The School Board of Polk County Guía de Beneficios

Medical Benefit
Lifetime Maximum
Calendar Year Deductible (CYD)
SCHEDULE OF BENEFITS
PCSB Health Plan
Unlimited
In-Network / YOU PAY
Out-of-Network*/ YOU PAY
Individual
Family
Calendar Year Out-of-Pocket Maximum
Individual
$750
$1,500
Includes CYD, Copays & Coinsurance
$5,000
$1,500
$3,000
Family
Hospital Services
Inpatient or Outpatient
$9,000 Unlimited
Option 1 - CYD +20% Coinsurance
Option 2 –CYD + 25% Coinsurance
CYD + 40% Coinsurance
Emergency Room CYD + 20% Coinsurance CYD + 20% Coinsurance
Urgent Care $40 Copay CYD + 40% Coinsurance
Outpatient Surgery
Ambulatory Surgical Center Facility
Services
Hospital Facility Services
Family Physician Office Visit (Includes
General Practice, Family Practice, Internal
Medicine & Pediatrics)
Specialist Physician Office Visit
(Includes all other physician specialties)
Maternity Care
OB Specialist
Hospital Services
Outpatient Therapy (Includes Cardiac,
Occupational, Physical, Speech &
Massage Therapies and Chiropractic
Visits)
CYD + 20% Coinsurance
Option 1 - CYD + 20% Coinsurance
Option 2 – CYD + 25% Coinsurance
CYD + 40% Coinsurance
CYD + 40% Coinsurance
$40 Copay CYD + 40% Coinsurance
$40 Copay CYD + 40% Coinsurance
$40 (Initial OB Visit Only)
Option 1 - CYD +20% Coinsurance
Option 2 –CYD + 25% Coinsurance
Option 1 - CYD + 20% Coinsurance
Option 2 – CYD + 25% Coinsurance
CYD + 40% Coinsurance
CYD + 40% Coinsurance
Benefit Period Maximum
Independent Clinical Lab
(outside the office visit setting)
Independent Diagnostic Testing Facility
(IDTF)
(includes physician services)
Advanced Imaging
(MRI, MRA, PET, CT, Nuclear Medicine)
Routine Preventive Health & Screening
Services
(includes well-woman exam)
Family Physician/PCP or Specialist
35 Visits (Includes up to 26 Spinal
Manipulations)
CYD
CYD + 20% Coinsurance
No Maximum
$0
35 Visits (Includes up to 26 Spinal
Manipulations)
CYD + 40% Coinsurance
CYD + 40% Coinsurance
No Maximum
CYD + 40% Coinsurance