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Cross <br />A BENEFIT- COMPARISON ;'; BlueShhWW <br />for Employees of Indian River County _�.u�.... n cy mn4-Rr _u. <br />BENEFIT Indian River Countv's BCBSF's Preferred Patient Care'" <br />1995 Benefit Plan I (PPCI - Effective 10/01/% <br />PPO PROVIDER NON -PPO PPC PROVIDER NON -PPC <br />Deductible - Per Person t_ per tatn[iv, 5200 5300 5200 I 5300 <br />ri.rn:r r -; •:,,> r d: r to i o ' uuimrdtmis m rmnrUr (la c to smsru f Amt M-1. numbers darns go toward <br />irnoanRr.'rt6+nornu aoorormarednimuhle I satlsj*g2dedadibles(gprgaw <br />Coinsurance 80% 609 809 609c <br />Out-ot-Pocket Maximum (2 per tamily) 52.000 I 54.000 <br />52A()0 54,000 <br />Cw+runietrucni it d!n> not a[griv ttrturd ? indmiduals nt rami!u ime to satrsry <br />tilemit-f-w Act nlarllrrlrm I appropriate marnmtm <br />Anytanubj member's down go toward <br />satisftmg2 na> laggregatt) <br />Per Admission Deductible (PAD) <br />Wnridlrvr.•rces m"Idediv 5200 <br />55005200 <br />l 5500 <br />lndwv Rl: rr adc rnornrl <br />B. Inpatient <br />80% I 60`i0 <br />Lifetime Maximum 51.000.000 51.000.000 <br />1. Phvs[c[an Sen -ices <br />31 Inpatient dausrrtsns per Person <br />3I Inpatient dausmis[ts per person <br />A. Office Visit <br />I 515 copav <br />I 60% I 515 copay <br />60% <br />B. Other Services Provided in Dr's Office <br />1 80% 60% 100% 60% <br />C. Other Services <br />80% I 60% j 80% I 60% <br />11. Hospital <br />I I <br />, I <br />A. Outpatient Hospital & Surgical Centers <br />80% 609 <br />80% 609 <br />B. Inpatient <br />80% 60% 80% 60% <br />C. Emergencv Room for Accident <br />$50 copay $50 copay 100% 100% <br />WSW baiance subiect to normal <br />V1. Pre--cnrnon Druz reta[i and maii order <br />deductible/eonumanee <br />II1. Other <br />1 <br />1 Partrapanng vnarmacv I <br />58 copay 510 copay I <br />58 copay i $16cD y <br />A. Preventive <br />i 609 <br />1. Annual Health Assessment <br />I n/a <br />nia <br />S15copay Non -covered <br />EnrPdouee oniv, deductible war, <br />I <br />S?00 maximum per calendar vein <br />_. Well Child (limitations apply) <br />i 809 609 I 515 copay j 60% <br />80% - 510.000 maximum per person 80% - S10A00 maxurtunt per person <br />per calendar vear per mlendar uear <br />B. Skilled Nursing Facility <br />80% - S23W maximum per person I 8017o - S2a00 maximum per person <br />per calendar uear per calendar year <br />C. Home Health Care <br />I. n/a 1 809 n/a 1 80% <br />D. Senices Outside Service Area <br />R'. Mental Health <br />515 copay I <br />A. Outpanent <br />(Ist 10 visits) � 6007c i <br />I <br />S15copay 6090 <br />f <br />-limitation ; <br />55.000 mxr m im per person i <br />55.000 mrnmunt per person <br />per calendar veer <br />per calendar utar <br />B. Inpatient <br />80% I 60`i0 <br />800/c I 609 <br />-unrtnrtion <br />31 Inpatient dausrrtsns per Person <br />3I Inpatient dausmis[ts per person <br />per calendar vear <br />per calendar near <br />C. Partial Hospital <br />i <br />80% 60% <br />80% 1 609 <br />iinrn noir <br />Not to exceed cost of 31 invattent daysmisits <br />Uot to exceed cost of 31 intmttent dausivisus <br />Per calendar ucar <br />Per calendar Year <br />j V. Alcohol and Druz Abuse <br />i <br />809 60% <br />809 - 6007c <br />brraaevrr. c urtxrne [a. ar f <br />S10A00lifetime maximum per member j <br />S10,000 Iifct»nc [naxmtun: pct member <br />• : onrrnrnnmr n* ; •�• <br />c tris <br />V1. Pre--cnrnon Druz reta[i and maii order <br />i <br />1 <br />1 Partrapanng vnarmacv I <br />58 copay 510 copay I <br />58 copay i $16cD y <br />Non-Parnarannz harmacv <br />i 609 <br />MAY 20, 1997 <br />81 <br />