| In-Network (PPO benefit) - You pay: | Out-of-Network (Non-PPO benefit)* - You pay: | |
|---|---|---|
| Preventive Care | Nothing for covered preventive screenings, immunizations and services | 35% of our allowance† |
| Physician Care | $25 for primary care | 35% of our allowance† |
| Virtual Doctor Visits by Teladoc® | $0 for first 2 visits | N/A |
| Urgent Care Center | Accidental Injury: $0 Medical Emergency: $30 copay | Accidental Injury: $0 Medical Emergency: 35% of our allowance† |
| Prescription Drugs | Preferred Retail Pharmacy: Tier 1 (Generics): $7.50 copay1 Tier 2 (Preferred brand): 30% of our allowance Tier 3 (Non-preferred brand): 50% of our allowance Tier 4 (Preferred specialty): 30% of our allowance Tier 5 (Non-preferred specialty): 30% of our allowance Mail Service Pharmacy: Tier 1 (Generics): $15 copay1 Tier 2 (Preferred brand): $90 copay Tier 3 (Non-preferred brand): $125 copay Specialty Pharmacy2: Tier 4 (Preferred specialty): $65 copay Tier 5 (Non-preferred specialty): $85 copay | Retail Pharmacy: 45% of our allowance Mail Service Pharmacy: Not covered Specialty Pharmacy: Not covered |
| Maternity Care | $0 copay | Pre-/postnatal professional care: 35% of our allowance† Inpatient hospital: $450 per admission copay for unlimited days, plus 35% of our allowance Outpatient facility care: 35% of our allowance† |
| Hospital Care | Inpatient (Precertification is required): $350 per admission Outpatient: 15% of our allowance† | Inpatient (Precertification is required): $450 per admission copay, plus 35% of our allowance Outpatient: 35% of our allowance† |
| Surgery | 15% of our allowance† | 35% of our allowance† |
| ER (accidental injury) | $0 within 72 hours | Nothing for covered services |
| ER (medical emergency) | 15% of our allowance† | 15% of our allowance† |
| Lab work (such as blood tests) | 15% of our allowance† | 35% of our allowance† |
| Diagnostic services (such as sleep studies, X-rays, CT scans) | 15% of our allowance† | 35% of our allowance† |
| Chiropractic Care | $25 per treatment; up to 12 visits per year | 35% of our allowance†; up to 12 visits per year |
| Dental Care | The difference between the fee schedule amount and the Maximum Allowable Charge (MAC) | 35% of our allowance† |
| Rewards Program | Earn $50 for completing the Blue Health Assessment.3 Earn up to $120 for completing three eligible Online Health Coach goals.3 | Earn $50 for completing the Blue Health Assessment.3 Earn up to $120 for completing three eligible Online Health Coach goals.3 |
Florida Blue Emergency Room Copays
Emergency Room Description
4 If admitted as an Inpatient from the Emergency Room member pays Out -of Network DED and In Network Emergency Room Copay. Note: Out-of-Network services may be subject to balance billing. Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc., an Independent Licensee of the Blue Cross and Blue Shield Association. Medical Emergency: $30 copay Accidental Injury: $0 Medical Emergency: 35% of our. This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. Before making a final decision, please read the Plan’s federal brochure (RI 71-005). All benefits are subject to the definitions, limitations, and exclusions set forth.