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`; Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 <br /> Florida Blue — BlueOptions PPO 3748 Plan At-A-Glance <br /> Network BlueOptions <br /> Calendar Year Deductible(CYD) In-Network Out-of-Network* <br /> Single $0 $500 <br /> f Family '. $0- -- - 1 — $1,000 -- <br /> Coinsurance <br /> Locate a Provider Member Responsibility 20% 40% <br /> To search for a participating provider, <br /> contact Florida Blue's customer service Calendar Year Out-of-Pocket Limit <br /> or visitwww.floridablue.com.When Single $3,000 $6,000 <br /> completing the necessary search `-`-- <br /> criteria,select BlueOptions network. i Family , $6,000 $12,000 <br /> Fit;Applies the Out-of-Pocket Limit? Deductible,Coinsurance,Copays and Rx <br /> 0 Physician Services <br /> Primary Care Physidan(PCP)Office Visit - $30 Copay 40%After CYD <br /> �pedalist Office Visit $60 Copay 40%After CYD <br /> Plan References I Telehealth Services No Charge Not Covered <br /> *Out-Of-NetworkBalance Billing: Non-Hospital Services;Freestanding Facility <br /> For information regarding out-of- <br /> network balance billing that may be Clinical lab(Bloodwork)*" $20 Copay 40%After CYD <br /> charged by out-of-network providers, X-rays $75 Copay 40%After CYD <br /> � <br /> please refer to the Summary of Benefits —-- -= -- - - -- <br /> and Coverage(SBC)document. Advanced Imaging(MRI,PET,CT) $75 Copay 40%After CYD <br /> Outpatient Surgery in Surgical Center $30 Copay 40%After CYD <br /> **Quest Diagnostics is the preferred <br /> lab for bloodwork through Florida Blue. Physician Services at Surgical Center $60 Copay 40%After CYD <br /> When using a lob other than Quest, Lrgent Care Center(Per Visit) 1 $100 Copay $100 Copay After CYD <br /> please confirm they are contracted with <br /> Florida Blue's BlueOptions network prior Hospital Services <br /> to receiving services. Inpatient Hospital(Per Admission)*** _ Option 1:$500 Copay Option 2:$1,000 Copay 40%After CYD <br /> **"Option 1 and Option 2 Hospitals:To Outpatient Hospital(Per Visit)*** — _v Option 1:$250 Copay Option 2:$500 Copay 40%After CYD <br /> determine if a hospital is Option 1 or -— <br /> Option 2,please contact Florida Blue's [Physician Services at Hospital $30 Copay Per Provider's Visit $30 Copay Per Provider Visit <br /> customer serviCe. X-rays/Advanced Imaging at Hospital1 Option 1:$250 Copay Option 2:$500 Copay 40%After CYD <br /> Emergency Room(Per Visit,Waived if Admitted) 1 $250 Copay $250 Copay <br /> Mental Health/Alcohol&Substance Abuse <br /> I Inpatient Hospitalization(Per Admission) $500 Copay 40%After CYD <br /> Outpatient Services(Per Visit) _I $30 Copay 40%After CYD <br /> Physidan Office Visit 1 $60Copay 40%Coinsurance <br /> Prescription Drugs(Rx) <br /> Generic -- ] $15 Retail Copay Not Covered <br /> [Preferred Brand Name $45 Retail Copay Not Covered <br /> Non-Preferred Brand Name $75 Retail Copay Not Covered <br /> 'Specialty Pharmacy 25%Coinsurance($150 Maximum Per Prescription) Not Covered <br /> Mail Order Drug(90 Day Supply) - <br /> 5 114_1 $0/$90/$150 Retail Copay II Cgvered <br /> ©2016,Gehring Group,Inc.,All Rights Reserved <br />