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Martin County Sheriff's Office I Employee Benefit Highlights 12020-20210 <br /> Florida Blue — BlueOptions Alternative Health 5360 Plan At-A-Glance <br /> Network BlueOptions <br /> CalendarYear Deductible(CYD) In-Network Out-of-Network* <br /> I Single $1,250 $2,500 <br /> is - <br /> Family $2,500 $5,000q <br /> Coinsurance <br /> Member Responsibility 1 . 20% 40% Locate a Provider <br /> • <br /> To search for a participating provider, <br /> Calendar Year Out-of-Pocket Limit contact Florida Blue's customer service <br /> Single $5,000 $10,000 or visitwww.floridablue.com.When <br /> = _ -- -• completing the necessary search <br /> I Family $5,000 $10,000 criteria,select BlueOptions network. <br /> What Applies to the Out-of-Pocket limit? j. - Deductible,Coinsurance,Copays and Rx <br /> Physidan Services <br /> Primary Care Physician(PCP)Office Visit 20%After CYD 40%After CYD -; 0 <br /> L pedalist Office Visit 20%After CYD 40%After CYD <br /> Telehealth Services No Charge Not Covered Plan References <br /> "Out-Of-Network Balance Billing: <br /> Non-Hospital Services;Freestanding Facility <br /> For information regarding our-of- <br /> [Clinical Lab B!oodworkt* No Charge 40%After CYD network balance billing that may be <br /> X-rays i _— — 20%After CYD 40%After CYD charged by out-of-network providers, <br /> please refer to the Summary of Benefits <br /> Advanced Imaging(MRI,PET,(7) ---, 20%After CYD 40%After CYD and Coverage(SBC)document. <br /> E Outpatient Surgery in Surgical Center 20%After CYD 40%After CYD <br /> - -- ; "*Quest Diagnostics is the preferred <br /> 1.thysician Services at Surgical Center 20%After CYD40%After CYD _ lab for bloodwork through Florida Blue. <br /> Urgent Care Center(Per Visit) 20%After CYD 20%After CYD When using a lab other than Quest, <br /> please confirm they are contracted with <br /> Hospital Services Florida Blue's BlueOptions network prior <br /> - to receiving services. <br /> Inpatient Hospital(PerAdm,ssian) Option 1:20%After CYD Option 2:20%After CYD 40%After CYD <br /> Outpatient Hospital(Per Visit)"*"` 1 Option 1:20%After CYD Option 2:20%After CYD 40%After CYD ***Option land Option 2 Hospitals:To <br /> determine if a hospital is Option 1 or <br /> [Physician Services at Hospital 1 20%After CYD 20%After In-Network CYD . Option 2,please contact Florida Blue's <br /> X-rays/Advanced Imaging at Hospital 20%AfterCYD 40%After CYD customer service. <br /> Emergency Room(Per Visit) 20%After CYD 20%After CYD <br /> Mental Health/Alcohol&Substance Abuse <br /> LInpatient Hospital Services(Per Admission) - 1 20%After CYD 40%After CYD <br /> r Outpatient Services(Per Visit) 20%After CYD 40%After CYD <br /> [Outpatient Office Visit 20%After CYD 40%After CYD <br /> Prescription Drugs(Rx) <br /> Generic $15 Retail Copay Not Covered <br /> [Preferred Brand Name $30 Retail Copay Not Covered <br /> Non-Preferred Brand Name $50 Retail Copay Not Covered <br /> [Specialty Pharmacy ] $75 Retail Copay Not Covered <br /> [ail Order Drug(90 Day Supply)) _1 $0/$60/$100 Retail Copay Not Covered 115 <br /> 6 <br /> ©2016,Gehring Group,Inc.,All Rights Reserved <br />