School Board of Highlands County
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The District School Board of Sumter County, FL Benefits Match-Up Exhibit Item 4c – 47 HMO Plan BENEFIT HIGHLIGHTS IN-NETWORK Write “Match” or Fill In Differences Plan Name: Florida Blue Plan 47 - HMO
MEDICAL
Lifetime Max imum Unlimited
Cale n dar Y ea r De d u ctible Individual / Family Maximum $1,500 / $4,500
Out-of-Pocket Maximum Individual / Family Maximum $4,500 / $9,000
Out-of-Pocket Limit What is included: Deductible Coinsurance Copayments Prescription Drugs Coinsurance 20%
Medical Pharmacy In-Network Monthly OOP $200 In-Network 20% coins Out-of-Network Not Covered Physician’s Services
Primary Care Visit – Office visits $30 copay and minor surgical procedures
Specialist Visit $55 copay
Urgent Care $60 copay
Independent Clinical Lab $0 Required Lab Provider? Services Quest – Exclusive In-Network Provider Advanced Imaging Services $250 copay
Preventive Care
Per Benefit Period Unlimited
Adult Wellness Services $0 Routine Adult Physical Exams and Immunizations Family Physician
Page 1 The District School Board of Sumter County, FL Benefits Match-Up Exhibit Item 4c – 47 HMO Plan BENEFIT HIGHLIGHTS IN-NETWORK Write “Match” or Fill In Differences Plan Name: Florida Blue Plan 47 - HMO
Specialist $0
Mammograms $0
Routine Colonoscopy $0 (50+)
Well Child Care $0 Services Family Physician Specialist $0
Other Types of Facility and Provider Services
Inpatient CYD + 20%
Physician and other CYD + 20% health care professional Outpatientservices Facility CYD + 20%
Physician and other CYD + 20% health care professional services
Emergency Room Visits $250 copay Facility In/Out-of- Network
Physician and other CYD + 20% health care professional services Ambulance – Ground/Air & CYD + 20% / CYD + 20% Water Ambulatory Surgical Center $200 copay Facility Services
Radiology, Pathology, Family Physician - $30 copay Anesthesiology Provider Services Specialist - $55 copay at an Ambulatory Surgical Center
Page 2 The District School Board of Sumter County, FL Benefits Match-Up Exhibit Item 4c – 47 HMO Plan BENEFIT HIGHLIGHTS IN-NETWORK Write “Match” or Fill In Differences Plan Name: Florida Blue Plan 47 - HMO
Therapy Services Cardiac Rehabilitation, Occupational, Speech, Physical, Massage & Spinal Manipulations
Outpatient Rehab Therapy Center $55 copay In-Network
$55 copay Outpatient Hospital Facility Services (per visit) Calendar Year 35 visits Maximums:
Home Health Care $0
Calendar Year Maximum: 20 visits
Skilled Nursing Facility CYD + 20%
Calendar Year Maximum: 60 days
Hospice CYD + 20%
Calendar Year Maximum: Unlimited
Durable Medical Equipment & Prosthetics and Orthotics Motorized Wheelchair $500 copay All Other $0
Allergy Injections $10 copay
Mental Health and Substance Abuse Services
Page 3 The District School Board of Sumter County, FL Benefits Match-Up Exhibit Item 4c – 47 HMO Plan BENEFIT HIGHLIGHTS IN-NETWORK Write “Match” or Fill In Differences Plan Name: Florida Blue Plan 47 - HMO
Mental Health and Substance Dependency Care and Treatment Services Inpatient / Outpatient Facility Services $0
Emergency Room $0 / $0
Physician Services at $0 Hospital and ER
Physician and Other $0 Health Care Professionals Family Physician Office
Specialist Office $0
Prescription Drug Benefits
RETAIL – 30 DAY SUPPLY
Pharmacy Deductible $100 – both retail and mail
Retail Preferred Generic $20 copay
Retail Preferred Brand $50 copay
Retail Non-Preferred Brand $80 copay
MAIL ORDER – 90 DAY SUPPLY Mail Order Generic $40 Copay
Mail Order Brand Preferred $100 Copay
Mail Order Brand Non- $160 Copay Preferred
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