Page 6 - Draken Intl. 2022 OE Flipbook
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Medical and Pharmacy Coverage
Florida Blue – BlueOptions 05906
Medical Plan Provisions In-Network
Annual Deductible (Individual/Family) $5,000/$10,000
Coinsurance (Florida Blue/You) 80%/20%
Out-of-Pocket Maximum (Includes Deductible) $7,900/$15,800
Preventive Care/Wellness Visit Covered at 100%
Primary Care Provider Office Visit $10 copay
Specialist Office Visit $100 copay ($20 Value Choice Provider)
Radiology Services deductible & 20% coinsurance
Inpatient Hospital Services deductible & 20% coinsurance
Outpatient Hospital Services deductible & 20% coinsurance
Urgent Care $75 copay
Emergency Room (waived if admitted) $250 copay + deductible & 20%
Pharmacy Provisions In-Network
Prescription Drug Deductible (Individual/Family) None
Retail Pharmacy (up to a 30-day supply)
Tier 1 $10 copay
Tier 2 $50 copay
Tier 3 $80 copay
Mail Order Pharmacy (90-day supply)
Tier 1 $25 copay
Tier 2 $125 copay
Tier 3 $200 copay
*After deductible
Florida Blue – BlueOptions 05906
Medical Plan Provisions Out-of-Network
Annual Deductible (Individual/Family) $10,000/$20,000
Coinsurance (Florida Blue/You) 50%/50%
Out-of-Pocket Maximum (Includes Deductible) $20,000/$40,000
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