MEDICAL INSURANCE
Mezrah Consulting offers two medical plans through FloridaBlue. To find participating providers go to www.floridablue.com and click on “Find a Doctor”, choose the appropriate provider type. The Low and the High plan use the BlueCare (HMO) Network.
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.
LOW BlueCare 15572 Essential (HSA)
HIGH BlueCare 14256 All Copay
IN-NETWORK: Plan or Calendar Year Basis
Calendar Year
Calendar Year
Deductible (Individual/Family)
$2,700 / $7,000
$1,000 / $3,000
Coinsurance
80% / 20%
80% / 20%
Maximum Out-of-Pocket (Individual/Family)
$5,000, $10,000
$4,000 / $8,000
Maximum Out-of-Pocket Includes
Deductible, Coinsurance & Copayments
Deductible, Coinsurance & Copayments
Lifetime Medical Maximum
Unlimited
Unlimited
PREVENTIVE CARE:
Wellness Immunizations Mammography/Colonoscopy COPAYMENTS: Primary Physician Office Visits – No Referral Required
Covered 100%
Covered 100%
Deductible & Coinsurance
$25 Copayment
Specialist Visits
Deductible & Coinsurance
$45 Copayment
Inpatient Hospital
Deductible & Coinsurance
$300/day to a Max of $1,500
Outpatient Surgery
Deductible & Coinsurance
$350 Copayment
Emergency Room
Deductible & Coinsurance
$300 Copayment
Urgent Care
Deductible & Coinsurance
$50 Copayment
OUTPATIENT DIAGNOSTIC SERVICES:
Lab Services
Deductible & Coinsurance
$100 Copayment
X-Ray Services
Deductible & Coinsurance
$60 Copayment
Complex Diagnostic
Deductible & Coinsurance
$250 Copayment
PRESCRIPTIONS: Retail (30 day supply)
$10 / $30 / $50 copays after Deductible
$15 / $60 / $100
Mail Order (90 day supply)
2 X retail
2 X retail
OUT-OF-NETWORK: Deductible (Individual/Family)
$5,600 / $11,200
In-Network Only
Maximum Out-of-Pocket (Individual/Family)
$11,600 / $23,200
In-Network Only
Lifetime Medical Maximum
Unlimited
In-Network Only
Coinsurance
50% / 50%
In-Network Only
3
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