Page 4 - 2020FCSBenefitsGuide
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Medical Providers BCBS Medical
To research medical providers please Medical/Rx Combined Out-of-Pocket Maximum
go to www.myhealthtoolkitl.com
High Deductible
and click “Find a Provider”, enter in ZIP Beneit Highlights Core Plan Prime Plan Health Plan with HSA
code and click “Save”, select “Show In-Network
me Only Doctors and Hospitals in my Financials
Plan”, enter in the irst 3 letters from Deductible (single/ $2,500/$5,000 $1,500/$3,000 $2,800/$5,600
family)
the ID card “FGG”, then enter in any Coinsurance (carrier/ 30% after deductible 20% after deductible 10% after deductible
search information (name, location, and/ member)
$8,000/$16,000
$4,500/$9,000
or specialty.) Maximum Out-of- includes deductible, includes deductible, $6,500/$13,000
Pocket (single/family)
coinsurance, and coinsurance, and
copays
copays
Chemotherapy Services Lifetime Maximum Unlimited Unlimited Unlimited
When receiving chemotherapy services, (per person)
if the provider or service facility is in- Physician Services Preventive Care is Covered at 100%
$30 copay (does not $25 copay (does not 10% after deductible
Primary Care
network, covered services will be paid apply to deductible; apply to deductible;
and no referral or requirement involving applies to MOOP) applies to MOOP)
10% after deductible
an FCS provider/facility applies. Specialist $60 copay $55 copay $45 copay, then 10%
$10 copay
Teladoc
$10 copay
after deductible
FCS Provider/facility (In Network): If Hearing Aids Subject to a deductible and $1,000 in- 10% after deductible
you do choose to go to an FCS provider/ network coinsurance every 3 years
facility, it will be free after the deductible, Hospitalization
and coinsurance will be waived after the Inpatient 30% after deductible 20% after deductible 10% after deductible
Hospitalization
deductible is met. Outpatient Surgery 30% after deductible 20% after deductible 10% after deductible
Physician Services at 30% after deductible 20% after deductible 10% after deductible
Important Plan Features Hospital and ER $30 copay $25 copay 10% after deductible
Urgent Care
X Labwork: in Florida you must use Emergency Room 30% after deductible 20% after deductible 10% after deductible
Outpatient
Quest Diagnostics; for lab work Diagnostics Lab Services—Quest Diagnostics
outside of Florida you must call Routine Diagnostics 30% after deductible 20% after deductible 10% after deductible
Blue Cross Blue Shield customer (lab and x-ray) 30% after deductible 20% after deductible 10% after deductible
Major Diagnostics
service (800.830.1501) to locate a (MRI, CAT, PET
contracted lab scans, etc.)
Outpatient Therapies (60 visits combined)
X Prior authorizations are required, Physical Therapy 30% after deductible 20% after deductible 10% after deductible
but not limited to surgery, advanced Speech Therapy 30% after deductible 20% after deductible 10% after deductible
Occupational Therapy 30% after deductible 20% after deductible 10% after deductible
imaging, etc.; please call Blue Cross Out-of-Network
Blue Shield customer service for prior Deductible (single/ $7,500/$15,000 $4,500/$9,000 $8,400/$16,800
authorization requirements family) 50% after deductible 50% after deductible 50% after deductible
Coinsurance
$13,500/$27,000
$24,000/$48,000
X Durable medical equipment: Maximum Out-of- includes deductible, includes deductible, $19,500/$39,000
Pocket (single/family)
pre-authorization is required for any coinsurance, and coinsurance, and
claims over $1,000 copays copays
Lifetime Maximum Unlimited Unlimited Unlimited
X Gastric bypass and/or lapband is not (per person)
covered, but treatment leading up Always conirm the medical procedure is covered under the plan before
to it is beginning. For example gastric bypass/lap band, ABA Therapy, and breast
reduction procedures are not covered.
4 2020 Benefits Guide
To research medical providers please Medical/Rx Combined Out-of-Pocket Maximum
go to www.myhealthtoolkitl.com
High Deductible
and click “Find a Provider”, enter in ZIP Beneit Highlights Core Plan Prime Plan Health Plan with HSA
code and click “Save”, select “Show In-Network
me Only Doctors and Hospitals in my Financials
Plan”, enter in the irst 3 letters from Deductible (single/ $2,500/$5,000 $1,500/$3,000 $2,800/$5,600
family)
the ID card “FGG”, then enter in any Coinsurance (carrier/ 30% after deductible 20% after deductible 10% after deductible
search information (name, location, and/ member)
$8,000/$16,000
$4,500/$9,000
or specialty.) Maximum Out-of- includes deductible, includes deductible, $6,500/$13,000
Pocket (single/family)
coinsurance, and coinsurance, and
copays
copays
Chemotherapy Services Lifetime Maximum Unlimited Unlimited Unlimited
When receiving chemotherapy services, (per person)
if the provider or service facility is in- Physician Services Preventive Care is Covered at 100%
$30 copay (does not $25 copay (does not 10% after deductible
Primary Care
network, covered services will be paid apply to deductible; apply to deductible;
and no referral or requirement involving applies to MOOP) applies to MOOP)
10% after deductible
an FCS provider/facility applies. Specialist $60 copay $55 copay $45 copay, then 10%
$10 copay
Teladoc
$10 copay
after deductible
FCS Provider/facility (In Network): If Hearing Aids Subject to a deductible and $1,000 in- 10% after deductible
you do choose to go to an FCS provider/ network coinsurance every 3 years
facility, it will be free after the deductible, Hospitalization
and coinsurance will be waived after the Inpatient 30% after deductible 20% after deductible 10% after deductible
Hospitalization
deductible is met. Outpatient Surgery 30% after deductible 20% after deductible 10% after deductible
Physician Services at 30% after deductible 20% after deductible 10% after deductible
Important Plan Features Hospital and ER $30 copay $25 copay 10% after deductible
Urgent Care
X Labwork: in Florida you must use Emergency Room 30% after deductible 20% after deductible 10% after deductible
Outpatient
Quest Diagnostics; for lab work Diagnostics Lab Services—Quest Diagnostics
outside of Florida you must call Routine Diagnostics 30% after deductible 20% after deductible 10% after deductible
Blue Cross Blue Shield customer (lab and x-ray) 30% after deductible 20% after deductible 10% after deductible
Major Diagnostics
service (800.830.1501) to locate a (MRI, CAT, PET
contracted lab scans, etc.)
Outpatient Therapies (60 visits combined)
X Prior authorizations are required, Physical Therapy 30% after deductible 20% after deductible 10% after deductible
but not limited to surgery, advanced Speech Therapy 30% after deductible 20% after deductible 10% after deductible
Occupational Therapy 30% after deductible 20% after deductible 10% after deductible
imaging, etc.; please call Blue Cross Out-of-Network
Blue Shield customer service for prior Deductible (single/ $7,500/$15,000 $4,500/$9,000 $8,400/$16,800
authorization requirements family) 50% after deductible 50% after deductible 50% after deductible
Coinsurance
$13,500/$27,000
$24,000/$48,000
X Durable medical equipment: Maximum Out-of- includes deductible, includes deductible, $19,500/$39,000
Pocket (single/family)
pre-authorization is required for any coinsurance, and coinsurance, and
claims over $1,000 copays copays
Lifetime Maximum Unlimited Unlimited Unlimited
X Gastric bypass and/or lapband is not (per person)
covered, but treatment leading up Always conirm the medical procedure is covered under the plan before
to it is beginning. For example gastric bypass/lap band, ABA Therapy, and breast
reduction procedures are not covered.
4 2020 Benefits Guide
