Health Insurance 2020
Cost Sharing - Member's Responsibility
Cost Sharing - Member's Responsibility
| HMO BlueCare 10 | BlueOptions 3766 | Blue Options HSA 05190 Individual Plan Account Funding: EE Only=$500 | Blue Options HSA 05191 Family Plan Account Funding: EE+1=$1,000 or EE+2=$1,500 | |
|---|---|---|---|---|
| Partially Health Care Reform Compliant (Grandfathered) | Partially Health Care Reform Compliant (Grandfathered) | Health Care Reform Compliant | Health Care Reform Compliant | |
| Deductible (DED) (Per Person/Family Aggregate) | ||||
| In-Network | N/A | $500 / $1,500 | $1,500 / NA | $3,000 / $3,000 |
| Out-of-Network | N/A | Combined w/ INN | $3,000 / NA | $6,000 / $6,000 |
| Coinsurance (BCBSF pays / Member pays) | ||||
| In-Network | N/A | 80% / 20% | 80% / 20% | 80% / 20% |
| Out-of-Network | N/A | 70% / 30% | 60% / 40% | 60% / 40% |
| Out of Pocket Maximum (Per Person/Family Aggregate) | ||||
| In-Network | Includes Pharmacy - $5,000 / $10,000 | Includes Pharmacy - $5,000 / $10,000 | $4,500 / NA | $6,850 / $9,000 |
| Out-of-Network | Includes Pharmacy - N/A | Includes Pharmacy - Combined w/ INN | $9,000 / NA | $18,000 / $18,000 |
Medical / Surgical Care by a Physician
Medical / Surgical Care by a Physician
| HMO BlueCare 10 | BlueOptions 3766 | Blue Options HSA 05190 Individual Plan Account Funding: EE Only=$500 | Blue Options HSA 05191 Family Plan Account Funding: EE+1=$1,000 or EE+2=$1,500 | |
|---|---|---|---|---|
| Partially Health Care Reform Compliant (Grandfathered) | Partially Health Care Reform Compliant (Grandfathered) | Health Care Reform Compliant | Health Care Reform Compliant | |
| Office Services | ||||
| In-Network Family Physician | $25 | $25 | DED + 20% | DED + 20% |
| In-Network Specialist | $40 | $40 | DED + 20% | DED + 20% |
| Out-of-Network | Not Covered | DED + 30% | DED + 40% | DED + 40% |
| Physician Services at Hospital | ||||
| In-Network | $0 | DED + 20% | DED + 20% | DED + 20% |
| Out-of-Network | Not Covered | DED + 30% | INN DED + 20% | INN DED + 20% |
Medical / Surgical Care at a Facility
Medical / Surgical Care at a Facility
| HMO BlueCare 10 | BlueOptions 3766 | Blue Options HSA 05190 Individual Plan Account Funding: EE Only=$500 | Blue Options HSA 05191 Family Plan Account Funding: EE+1=$1,000 or EE+2=$1,500 | |
|---|---|---|---|---|
| Partially Health Care Reform Compliant (Grandfathered) | Partially Health Care Reform Compliant (Grandfathered) | Health Care Reform Compliant | Health Care Reform Compliant | |
| Inpatient Hospital Facility (per admit) | ||||
| In-Network | $150 per day up to $750 per admission | Option 1: $750 Option 2: $1,500 | Option 1: Ded + 20% Option 2: Ded + 25% | Option 1: Ded + 20% Option 2: Ded + 25% |
| Out-of-Network | Not Covered | $2500 | $500 PAD + DED + 40% | $500 PAD + DED + 40% |
| Outpatient Hospital Facility (per visit) (Surgical) | ||||
| In-Network | $200 | Option 1: $150 Option 2: $250 | Option 1: Ded + 20% Option 2: Ded + 25% | Option 1: Ded + 20% Option 2: Ded + 25% |
| Out-of-Network | Not Covered | $350 | DED + 40% | DED + 40% |
| Outpatient Hospital Facility (per visit) (Non-Surgical) | ||||
| In-Network | $0 | Included with Surgical Services | Option 1: Ded + 20% Option 2: Ded + 25% | Option 1: Ded + 20% Option 2: Ded + 25% |
| Out-of-Network | Not Covered | Included with Surgical Services | DED + 40% | DED + 40% |
Emergency and Urgent Care
Emergency and Urgent Care
| HMO BlueCare 10 | BlueOptions 3766 | Blue Options HSA 05190 Individual Plan Account Funding: EE Only=$500 | Blue Options HSA 05191 Family Plan Account Funding: EE+1=$1,000 or EE+2=$1,500 | |
|---|---|---|---|---|
| Partially Health Care Reform Compliant (Grandfathered) | Partially Health Care Reform Compliant (Grandfathered) | Health Care Reform Compliant | Health Care Reform Compliant | |
| Emergency Room Facility (per visit) - 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 | $50 | $100 + 20% | Ded + 20% | Ded + 20% |
| Out-of-Network | $50 | $100 + 30% | INN DED + 20% | INN DED + 20% |
| Urgent Care Centers | ||||
