Example_Medical_SBC.pdf

BlueOptions 05904 with Rx $10/$50/Not Covered Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 10/01/2018 - 09/30/2019 Coverage for: Individual and/or Family | Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help...

BlueOptions 05904 with Rx $10/$50/Not Covered Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 10/01/2018 - 09/30/2019 Coverage for: Individual and/or Family | Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, www.floridablue.com/plancontracts/group. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.floridablue.com/plancontracts/group or call 1-800-352-2583 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? In-Network: $2,500 Per Person/$7,500 Family. Out-ofNetwork: $5,000 Per Person/$15,000 Family. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.6 Are there services covered before you meet your deductible? Yes. Preventive care. Are there other deductibles for specific services? This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/. No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? What is not included in the out-of-pocket limit? Will you pay less if you use a network provider? Do you need a referral to see a specialist? Yes. In-Network: $6,000 Per Person/$12,000 Family. Out-OfNetwork: $8,000 Per Person/$20,000 Family. Premium, balance-billed charges, and health care this plan doesn't cover. Yes. See https://providersearch.floridablue.c om/providersearch/pub/index.htm or call 1-800-352-2583 for a list of network providers. No. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Even though you pay these expenses, they don’t count toward the out–of–pocket limit. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. You can see the specialist you choose without a referral. 1 of 6 SBCID: 1686503 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need Primary care visit to treat an injury or illness If you visit a health care provider’s office or clinic Specialist visit Preventive care/screening/ immunization No Charge 40% Coinsurance Diagnostic test (x-ray, blood work) Independent Clinical Lab: No Charge/ Independent Diagnostic Testing Center: $65 Copay per Visit Deductible + 40% Coinsurance $450 Copay per Visit Deductible + 40% Coinsurance If you have a test Imaging (CT/PET scans, MRIs) If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.floridablue.com/to olsresources/pharmacy/me dication-guide What You Will Pay Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) Deductible + 40% $35 Copay per Visit Coinsurance Deductible + 40% $65 Copay per Visit Coinsurance Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs $10 Copay per Prescription at retail, $25 Copay per Prescription by mail $50 Copay per Prescription at retail, $125 Copay per Prescription by mail Not Covered Specialty drugs are subject to the cost share based on applicable drug tier. 50% Coinsurance Limitations, Exceptions, & Other Important Information Physician administered drugs may have higher cost shares. Physician administered drugs may have higher cost shares. Physician administered drugs may have higher cost shares. You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Tests performed in hospitals may have higher cost-share. Prior Authorization may be required. Your benefits/services may be denied. Tests performed in hospitals may have higher costshare. Up to 30 day supply for retail, 90 day supply for mail order. Responsible Rx programs such as Prior Authorization may apply. See Medication guide for more information. 50% Coinsurance Up to 30 day supply for retail, 90 day supply for mail order. Not Covered Not Covered Specialty drugs are subject to the cost share based on the applicable drug tier. Not covered through Mail Order. Up to 30 day supply for retail. For more information about limitations and exceptions, see the plan or policy document at www.floridablue.com/plancontracts/group. 2 of 6 SBCID: 1686503 Common Medical Event If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you need mental health, behavioral health, or substance abuse services If you are pregnant If you need help recovering or have other special health needs What You Will Pay Limitations, Exceptions, & Other Important Network Provider Out-of-Network Provider Information (You will pay the least) (You will pay the most) Facility fee (e.g., ambulatory Deductible + 20% Deductible + 40% ––––––––none–––––––– surgery center) Coinsurance Coinsurance Ambulatory Surgical Center: Deductible + 40% Deductible + 20% Physician/surgeon fees Coinsurance/ Hospital: In––––––––none–––––––– Coinsurance Network Deductible + 20% Coinsurance Deductible + 20% Deductible + 20% Emergency room care ––––––––none–––––––– Coinsurance Coinsurance Emergency medical Deductible + 20% In-Network Deductible + ––––––––none–––––––– transportation Coinsurance 20% Coinsurance Deductible + $70 Copay per Urgent care $70 Copay per Visit ––––––––none–––––––– Visit Deductible + 20% Deductible + 40% Facility fee (e.g., hospital room) Inpatient Rehab