BlueChoice / Franchise Contract
Benefit Summary -- $1,000 Deductible
With the BlueChoice PPO Health Plan, you get the freedom
to choose between convenient, affordable care from you PPO network Physician, or
other providers for care as you see fit. In order to take advantage of lower
out-of-pocket costs, simply choose a PPO network provider.
Benefits
Your Financial Responsibilities for Covered Services
Deductible:
|
Individual Calendar Year Deductible |
$1,000 |
|
The Individual Calendar Year deductible
will be waived |
|
|
by BCBSF for outpatient surgical
procedures |
|
|
Family Calendar Year Deductible |
$2,000 |
Coinsurance Percentage Payable by BCBSF:
|
PPO Providers - Allowed Amount |
90% |
|
Providers Not Participating In PPO - Allowance |
70% |
|
AmbulanceServices - Allowance |
90% |
|
Family Calendar Year Deductible |
$2,000 |
Coinsurance Responsibility Per Calendar Year:
|
Individual Coinsurance Limit |
$2,000 |
|
Family Coinsurance Limit |
$4,000 |
Benefit Maximums
Calendar Year Maximums Per Insured:
|
Mental Health Services Benefit
Maximum: |
|
|
Inpatient days/visits or combination of inpatient and Partial Hospitalization days..... |
30 |
|
Outpatient Visits |
20 |
|
Home Health Care Benefit Maximum |
$1,000 |
|
Skilled Nursing Facility Days Benefit Maximum |
60 |
|
Enteral Formula Benefit Maximum |
$2,500 |
|
Combination Outpatient Cardiac Occupation, Physical, Speech and |
|
|
Massage Therapies and Spinal
Manipulations Benefit Maximum |
$1,000 |
Lifetime Maximums Per Insured
|
Total Lifetime Maximum Benefit |
$2,000,000 |
|
Mental Helth Services Lifetime Benefit Maximum |
$50,000 |
|
Substance Dependency Care and Treatment Benefit Maximum
(inpatient, outpatient, or any combination) |
$2,000 |
|
Hospice Benefit Maximum |
$5,200 |
Additional Benefits and Features
4th Quarter Deductible Carry-over
Any charges credited by BCBSF toward you Calendar Year Deductible for claims
incurred during the last three months of the prior Calendar year will be carried
over to reduce your Individual Calendar Year Deductible requirement for the
Current Calendar Year.
Accident Care
Covered Services in connection with an Accident are not subject to the
Individual Calendar Year deductible. All other financial responsibilities,
including Coinsurance will continue to apply.
Admission Certification Requirements
All Hospital admissions in the State of Florida must be certified. The following
penalties will apply for admissions within the State of Florida which are not
certified:
Admissions to a Hospital that is a BCBSF PPC Provider -
No penalty for you. It is the responsibility of the PPC Hospital/Physician to
obtain admission certification.
Hospitals that are not BCBSF PPC Providers - any
non-certified admission in the State of Florida are subject to a 25% benefit
penalty reduction. You are responsible for obtaining certification for the
admission from BCBSF and for any applicable benefit reduction for failure to
obtain such certification.
Pharmacy Program
After satisfying the calendar year deductible, covered drugs will be reimbursed
at 70% of our allowance.
This Benefit Summary is only a partial description of the
coverage and benefits provided or authorized by Blue Cross Blue Shield of
Florida, Inc., an independent licensee of the Blue Cross and Blue Shield
Association. This does not constitute an insurance contract or Certificate of
Coverage. For a complete description of benefits and exclusions, please see your
Certificate of Coverage; its terms prevail.