BlueSelect Bronze (HSA) 27L01-04V ($40 PCP Visits / Adult Vision / Rewards)
Florida Blue (BlueCross BlueShield FL) · 2027 plan year
Expanded BronzeHSA eligible
- Ind. medical deductible
- $0
- Rx deductible (separate)
- $1,375
- Family deductible
- $0
- Ind. OOP max
- $12,000
- Family OOP max
- $24,000
This plan sets a separate deductible for prescription drugs. The medical deductible shown does not cover prescriptions; they have their own.
Other cost-sharing reduction variants for this plan:
More Florida Blue (BlueCross BlueShield FL) plans in FL
BlueOptions Bronze (HSA) 24J01-04 (3 PCP Visits for $0 then $55 / $70 Specialist Visits / Rewards)BlueOptions Bronze (HSA) 24J01-06 (Rewards)BlueOptions Bronze (HSA) 24J01-10 (Rewards / $4 select RX)BlueOptions Bronze (HSA) 24J01-17 ($40 PCP Visits / Rewards)BlueOptions Bronze (HSA) 24J01-18S ($50 PCP Visits / Rewards)
Live premium estimate
Benefits & cost sharing
Primary Care
| Benefit | In-network |
|---|---|
| Preventive Care/Screening/Immunization | No charge |
| Primary Care Visit to Treat an Injury or Illness | $40.00 |
Specialist
| Benefit | In-network |
|---|---|
| Specialist Visit | $105.00 |
Hospital
| Benefit | In-network |
|---|---|
| Emergency Room Services | $1,800.00 |
| Inpatient Hospital Services (e.g., Hospital Stay) | $3000.00 Copay per Day |
| Outpatient Surgery Physician/Surgical Services | 50.00% |
| Urgent Care Centers or Facilities | $75.00 |
Pharmacy
| Benefit | In-network |
|---|---|
| Generic Drugs | $35.00 |
| Non-Preferred Brand Drugs | 47.00% Coinsurance after deductible |
| Off Label Prescription Drugs | 47.00% Coinsurance after deductible |
| Preferred Brand Drugs | $200.00 Copay after deductible |
| Specialty Drugs | 50.00% Coinsurance after deductible |
Mental Health
| Benefit | In-network |
|---|---|
| Mental/Behavioral Health Inpatient Services | $3000.00 Copay per Day |
| Mental/Behavioral Health Outpatient Services | $105.00 |
Other
| Benefit | In-network |
|---|---|
| Abortion for Which Public Funding is Prohibited | Not covered |
| Accidental Dental | $105.00 |
| Acupuncture | Not covered |
| Allergy Testing | $105.00 |
| Bariatric Surgery | Not covered |
| Basic Dental Care - Adult | Not covered |
| Basic Dental Care - Child | Not covered |
| Bone Marrow Transplant | $3,000.00 |
| Chemotherapy | $1,800.00 |
| Chiropractic Care | $105.00 |
| Congenital Anomaly, including Cleft Lip/Palate | $1,800.00 |
| Cosmetic Surgery | Not covered |
| Delivery and All Inpatient Services for Maternity Care | $3,000.00 |
| Dental Anesthesia | $105.00 |
| Dental Check-Up for Children | Not covered |
| Diabetes Care Management | $105.00 |
| Diabetes Education | $105.00 |
| Dialysis | $1,800.00 |
| Durable Medical Equipment | 50.00% |
| Emergency Transportation/Ambulance | 50.00% |
| Eye Glasses for Children | No charge |
| Habilitation Services | $105.00 |
| Hearing Aids | Not covered |
| Home Health Care Services | No charge |
| Hospice Services | No charge |
| Imaging (CT/PET Scans, MRIs) | $500.00 |
| Infertility Treatment | Not covered |
| Infusion Therapy | $1,800.00 |
| Inpatient Physician and Surgical Services | 50.00% |
| Laboratory Outpatient and Professional Services | $55.00 |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Major Dental Care - Adult | Not covered |
| Major Dental Care - Child | Not covered |
| Nutrition/Formulas | $105.00 |
| Nutritional Counseling | $105.00 |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | Not covered |
| Osteoporosis | $105.00 |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $105.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $1,800.00 |
| Outpatient Rehabilitation Services | $105.00 |
| Prenatal and Postnatal Care | $105.00 |
| Private-Duty Nursing | Not covered |
| Prosthetic Devices | 50.00% |
| Radiation | $1,800.00 |
| Reconstructive Surgery | $1,800.00 |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $105.00 |
| Rehabilitative Speech Therapy | $105.00 |
| Routine Dental Services (Adult) | Not covered |
| Routine Eye Exam (Adult) | No charge |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | $105.00 |
| Skilled Nursing Facility | 50.00% |
| Substance Abuse Disorder Inpatient Services | $3000.00 Copay per Day |
| Substance Abuse Disorder Outpatient Services | $105.00 |
| Transplant | $3,000.00 |
| Treatment for Temporomandibular Joint Disorders | $105.00 |
| Weight Loss Programs | Not covered |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $275.00 |
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