Page 8 - 2016 Open Enrollment

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Medical—Florida Associates

Florida associates have coverage under Florida Blue (BCBS). For 2016,
Busey will offer a CDHP only.

PPO 1300 CDHP
In-Network Out-of-Network
Calendar Year Deductible
Individual $1,300 $2,600
Family $2,500 $5,000
Out-of-Pocket Maximum
Individual $5,000 $10,000
Family $5,000 $10,000
Physician Ofice Visits
Primary Care 20% coinsurance 40% coinsurance
Specialist 20% coinsurance 40% coinsurance
Wellness/Preventive Care
$0 40% coinsurance
Urgent Care
20% coinsurance 40% coinsurance
Lab Services/X-Ray
Physician Ofice 20% coinsurance 40% coinsurance
Outpatient Facility 20% coinsurance 40% coinsurance
Outpatient Hospital 20% coinsurance 40% coinsurance
Hospital Services
Inpatient 20% coinsurance 40% coinsurance
Outpatient 20% coinsurance 40% coinsurance
Emergency Room 20% coinsurance 20% coinsurance
Mental Health/Substance Abuse
Inpatient 20% coinsurance 40% coinsurance
Outpatient 20% coinsurance 40% coinsurance
Ofice Visits 20% coinsurance 40% coinsurance
Chiropractic Care
20% coinsurance 40% coinsurance
Prescription Drugs
Retail Supply Limit After Deductible
Bi-Weekly Rates PPO 1300 Tier 1 $10
CDHP Tier 2 $50
Associate Only $24.20 Tier 3 $80
Associate + Spouse $241.99 Tier 4 20% coinsurance
Associate + Child(ren) $150.15
Family $306.98 Visit www.loridablue.com.

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