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Welcome
2021 Benefit Plans Overview
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Florida Gateway’s Plan Choices
MEDICAL – Health Insurance Plan Options
• Florida Blue BlueOptions PPO 03559
• Florida Blue BlueOptions PPO 03769
• Florida Blue BlueCare HMO 58
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Overview of Health Plans
BlueOptions PPO 03766
Monthly Premium
Preventative Services (Adult & Child)
$0 copay
BlueOptions PPO 03769
Monthly Premium
Preventative Services (Adult & Child)
$0 copay
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Office VisitsPPO 03559 PPO 03769
Family Physician/PCPSpecialist
$40
$60
$40
$60
Any services received at doctors office will apply to copay.
Teledoc $10 $10 When you need care nowOn vacation, on a business trip, or away from home
LabIn-Network –QuestOut of Network
$0
CYD + 30%
$0
CYD + 40%
Lab is paid at 100% by using Quest. You can make appointments online!!!www.questdiagnostics.com
Out-of-Network CYD + 30% CYD + 40% Anything other than Blue Options is Out of Network. Using Traditional doctors will protect you from balance billing.
4CYD = Calendar Year Deductible
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Preventative HealthPPOPlan 03559
PPOPlan 03769
Adult Wellness Includes:• Annual physical• Mammogram• PSA Exam
$0 $0 See 2020 Clinical Preventive Care Guidelines. See slides 22-23.
Colonoscopy• Adult Wellness Benefit • One routine
colonoscopy (age 50+ paid in full of allowed amount)
• Colaguard- noninvasive option for colon cancer screening
$0 $0Talk to your doctor about which screening method is right for you.
The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer (CRC) using a colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary.
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Hospital Services – Inpatient
PPO Plan 03559 PPO Plan 03769
Inpatient Facility Copay
In-NetworkOut of Network
$9,000 / $1,650$2,500
$1,250 / $2,250DED + 40%
To determine Option levels or participation, go to the Online Provider Directory www.floridablue.com
Provider Services while Inpatient
In NetworkOut of Network
DED + 20%INN DED + 20%
DED + 20%INN DED + 20%
Any services received by a Provider while in the hospital.
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Option 1 / Option 2
Option 1 facility / Option 2 facility (teaching or specialized hospital)
Option 1 / Option 2
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Hospital Services – Outpatient
PPO Plan 03559
PPO Plan B 03769
Outpatient In-Network HospitalOut of Network
$250/$350
DED + 30%
CYD + 20%/ CYD + 20%
DED + 40%
To determine Option levels or participation, go to the Online Provider Directory www.floridablue.com
Provider Services while Outpatient
In NetworkSpecialistOut of Network
DED + 20%/ DED + 20%DED + 30%
$40 / $60 CopayDED + 40%
Any services received by a Provider
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Option 1 / Option 2 Option 1 / Option 2
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Deductible & Coinsurance
PPO Plan 03559
PPO Plan 03769
Calendar Year Deductible
CoinsuranceIn NetworkOut of Network
$700/$2,100
20%40%
$800/$2,400
20%30%
Applies to services such as Provider Services in Hospital, Independent Diagnostic Testing Facility, Durable Medical Equipment, Prosthetics & Orthotics and Ambulance Services
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Out of Pocket MaximumPPO Plan 03559
Plan PPO 03769
In Network and Out of Network (Combined)
Per Person/Family $7,000/$14,000 $7,000/$14,000
The maximum a members pays out of pocket in a benefit year. All of the following is applied to Max Out of Pocket: Copays, Calendar Year Deductible and Coinsurance
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Lifetime maximums are no longer in effect due to Health Care Rform
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Overview of Health Products
BlueCare HMO Plan58
Preventative Services (Adult & Child)
$0 copay
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Office VisitsHMO 58
Family Physician / PCP
Specialist
$40
$60
Any services received at doctors office will apply to copay.
Teledoc $10 When you need care nowOn vacation, on a business trip, or away from home.
