Florida Blue Five-Year Renewal History Monthly Change from Plan - - PDF document
Citrus County Mosquito Control District 2020 Florida Blue Renewal Florida Blue Five-Year Renewal History Monthly Change from Plan Year Employer Sponsored Plan Employee Previous Year Only Rate 2016 BlueOptions 5461 $865.02 1.7% 2017
Citrus County Mosquito Control District 2020 Florida Blue Renewal
Florida Blue Five-Year Renewal History
Plan Year Employer Sponsored Plan Monthly Employee Only Rate Change from Previous Year 2016 BlueOptions 5461 $865.02 1.7% 2017 BlueOptions 5461 $882.88 2.1% 2018 BlueOptions 5461 $991.09 12.3% 2019 BlueOptions 5461 $1,087.09 9.7% 2020 BlueOptions 5461 $1,239.84 14.1% Page 1
Citrus County Mosquito Control District 2020 Florida Blue Renewal
Renewal Summary
Deductible (per person/family) In-Network Out-of-Network Coinsurance (amount member pays) In-Network Out-of-Network Family Physician Specialist Out-of-Network Physician Office Services Family Physician Specialist Out-of-Network Inpatient Hospital Facility (per admission) Option 1 Option 2 Out-of-Network ER Facility (waived if admitted) In-Network Out-of-Network Outpatient Hospital Facility Option 1 Option 2 Out-of-Network Provider Services at Hospital & ER Independent Diagnostic Testing Facility In-Network Advanced2 Out-of-Network Independent Clinical Lab In-Network Out-of-Network Out-of-Pocket Maximum In-Network Out-of-Network Prescription Drug Program Rx Deductible
(Generic/Brand/Non-Preferred)
Retail Mail-Order CURRENT RENEWAL CURRENT RENEWAL CURRENT RENEWAL Employee Only $1,087.09 $1,239.84 $726.68 $828.80 $535.98 $611.31 Employee + Spouse $2,587.27 $2,950.82 $1,634.99 $1,864.73 $1,032.28 $1,177.34 Employee + Child(ren) $2,043.72 $2,330.90 $1,291.50 $1,472.98 $815.41 $930.00 Family $3,451.50 $3,936.49 $2,181.12 $2,487.61 $1,377.10 $1,570.61 Total Monthly Premium (based on 22 enrolled) $23,915.98 $27,276.48 Monthly Increase Annual Increase Percentage of Increase
1 CYD = Calendar Year Deductible 2 In-Network Advanced Imaging Services = MRI, MRA, PET, CT & Nuclear Medicine
This matrix is only a highlight of the many benefits and services provided or authorized by Blue Cross and Blue Shield of Florida, Inc. and does not constitute a contract. Wellness (Routine Exam, Well Woman Exam, Mammogram, Well Child) PLAN N A PLAN N B PLAN N C BlueOptions BlueOptions BlueOptions Predictable Cost 5461 HSA-Compatible 5070/5071 HSA-Compatible 5022/5023 $250/$750 $3,500/$7,000 $2,500/$5,000 $1,000/$3,000 $7,000/$14,000 $5,000/$10,000 10% 0% 20% 50% 20% 40% $10 CYD CYD + 20% $0 $0 $0 $0 $0 $0 Coinsurance Coinsurance Coinsurance $25 CYD CYD + 20% CYD1 + 50% CYD + 20% CYD + 40% $250 CYD CYD + 20% $375 CYD CYD + 20% CYD + 50% CYD + 20% CYD + 40% $100 CYD CYD + 20% $100 CYD + 20% CYD + 40% $100 CYD CYD + 20% $150 CYD CYD + 20% CYD + 50% CYD + 20% CYD + 40% $50 CYD CYD + 20% $50 CYD CYD + 20% $75 CYD CYD + 20% CYD + 50% CYD + 20% CYD + 40% $0 CYD CYD CYD + 50% CYD + 20% CYD + 40% $2,000/$4,000 $3,500/$7,000 $5,800/$11,600 $5,000/$10,000 $14,000/$28,000 $11,600/$23,200 $0 Combined with In-Network CYD BlueRx Discounts Only $10/$30/$50 100% after CYD $25/$75/$125 100% after CYD MONTHLY RATES MONTHLY EMPLOYER COST $3,360.50 $40,326.00 14.05% Page 2
Citrus County Mosquito Control District 2020 Florida Blue Renewal
Employer-Sponsored Alternate
