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.
Copay Plan Options
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 0402 HMO
BlueOptions 0307 PPO
New plan names:
FBA 305
FBA 004
IN-NETWORK Deductible (Individual / Family)
$3,500 / $5,000
$750 / $2,250
Maximum Out-of-Pocket (Individual / Family)
$6,350 / $12,700
$3,250 / $6,750
Out-of-Pocket Includes
Deductible, Coinsurance, Copays, & Prescriptions
Coinsurance
70% / 30%
80% / 20%
Routine Preventive Services Wellness, Immunizations, & Mammography/Colonoscopy
Covered 100%
CO-PAYS
TelaDoc
$0 Copay
$0 Copay
Office Visits for Illness / Injury
$40 Copay
$30 copay
Specialist Visits
$65 Copay
$60 Copay
Inpatient Hospital
Deductible & Coinsurance
Deductible & Coinsurance
Outpatient Surgery
Deductible & Coinsurance
Deductible & Coinsurance
Emergency Room
$300 Copay
$300 Copay
Urgent Care
$85 Copay
$65 Copay
OUTPATIENT DIAGNOSTIC SERVICES
Lab Services (Freestanding Lab)
100% Covered
100% Covered
X-Ray Services (Freestanding Lab)
$65 Copay
$50 Copay
Complex Diagnostic
$200 Copay
Deductible & Coinsurance
PRESCRIPTIONS
Retail (30 day supply)
$10 / $40 / $80 / $125
$10 / $40 / $80 / $125
Mail Order (90 day supply)
2.5 x retail
2.5 x retail
OUT-OF-NETWORK Deductible
$1,750 / $5,250
Maximum Out-of-Pocket
Not Available
$6,000 / $12,000
Coinsurance
50% / 50%
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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