Overview
Cost Sharing - Member's Responsibility
Cost Sharing - Member's Responsibility
BlueCare HMO Gold 47 | BlueOptions PPO Gold 3359 | BlueOptions HDHP Silver Individual Plan 5194 Account Funding: EE Only=$300 | BlueOptions HDHP Silver Family Plan 5195 Account Funding: EE+1=$600 or EE+2=$900 | |
|---|---|---|---|---|
| Deductible (DED) (Per Person/Family Aggregate) | ||||
| In-Network | $600 / $1,200 | $1,200 / $2,400 | $2,800 | $5,600 / $5,600 |
| Out-of-Network | N/A / N/A | $2,400 / $4,800 | $5,600 | $11,200 / $11,200 |
| Coinsurance (BCBSF pays / Member pays) | ||||
| In-Network | 80% / 20% | 80% / 20% | 80% / 20% | 80% / 20% |
| Out-of-Network | N/A / N/A | 60% / 40% | 50% / 50% | 50% / 50% |
| Out of Pocket Maximum (Per Person/Family Aggregate) | ||||
| In-Network | $5,000 / $10,000 | $6,000 / $12,000 | $7,000 | $7,050 / $14,000 |
| Out-of-Network | N/A / N/A | $12,000 / $24,000 | $14,000 | $28,000 / $28,000 |
Medical / Surgical Care by a Physician
Medical / Surgical Care by a Physician
| BlueCare HMO Gold 47 | BlueOptions PPO Gold 3359 | BlueOptions HDHP Silver Individual Plan 5194 Account Funding: EE Only=$300 | BlueOptions HDHP Silver Family Plan 5195 Account Funding: EE+1=$600 or EE+2=$900 | |
|---|---|---|---|---|
| Office Services | Nutritional counseling for a diagnosis of diabetes is covered at $0 copayment when billed by a VCP Specialist in the office. | |||
| Value Choice PCP | $0 Copayment | $0 Copayment | DED | DED |
| Value Choice Specialist | $20 Copayment | $20 Copayment | DED | DED |
| In-Network Family Physician | $45 Copayment | $50 Copayment | DED + 30% | DED + 30% |
| In-Network Specialist | $65 Copayment | $70 Copayment | DED + 30% | DED + 30% |
| Out-of-Network | Not Covered | DED + 40% | DED + 50% | DED + 50% |
| Convenient Care Center | ||||
| In-Network | $45 Copayment | $50 Copayment | DED + 30% | DED + 30% |
| Out-of-Network | Not Covered | DED + 40% | DED + 40% | DED + 40% |
| Physician Services at Hospital | ||||
| In-Network | DED + 20% | DED + 20% | DED + 30% | DED + 30% |
| Out-of-Network | Not Covered | INN DED + 20% | INN DED + 50% | INN DED + 50% |
Preventive Services-Adult & Child Wellness Services
Preventive Services-Adult & Child Wellness Services
| BlueCare HMO Gold 47 | BlueOptions PPO Gold 3359 | BlueOptions HDHP Silver Individual Plan 5194 Account Funding: EE Only = $300 | BlueOptions HDHP Silver Family Plan 5195 Account Funding: EE+2 = $900 | |
| Office Services | ||||
| In-Network Family Physician | $0 Copayment | $0 | $0 Copayment | $0 Copayment |
| In-Network Specialist | $0 Copayment | $0 | $0 Copayment | $0 Copayment |
| Out-of-Network | Not Covered | 40% | 40% | 40% |
Medical / Surgical Care at a Facility
Medical / Surgical Care at a Facility
BlueCare HMO Gold 47 | BlueOptions PPO Gold 3359 | BlueOptions HDHP Silver Individual Plan 5194 Account Funding: EE Only=$300 | BlueOptions HDHP Silver Family Plan 5195 Account Funding: EE+1=$600 or EE+2=$900 | |
|---|---|---|---|---|
| Ambulatory Surgical Center (ASC) | ||||
| In-Network | $200 Copayment | $200 Copayment | DED + 30% | DED + 30% |
| Out-of-Network | Not Covered | Ded + 40% | Ded + 40% | Ded + 40% |
| Inpatient Hospital Facility (per admit) | OON only; if admitted as an Inpatient from ER, apply Inpatient Hospital Facility (per admit) Inpatient Hospital INN Option 1 cost share | |||
| In-Network | $300 per day/$1500 max | $300 per day/$1500 max | DED + 30% | DED + 30% |
| Out-of-Network | Not Covered | DED + 40% | DED + 50% | DED + 50% |
| Outpatient Hospital Facility (per visit) (Surgical) | ||||
| In-Network | $300 copay | $300 copay | DED + 30% | DED + 30% |
| Out-of-Network | Not Covered | DED + 40% | DED + 50% | DED + 50% |
Emergency and Urgent Care
Emergency and Urgent Care
BlueCare HMO Gold 47 | BlueOptions PPO Gold 3359 | BlueOptions HDHP Silver Individual Plan 5194 Account Funding: EE Only=$300 | BlueOptions HDHP Silver Family Plan 5195 Account Funding: EE+1=$600 or EE+2=$900 | |
|---|---|---|---|---|
| Emergency Room Facility (per visit) (No surgery performed or not admitted) | If admitted as an inpatient from ER, the hospital will submit an inpatient hospital claim instead of an ER facility claim. ER Copay will not apply on the claim; only inpatient facility cost share will apply. | |||
| In-Network | $250 Copayment | $250 Copayment | DED + 30% | DED + 30% |
| Out-of-Network | $250 Copayment | $250 Copayment | INN DED + 30% | INN DED + 30% |
| Urgent Care Centers | Out-of-Network only covered out-of-state. | |||
