Overview
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 | $600 / $1,800 | $1,750 / NA | $3,500 / $3,500 |
| Out-of-Network | N/A | Combined w/ INN | $5,000 / NA | $10,000 / $10,000 |
| 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 - $6,000 / $12,000 | $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 | $35 | $35 | DED + 20% | DED + 20% |
| In-Network Specialist | $50 | $50 | 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 | $220 per day up to $1,100 per admission | Option 1: $900 Option 2: $1,650 | Option 1: Ded + 20% Option 2: Ded + 25% | Option 1: Ded + 20% Option 2: Ded + 25% |
| Out-of-Network | Not Covered | $2,500 | $500 PAD + DED + 40% | $500 PAD + DED + 40% |
| Outpatient Hospital Facility (per visit) (Surgical) | ||||
| In-Network | $250 | Option 1: $250 Option 2: $350 | 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 | $250 | $150 + 20% (no DED) | 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 | $100 | $150 + 20% (no DED) | DED + 20% | DED + 20% |
| Urgent Care Centers | ||||
| In-Network | $35 | $35 | DED + 20% | DED + 20% |
| Ambulance | ||||
| In-Network | $0 | $35 | DED + 20% | 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 / $250 | $15 / $45 / $65 /$250 | 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) | ||||
| $958 | $758 | $438 | $458 | |
| Employee + 1 | ||||
| $958 | $758 | $384 | $384 | |
| Employee + Family | ||||
| $1577 | $880 | $399 | $399 | |
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 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.
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.