| In-Network | $35 | $35 | DED + 20% | DED + 20% |
| Ambulance | ||||
| In-Network | $0 | DED + 20% | DED + 20% | DED + 20% |
| Out-of-Network | $0 | INN DED + 20% | INN DED + 20% | INN DED + 20% |
Other Special Services
Other Special Services
| HMO BlueCare 10 | BlueOptions 3766 | Blue Options HSA 05190 Individual Plan Account Funding: EE Only=$500 | Blue Options HSA 05191 Family Plan Account Funding: EE+1=$1,000 or EE+2=$1,500 | |
|---|---|---|---|---|
| Partially Health Care Reform Compliant (Grandfathered) | Partially Health Care Reform Compliant (Grandfathered) | Health Care Reform Compliant | Health Care Reform Compliant | |
| Gastric Bypass | ||||
| 1 PBP | 1 PBP | 1 PBP | 1 PBP | |
| TeleMedicine Services | ||||
| $10 | $10 | DED + Coin, Allowance Maximum $45 | DED + Coin, Allowance Maximum $45 | |
Prescription Drugs
Prescription Drugs
| HMO BlueCare 10 | BlueOptions 3766 | Blue Options HSA 05190 Individual Plan Account Funding: EE Only=$500 | Blue Options HSA 05191 Family Plan Account Funding: EE+1=$1,000 or EE+2=$1,500 | |
|---|---|---|---|---|
| Partially Health Care Reform Compliant (Grandfathered) | Partially Health Care Reform Compliant (Grandfathered) | Health Care Reform Compliant | Health Care Reform Compliant | |
| In-Network - Generic / Brand / Non-Preferred | ||||
| Retail | $15 / $45 / $65 | $15 / $45 / $65 | DED | DED |
| Mail Order | $30 / $90 / $130 | $30 / $90 / $130 | DED | DED |
Monthly premiums
Monthly premiums
| HMO BlueCare 10 | BlueOptions 3766 | Blue Options HSA 05190 Individual Plan Account Funding: EE Only=$500 | Blue Options HSA 05191 Family Plan Account Funding: EE+1=$1,000 or EE+2=$1,500 | |
|---|---|---|---|---|
| Partially Health Care Reform Compliant (Grandfathered) | Partially Health Care Reform Compliant (Grandfathered) | Health Care Reform Compliant | Health Care Reform Compliant | |
| Employee (College paid) | ||||
| $912 | $721 | $417 | $417 | |
| Employee + 1 | ||||
| $912 | $721 | $365 | $365 | |
| Employee + Family | ||||
| $1501 | $838 | $380 | $380 | |
Health Insurance 2019
Cost Sharing - Member's Responsibility
Cost Sharing - Member's Responsibility
| HMO BlueCare 10 | BlueOptions 3766 | Blue Options HSA 05190 Individual Plan Account Funding: EE Only=$500 | Blue Options HSA 05191 Family Plan Account Funding: EE+1=$1,000 or EE+2=$1,500 | |
|---|---|---|---|---|
| Partially Health Care Reform Compliant (Grandfathered) | Partially Health Care Reform Compliant (Grandfathered) | Health Care Reform Compliant | Health Care Reform Compliant | |
| Deductible (DED) (Per Person/Family Aggregate) | ||||
| In-Network | N/A | $500 / $1,500 | $1,500 / NA | $3,000 / $3,000 |
| Out-of-Network | N/A | Combined w/ INN | $3,000 / NA | $6,000 / $6,000 |
| Coinsurance (BCBSF pays / Member pays) | ||||
| In-Network | N/A | 80% / 20% | 80% / 20% | 80% / 20% |
| Out-of-Network | N/A | 70% / 30% | 60% / 40% | 60% / 40% |
| Out of Pocket Maximum (Per Person/Family Aggregate) | ||||
| In-Network | Includes Pharmacy - $5,000 / $10,000 | Includes Pharmacy - $5,000 / $10,000 | $4,500 / NA | $6,850 / $9,000 |
| Out-of-Network | Includes Pharmacy - N/A | Includes Pharmacy - Combined w/ INN | $9,000 / NA | $18,000 / $18,000 |
Medical / Surgical Care by a Physician
Medical / Surgical Care by a Physician
| HMO BlueCare 10 | BlueOptions 3766 | Blue Options HSA 05190 Individual Plan Account Funding: EE Only=$500 | Blue Options HSA 05191 Family Plan Account Funding: EE+1=$1,000 or EE+2=$1,500 | |
|---|---|---|---|---|
| Partially Health Care Reform Compliant (Grandfathered) | Partially Health Care Reform Compliant (Grandfathered) | Health Care Reform Compliant | Health Care Reform Compliant | |
| Office Services | ||||
| In-Network Family Physician | $25 | $25 | DED + 20% | DED + 20% |
| In-Network Specialist | $40 | $40 | DED + 20% | DED + 20% |
| Out-of-Network | Not Covered | DED + 30% | DED + 40% | DED + 40% |
| Physician Services at Hospital | ||||
| In-Network | $0 | DED + 20% | DED + 20% | DED + 20% |
| Out-of-Network | Not Covered | DED + 30% | INN DED + 20% | INN DED + 20% |
Medical / Surgical Care at a Facility
