| BLUE
PLAN |
|
| Lifetime
Maximum |
No Maximum |
| |
|
| Calendar
Year Deductible |
|
| Individual |
$500 |
| Family |
$1500 |
| |
|
Physician
Office Visit Copay
(PPO Network Only) |
$20 |
| |
|
| In-Network
Specialist Copay |
$40 |
| |
|
| Coinsurance
(Blue Cross Share) |
|
| Preferred
Providers |
80%
of PPO Schedule |
| Non-Preferred
Providers |
60%
of Allowance |
| |
|
Calendar
Year Maximum Out of Pocket
(Deductible & Your Share of Coinsurance)
|
|
| Individual: Utilizing
the PPO Network |
$2,500 |
| Individual:
Non-PPO |
$5,000 |
| Family: Utilizing
the PPO Network |
$5,000 |
| Family:
Non-PPO |
$10,000 |
| |
|
Well
Care Benefit
(PPO Network Only) |
Adult
annual preventive exam paid at 100%.
|
| |
|
| Prescription
Drug Benefits |
- Deductible
- $0
- Preferred
Generic Presciption Drugs - $15 Copayment ($30 Mail
Order Copayment)
- Preferred
Brand Name Prescription Drugs - $30 Copayment ($60
Mail Order Copayment)
- Non-Preferred
Prescription Drugs - $50 Copayment ($100 Mail Order
Copayment)
|
| |
|
| PAYROLL
RECOVERY (Your Cost Before Flex Discount) |
|
| Individual
Employee |
$200.00
month / $46.15 week |
| Family |
$550.00
Month / $126.92 week |
| GREEN
PLAN |
|
| Lifetime
Maximum |
No Maximum |
| |
|
| Calendar
Year Deductible |
|
| Per
Person In-Network |
$1,500 |
| Per
Person Out-of Network |
$4,500 |
| |
|
Family
Physician Office Visit Copay
(PPO Network Only) |
$35 |
| |
|
| Coinsurance
(Blue Cross Share) |
|
| Preferred
Providers |
50%
of PPO Schedule |
| Non-Preferred
Providers |
50%
of Allowance |
| |
|
Calendar
Year Maximum Out of Pocket
(Deductible & Your Share of Coinsurance)
|
|
| Individual: Utilizing
the PPO Network |
$10,000 |
| Individual:
Non-PPO |
$10,000 |
| Family: Utilizing
the PPO Network |
$20,000 |
| Family:
Non-PPO |
$20,000 |
| |
|
Well
Care Benefit
(PPO Network Only) |
Adult
annual preventive exam paid are $35 at participants
family physician.
|
| |
|
| Prescription
Drug Benefits |
$15 Copay Plan for Generics- $500 Prescription Deductible
and 50% Coinsurance for Brand Name Drugs. |
| |
|
| PAYROLL
RECOVERY (Your Cost Before Flex Discount) |
|
| Individual
Employee |
$0.00
month/$0.00 week |
| Family |
$275.00
month / $63.46 week |
| YELLOW
PLAN |
|
| Lifetime
Maximum |
No Maximum |
| |
|
| Calendar
Year Deductible |
|
| Per
Person In-Network |
$1,500 |
| Per
Person Out-of Network |
$3,000 |
| |
|
Physician
Office Visit Copay
(PPO Network Only) |
DED
+ 10% |
| |
|
| Coinsurance
(Blue Cross Share) |
|
| Preferred
Providers |
10%
of PPO Schedule |
| Non-Preferred
Providers |
40%
of Allowance |
| |
|
Calendar
Year Maximum Out of Pocket
(Deductible & Your Share of Coinsurance)
|
|
| Individual: Utilizing
the PPO Network |
$5,000 |
| Individual:
Non-PPO |
$10,000 |
| Family: Utilizing
the PPO Network |
$5,000 |
| Family:
Non-PPO |
$10,000 |
| |
|
Well
Care Benefit
(PPO Network Only) |
Adult
annual preventive exam paid at 90%.
|
| |
|
| Prescription
Drug Benefits |
-
Apply to deductible, then copays of:
- Preferred
Generic Presciption Drugs - $15 Copayment ($40 Mail
Order Copayment)
- Preferred
Brand Name Prescription Drugs - $30 Copayment ($75
Mail Order Copayment)
- Non-Preferred
Prescription Drugs - $50 Copayment ($125 Mail Order
Copayment)
- Until
out of pocket maximum is reached.
|
| |
|
| PAYROLL
RECOVERY (Your Cost Before Flex Discount) |
|
| Individual
Employee |
$95.00 month / $21.92 week |
| Family |
$320.00 month / $73.84 week |

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Acousti
Engineering Company of Florida
4656 34th Street, S. W.
Orlando, Florida 32811 |
E-mail:
info@acousti.com
Phone: (407) 425-3467
Fax: (407) 422-6502 |
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Copyright 2000 by Acousti Engineering Company of Florida.
All rights reserved.
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