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

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

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

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

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

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

Overview of Health Products

BlueCare HMO Plan58

Preventative Services (Adult & Child)

$0 copay

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)

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.

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.

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.

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) 833-7873catherine.muroski@bcbsfl.com