Medical / Surgical Care at a Facility
| HMO BlueCare 10 | BlueOptions 3766 | Blue Options HSA 05190 Individual Plan Account Funding: EE Only=$500 | Blue Options HSA 05191 Family Plan Account Funding: EE+1=$1,000 or EE+2=$1,500 | |
|---|---|---|---|---|
| Partially Health Care Reform Compliant (Grandfathered) | Partially Health Care Reform Compliant (Grandfathered) | Health Care Reform Compliant | Health Care Reform Compliant | |
| Inpatient Hospital Facility (per admit) | ||||
| In-Network | $150 per day up to $750 per admission | Option 1: $750 Option 2: $1,500 | Option 1: Ded + 20% Option 2: Ded + 25% | Option 1: Ded + 20% Option 2: Ded + 25% |
| Out-of-Network | Not Covered | $2500 | $500 PAD + DED + 40% | $500 PAD + DED + 40% |
| Outpatient Hospital Facility (per visit) (Surgical) | ||||
| In-Network | $200 | Option 1: $150 Option 2: $250 | Option 1: Ded + 20% Option 2: Ded + 25% | Option 1: Ded + 20% Option 2: Ded + 25% |
| Out-of-Network | Not Covered | $350 | DED + 40% | DED + 40% |
| Outpatient Hospital Facility (per visit) (Non-Surgical) | ||||
| In-Network | $0 | Included with Surgical Services | Option 1: Ded + 20% Option 2: Ded + 25% | Option 1: Ded + 20% Option 2: Ded + 25% |
| Out-of-Network | Not Covered | Included with Surgical Services | DED + 40% | DED + 40% |
Emergency and Urgent Care
Emergency and Urgent Care
| HMO BlueCare 10 | BlueOptions 3766 | Blue Options HSA 05190 Individual Plan Account Funding: EE Only=$500 | Blue Options HSA 05191 Family Plan Account Funding: EE+1=$1,000 or EE+2=$1,500 | |
|---|---|---|---|---|
| Partially Health Care Reform Compliant (Grandfathered) | Partially Health Care Reform Compliant (Grandfathered) | Health Care Reform Compliant | Health Care Reform Compliant | |
| Emergency Room Facility (per visit) - 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 | $50 | $100 + 20% | Ded + 20% | Ded + 20% |
| Out-of-Network | $50 | $100 + 30% | INN DED + 20% | INN DED + 20% |
| Urgent Care Centers | ||||
| In-Network | $35 | $35 | DED + 20% | DED + 20% |
| Ambulance | ||||
| In-Network | $0 | DED + 20% | DED + 20% | DED + 20% |
| Out-of-Network | $0 | INN DED + 20% | INN DED + 20% | INN DED + 20% |
Other Special Services
Other Special Services
| HMO BlueCare 10 | BlueOptions 3766 | Blue Options HSA 05190 Individual Plan Account Funding: EE Only=$500 | Blue Options HSA 05191 Family Plan Account Funding: EE+1=$1,000 or EE+2=$1,500 | |
|---|---|---|---|---|
| Partially Health Care Reform Compliant (Grandfathered) | Partially Health Care Reform Compliant (Grandfathered) | Health Care Reform Compliant | Health Care Reform Compliant | |
| Gastric Bypass | ||||
| 1 PBP | 1 PBP | 1 PBP | 1 PBP | |
| TeleMedicine Services | ||||
| $10 | $10 | DED + Coin, Allowance Maximum $45 | DED + Coin, Allowance Maximum $45 | |
Prescription Drugs
Prescription Drugs
| HMO BlueCare 10 | BlueOptions 3766 | Blue Options HSA 05190 Individual Plan Account Funding: EE Only=$500 | Blue Options HSA 05191 Family Plan Account Funding: EE+1=$1,000 or EE+2=$1,500 | |
|---|---|---|---|---|
| Partially Health Care Reform Compliant (Grandfathered) | Partially Health Care Reform Compliant (Grandfathered) | Health Care Reform Compliant | Health Care Reform Compliant | |
| In-Network - Generic / Brand / Non-Preferred | ||||
| Retail | $15 / $45 / $65 | $15 / $45 / $65 | DED | DED |
| Mail Order | $30 / $90 / $130 | $30 / $90 / $130 | DED | DED |
Monthly premiums
Monthly premiums
| HMO BlueCare 10 | BlueOptions 3766 | Blue Options HSA 05190 Individual Plan Account Funding: EE Only=$500 | Blue Options HSA 05191 Family Plan Account Funding: EE+1=$1,000 or EE+2=$1,500 | |
|---|---|---|---|---|
| Partially Health Care Reform Compliant (Grandfathered) | Partially Health Care Reform Compliant (Grandfathered) | Health Care Reform Compliant | Health Care Reform Compliant | |
| Employee (College paid) | ||||
| $864 | $683 | $395 | $395 | |
| Employee + 1 | ||||
| $864 | $683 | $345 | $345 | |
| Employee + Family | ||||
| $1422 | $794 | $360 | $360 | |
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.