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Martin County Board of County Commissioners I Employee Benefit Highlights 1202117E:1 <br /> Florida Blue — BlueOptions Plan At-A-Glance <br /> Network BlueOptions <br /> CalendarYear Deductible(CYD) In-Network Out-of-Network* <br /> Single $500 $1,500 <br /> ._ _ q <br /> Family — $1,500 $4,500 <br /> Coinsurance <br /> Member Responsibility 20% 50% Locate a Provider <br /> To search for a participating provider, <br /> CalendarYear Out-of-Pocket Limit contact Florida Blue's customer service <br /> Single __ $3,000 $6,000 or visit www.floridablue.com.When <br /> Family $6,000 $12,000 completing the necessary search <br /> _ ; criteria,select BlueOptions network. <br /> What Applies to the Out-of-Pocket Limit? - Deductible,Coinsurance,Copays and Rx <br /> Physician Services <br /> Primary Care Physician(PCP)Office Visit $25 Copay 50%After CYD <br /> ; _ . 0 <br /> [pecialist Office Visit - __I $50 Copay 5096 After CYD <br /> Telehealth-Teladoc No Charge Not Covered Plan References <br /> Non-Hospital Services;Freestanding Facility *Out-ofNetworkBalance Billing: <br /> [Clinical Lab(Bloodwork)" -=_ -- No Charge 50%After CYD For information regarding out-of- <br /> network balance billing that may be <br /> CX rays $50 Copay 50%After CYD charged by out-of-network providers, <br /> Advanced Imaging(MRI,PET Q) 20%After CYD 50%After CYD - please refer to the Summary of Benefits <br /> and Coverage(SBC)document. <br /> [Outpatient Surgery in Surgical Center —1 $50 Copay 50%After CYD 1 <br /> Lysician Services at Surgical Center $50 Copay 50%After CYD "Quest Diagnostic is the preferred <br /> -— - -_ _ lab for bloodwork through Florida Blue. <br /> Urgent Care(Per Visit) $65 Copay $65 Copay 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 /> [Inpatient Hospital(Per Admission) J 20%After CYD So%After CYD ' to receivingservices. <br /> Outpatient Hospital(Per Visit) 20%After CYD 50%After CYD <br /> Physician Services at Hospital $100 Copay $100 Copay <br /> Emergency Room(Per Visit) , $300 Copay $300 Copay <br /> Mental Health/Alcohol&Substance Abuse <br /> fInpatient Hospital Services(PerAdmission) v` `_ $500 Copay 50%Coinsurance <br /> [Outpatient Services(Per Visit) m $25 Copay 50%Coinsurance <br /> Outpatient Office Visit $25 Copay 50%Coinsurance <br /> Prescription Drugs(Rx) <br /> Generic —1 $15 Copay 50%Coinsurance <br /> Preferred Brand Name j $30 Copay 50%Coinsurance <br /> Non-Preferred Brand Name $50 Copay 50%Coinsurance <br /> Lail Order Drug(90-Day Supply) 2x Retail Copay 50%Coinsurance . <br /> 88 <br /> 6 <br /> ©2016,Gehring Group,Inc.,All Rights Reserved <br />