Covered
No Charge 50.00% Coinsurance after deductible
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$60.00 $60.00 Copay after deductible Reduced cost available at Value Choice Providers. Check your Online Provider Directory for providers in your area.
Home Health Care Services
Covered
No Charge 50.00% Coinsurance after deductible60 Visit(s) per Benefit Period
Emergency Room Services
Covered
$350.00 $350.00
Emergency Transportation/Ambulance
Covered
40.00% 40.00%
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
$600.00 Copay per Day 50.00% Coinsurance after deductible In-Network Only: The cost share is applied for a max of 3 days per admission.
Inpatient Physician and Surgical Services
Covered
No Charge No Charge
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
$500.00 Copay per Stay 50.00% Coinsurance after deductible60 Days per Benefit Period
Prenatal and Postnatal Care
Covered
$60.00 50.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
Covered
$600.00 50.00% Coinsurance after deductible In-Network Only: The cost share is applied for a max of 3 days per admission.
Mental/Behavioral Health Outpatient Services
Covered
$60.00 50.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
Covered
$600.00 Copay per Day No Charge after deductible In-Network Only: The cost share is applied for a max of 3 days per admission.
Substance Abuse Disorder Outpatient Services
Covered
$60.00 50.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
Covered
$600.00 Copay per Day No Charge after deductible In-Network Only: The cost share is applied for a max of 3 days per admission.
Generic Drugs
Covered
$15.00 100.00% In-Network Only: $0 preventive and $4 generics for certain drugs, plus Mail Order for these drugs is $0.
Preferred Brand Drugs
Covered
$50.00 100.00% In-Network Only: Certain drugs are available for a lower cost.
Non-Preferred Brand Drugs
Covered
50.00% 100.00%
Specialty Drugs
Covered
50.00% 100.00%
Outpatient Rehabilitation Services
Covered
$60.00 50.00% Coinsurance after deductible35 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic.
Habilitation Services
Covered
$60.00 50.00% Coinsurance after deductible35 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.
Chiropractic Care
Covered
$60.00 50.00% Coinsurance after deductible35 Procedure(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic.
Durable Medical Equipment
Covered
No Charge 50.00% Coinsurance after deductible
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
$250.00 50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
Covered
No Charge 50.00%
Routine Foot Care
Covered
$20.00 50.00% Coinsurance after deductible Only covered when medically necessary. Reduced cost available at Value Choice Providers. Check your Online Provider Directory for providers in your area.
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge 100.00%1 Visit(s) per Year
Eye Glasses for Children
Covered
No Charge 100.00%1 Item(s) per Year
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$60.00 50.00% Coinsurance after deductible35 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$60.00 50.00% Coinsurance after deductible35 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic.
Well Baby Visits and Care
Covered
No Charge 50.00%
Laboratory Outpatient and Professional Services
Covered
$20.00 50.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
Covered
$135.00 50.00% Coinsurance after deductible
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
$600.00 50.00% Coinsurance after deductible In-Network Only: The cost share is applied for a max of 3 days per admission.
Accidental Dental
Covered
$60.00 50.00% Coinsurance after deductible
Dialysis
Covered
$450.00 50.00% Coinsurance after deductible
Allergy Testing
Covered
$60.00 50.00% Coinsurance after deductible
Chemotherapy
Covered
$450.00 50.00% Coinsurance after deductible
Radiation
Covered
$450.00 50.00% Coinsurance after deductible
Diabetes Education
Covered
No Charge 50.00% Coinsurance after deductible
Prosthetic Devices
Covered
No Charge 50.00% Coinsurance after deductible
Infusion Therapy
Covered
$450.00 50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
Covered
$60.00 50.00% Coinsurance after deductible
Nutritional Counseling
Covered
$20.00 50.00% Coinsurance after deductible 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’.
Reconstructive Surgery
Covered
$450.00 50.00% Coinsurance after deductible Only for Breast reconstruction following a Mastectomy.

Free Preventive Services

There is no copayment or coinsurance for any of the following BlueOptions Gold 1505 ($0 Virtual Visits / $20 PCP Visits / $15 Generic Meds / Rewards $$$) preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for BlueOptions Gold 1505 ($0 Virtual Visits / $20 PCP Visits / $15 Generic Meds / Rewards $$$) including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for BlueOptions Gold 1505 ($0 Virtual Visits / $20 PCP Visits / $15 Generic Meds / Rewards $$$)?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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