1 Real world practical solutions designed with you in mind2017 Benefits Overview
2 Overview of Health ProductsPPO BlueOptions Plan 03769 Health Care Reform Complaint Plan Plan 03359 & HRA Health Care Reform Compliant
3 Office Visits PPO 03769 PPO 03359 & HRA Family Physician/PCPSpecialist (BlueOptions) $30 $50 CYD + 20% Any services received at doctors office will apply to copay. Lab In Network – Quest Out of Network $0 CYD + 40% Lab is paid at 100% by using Quest. You can make appointments online!!! Out-of-Network Anything other than BlueOptions is Out of Network. Using Traditional doctors will protect you from balance billing.
4 Preventative Health PPO 03769 PPO 03359 & HRA Mammogram $0Based on doctor’s recommendation. Adult Wellness No Member Cost Share See 2017 Clinical Preventive Care Guidelines. Colonoscopy Adult Wellness Benefit One routine colonoscopy (age 50+ paid in full of allowed amount) The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer (CRC) using a colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary.
5 Hospital Services – InpatientPPO 03769 PPO & HRA Inpatient Facility Copay In-Network Out of Network $1,000 Option 1 $2,000 Option 2 CYD + 40% 20% Option 1 25% Option 2 To determine Option levels or participation, go to the Online Provider Directory Provider Services while Inpatient In Network $0 CYD + 20% Any services received by a Provider while in the hospital. Option 1 facility / Option 2 facility (teaching or specialized hospital)
6 Hospital Services – OutpatientPPO 03769 PPO & HRA Outpatient In-Network Hospital Out of Network $0 Option 1 CYD + 40% 20% Option 1 25% Option 2 To determine Option levels or participation, go to the Online Provider Directory Provider Services while Outpatient In Network $30 Copay $50 Copay CYD + 20% Any services received by a Provider
7 Deductible & CoinsurancePPO 03769 PPO & HRA Calendar Year Deductible Coinsurance In Network Out of Network $600/$1,800 20% 40% $1,500/$3,000 Applies to services such as Provider Services in Hospital, Independent Diagnostic Testing Facility, Durable Medical Equipment, Prosthetics & Orthotics and Ambulance Services.
8 Lifetime maximums are no longer in effect due to Health Care ReformOut of Pocket Maximum PPO 03769 PPO & HRA In Network and Out of Network (Combined) Per Person/Family $6,000/$12,000 $3,000 / $9,000 The maximum a members pays out of pocket in a benefit year. All of the following is applied to Max Out of Pocket: Copays, Calendar Year Deductible and Coinsurance and Rx. Lifetime maximums are no longer in effect due to Health Care Reform
9 Health Reimbursement Account (HRA) Funding (03359)Employee = $500 Employee + 1 = $1,000 Employee + 2 = $1,500 HRA funds are provided in January. Any monies not used by the end of the calendar year will be carried over and added to your HRA account the following year. If you terminate employment any unused balance will be forfeited. If you retire, you may take the account balance with you for use for future medical expenses. If you use your debit card you may need to submit detailed receipts to Health Equity, as validation of claim(s) are an IRS requirement. If a claim is a recurring claim (doctors office visit, prescription) you can indicate “recurring” on the letter or receipt, which will eliminate further validation for the remainder for the plan year.
10 Pharmacy – ALL PLANS Plans PPO 03769 PPO 03359 Mandatory Generic(30 day supply) Mail order (90 day supply) PPO 03769 PPO 03359 $15 - generic $45 - preferred brand $65 - non-preferred brand *25% - $250 Monthly Member Out of Pocket Maximum per specialty prescription applies $30/$90/$130/25% Specialty drugs are cost share and not available through mail order If a Brand Name Rx is purchased when a Generic Rx is available and the Physician has not indicated that a Brand Name Rx is medically necessary, member will be required to pay the difference between the cost of the Brand Name and Generic Rx in addition to the Rx copay. Pharmacy expenses apply to out-of-pocket maximums. * The 4th tier are Specialty Pharmacy medications that are high-cost injectable, infused, oral or inhaled medications that generally require close supervision and monitoring of the patients therapy. Please see the Medication Guide and a listing of the Specialty self-administered and provider-administered drugs.
11 Want to get the most out of your next doctor's visit?The more you tell your doctor about your health concerns, the better he or she can prevent, diagnose, or treat any problems. Follow these tips to get the most from each doctor visit. Preparing for your doctor's visit A little preparation can go a long way, saving you time and money. Be sure to check our online provider directory to see if your doctor participates in our network. Your cost will be lowest when you use a participating health care provider. Write down your concerns and questions before your visit, and bring them with you. Bring paper and pen to take notes. Ask a family member or friend to come along. They can help you ask questions and understand the answers. What Your Doctor Needs to Know Be sure you cover these topics: Any health concerns you have–even sensitive subjects Your symptoms, including when they began, how often they occur, how long they last, and whether they're getting worse Services or tests other doctors have performed for you All medications and supplements you take; bring a list or the actual products Your family's medical history Let your doctor know before your visit what language you prefer to speak or if you need an interpreter. What You Need to Know Before you leave the doctor's office, you may want to ask these questions: What is my condition, and what caused it? Which medications or other treatments do you recommend? How will they help? Will there be any side effects? Can lifestyle measures help my condition? Should I avoid certain medicines, activities, or foods? What kind of tests do I need–and why? How soon will test results be available, and how will I get them? If you don't understand an answer or feel concerned about it, speak up!
