MEDICAL INSURANCE
Colonial Distributing offers three medical plans through FloridaBlue. To find participating providers go to www.bcbsfl,com and click on “Find a Doctor”, then follow the prompts to complete the search. The chart below provides a brief overview of the medical plans. This chart is intended only to highlight the benefits available and should not be relied upon to fully determine your coverage.
If the below illustration of benefits conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your exact description of services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage .
BlueOptions 05302 BRONZE PLAN
BlueCare 68 PREMIUM PLAN
BlueOptions 05770 DELUXE PLAN
IN-NETWORK: Plan Year or Calendar Year Basis
Calendar Year
Calendar Year
Calendar Year
Deductible (Individual / Family)
$5,000 / $10,000
$1,000 / $3,000
$1,000 / $3,000
Coinsurance
70% / 30%
80% / 20%
80% / 20%
Maximum Out-of-Pocket (Individual/Family) Maximum Out-of-Pocket Includes
$6,350 / $12,700
$4,500 / $9,000
$3,500 / $7,000
Deductible, Coinsurance & Copayments
Deductible, Coinsurance & Copayments
Deductible, Coinsurance & Copayments
Lifetime Maximum
Unlimited
Unlimited
Unlimited
PREVENTIVE CARE:
Wellness Immunizations Mammography/Colonoscopy COPAYMENTS: Referral Required
Covered 100%
Covered 100%
Covered 100%
No
No
No
Office Visits Consultations for
$30 Copayment
$35 Copayment
$25 Copayment
Illness/Injury
Specialist Visits
$55 Copayment
$60 Copayment
$45 Copayment
$500 Copay per Day $1,500 Max
Inpatient Hospital
Deductible & Coinsurance
Deductible & Coinsurance
Outpatient Surgery
Deductible & Coinsurance
$600 Copay
Deductible & Coinsurance
Emergency Room Urgent Care
$300 Copayment $60 Copay
$500 Copay $80 Copay
$200 Copayment $50 Copay
OUTPATIENT DIAGNOSTIC SERVICES: Independent/Freestanding Lab Complex Diagnostic (MRI, CT, PET, Etc.) – Freestanding Facility
100%
100%
100%
Deductible & Coinsurance
$500 Copay
$200 Copay
PRESCRIPTIONS:
Tier 1: $10 copay Tier 2: 20% Coinsurance Tier 3: Not Covered
Tier 1: $10 copay Tier 2: $50 copay Tier 3: $80 copay
Tier 1: $10 copay Tier 2: $50 copay Tier 3: $80 copay
Retail (30 day supply)
OUT-OF-NETWORK 2 Deductible (Individual / Family)
$10,000 / $30,000
Not Covered
$3,000 / $6,000
Maximum Out-of-Pocket (Individual/Family)
$20,000 / $40,000
Not Covered
$7,000 / $14,000
Coinsurance
50 / 50%
Not Covered
50 / 50%
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