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Summary of Benefits
| Monthly Rates | ||||
|---|---|---|---|---|
| Plan | Individual | + Child(ren) | + Spouse/Partner | Family |
| FIC PPO 3 | $235.00 | $433.00 | $478.00 | $688.00 |
| Plan Highlights | |
|---|---|
| In- and out-of-network coverage | Yes |
| Primary care office visit copay (in-network) | $30 |
| Specialist copay office visit (in-network) | $50 |
| Prescription copay: generic drugs only | $10 |
| Prescription deductible | $100 |
| Emergency care copay | $100 |
| Hospital* deductible (in-network) | $3,000 |
| Hospital* coinsurance (in-network) | 20% |
| Outpatient mental health visits per year | 20 |
| Outpatient mental health copay (in-network) | $50 |
| Out-of-network deductible | $6,000 |
| Out-of-network coinsurance | 50% |
| Eye exam | Yes |
| Glasses or contact lenses | Yes |
About the Provider Network
FIC uses the BlueCard PPO® network, indicated by these logos,
which appear on your ID card:
Ask your doctor if he or she participates in the BlueCard PPO network, which includes all of the doctors and hospitals in the Empire BlueCross BlueShield network. You can also use the provider search to check if a certain doctor or hospital is in-network. If a doctor or hospital is in the Bluecard PPO network, they are required to accept FIC insurance.
Important Enrollment Information
If you are enrolling in both health and dental insurance, you must enroll in both at the same time. If you don’t enroll in dental when you enroll in health, you will have to wait until open enrollment (September). If you don’t enroll in health when you enroll in dental, you will have to complete the insurance eligibility application process again to enroll.
This page was updated on January 13, 2009.