Services limited to 30 days. Coinsurance Coinsurance Deductible + 20% In-Network Deductible + Physician/surgeon fees ––––––––none–––––––– Coinsurance 20% Coinsurance Services You May Need Outpatient services No Charge 40% Coinsurance ––––––––none–––––––– Inpatient services No Charge Physician Services: No Charge/ Hospital: 40% Coinsurance Prior Authorization may be required. Your benefits/services may be denied. Office visits $65 Copay on initial Visit Deductible + 40% Coinsurance Deductible + 20% Coinsurance Deductible + 20% Coinsurance Deductible + 20% Coinsurance In-Network Deductible + 20% Coinsurance Deductible + 40% Coinsurance Deductible + 40% Coinsurance Deductible + 40% Coinsurance Childbirth/delivery professional services Childbirth/delivery facility services Home health care Rehabilitation services $65 Copay per Visit Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.) ––––––––none–––––––– ––––––––none–––––––– Coverage limited to 20 visits. Coverage limited to 35 visits, including 26 manipulations. Services performed in hospital For more information about limitations and exceptions, see the plan or policy document at www.floridablue.com/plancontracts/group. 3 of 6 SBCID: 1686503 Common Medical Event Services You May Need Habilitation services Skilled nursing care Durable medical equipment Hospice services If your child needs dental or eye care Children’s eye exam Children’s glasses Children’s dental check-up What You Will Pay Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) Not Covered Deductible + 20% Coinsurance Not Covered Deductible + 40% Coinsurance Deductible + 20% Coinsurance Deductible + 40% Coinsurance Deductible + 20% Coinsurance Not Covered Not Covered Not Covered Deductible + 40% Coinsurance Not Covered Not Covered Not Covered Limitations, Exceptions, & Other Important Information may have higher cost-share. Prior Authorization may be required. Your benefits/services may be denied. Not Covered Coverage limited to 60 days. Excludes vehicle modifications, home modifications, exercise, bathroom equipment and replacement of DME due to use/age. ––––––––none–––––––– Not Covered Not Covered Not Covered Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Infertility treatment • Pediatric glasses • Bariatric surgery • Long-term care • Private-duty nursing • Cosmetic surgery • Non-preferred brand drugs • Routine eye care (Adult) • Dental care (Adult) • Pediatric dental check-up • Routine foot care unless for treatment of diabetes • Habilitation services • Pediatric eye exam • Weight loss programs • Hearing aids For more information about limitations and exceptions, see the plan or policy document at www.floridablue.com/plancontracts/group. 4 of 6 SBCID: 1686503 Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Chiropractic care - Limited to 35 visits • Most coverage provided outside the United • Non-emergency care when traveling outside the States. See www.floridablue.com. U.S. Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: State Department of Insurance at 1-877-693-5236, the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform or the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact the insurer at 1-800-352-2583. You may also contact your State Department of Insurance at 1-877-693-5236 or the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. For group health coverage subject to ERISA contact your employee services department. For non-federal governmental group health plans and church plans that are group health plans contact your employee services department. You may also contact the state insurance department at 1-877-693-5236. Additionally, a consumer assistance program can help you file your appeal. Contact U.S. Department of Labor Employee Benefits Security Administration at 1-866-4-USA-DOL (866-487-2365) or www.dol.gov/ebsa/consumer_info_health.html . Does this plan provide Minimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.–––––––––––––––––––––– For more information about limitations and exceptions, see the plan or policy document at www.floridablue.com/plancontracts/group. 5 of 6 SBCID: 1686503 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery)  The plan’s overall deductible  Specialist Copayment  Hospital (facility) Coinsurance  Other No Charge $2,500 $65 20% $0 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost In this example, Peg would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Peg would pay is $12,800 $2,500 $30 $1,800 $60 $4,390 Managing Joe’s type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition)  The plan’s overall deductible  Specialist Copayment  Hospital (facility) Coinsurance  Other Coinsurance $2,500 $65 20% 20% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost In this example, Joe would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Joe would pay is $7,400 $0 $2,600 $0 $60 $2,660 Mia’s Simple Fracture (in-network emergency room visit and follow up care)  The plan’s overall deductible  Specialist Copayment  Hospital (facility) Coinsurance  Other Coinsurance $2,500 $65 20% 20% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $1,900 In this example, Mia would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Mia would pay is $1,300 $300 $0 $0 $1,600 Note: These numbers assume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact: www.floridablue.com. 6 of 6 SBCID: 1686503 Section 1557 Notification: Discrimination is Against the Law Florida Blue, Florida Blue HMO, Florida Blue Preferred HMO (collectively, “Florida Blue”), Florida Combined Life and the Blue Cross and Blue Shield Federal Employee Program® (FEP) comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. We do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Florida Blue, Florida Blue HMO, Florida Blue Preferred HMO, Florida Combined Life and FEP: • Provide free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provide free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact: • Florida Blue (health and vision coverage): 1-800-352-2583 • Florida Combined Life (dental, life, and disability coverage): 1-888-223-4892 • Federal Employee Program: 1-800-333-2227 If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Florida Blue (including FEP members): Section 1557 Coordinator 4800 Deerwood Campus Parkway, DCC 1-7 Jacksonville, FL 32246 1-800-477-3736 x29070 1-800-955-8770 (TTY) Fax: 1-904-301-1580 [email protected] Florida Combined Life: Civil Rights Coordinator 17500 Chenal Parkway Little Rock, AR 72223 1-800-260-0331 1-800-955-8770 (TTY) [email protected] Health insurance is offered by Florida Blue. HMO coverage is offered by Florida Blue HMO, an affiliate of Florida Blue. Dental insurance is offered by Florida Combined Life Insurance Company, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Section 1557 Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019 1-800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-352-2583 (TTY: 1-877-955-8773). FEP: Llame al 1-800-333-2227 ATANSYON: Si w pale Kreyòl ayisyen, ou ka resevwa yon èd gratis nan lang pa w. Rele 1-800-352-2583 (pou moun ki pa tande byen: 1-800-9558770). FEP: Rele 1-800-333-2227 CHÚ Ý: Nếu bạn nói Tiếng Việt, có dịch vụ trợ giúp ngôn ngữ miễn phí dành cho bạn. Hãy gọi số 1-800-352-2583 (TTY: 1-800-955-8770). FEP: Gọi số 1-800-333-2227 ATENÇÃO: Se você fala português, utilize os serviços linguísticos gratuitos disponíveis. Ligue para 1-800-352-2583 (TTY: 1-800-955-8770). FEP: Ligue para 1-800-333-2227 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電1-800-352-2583（TTY: 1-800-955-8770)。FEP：請致電1-800-3332227 ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-352-2583 (ATS : 1-800955-8770). FEP : Appelez le 1-800-333-2227 PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800352-2583 (TTY: 1-800-955-8770). FEP: Tumawag sa 1-800-333-2227 Health insurance is offered by Florida Blue. HMO coverage is offered by Florida Blue HMO, an affiliate of Florida Blue. Dental insurance is offered by Florida Combined Life Insurance Company, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association. ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-352-2583 (телетайп: 1800-955-8770). FEP: Звоните 1-800-333-2227 -ÑÞã åÇÊÝ ÇáÕã æÇáÈßã: 1) 3852-253-008-ãáÍæÙÉ: ÅÐÇ ßäÊ ÊÊÍÏË ÇÐßÑ ÇááÛÉ¡ ÝÅä ÎÏãÇÊ ÇáãÓÇÚÏÉ ÇááÛæíÉ ÊÊæÇÝÑ áß ÈÇáãÌÇä. ÇÊÕá ÈÑÞã 1 .7222-333-008-ÈÑÞã 1 ÇÊÕá .0778-559-008 ATTENZIONE: Qualora fosse l'italiano la lingua parlata, sono disponibili dei servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800352-2583 (TTY: 1-800-955-8770). FEP: chiamare il numero 1-800-333-2227 ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: +1-800-352-2583 (TTY: +1-800-955-8770). FEP: Rufnummer +1-800-333-2227 주의: 한국어 사용을 원하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-352-2583 (TTY: 1-800-955-8770) 로 전화하십시오. FEP: 1-800-333-2227 로 연락하십시오. UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-352-2583 (TTY: 1-800-9558770). FEP: Zadzwoń pod numer 1-800-333-2227. ુ ના: જો તમે �જ ુ રાતી બોલતા હો, તો િન:�લ્ુ ક ભાષા સહાય સેવા તમારા માટ� ઉપલબ્ધ છે . �ચ ફોન કરો 1-800-352-2583 (TTY: 1-800-955-8770). FEP: ફોન કરો 1-800-333-2227 ประกาศ:ถาคุณพูดภาษาไทย คุณสามารถใชบริการชวยเหลือทางภาษาไดฟรี โดยติดตอหมายเลขโทรฟรี 1-800-352-2583 (TTY: 1-800-955-8770) หรือ FEP โทร 1-800-333-2227 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-352-2583（TTY: 1-800-955-8770）まで、お電話にて ご連絡ください。FEP: 1-800-333-2227 .‫ ﺗﺳﮭﯾﻼت زﺑﺎﻧﯽ راﯾﮕﺎن در دﺳﺗرس ﺷﻣﺎ ﺧواھد ﺑود‬،‫ اﮔر ﺑﮫ زﺑﺎن ﻓﺎرﺳﯽ ﺻﺣﺑت ﻣﯽ ﮐﻧﯾد‬:‫ﺗوﺟﮫ‬ .Ï‫ی‬Ñ‫ی‬ÊãÇÓ È 1-800-333-2227 ÈÇ ÔãÇÑå :FEP .Ï‫ی‬Ñ‫ی‬ÊãÇÓ È 1-800-352-2583 (TTY: 1-800-955-8770) ÈÇ ÔãÇÑå Baa ákonínzin: Diné bizaad bee yáníłti’go, saad bee áká anáwo’, t’áá jíík’eh, ná hólǫ́. Kojį’ hodíílnih 1-800-352-2583 (TTY: 1-800-955-8770). FEP ígíí éí kojį’ hodíílnih 1-800-333-2227. Health insurance is offered by Florida Blue. HMO coverage is offered by Florida Blue HMO, an affiliate of Florida Blue. Dental insurance is offered by Florida Combined Life Insurance Company, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association.