Page 4 - 2020FCSBenefitsGuide

To research medical providers please BCBS Medical
go to www.myhealthtoolkitl.com
and click “Find a Provider”, enter in ZIP Medical/Rx Combined Out-of-Pocket Maximum
code and click “Save”, select “Show Beneit Highlights Core Plan Prime Plan High Deductible
me Only Doctors and Hospitals in my Health Plan with HSA
Plan”, enter in the irst 3 letters from Financials In-Network
the ID card “FGG”, then enter in any Deductible (single/ $2,500/$5,000 $1,500/$3,000 $2,800/$5,600
search information (name, location, and/ family)
or specialty.) Coinsurance (carrier/ 30% after deductible 20% after deductible 10% after deductible
member)
$8,000/$16,000
$4,500/$9,000
FCS is the only in-network provider for Maximum Out-of- includes deductible, includes deductible, $6,500/$13,000
Pocket (single/family)
chemotherapy services. An FCS facility coinsurance, and coinsurance, and
and provider must be used to receive in- copays copays
network beneits. The only exceptions are Lifetime Maximum Unlimited Unlimited Unlimited
(per person)
the following. Physician Services Preventive Care is Covered at 100%
Primary Care $30 copay (does not $25 copay (does not 10% after deductible
X Your FCS doctor refers you to apply to deductible; apply to deductible;
another provider or facility which is Specialist applies to MOOP) applies to MOOP) 10% after deductible
$55 copay
$60 copay
in the BCBS network OR Teladoc $10 copay $10 copay $45 copay, then 10%
after deductible
X An FCS treatment facility is not Hearing Aids Subject to a deductible and $1,000 in- 10% after deductible
within 40 miles of the patient’s home network coinsurance every 3 years
Hospitalization
Note: Coinsurance will be waived for these Inpatient 30% after deductible 20% after deductible 10% after deductible
FCS services Hospitalization
Outpatient Surgery 30% after deductible 20% after deductible 10% after deductible
Important Plan Features Physician Services at 30% after deductible 20% after deductible 10% after deductible
Hospital and ER
Urgent Care
10% after deductible
$25 copay
$30 copay
X Labwork: in Florida you must use Emergency Room 30% after deductible 20% after deductible 10% after deductible
Quest Diagnostics; for lab work Outpatient Lab Services—Quest Diagnostics
outside of Florida you must call Diagnostics 30% after deductible 20% after deductible 10% after deductible
Routine Diagnostics
Blue Cross Blue Shield customer (lab and x-ray)
service (800.830.1501) to locate a Major Diagnostics 30% after deductible 20% after deductible 10% after deductible
contracted lab (MRI, CAT, PET
scans, etc.)
X Prior authorizations are required, Outpatient Therapies (60 visits combined)
30% after deductible 20% after deductible 10% after deductible
Physical Therapy
but not limited to surgery, advanced Speech Therapy 30% after deductible 20% after deductible 10% after deductible
imaging, etc.; please call Blue Cross Occupational Therapy 30% after deductible 20% after deductible 10% after deductible
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)
Coinsurance 50% after deductible 50% after deductible 50% after deductible
X Durable medical equipment: Maximum Out-of- $24,000/$48,000 $13,500/$27,000 $19,500/$39,000
pre-authorization is required for any Pocket (single/family) includes deductible, includes deductible,
claims over $1,000 coinsurance, and coinsurance, and
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