MEDICAL INFORMATION
Fast Track Urgent Care offers medical coverage through FloridaBlue, you have three plan options to choose from. To find participating providers go to www.bcbsfl.com and click on “Find a Doctor”, then follow the prompts to complete the search within the “BlueCare HMO” network. The chart below provides a brief overview of the medical plan offered.
BUY-UP PLAN #1 BlueCare 54
BUY-UP PLAN #2 BlueCare 48
BASE PLAN BlueCare 128/129
IN-NETWORK DEDUCTIBLE
(your first dollar cost for covered in-network claims)
Deductible (Individual / Family)
$2,500 / $5,000
$5,000 / $10,000
$2,000 / $6,000
COINSURANCE (your responsibility on claims costs once you’ve met the deductible) 20% 30% OUT OF POCKET MAXIMUM (once met all in-network covered services are covered by the plan) Maximum Out-of-Pocket (Individual / Family) $5,000 / $10,000 $6,350 / $12,700
20%
$5,500 / $11,000
Maximum Includes
Deductible, Coinsurance, Prescription Costs & Copays
PREVENTIVE CARE Wellness, Immunizations, Mammography, Colonoscopy, etc.
Covered 100%, no cost to you
OFFICE VISITS
Referral Required
No (PCP Required)
Office Visits (Illness/Injury)
Deductible & Coinsurance
$40 Copay
$35 Copay
Specialist Visits
Deductible & Coinsurance
$65 Copay
$65 Copay
HOSPITAL SERVICES
$100 POD 1 + Deductible & Coinsurance
Inpatient Hospital
Deductible & Coinsurance Deductible & Coinsurance
Outpatient Surgery
Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance
Emergency Room
Deductible & Coinsurance
$300 Copay
$300 Copay
Urgent Care
Deductible & Coinsurance
$85 Copay
$70 Copay
2 Free visits per calendar year & Flu Shot
2 Free visits per calendar year & Flu Shot
2 Free visits per calendar year & Flu Shot
FAST TRACK URGENT CARE
DIAGNOSTIC TESTING Lab – Freestanding facility
Deductible & Coinsurance
Covered 100%
Covered 100%
Advanced Imaging (MRI, CAT, PET, etc.)
Deductible & Coinsurance
$300 Copay
$300 Copay
(once deductible has been met)
PRESCRIPTIONS
Retail (30 day supply) Tier 1 / 2 / 3
$10 / $50 / $80
$10 / $50 / $80
$10 / $50 / $80
OUT-OF-NETWORK 1
Refer to plan summary for details Semi Monthly Cost for Coverage
Employee Only
$81.72
$124.23
$150.53
Employee + Spouse
$372.14
$440.75
$540.07
Employee + Child(ren)
$257.81
$313.15
$387.64
Employee + Family
$528.81
$615.60
$748.96
1 Per Occurrence Deductible 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. 3
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