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Medical - Florida Blue F ' <br /> The District seeks to provide the best possible medical and prescription drug benefits at a reasonable cost to <br /> you. The information below is a summary of medical coverage only. Please contact Florida Blue, the Benefit <br /> Administrator, at www.floridablue.com,for plan summaries detailing coverage information and exclusions. <br /> Blue Options 05770 Blue Options 05772 Blue Options 05774 <br /> Benefit <br /> In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network <br /> Annual Calendar Year Deductible <br /> Single $1,000 $3,000 $2,000 $6,000 $3,000 $6,000 <br /> Family $3,000 $6,000 $6,000 $18,000 $9,000 $18,000 <br /> Out-of-Pocket Maximum <br /> Single $3,500 $7,000 $5,500 $11,000 $6,350 $15,000 <br /> Family $7,000 $14,000 $11,000 $22,000 $12,700 $30,000 <br /> Coinsurance <br /> (%member pays of bill) 20% 50% 20% 50% 20% 50% <br /> Physician Services <br /> Doctor's Office Visit $25 50%after ded. $35 50%after ded. $40 50%after ded. <br /> Specialist Office Visit $25 50%after ded. $65 50%after ded. $100 50%after ded. <br /> Preventive Care No Charge 50% No Charge 50% No Charge 50% <br /> Imaging Facility $100 50%after ded. 20%after ded. 50%after ded. 20%after ded. 50%after ded. <br /> Hospital Facility Fees <br /> Inpatient 20%after ded. $3,500 $100+20%after $500+50% $500+20%after $500+50% <br /> ded. after ded. ded. after ded. <br /> Ambulatory Ambulatory Ambulatory <br /> Surgical Center: Surgical Center: • Surgical Center: <br /> Outpatient $150 50%after ded. $250 50%after ded. $350 50%after ded. <br /> Hospital Option 1: Hospital Option 1: Hospital Option <br /> 20%after ded. 20%after ded. 1:20%after ded. <br /> Imaging Center $100 50%after ded. $300 50%after ded. $400 50%after ded. <br /> Emergency Care $200 $300 $400 <br /> Pregnancy and Maternity <br /> Care(prenatal and postnatal) $25 50%after ded. $65 50%after ded. $100 50%after ded. <br /> -Office Services <br /> Semi-Monthly Per Paycheck Deductions <br /> Employee Only $108.50 $59.00 $14.50 <br /> Employee+Spouse $363.00 $281.00 $211.00 <br /> Employee+Child(ren) $350.00 $270.00 $201.50 <br /> Family $438.00 $346.50 $268.50 <br /> 2 Credit <br /> Employee+Spouse $34.00 each $0.00 each $0.00 each <br /> 2 Credit <br /> Employee+Family $71.50 each $25.75 each $0.00 each <br /> Note:The District's Contribution for the 2020/2021 school year is$295.00 per pay or$590.00 per month. <br /> Note: Any deductibles ("ded") and copays in the chart above are amounts for which you are responsible. Deductibles, copays and <br /> coinsurance accumulate toward the out-of-pocket maximums. Usual, Customary and Reasonable charges apply for all out-of-network <br /> benefits. Prior authorization may be required for imaging services. 9 <br /> 14 <br />