Health Insurance Plans

Overview

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

	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

	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 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

	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

	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	$0 Copayment- Visits - 1-2 PBP $65 Copay for remaining Visits PBP	$0 Copayment- Visits - 1-2 PBP $70 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

	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 + 30%	DED + 30%
In-Network Specialist	$0 Copayment	$0 Copayment	DED + 30%	DED + 30%
Out-of-Network	Not Covered	40%	DED + 40%	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

	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

	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

	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)
	$768	$751	$660	N/A
Spouse (Employee Paid)
	$844	$827	N/A	$409
Child(ren) (Employee Paid)
	$614	$600	N/A	$298
Family (Employee Paid)
	$1,458	$972	N/A	$528

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.

Schedule of Benefits

BlueCare HMO Gold 47

BlueOptions PPO Gold 3359

BlueOptions HDHP Silver Individual Plan 5194

BlueOptions HDHP Silver Family Plan 5195

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.

Florida Blue Health Member Registration