LabIn Network – QuestOut of Network
$0Not Covered
Lab is paid at 100% by using Quest. You can make appointments online!!!www.questdiagnostics.com
Out-of-Network Not Covered Anything other than BlueOptions is Out of Network. Using Traditional doctors will protect you from balance billing.
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Preventative HealthHMO 58
Adult Wellness Includes:• Annual physical• Mammogram• PSA Exam
$0 See 2020 Clinical Preventive Care Guidelines. See slides 22-23.
Colonoscopy• Adult Wellness Benefit.
One routine colonoscopy (age 50+ paid in full of allowed amount)
CologuardA noninvasive option for colon cancer screening
$0 The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer (CRC) using a colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary.
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Hospital Services – InpatientHMO 58
Inpatient Facility CopayIn-Network
Out of Network
$350 per day up to a maximum of $1,750 per admission
Not Covered
To determine Option levels or participation, go to the Online Provider Directory www.floridablue.com
Provider Services while Inpatient
In-NetworkOut of Network
$0Not Covered
Any services received by a Provider while in the hospital.
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Option 1 facility / Option 2 facility (teaching or specialized hospital)
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Hospital Services – Outpatient
HMO 58
Outpatient In-Network Hospital
Out of Network
$750
Not Covered
To determine Option levels or participation, go to the Online Provider Directory www.floridablue.com
Provider Services while Outpatient
In-Network
Out of Network
$40 / $60 Copay
Not Covered
Any services received by a Provider
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Deductible & Coinsurance
HMO 58
Calendar Year Deductible
CoinsuranceIn NetworkOut of Network
N/A
80% / 20%Not Covered
Applies to services such as Provider Services in Hospital, Independent Diagnostic Testing Facility, Durable Medical Equipment, Prosthetics & Orthotics and Ambulance Services
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Out of Pocket MaximumHMO 58
In Network and Out of Network (Combined)
Per Person/Family $6,000 / $12,000
The maximum a members pays out of pocket in a benefit year. All of the following is applied to Max Out of Pocket: Copays, Calendar Year Deductible and Coinsurance
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Pharmacy
PlansRetail – In-Network(30 day supply)
Mail order (90 day supply)
PPO 03769PO 03559HMO 58
$15 - generic$45 - preferred brand$65 - non-preferred brand$250 - Monthly Member Out of Pocket Maximum per specialty prescription applies
$30/$90/$130Specialty drugs are cost share and not available through mail orderThe use of specialty mediations is a major factor in drug trends across the industry.
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If a Brand Name Rx is purchased when a Generic Rx is available and the Physician has not indicated that a Brand Name Rx is medically necessary, member will be required to pay the difference between the cost of the Brand Name and Generic Rx in addition to the Rx copay. Pharmacy expenses apply to out-of-pocket maximums.
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Pharmacy
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Florida Blue Rx – Condition Care Value Drug BenefitWaived Copay for Generic and Preferred Brand.
Drugs Classes as applicable for the following:
• Depression• Diabetes Supply (including Insulin)• High Blood Pressure• High Cholesterol• Respiratory• Smoking Cessation
The most current listing can be found as a link within the Medicare Guide when you log into your account online.
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Condition Care Rx Program
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Register for Teledoc today!
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There is No cost to register!
It only takes a few minutes.
Do it today before you don’t feel well.
You can down load the app to your phone too.
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Member Care Programs
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Well At Risk Acute/Chronic
Better You from Blue
800-477-3736 ext.54837
• Better You from Blue
• Lifestyle Coaching
• Behavioral Risk Screening
24/7 Nurse Advice Line
877-789-2583
• Symptom Support
• Behavioral Health Coaching
• Decision Support
Care Consultant Team (CCT)
888-476-2227
• Benefit Optimization
• Care Referrals
• Social and Community Resources
Condition Management
• Core Chronic • Rare Chronic• Oncology • Transplants • High Risk • Maternity• Prenatal and
much more
Care Coordination
• Case Management
• Transition of care
• Pediatric • Hospice• PCMH/ACO
and much more
Catherine MuroskiFCSRMC Case Manager
(407) [email protected]