CRO ROSSWALK BlueOptions All Copay 14001 Deductible (per person/family) In-Network $250/$750 Out-of-Network $1,000/$3,000 Coinsurance (amount member pays) In-Network 10% Out-of-Network 50% Family Physician $0 Specialist $0 Out-of-Network Coinsurance Physician Office Services Family Physician $10 Specialist $25 Out-of-Network CYD + 50% Inpatient Hospital Facility (per admission) Option 1 $250/day ($750 max) Option 2 $375/day ($1,125 max) Out-of-Network CYD + 50% ER Facility (copay waived if admitted) In-Network $100 Out-of-Network $100 Outpatient Hospital Facility Option 1 $150 Option 2 $200 Out-of-Network CYD + 50% Provider Services at Hospital & ER $0 Independent Diagnostic Testing Facility In-Network $50 Advanced2 $75 Out-of-Network CYD + 50% Independent Clinical Lab In-Network $0 Out-of-Network CYD + 50% In-Network $2,000/$4,000 Out-of-Network $5,000/$10,000 Prescription Drug Program Rx Deductible $0
Generic (Preventive/Condition Care/All Other)
Retail $0/$4/$10
Brand (Condition Care/All Other)
$15/$30
Non-Preferred/Speciality
$50/$150 Mail-Order 2X Copay for 3 Months Employee Only $1,064.83 Employee + Spouse $2,129.66 Employee + Child(ren) $1,969.94 Family $3,034.77 Total Monthly Premium (based on 22 enrolled) $23,426.26 Monthly Increase
Annual Increase
Percentage of Increase
Current Monthly Employee Only Rate $1,087.09 Current Monthly Premium $23,915.98
1 CYD = Calendar Year Deductible 2 In-Network Advanced Imaging Services = MRI, MRA, PET, CT & Nuclear Medicine 3 Prescription copays DO NOT count towards the Out-of-Pocket maximum on Plan 5461.
This matrix is only a highlight of the many benefits and services provided or authorized by Blue Cross and Blue Shield of Florida, Inc. and does not constitute a contract. Wellness (Routine Exam, Well Woman Exam, Mammogram, Well Child) 10% CURR RRENT BlueOptions Predictable Cost 5461 $250/$750 $1,000/$3,000 CYD + 50% 50% $10 $25 CYD1 + 50% $250 $375 CYD + 50% $100 $100 $100 $150 $0 $0 Coinsurance $30 $50 $50 $75 CYD + 50% $0 CYD + 50% Out-of-Pocket Maximum (includes CYD, Coinsurance, Copays, & Rx on ACA3) $2,000/$4,000 $5,000/$10,000 $0 $10 14.05% $50/NA $25/$75/$125 MONTHLY RATES $1,239.84 $2,950.82 $2,330.90 $3,936.49 MONTHLY EMPLOYER COST $27,276.48 $3,360.50 $40,326.00 Page 3
Citrus County Mosquito Control District 2020 Florida Blue Renewal
As-Is Renewal with Contributions
Deductible (per person/family) In-Network Out-of-Network Coinsurance (amount member pays) In-Network Out-of-Network Family Physician Specialist Out-of-Network Physician Office Services Family Physician Specialist Out-of-Network Inpatient Hospital Facility (per admission) Option 1 Option 2 Out-of-Network ER Facility (waived if admitted) In-Network Out-of-Network Outpatient Hospital Facility Option 1 Option 2 Out-of-Network Provider Services at Hospital & ER Independent Diagnostic Testing Facility In-Network Advanced2 Out-of-Network Independent Clinical Lab In-Network Out-of-Network Out-of-Pocket Maximum In-Network Out-of-Network Prescription Drug Program Rx Deductible
(Generic/Brand/Non-Preferred)
Retail Mail-Order Employee Only Employee + Spouse Employee + Child(ren) Family Payroll Deduction Monthly HSA Contribution3 Payroll Deduction Monthly HSA Contribution3 Employee Only $0.00 $294.04 $0.00 $294.04 Employee + Spouse $624.89 $0.00 $0.00 $62.50 Employee + Child(ren) $233.14 $0.00 $0.00 $309.84 Family $1,247.77 $0.00 $330.77 $0.00
1 CYD = Calendar Year Deductible 2 In-Network Advanced Imaging Services = MRI, MRA, PET, CT & Nuclear Medicine 3 Monthly HSA Contribution for Employee Only coverage has been calculated to avoid excess contributions.
