Jacksonville, Florida 32246. Florida Blue HMO is a trade name of Health Options, Inc., an HMO subsidiary of Blue Cross and Blue Shield of Florida, Inc. D/B/A Florida Blue. These companies are Independent Licensees of the Blue Cross and Blue Shield Association. BCRQ.IU.BB.BNO-ND 0914 BCRQ.IU.BB 0413. If you are a Florida Blue member, you can also obtain your current SBC anytime by logging into the Florida Blue Member Portal. Use the Search box below to search for an SBC by Group Number or Plan Number. If you are unable to locate your SBC, or wish to have an SBC sent to you free of charge, call 1-800-352-2583. PPO Standard Health Benefit Plan 03768. Deductible (DED1) (PBP2) $1,000 per person $3,000 per person (DED is the amount the member is responsible for before Florida Blue pays) $3,000 per family $9,000 per family. Value Choice Provider (in select counties) $0 Copay Not Covered Primary Care Physician $30 Copay 40% after Deductible. STATE OF FL Employees’ PPO Coverage Period: 01/01/20 21- 12/31/20 Standard PPO Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage for: Individual and/or Family Plan Type: Standard PPO Page 1 of 7 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan.
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Florida Blue Ppo Copay
With this option, there is a $35 copay for the initial office visit, then $150 inpatient hospital copay per day up to $750 maximum. Deductible: Copay Enabled: Saturday, July 21, 2012 Rider. Please call Florida Blue at the help number listed on this website and read them the message on your screen, including the Application ID.
Florida Blue Ppo Urgent Care Copay
| Basic Option | |
|---|---|
| Preventive Care | Nothing for covered preventive screenings, immunizations and services |
| Physician Care | $30 for primary care1 |
| Virtual doctor visits by Teladoc® | $0 for first 2 visits |
| Urgent Care Center | $35 copay |
| Prescription Drugs | Preferred Retail Pharmacy: Tier 1 (Generics): $10 copay Tier 2 (Preferred brand): $55 copay2 Tier 3 (Non-preferred brand): 60% of our allowance ($75 minimum)2 Tier 4 (Preferred specialty): $65 copay2 Tier 5 (Non-preferred specialty): $90 copay2 Mail Service Pharmacy: Available to members with Medicare Part B primary only. Visit the Medicare page for more information. Tier 1 (Generics): $20 Tier 2 (Preferred brand): $100 copay Tier 3 (Non-preferred brand): $125 copay Specialty Pharmacy: Tier 4 (Preferred specialty): $85 copay2 Tier 5 (Non-preferred specialty): $110 copay2 |
| Maternity Care | $175 inpatient $0 outpatient |
| Hospital Care | Inpatient (Precertification is required): $175 per day; up to $875 per admission Outpatient: $100 per day per facility1 |
| Surgery | $150 in an office setting1 $200 in a non-office setting1 |
| ER (accidental injury) | $175 per day per facility |
| ER (medical emergency) | $175 per day per facility |
| Lab work (such as blood tests) | $0 copay1 |
| Diagnostic services (such as sleep studies, CT scans) | Up to $100 in an office1 Up to $150 in a hospital1 |
| Chiropractic Care | $30 per treatment; up to 20 visits per year |
| Dental Care | $30 copay per evaluation; up to 2 per year |
| Rewards Program | Earn $50 for completing the Blue Health Assessment3 Earn up to $120 for completing three eligible Online Health Coach goals3 |