Employee Benefits
Effective Date:
- First of the month following three months of service
Benefits
St. Johns County Medical Plan Options Effective January 1, 2009
| Benefit Description |
Option 1 |
Option 2 |
| Cost Sharing Options |
Blue Choice |
Blue Options |
| Calendar Year Deductible (CYD) |
| Per Individual |
$250 |
$500 |
| Family Aggregate |
$750 |
$1,500 |
| Coinsurance |
| In-Network Provider / Out of Network Provider |
80% / 60% |
80% / 60% |
| Office Services |
| In-Network Family Physician |
CYD + coinsurance |
$20 Copay (Ped / Gen Prac / Internist / Family Doc) |
In-Network Specialist
(no referral needed) |
CYD + coinsurance |
CYD + coinsurance |
| Out of Network Provider |
CYD + coinsurance |
CYD + coinsurance |
| Hospitalization |
| Inpatient Hospital Facility |
|
Option 1 / Option 2 |
| In-Network |
CYD + coinsurance |
$600 / $900 |
| Out of Network |
$200 PAD, CYD + coinsurance |
CYD + coinsurance |
| Outpatient Hospital Facility |
|
Option 1 / Option 2 |
| In-Network |
CYD + coinsurance |
$150 / $250 |
| Out of Network |
CYD + coinsurance |
CYD + coinsurance |
| Physician Services at Hospital & ER |
CYD + coinsurance |
CYD + coinsurance |
| Physician Services at Locations other than Office, Hospital & ER |
| In-Network Family Physicians |
CYD + coinsurance |
CYD + coinsurance |
| In-Network Specialists |
CYD + coinsurance |
CYD + coinsurance |
| Out of Network Providers |
CYD + coinsurance |
CYD + coinsurance |
| Emergency Room Facility |
| In-Network |
CYD + coinsurance |
$100 copayment |
| Out of Network |
CYD + coinsurance |
$200 copayment |
| Urgent Care Center |
CYD + coinsurance |
$20 Copay |
| Additional Benefits and Features |
| Ambulatory Surgical Center Facility |
| In-Network Facility |
CYD + coinsurance |
$100 copayment |
| Out of Network Facility |
CYD + coinsurance |
CYD + coinsurance |
| Independent Clinical Lab |
| In-Network |
CYD + coinsurance |
$0 (Quest) |
| Out of Network |
CYD + coinsurance |
CYD + 40% coinsurance |
| Independent Diagnostic Testing Facility |
CYD + coinsurance |
$100 copayment (includes radiologists fees) |
| Mammograms (member cost) |
$0 |
$0 |
| Out of Pocket Maximum |
Includes coinsurance only |
Includes CYD, Coinsurance, & copayments |
| Per Individual/ |
$2,000 + $250 Deductible |
$2,500 |
| Family Aggregate |
$6,000 + $750 Deductible |
$7,500 |
| Calendar Year Maximum Per Insured |
| Adult Wellness (CYD is waived) |
100% up to $250 CYM |
100% up to $250 CYM |
| Home Health Care |
$3,000 |
$2,500 |
| Mental Health (Inpatient / Outpatient) |
30 Days / 20 Visits |
30 Days / 20 Visits |
| Outpatient Theraphy and Spinal Manipulations |
$2,500 |
$2,500 |
| Skilled Nursing Facility |
60 Days |
60 Days |
| Lifetime Maximum Per Insured |
| Lifetime Maximum Per Insured |
$1,000,000 |
$1,000,000 |
| Hospice |
$5,200 |
$7,500 |
| Substance Dependency Care & Treatment |
$5,000 |
$5,000 LTM/$1600 CYM |
| Monthly Employee Contributions |
| Single |
$20.00 |
$0.00 |
| Employee/Child(ren) |
$135.00 |
$100.00 |
| Employee/Spouse |
$208.00 |
$150.00 |
| Family |
$323.00 |
$230.00 |
| Dental Schedule of Benefits |
| Deductible for Preventive Services |
None |
|
| Individual Deductible per person, per calendar year for Basic, Major and Orthodontic Services |
$50.00 |
|
| Family Deductible per person, per calendar year for Basic, Major and Orthodontic Services |
$100.00 |
|
| Coinsurance Percentage Payable by BCBS Florida Combined Life (FCL) Dental Plan |
| Preventive |
100% of scheduled allowance |
| Basic |
80% of scheduled allowance |
| Major |
50% of scheduled allowance |
| Orthodontics |
100% until lifetime maximum is utilized |
| Maximum Benefit |
| Calendar Year Maximum per person |
$1000.00 |
|
| Orthodontia Lifetime Maximum |
$1000.00 |
|
| Third Molar Extractions (Wisdom Teeth) |
$1000.00 |
|
| The surgical removal of impacted third molars (wisdom teeth) and associated services are payable under the dental plan at 80%. The payment of these reported services are not included in the calculation of the calendar year maximum of $1,000. These services are subject to the $50 individual deductible and a separate yearly maximum of $1,000 payable per person for the removal of impacted third molars. |
| Vision Care |
80% of cost with $250 calendar year maximum: |
| Deductible is waived. |
Eye exam, frames, lenses or contact lenses. |
| Pharmacy Prescription Drug Coverage |
| |
Retail (30 day supply) |
Mail (90 day supply) |
| Generic |
$10.00 |
$20.00 |
| Formulary Brandname |
$35.00 |
$70.00 |
| Non Formulary Brandname |
$50.00 |
$100.00 |
NOTE: There will always be at least two alternative formulary brandname drugs for each nonformulary brandname drug. Coverage for injectable drugs is under the PharmaCare plan. They are subject to 80/20 coinsurance until the member reaches a maximum out-of-pocket expense of $500.00. After that, the normal co-pays apply.
NOTE: Maximum out-of-pocket coinsurance responsibility limits under the medical plan do not include prescription co-pays. |
| Customer Service Numbers and Links to Websites |
| Medical Blue Choice PPO |
1 (800) 322-2808 (Blue Cross Blue Shield) |
| Medical Blue Options PPO |
1 (877) 352-2583 (Blue Cross Blue Shield) |
| Dental |
1 (877) 203-9921 |
|
| Website |
www.bcbsfl.com
(access BlueChoice PPO provider listings) |
| Prescriptions |
1-800-581-5300 |
|
| Website |
www.pharmacare.com |
|
| All Benefits |
www.sjcbcc.benergy.com |
|
| This is a summary of benefits and not a contract. All benefits are subject to the provisions, exclusions and limitations set forth in the master contract. To verify a provider's specialty or participation status, the insured may contact the local BCBSFL office, contact the provider's office, or review the most recent Provider Directory. It is the insured's sole responsibility to select and verify a provider's network participation status at the time services are rendered. |
Group Life Insurance:
-
$20,000 term life coverage for employee
-
$5,000 term life for covered spouse
-
$2,000 term life for each covered child
125 Flex Plan:
Flexible Spending Account:
-
Pre-tax dollars for qualified medical expenses
-
Debit card or automatic reimbursement for medical expenses
-
Automatic reimbursement for dependent care expenses
Other plans you can choose to enroll in:
Deferred Compensation:
Credit Union:
Holidays:
Retirement:
Sick Leave:
Vacation:
| Years Employed |
Number of Vacation Days |
| 0 year through 3 years |
10 days |
| 4 years through less than 10 years |
15 days |
| 10 years or more |
20 days |
Pay Day:
Direct Deposit:
Sick Leave Pool:
Birthday:
|