12 When you need to see a doctor right away…For non-emergency assistance—when you can’t get in to see your family doctor or don’t want to wait hours in the emergency room—urgent care centers are designed to provide prompt, quality service and help you save up to 50% on your out-of-pocket costs. Urgent care centers are staffed with qualified doctors and nurses that can handle medical problems like cuts and colds, flu symptoms, minor fractures, sprains and burns, ear infections, allergic reactions, animal bites, sprains and even immunizations. Most urgent care centers offer: Quality care and prompt service Shorter wait times—compared to an emergency room Weekend and after-hours care Service without an appointment Convenient locations Check our online provider directory to find participating urgent care centers located near you. Keep the names and addresses in a convenient place should you need them in a hurry. Serious injuries and emergencies If you have a serious injury or require immediate attention due to shortness of breath, severe abdominal or chest pains, uncontrolled bleeding, loss of consciousness, changes in vision, severe vomiting or other emergency conditions, call 911 or visit the nearest hospital. Be sure to contact your family doctor so that follow-up care can be scheduled, if necessary. Help is a phone call away If you have questions about a health condition or when to visit an urgent care center, you can speak to a Health Coach by calling
13 Know about generics and how to get them…One of the easiest ways to save money is to use the generic version of a prescribed brand-name drug when one is available. Your cost will be lower without sacrificing quality. So if you are starting a new medicine or re-filling one, you may want to talk to your doctor, or have your pharmacist talk with your doctor, about whether a generic is available and right for you. Check out this comparison chart and find generics using our online pharmacy tool. Over-the-Counter options can lower your costs Looking for ways to save money on medicine? There are other ways of filling the medicine cabinet without depleting your pocketbook. The key? Look for nonprescription, over-the-counter (OTC) medication. Check with your doctor. An OTC may work for you. OTC medication is medicine that can be sold without a prescription and is found on the shelves of stores like other packaged products. Many OTC medications are just as effective as prescription drugs. In fact, many OTC drugs were once available only with a prescription. These include popular pain relievers and allergy medications as well as drugs that fight ulcers, help you quit smoking, and more. Your doctor can tell you if an OTC medication can replace one of your prescriptions.
14 How to save on your next scanNot all imaging providers charge the same for their services. For example, an independent imaging center may charge less than a hospital. To help you reduce your out-of-pocket costs, it pays to do a little legwork. Discuss your imaging options with your doctor. Are there other ways to diagnose your condition that are just as effective? If your doctor recommends a CAT scan, PET scan, MRI, MRA or nuclear cardiology, ask where it will be performed. You’ll have lower out-of-pocket costs if you use providers and facilities that participate in your plan’s network. To save even more money, ask your doctor if your test can be done at an in-network Independent Diagnostic Testing Facility (IDTF). Services at an IDTF generally cost less than the same services done in an outpatient hospital setting. Use our online provider directory or call the number on your ID card to verify whether or not the providers and facilities participate in your plan’s network. Ask your doctor to request a pre-service review for these procedures. That way, you’ll always know up front whether the service is a covered benefit. Please be aware that you may be responsible for the cost of procedures you receive that are not considered medically necessary.
15 FAQ’s Where can I go to get information about a claim?Visit and go to Claims under the My Benefits menu section to view and print details of your claims. When I receive services outside the State of Florida, who submits the claim to BCBSF? Under the BlueCard Program, if the physician or provider is participating in the Blue Cross and Blue Shield network in that state, they will reimburse the physician or provider for the services you receive and them submit claim to BCBSF for reimbursement. If you should receive a bill from the physician or provider, please contact Customer Service at for assistance. What makes up Member Responsibility? Member Responsibility is the out-of-pocket portion of a claim that a member is expected to pay. For example, deductibles, copayments, and non-covered services are Member Responsibility. What is a Member Health statement? A Member Health Statement is a detailed reference of finalized health and pharmacy claims activities for the preceding 28-days. This statement allows members to track claims and reconcile provider balances and can be used as documentation for FSA, HRA and HSA accounts. What if I have a question about a claim? When you log onto FloridaBlue, you can us a question concerning your claim by selecting Ask a Question about this Claim at the bottom of the Claim Status Detail page. You will receive a reply in the Message Center or you may call us at Do I have to submit claims? Not if you choose a provider from within your plan provider network. Your provider should process all claim submission paperwork on your behalf. If you choose a provider outside the network, you may have to file claims for reimbursement.
16 Save Money Use In-Network doctors (BlueOptions for PPO plans)Use Quest Laboratories Stay in network using Online Provider Directory Provide doctor and pharmacy your ID card Log in to Florida Blue to view claims, benefit information, order new ID Cards and Member Handbooks Call Customer Service when you have questions