| Value Choice Urgent Care Provider | $65 Copay for remaining Visits PBP | DED | DED | |
| In-Network | $65 Copayment | $70 Copayment | DED + 30% | DED + 30% |
| Out-of-Network | Not Covered | INN DED + $70 Copayment | INN DED + 30% | INN DED + 30% |
Mental Health and Substance Dependency Services
Mental Health and Substance Dependency Services
| BlueCare HMO Gold 47 | BlueOptions PPO Gold 3359 | BlueOptions HDHP Silver Individual Plan 5194 Account Funding: EE Only=$300 | BlueOptions HDHP Silver Family Plan 5195 Account Funding: EE+1=$600 or EE+2=$900 | ||
|---|---|---|---|---|---|
| Physician Office | |||||
| In-Network Family Physician | $0 Copayment | $0 Copayment | DED + 40% | DED + 30% | |
| In-Network Specialist | $0 Copayment | $0 Copayment | DED + 30% | DED + 30% | |
| Out-of-Network | Not Covered | 40% | DED + 50% | DED + 40% | |
| Inpatient Hospital Facility | ER, apply Inpatient Hospital INN Option 1 cost share. | ||||
| In-Network | $0 Copayment | $0 Copayment | DED + 30% | DED + 30% | |
| Out-of-Network | Not Covered | 40% | DED + 50% | DED + 50% | |
| Outpatient Hospital Facility | |||||
| In-Network | $0 Copayment | $0 Copayment | DED + 30% | DED + 30% | |
| Out-of-Network | Not Covered | 40% | DED + 50% | DED + 50% | |
Teladoc
Teladoc
| BlueCare HMO Gold 47 | BlueOptions PPO Gold 3359 | BlueOptions HDHP Silver Individual Plan 5194 Account Funding: EE Only=$300 | BlueOptions HDHP Silver Family Plan 5195 Account Funding: EE+1=$600 or EE+2=$900 | |
|---|---|---|---|---|
| Standalone Telemedicine with Teladoc - General Medicine | ||||
| In-Network | $0 | $0 | Deductible | Deductible |
| Out-of-Network | Not Covered | Not Covered | Not Covered | Not Covered |
| Standalone Telemedicine with Teladoc - Dermatology | ||||
| In-Network | $10 | $10 | Deductible | Deductible |
| Out-of-Network | Not Covered | Not Covered | Not Covered | Not Covered |
| Standalone Telemedicine with Teladoc - Behavioral Health | ||||
| In-Network | $0 | $0 | Deductible | Deductible |
| Out-of-Network | Not Covered | Not Covered | Not Covered | Not Covered |
Prescription Drugs
Prescription Drugs
| BlueCare HMO Gold 47 | BlueOptions PPO Gold 3359 | BlueOptions HDHP Silver Individual Plan 5194 Account Funding: EE Only=$300 | BlueOptions HDHP Silver Family Plan 5195 Account Funding: EE+1=$600 or EE+2=$900 | |
|---|---|---|---|---|
| Deductible | ||||
| In-Network | ||||
| Retail - Generic/ Brand/ Non-Preferred | $15/$45/$65 | $15/$60/$100 | CYD + 30% | CYD + 30% |
| Rx- Specialty | $250 | $250 | CYD + 30% | CYD + 30% |
| Mail Order - Generic/Brand/Non-Preferred | $40/$115/$165 | $40/$150/$250 | CYD + 30% | CYD + 30% |
| Out-of-Network | ||||
| RETAIL - Generic/Brand/Non-Preferred | Not Covered | 50% | 50% | 50% |
| MAIL ORDER Generic/Brand/Non-Preferred | Not Covered | 50% | 50% | 50% |
Monthly premiums
Monthly premiums
| BlueCare HMO Gold 47 | BlueOptions PPO Gold 3359 | BlueOptions HDHP Silver Individual Plan 5194 Account Funding: EE Only=$300 | BlueOptions HDHP Silver Family Plan 5195 Account Funding: EE+1=$600 or EE+2=$900 | ||
|---|---|---|---|---|---|
| Employee (College paid) | |||||
| $726 | $710 | $624 | N/A | ||
| Spouse (Employee Paid) | |||||
| $798 | $782 | N/A | $388 | ||
| Child(ren) (Employee Paid) | |||||
| $581 | $568 | N/A | $282 | ||
| Family (Employee Paid) | |||||
| $1,379 | $919 | N/A | $500 | ||
HSA Voluntary Employee Contributions
Employees enrolled in either the HSA Individual Plan or HSA Family Plan are eligible to make additional contributions into their health savings account. Employees wishing to make voluntary contributions to their HSA or make changes to their voluntary contribution amount should contact Human Resources to complete the Employee HSA Payroll Deduction form and return it directly to Human Resources in the R-Annex for processing.
Accessibility Note: All forms are PDF format. If you need assistance accessing these file formats, please contact human.resources@sfcollege.edu or call HR directly at 352-395-5185.
For additional information regarding Florida Blue plan documents please contact Human Resouces at human.resources@sfcollege.edu or call HR directly at 352-395-5185.
If participating employees have not established a member account they may do so by logging onto the site below to register. Once registered you may access your personal account information, take advantage of plan discounts, and request replacement cards for your Florida Blue Health Plan.