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Summary of Premier Silver and Premier Gold Plan Benefits: <br />Florida Blue BQueOptivns Plan At -A -Glance <br />Plan Nurmer <br />�Casl_shwne�g,=,Puteseatrefs Fiesparusib <br />[Prr rrier.S�rer-P 053U2] <br />�remier1fiold lily-(KMW9, <br />In-Nebarnirk SINN) S11.000 f $2,000 WOO i S 1.2D0 <br />Out -of -Ne ym* $2.000:1$4.000 $1.2D0 I $2,40D <br />In -Net park 3D% 2D% <br />Out-of-Nelrmrk 4D% 3D-96 <br />• <br />In-NehvoA MOOC 1512,000 $3.00()1$8,000 <br />Out -of NeurEwk 58.0001$15,000 54.000 158,000 <br />In-NeWm* Family Physician <br />340 Copayment <br />$30 Copayment <br />In-Netucrk S idist <br />$fay Copayrnent <br />S50 Copayment <br />Out-oaf-Neuurexk <br />DED + 4D% <br />DED + 3D96 <br />In-NeWork General Medical <br />S10 Copayment <br />$10 Copayment <br />In-Nebwrk Dermatology <br />$20 Copayment <br />$20 Copayment <br />Out-aF-N-'.=Tk <br />NIA <br />NIA <br />In-Nehuork Family Physfician <br />$5 Copayment <br />35 Copayment <br />In-NeWerk Speci ist <br />$b Copayment <br />35 Copayment <br />Out-cf Ne.1,=a k <br />IDED + 40% <br />DED + 3D% <br />In-Netmrk <br />40 Copayment <br />S30 Copayment <br />Out-of-N=_irk <br />IDED + 4D% <br />DED + 30% <br />In-NeWmrk <br />PAD $50D + DED + 3096 <br />PAD $200 + DED +20% <br />Out-of-Neusmrk PAD $ I.WO + DED + 40% PAD S40D +IDED + 3D% <br />In-Nehvcrk IDED + 3DD6 DED + 2DO6 <br />Out-& Netrx rk INN DED + 30% INN DED + 20% <br />In-Nehnark IDED + 3D% DED + 2D% <br />Out -of Nensswk INTI DED + 30% INNDED + 20% <br />In-Neterork Family Physkian I Specialist. No Charge No Charge <br />Out -of Netumrir 411% 30% <br />In-Nehvcrk No Charge No Charge <br />Out-of-Nebwork DED + 40% DED + 30% <br />