MEDICAL INSURANCE
Pilot Bank offers five medical plans through Florida Blue. To find participating providers go to www.bcbsfl.com and click on “Find a Doctor”, choose the appropriate plan type (BlueOptions or BlueCare), and click continue. Then, narrow down your search based on location and provider type.
HDHP Plan Options, compatible with a Health Savings Account (H.S.A)
Pilot Bank is offering the same plans as current. Though these are the same plans you will notice a change in the plan names. The current and new plan names are shown in the chart below.
BlueCare 126/127 HMO H.S.A
BlueOptions 0314/0315 PPO H.S.A.
BlueOptions 0212/0213 PPO H.S.A.
FBA 201/202
FBA 105/106
FBA 103/104
New plan names:
IN-NETWORK
Deductible (Individual / Family)
$1,500 / $3,000
$2,500 / $5,000
$1,350 / $2,700
Maximum Out-of-Pocket (Individual / Family)
$3,000 / $6,000
$5,800 / $11,600
$5,000 / $5,000
Out-of-Pocket Includes
Deductible, Coinsurance, & Copays
Coinsurance
90% / 10%
80% / 20%
80% / 20%
Routine Preventive Services Wellness, Immunizations, & Mammography/Colonoscopy
Covered 100%
CO-PAYS
TelaDoc
$40 Copay
$40 Copay
$40 Copay
Office Visits for Illness / Injury
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
Specialist Visits
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
Inpatient Hospital
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
Outpatient Surgery
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
Emergency Room
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
Urgent Care
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
OUTPATIENT DIAGNOSTIC SERVICES Lab Services (Freestanding Lab)
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
X-Ray Services (Freestanding Lab)
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
Complex Diagnostic
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
PRESCRIPTIONS
(After Deductible)
(After Deductible)
(After Deductible)
Retail (30 day supply)
$10 / $50 / $80 / $125
$10 / $50 / $80 / $125
$10 / $50 / $80 / $125
Mail Order (90 day supply)
2.5 x retail
2.5 x retail
2.5 x retail
OUT-OF-NETWORK Deductible
$5,000 / $10,000
$2,500 / $5,000
Maximum Out-of-Pocket
$11,600 / $23,200
$10,000 / $10,000
Not available
Coinsurance
60% / 40%
60% / 40%
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.
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