Page 6 - 2017 Benefits Enrollment Busey Florida

2017 BENEFITS ENROLLMENT

Medical—Florida Associates

Florida associates have coverage under Florida Blue (BCBS). For 2017, Busey will offer two CDHP options. Visit
www.loridablue.com.

PPO 1300 CDHP PPO 2500 CDHP
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $1,300 $2,500 $2,500 $5,000
Family $2,600 $5,000 $5,000 $10,000
Out-of-Pocket Maximum
Individual $5,000 $10,000 $5,800 $11,600
Family $5,000 $10,000 $11,600 $23,200
Physician Ofice Visits
Primary care 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
Specialist 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
Wellness/Preventive Care
$0 40% coinsurance $0 40% coinsurance
Urgent Care
20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
Lab Services/X-Ray
Physician ofice 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
Outpatient facility 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
Outpatient hospital 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
Hospital Services $500 copay per

Inpatient 20% coinsurance 40% coinsurance Option 1: 20% coinsurance admission then 20%
Option 2: 25% coinsurance
coinsurance
Outpatient 20% coinsurance 40% coinsurance Option 1: 20% coinsurance 40% coinsurance
Option 2: 25% coinsurance
Emergency room 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance
Mental Health/Substance Abuse
Inpatient 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
Outpatient 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
Ofice visits 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
Chiropractic Care
20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
Prescription Drugs
Retail supply limit After deductible After Deductible
Tier 1 $10 $10
Tier 2 $50 $50
Tier 3 $80 $80
Tier 4 $125 $125

Bi-weekly Rates PPO 1300 CDHP PPO 2500 CDHP
Associate only $35.25 $23.65
Associate + spouse $270.86 $177.20
Associate + child(ren) $167.77 $109.76
Family $341.27 $223.26

6 FIRST BUSEY CORPORATION