MEDICAL INSURANCE
Palmetto Prime offers two 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 .
BlueCare OA HMO Plan NFQ54
BlueCare OA HMO Plan NFQ51
IN-NETWORK: Plan Year or Calendar Year Basis
Plan Year
Plan Year
Deductible (Individual / Family)
$5,000 / $10,000
$2,000 (per person)
Coinsurance
70% / 30%
50% / 50%
Maximum Out-of-Pocket (Individual/Family)
$6,350 / $12,700
$6,350 / $12,700
Maximum Out-of-Pocket Includes
Deductible, Coinsurance & Copayments
Deductible, Coinsurance & Copayments
Lifetime Maximum
Unlimited
Unlimited
PREVENTIVE CARE:
Wellness Immunizations Mammography/Colonoscopy COPAYMENTS: Referral Required Office Visits Consultations for Illness/Injury
Covered 100%
Covered 100%
No (PCP Required)
No (PCP Required)
$40 Copayment
$35 Copayment
Specialist Visits
$65 Copayment
$75 Copayment
Inpatient Hospital
Deductible & Coinsurance
$2,000 Copay
Outpatient Surgery
Deductible & Coinsurance
$300 Copay
Emergency Room Urgent Care
$300 Copayment $85 Copay
$400 Copayment $80 Copay
OUTPATIENT DIAGNOSTIC SERVICES: Independent/Freestanding Lab Complex Diagnostic (MRI, CT, PET, Etc.) – Freestanding Facility
100%
100%
$200 Copay
$200 Copay
PRESCRIPTIONS:
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)
Unavailable
Unavailable
Maximum Out-of-Pocket (Individual/Family)
Unavailable
Unavailable
Coinsurance
Unavailable
Unavailable
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