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Indian River County Health Plan Options - 2A, 2B, 38 <br />Effective October 1, 2020 <br />Product <br />:::. BlueOpt�ons <br />_ . <br />BlueOptionsBlueCptions <br />Gold Option 2b /.3b <br />87.4% <br />- -0.9% <br />524,042,000 <br />-5213,000 <br />. ---0.9% <br />PAD Per Admission <br />Sl ver,Optio. <br />79:1% <br />-0.6% <br />PAD ( Per Admission <br />- <br />.cj' 6i'y!Otirf^[.tP <br />r G <br />Premieold Ian + '5 ' <br />•rem:er Si ver,Plan 05302 <br />Go 6 0.tion _a <br />i ver.+pbon :a <br />Actuarial Value - <br />Savings% by Plan <br />Projected Claims <br />Savings$• - <br />Savings%Total <br />Mental Health/ Alcohol & Substance Abuse <br />88.2% <br />N/A <br />$24,255,000 <br />N/A <br />N/A <br />79.6% <br />N/A <br />86.2% <br />-2.3% <br />- 523705,000 <br />-5550,000 <br />-23% <br />PAD Per Admission <br />77.8% <br />-2.3% <br />SAD ( Per Admission <br />PAD(PerAdmissron <br />Deductible)t.� <br />PAD(Per Admission <br />�- <br />Deductible(. <br />In -Network. <br />Out -of -Network <br />PAD $200 + DED + 20% <br />PAD $400 + DED + 30% <br />$500 PAD + DED + 30% <br />51,000 PAD + DED + 40% <br />PAD 5200 + DED + 20% <br />PAD 5400 + DED + 30% <br />5500 PAD + DED + 30% <br />51,000 PAD + DED + 40% <br />PAD 5200 + DED + 20% <br />PAD 5400+DED + 309S <br />$500 PAD +DED + 30% <br />51,000 PAD + DED + 40% <br />Weifgangab <br />In -Network <br />545 Copayment <br />$60 Copayment <br />$45 Copayment <br />DED +30% - <br />N/A <br />510 Copayment <br />560 Copayment <br />DED+40% <br />$100 (must be met before <br />Copays apply) <br />55 Copayment <br />545 Copayment - <br />DED+30% <br />N/A <br />510 Copayment <br />560 Copayment <br />DED.+40%' <br />5100 (must be met before <br />Copays apply) <br />55 Copayment <br />Out -of -Network <br />DED +30% <br />DED +40% <br />Prescription Drugs rte. <br />(RX Administered'through RX Benefits) <br />1X Calendar,Year Deductible Per Person <br />Generic <br />Preferred Brand Name <br />Non -Preferred Brand Name <br />Mail Order Drug (90 -Day Supply) <br />Maintenance Medication <br />N/A <br />510 Copayment <br />$35 Copayment <br />550 Copayment <br />Express Script 2x Retail <br />Copayment <br />2x Copayment at Covered <br />Pharmacies <br />5100 (must be met before <br />Copays apply) <br />$5 Copayment <br />$50 Copayment <br />570 Copayment <br />Express Script 2x Retail <br />Copayment <br />2x Copayment at Covered <br />d Pharmacies <br />550 Copayment <br />$65 Copayment <br />.5.Copayment <br />$85 Copayment <br />$50 Copayment <br />$75 Copayment <br />65 Copayment <br />595 Copayment <br />Express Script 2x Retail <br />Copayment <br />2x Copayment at Covered <br />Pharmacies <br />Express Script 2x Retail <br />Copayment <br />2x Copayment at Covered <br />Pharmacies <br />Express Script 2x Retail <br />Copayment - <br />2x Copayment at Covered <br />Pharmacies <br />Express Script 2x Retail <br />Copayment <br />2x Copayment at Covered <br />Pharmacies <br />Billing that may be charged by an out -of -network provider, please refer to the Out -of -network Benefits <br />section on the Summary of Coverage document. "Quest Diagnostics <br />is the preferred lab for bloodwork through Florida Blue. When using a lab other than Quest, please be sure <br />87 <br />