Predictable Cost 5461 HSA-Compatible 5070/5071 HSA-Compatible 5022/5023 $250/$750 $3,500/$7,000 $2,500/$5,000 PLAN N A PLAN N B PLAN N C BlueOptions BlueOptions BlueOptions Wellness (Routine Exam, Well Woman Exam, Mammogram, Well Child) $0 $0 $0 $0 $0 $0 $1,000/$3,000 $7,000/$14,000 $5,000/$10,000 10% 0% 20% Coinsurance Coinsurance Coinsurance $10 CYD CYD + 20% 50% 20% 40% $250 CYD CYD + 20% $375 CYD CYD + 20% $25 CYD CYD + 20% CYD1 + 50% CYD + 20% CYD + 40% $100 CYD + 20% CYD + 40% $100 CYD CYD + 20% CYD + 50% CYD + 20% CYD + 40% $100 CYD CYD + 20% $50 CYD CYD + 20% $50 CYD CYD + 20% $150 CYD CYD + 20% CYD + 50% CYD + 20% CYD + 40% $0 CYD CYD CYD + 50% CYD + 20% CYD + 40% $75 CYD CYD + 20% CYD + 50% CYD + 20% CYD + 40% $0 Combined with In-Network CYD BlueRx Discounts Only $10/$30/$50 100% after CYD $25/$75/$125 100% after CYD $2,000/$4,000 $3,500/$7,000 $5,800/$11,600 $5,000/$10,000 $14,000/$28,000 $11,600/$23,200 $2,330.90 $1,472.98 $930.00 $3,936.49 $2,487.61 $1,570.61 MONTHLY RATES $1,239.84 $828.80 $611.31 $2,950.82 $1,864.73 $1,177.34 EMPLOYEE CONTRIBUTION SUMMARY Payroll Deduction $0.00 $1,710.98 $1,091.06 $2,696.65 Page 4
Citrus County Mosquito Control District 2020 Florida Blue Renewal
ACA Alternate Renewal with Contributions
PLA LAN N A BlueOptions All Copay 14001 Deductible (per person/family) In-Network $250/$750 Out-of-Network $1,000/$3,000 Coinsurance (amount member pays) In-Network 10% Out-of-Network 50% Family Physician $0 Specialist $0 Out-of-Network Coinsurance Physician Office Services Family Physician $10 Specialist $25 Out-of-Network CYD1 + 50% Inpatient Hospital Facility (per admission) Option 1 $250/day ($750 max) Option 2 $375/day ($1,125 max) Out-of-Network CYD + 50% ER Facility (copay waived if admitted) In-Network $100 Out-of-Network $100 Outpatient Hospital Facility Option 1 $150 Option 2 $200 Out-of-Network CYD + 50% Provider Services at Hospital & ER $0 Independent Diagnostic Testing Facility In-Network $50 Advanced2 $75 Out-of-Network CYD + 50% Independent Clinical Lab In-Network $0 Out-of-Network CYD + 50% In-Network $2,000/$4,000 Out-of-Network $5,000/$10,000 Prescription Drug Program Rx Deductible $0
Generic (Preventive/Condition Care/All Other)
Retail $0/$4/$10
Brand (Condition Care/All Other)
$15/$30
Non-Preferred/Speciality
$50/$150 Mail-Order 2X Copay for 3 Months Employee Only $1,064.83 Employee + Spouse $2,129.66 Employee + Child(ren) $1,969.94 Family $3,034.77 Payroll Deduction Payroll Deduction Monthly HSA Contribution Payroll Deduction Monthly HSA Contribution3 Employee Only $0.00 $0.00 $292.21 $0.00 $294.04 Employee + Spouse $1,064.83 $480.41 $0.00 $0.00 $45.85 Employee + Child(ren) $905.11 $364.52 $0.00 $0.00 $122.27 Family $1,969.94 $1,137.14 $0.00 $387.22 $0.00
1 CYD = Calendar Year Deductible 2 In-Network Advanced Imaging Services = MRI, MRA, PET, CT & Nuclear Medicine
* Deductible does not apply
3 Monthly HSA Contribution for Employee Only coverage has been
calculated to avoid excess contributions. Wellness (Routine Exam, Well Woman Exam, Mammogram, Well Child) $0 $0 $0 $0 $0*/$4*/$10 $0*/$0*/$0 $15*/$30 $0*/$0 $50/$150 2X Copay for 3 Months 100% after CYD MONTHLY RATES $772.62 $509.49 $0/$0 EMPLOYEE CONTRIBUTION SUMMARY $1,545.24 $1,018.98 $1,429.35 $942.56 $2,201.97 $1,452.05 Out-of-Pocket Maximum (includes CYD, Coinsurance, Copays, & Rx) $5,800/$11,600 $6,500/$13,000 $11,600/$23,200 $13,000/$26,000 Combined with In-Net CYD Combined with In-Net CYD CYD + 50% CYD + 50% CYD + 20% CYD CYD + 50% CYD + 50% CYD + 20% CYD CYD + 20% CYD CYD + 20% CYD CYD + 20% CYD CYD + 20% CYD CYD + 50% CYD + 50% CYD + 50% CYD + 50% CYD + 20% CYD CYD + 20% CYD CYD + 50% CYD + 50% CYD + 20% CYD CYD + 20% CYD 50% 50% CYD + 20% CYD CYD + 20% CYD Coinsurance Coinsurance $2,800/$5,600 $6,500/$13,000 $5,600/$11,200 $13,000/$26,000 20% 100% PLA LAN N B PLA LAN N C BlueOptions BlueSelect Essential HSA 15222 Essential HSA 18705 Page 5