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With the BlueChoice PPO Health Plan, you get the freedom to choose between convenient, affordable care from your PPO network Physician, or other providers for care as you see fit. In order to take advantage of lower out-of-pocket costs, simply choose a PPO network provider.
| BENEFITS |
| Financial Responsibilities for Covered Services / Deductibles |
| Individual Calendar Year Deductible |
$200 |
| Family Calendar Year Deductible |
$600 |
| Hospital Per Admission Deductible
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$0 |
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$300 |
- Emergency Room Per Visit Deductible (waived if admitted)
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$0 |
Note: The Hospital Per Admission Deductible and the Emergency Room Per Visit Deductible are in addition to the Calendar Year Deductible.
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| Coinsurance Percentage Payable by BCBSF |
| PPO Providers - Allowed Amount |
90% |
| Providers Not Participating in PPO - Allowance |
70% |
| Ambulance Services - Allowed
|
90% |
| Your Coinsurance Responsibility Per Calendar Year |
| Individual Coinsurance Limit |
$1,500 |
| Family Coinsurance Limit |
$3,000 |
| BlueScript Prescription Drug Program |
| Retail |
Mail Order |
| Generic |
$10.00 |
$20.00 |
| Brand |
$25.00 |
$50.00 |
| BENEFITS MAXIMUMS |
| Mental Health Services Benefit Maximum: |
- Inpatient days/visits or combination of inpatients and Partial Hospitalization days
|
30 |
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20 |
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| Home Health Care Benefit Maximum |
$1,000 |
| Skilled Nursing Facility Days Benefit Maximum |
60 |
| Enteral Formula (Low Protein Food Products) Benefit Maximum |
$2,500 |
Combined Outpatient Cardiac Rehabilitation and Occupational,
Speech, and Massage Therapies and Spinal
Manipulations Benefit Maximum |
$1,000 |
| Physical Therapy Benefit Maximum |
$2,500 |
| Adult Wellness Benefit Maximum Per Insured Per Calendar Year |
$250 |
| Covered Services for an adult |
- Annual physical and gynecological exam (including family planning/contraceptive services);
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- Related wellness services (e.g., Pap smears, Prostate Specific Antigen [PSA], X-rays, laboratory services, and immunizations). Routine vision and hearing examinations and screening are not covered.
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| Lifetime Maximums Per Insured |
| Total Lifetime Maximum Benefit |
$5,000,000 |
| Substance Dependency Care and Treatment Benefit Maximum |
$2,000 |
| Hospice Benefit Maximum |
$5,200 |
This is not an insurance contract or Certificate of Coverage. The above Benefit Summary is only a partial description of the many benefits and services covered by Blue Cross and Blue Shield of Florida, Inc., an independent licensee of the Blue Cross and Blue Shield Association. For a complete description of benefits and exclusions, please see Blue Cross and Blue Shield of Florida’s BlueChoice Certificate of Coverage and Schedule of Benefits; its terms prevail. |
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Centennial Square Fountain, Downtown W.P.B.
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