COMPARISON of FLORIDA BLUE MEDICAL PLAN BENEFITS: HIDEAWAY BEACH ASSOCIATION JUNE 1, 2014 MEDICAL PLAN BENEFITS:
BCBS Core Plan 3900
BCBS Buy Up Plan 3559
BENEFITS SHOWN BELOW ARE FOR IN NETWORK PROVIDERS ONLY. OUT OF NETWORK BENEFITS ARE SUBJECT TO THE OUT OF NETWORK DEDUCTIBLE AND CO-INSURANCE Calendar Year Deductible (CYD) : Individual Calendar Year Deductible (CYD): Family Max. Coinsurance: (Co-Ins.)
$1,500 Ind / $4,500
$500 In/ $750 Out
N/A (No Max. Limit)
$1,500 In / $2,250 Out
50% In / 50% Out
80% In / 40% Out
Out-Of-Pocket Maximum In Network (Including Deductible)
$6,350 Ind / $12,700 Family
$2,500 Ind. / $5,000 Family
Out-Of-Pocket Maximum OUT Network (Including Deductible)
$20,000 Ind / $20,000 Family
$5,000 Ind. / $10,000 Family
Yes
Yes
Office Visit Co-Pay: Primary Care
$35 Co-Pay
$20 Co-Pay
Office Visit Co-Pay: Specialist
$50 Co-Pay
$40 Co-Pay
Covered under OV Co-Pay
Covered under OV Co-Pay
Well Child Care
Covered at 100%
Covered at 100%
Adult Wellness
Covered at 100%
Covered at 100%
Mammograms
Covered at 100%
Covered at 100%
Colonoscopy (Routine/Preventive over age 50, refer to schedule of benefits)
Covered at 100%
Covered at 100%
Hospital Admission Co-Pay
$1500 Facility Co-pay
$600 Facility Co-pay
Physician Services at Hospital / ER / Out Patient
Ded. And 50% Co-Ins.
Ded. And 20% Co-Ins.
Out Patient Hospital Facility Fee
$300 Facility Co-Pay
$200 Facility Co-Pay
Advanced Imaging Services (MRI / CT/ PET)
$200 Facility Co-Pay
$150 Facility Co-Pay
In-Network 100%
In-Network 100%
Ambulatory Surgery Center
Ded. And 50% Co-Ins.
$100 Facility Co-Pay
Emergency Room
Ded. And 50% Co-Ins.
$100 Facility Co-Pay
Urgent Care Centers
Ded. And 50% Co-Ins.
$45 Co-Pay
Up to 25 Visits Per Year
Up to 35 Visits Per Year
$10 Generic Only
$10/$30 /$50 Co-Pay
$500 Per PLAN YEAR
Not Available
Co-Pays Included in OOP
Surgery Performed in OV Setting
Independent Clinical Lab
Chiropractic Care Limitations Prescription Drug Plan Prescription Reimbursement Card (PRC) Life Time Maximum
Unlimited
This summary is not a guarantee of insurance, nor is it a full description of the benefits and limitations of the plan(s) shown. Carrier issued Summary of Benefits and SPD will prevail.
Presented by Case Benefit Consultants, LLC
