2. 1
Benefits Definition Example
Deductible Only
This is the dollar amount that you must pay
each year before insurance begins to pay for
certain health care services.
This plan includes a $6,850 health
deductible. If you need to visit your primary
care physician for a sick visit (non-
preventive), you will be responsible for the
entire Florida Blue allowed amount of $187.
Remember, you will be responsible for the
entire Florida Blue allowed amount for
covered services that are not preventive
until you meet your $6,850
deductible. Once your deductible is met,
you will pay $0 for all covered health
services.
Deductible +
Coinsurance
The deductible is the dollar amount that you
must pay each year before insurance begins to
pay for certain health care services.
After the deductible is met you will pay a
percentage (or coinsurance) of the allowed
amount until you have met the out-of-pocket
maximum (The maximum dollar amount you
spend on all applicable co-pays, coinsurance,
and deductibles combined during the benefit
period.)
This plan includes a $5,000 deductible and
10% coinsurance. For example, say you
have met $4,990 of your $5,000 deductible.
If you need an MRI done at a participating
advanced imagining center and Florida Blue
allows $110.00, making you responsible for
$10, which applies towards the deductible,
thus satisfying your calendar year
deductible. However, remember that this
plan also includes 10% coinsurance and you
will still need to pay 10% of the remaining
$100 allowed amount ($10 additional) up to
the out-of-pocket maximum.
Copay
A fixed dollar amount or flat fee you pay for
covered health care services
On this plan type you will pay the $75 copay
for a visit to a participating urgent care
center. Let’s say that the Florida Blue
allowed amount for the urgent care service
is $400. The member will only pay $75.
$0 Copayment The pays nothing for covered services.
When you go to a participating lab for your
lab services (e.g. Quest Labs), you will not
have to pay anything ($0 copay) for those
services.
Deductible + Copay
or Copay after
Deductible
Deductible is the dollar amount that you must
pay each year before insurance begins to pay
for certain health care services.
After you have met your deductible, you will
have a fixed dollar amount or flat fee (copay)
for covered health care services.
This plan includes a $6,700 deductible and a
copay for some services. For example, if
you are admitted inpatient at a participating
hospital and the total charge for the inpatient
stay is $8,000 and Florida Blue allowed
$6,700, you will be responsible for the entire
Florida Blue allowed amount plus $150
copay for a total member responsibility of
$6,850.
Copay + Deductible
This benefit design requires a member to pay a
copay amount and then the difference between
the allowed amount and the copay amount until
they have met their Deductible.
Member has a Specialist benefit of $80 +
Deductible. The deductible on the member’s
plan is $1,000 and the member has not met
any of their deductible yet this year. The
member goes to the Specialist. The allowed
amount for the visit is $150. The member
would pay $80 copay + $70 toward the
deductible. The total $150 would go toward
the out of pocket maximum.
3. 2
Benefits Definition Example
$Copay per day, up
to a max number of
days
This is where the member will pay a flat copay
for each day, for a certain number of days.
After the max number of days, the member will
not pay any additional copays for the
remainder of that stay.
Your plan has an inpatient benefit of $350
per day for 3 days. If you are admitted
inpatient for 10 days, you will only pay $350
for the first 3 days, totaling $1,050 for the
entire inpatient stay.
X% coinsurance up
to a max of $X per
admission
This is where the member would pay a percent
of the allowed amount (coinsurance) but only
up to a certain amount (the maximum amount
they would pay for that visit)
If you need Skilled Nursing Facility services,
your benefit is 20% up to $500 max per
admission. The participating facility bills a
total of $6,000 for a 10-day consecutive
stay, which Florida Blue allows $3,000.
Because the percentage of the allowed
(20% of $3,000 = $600) is more than the
benefit max ($500), you will only pay the
$500 benefit max (think of this like a $500
copay)
