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Indian River County Health Plan Options - 2A, 2B, 38 Effective October 1, 2020 Product _ BlueOptions Premie_ of .Plan C 59 r mi i �-lan 5302 BlueOptions Go d Option a•�. 86.2% -2.330 523,705,000 -5550,000 -2.356 - 77.8% -2.3% 87.4% 79.1% -0.9% -0.6% 524,042,000 -5213,000 -0.9% Actuarial Value Savings % by Plan Projected Claims Savings $ Savings %Total 88.2% N/A 524,255,000 N/A N/A 79.6% N/A a endar - ar Deductrb - (OED f _,, q_ / MEIFAIiiatj Ciro (8:Galh ogyliminu AtEt ttiIDk+A Aragititil89 In -Network (INN) Out -of -Network $400/5800 5800/51,600 5800/51,600 51,600/53,200 '0L4:rYsr,!' ':?trr X. 4,aiii. 1;�'ri *,c'eF r`its.P MIN5 - 4-1.1:2:4 -,.,L , t•,fif5 In -Network Out -of -Network 20% 30% 30% 40% 2096 3096 30% 40% 20% 30% 30% 40% aendar ear Out . Poc--t Maximum MEW%) INZWORS2 f In -Network Out -of -Network Medical/Surgical Care by a Physician 53,000/56,000 54,000/58,000 56,000/512,000 58,000/516,000 53,000/56,000 54,000/58,000 56,000/512,000 58,000/$16,000 53,000/56,000 54,000/58,000 56,000/512,000 58,000/516,000 In -Network Family Physician In -Network Specialist Out -of -Network $25 Copayment $45 Copayment DED + 30% 535 Copayment 560 Copayment DED + 40% 525 Copayment $45 Copayment DED + 30% 535 Copayment 560 Copayment DED +40% ;je;i .f40p4°:r11t; Lamt 2:.y]/rir' DEO + 30% ti ,;-.1y.o.o.g.is }5�•)3p�Ly3 DED + 4096 In -Network Family Physician In -Network Specialist Outof-Network 55 Copayment 55 Copayment DED +30% $5 Copayment 55 Copayment DEO +40% 55 Copayment 55 Copayment DED +30% 55 Copayment 55 Copayment DED +40% 55 Copayment 55 Copayment DED +30% 55 Copayment 55 Copayment DED +40% _CSS MIa Or.i.33 ;i In -Network Out -of -Network 525 Copayment DED + 30% 535 Copayment DED + 40% 525 Copayment DED + 30% 535 Copayment DED + 40% Iwo ,z.a4131000rte DED + 30% t '1S' ,,i:]q,:)yu a.19 DED + 40% nalitgaWiratIEMMiGgeiLM In -Network PAD 5200+DED + 20% PAD $400 + DED + 30% PAD 5500+DED + 30% PAD $1,000 + DED + 40% PAD 5200 + DED + 20% PAD $400 + DED + 30% PAD 5500+DEO + 30% PAD 51,000 + DED + 40% PAD 5200+DEO +2096 PAD $400+DEO +30% PAD 5500 + DED + 30% PAD $1,000 + DED + 40% In -Network Out -of -Network DED + 20% INN DEO + 20% DED + 30% INN DED + 30% DED + 20% INN DED + 20% DED + 30% INN DED + 30% DED + 20% INN DED + 20% DED + 30% INN DED + 30% r 7Y�`.. ,, P.th• I- gv, -nd Anesthesiology illazroggalyorairguln In -Network Out -of -Network Services DED + 20% INN DEO + 20% DED+ 30% INN OED + 30% DED + 2096 INN DED +20% DED + 30% INN DED + 30% DED + 20% INN DEO + 20% DED + 30% INN DED + 30% In -Network Family Physician/Specialist Out -of -Network Non Hospital Services Freestanding Facility Cinica( .b(8b.d /0 -}:Quest" No Charge 30% No Charge 40% No Charge 30% No Charge 40% No Charge 30% No Charge 40% In -Network Out -of -Network No Charge DED + 3096 No Charge DED + 40% No Charge DED + 30% No Charge DED + 40% No Charge DED + 30% No Charge DED+ 40% Xi rays Independent -Dia • nost:c ..enter In -Network Out -of -Network 515 Copayment DED +30% 525 Copayment DED +40% 515 Copayment DED +3096 525 Copayment DED +40% 515 Copayment DED +30% 525 Copayment DED+40% kirOLKaalarfliagei In -Network Out -of -Network Emergency and Urgent Care Option 1: DEO + 20% DED +30% Option 1: DED + 30% DEO+40% Option 1: DED + 20% DED +30% Option 1: DED + 30% DED +40% Option 1: DED + 20% DED+30% Option 1: DED + 30% DED+40% In -Network Out -of -Network 5250 Copayment + DED + 20% (Copayment Waived if Admitted) 5250 Copayment + INN DEO + 20% 5500 Copayment + DED + 3096 (Copayment Waived if Admitted) 5500 Copayment + INN DED + 30% - 5250 Copayment + DED+ 20% (Copayment Waived if Admitted) $250 Copayment+ INN DEO + 20% 5500 Copayment + DED + 3096 (Copayment Waived if Admitted) 5500 Copayment + INN DED + 30% $250 Copayment + DEO + 20% (Copayment Waived if Admitted) 5250 Copayment + INN DED + 20% $500 Copayment + DED + 30% (Copayment Waived if Admitted) 5500 Copayment INN DED + 30% lirAliftliGeralUg In -Network Out -of -Network 525 Copayment 525 Copayment 535 Copayment 535 Copayment 525 Copayment 525 Copayment 535 Copayment 535 Copayment IMIIVIIMSEMIII 11M1=1151 1 11 In -Network Out -of -Network Advanced -Imaging (MRI, MRA, PET, Cf & Nuclear Medicine) AIIVIORCREG DED +20% INN DED + 20% - ---- DED +30% INN DED 30% - DED +20% DED +30% INN DED +20% INN DED+3096 DED +20% INN DED +20% DED +30% INN DED +30% In -Network Family Physician or Specialist Out -of -Network $200 Copayment DED +30% 30% DED+40% $200 Copayment DED+30% 30% DED +40% $200 Copayment DED +30% 30% DED +40% In -Network Out -of -Network 5200 Copayment DED + 30% 30% DED + 4096 $200 Copayment DED + 30% 30% DED + 4056 5200 Copayment DED + 30% 30% DED + 40% In -Network Out -of -Network DED + 20% DED + 30% DED + 30% DED + 40% DED + 20% DED + 30% DED + 3056 DED + 40% DED + 20% DED + 30% DED + 30% DED + 40% tf6