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Heal t h-Dent al-Vi s i on pr es ent edby:

Ef f ec t i vedat e:1/ 1/ 21

For Small Groups Everyday Health Benefit Plan 18852

Amount Member Pays In-Network Out-of-Network

Summary of Benefits for Covered Services Financial Features Deductible (DED1) (PBP2) (DED is the amount the member is responsible for before Florida Blue HMO pays) Coinsurance (Coinsurance is the percentage the member pays for services)

$7,400 per person $14,800 per family 50% of the allowed amount

Not covered

Out-of-Pocket Maximum (PBP) (Out-of-Pocket Maximum includes DED, Coinsurance, Copayments and Prescription Drugs)

$8,550 per person $17,100 per family

Not covered

$0 Copay/ $20 Copay $50 Copay $100 Copay

Not covered Not covered Not covered

$0 Copay/$100 Copay $0 Copay

Not covered Not covered

Maternity (Cost Share for initial visit only) Primary Care Physician Specialist

$50 Copay $100 Copay

Not covered Not covered

Allergy Injections (per visit) Primary Care Physician Specialist

$10 Copay $10 Copay

Not covered Not covered

Advanced Imaging Services (AIS) (MRI, MRA, PET, CT, Nuclear Med.)

$100 Copay

Not covered

Medical Pharmacy - Physician-Administered Medications (applies to Office Setting and Specialty Pharmacy Vendors) In-Network Monthly Out-of-Pocket (OOP) Maximum3 Low: Standard: In Office Health Care Professional Administered Medications Low: Standard:

$100 $200

Not covered

Office Services Physician Office Services Value Choice Provider/Specialist5 (available in select counties) Primary Care Physician In Network Specialist Virtual Visits(designated providers only) Primary Care Physician/Specialist Behavioral Health Services

10% 20%

Not covered Not covered

Physician-Administered Medications – These medications require the administration to be performed by a health care provider. The medications are ordered by a provider and administered in an office or outpatient setting. Physician-Administered medications are covered under the medical benefit. Please refer to the Physician-Administered medication list in the Medication Guide for a list of drugs covered under this benefit.

Preventive Care Routine Adult & Child Preventive Services, Wellness Services, and Immunizations Mammograms

$0

Not covered

$0

Not covered

Colonoscopy (Routine for age 50+ then frequency schedule applies) $0 Not covered 1 DED = Deductible 2 PBP = Per Benefit Period 3 In-Network Medical Pharmacy will be paid at 100% for the remainder of the calendar month once OOP max is met.

5See Agent Toolkit for a full list of counties where Value Choice Providers are available.

Page 1 of 6

89300-0720R (Bronze)

For Small Groups Everyday Health Benefit Plan 18852

Amount Member Pays In-Network Out-of-Network

Summary of Benefits for Covered Services Emergency Medical Care Value Choice Urgent Care Provider (available in select counties)

$0 Copay Visits 1-2 PBP

Not covered

Urgent Care Centers Emergency Room Facility Services (per visit)

$105 Copay 50% after Deductible

Not covered 50% after In-Network Deductible

Ambulance Services

50% after Deductible

50% after In-Network Deductible

50% after Deductible 50% after Deductible

Not covered Not covered

Independent Clinical Lab (e.g., Blood Work) Outpatient Hospital Facility Services (per visit) (e.g., Blood Work and X-rays) Hospital / Surgical

$75 Copay 50% after Deductible

Not covered Not covered

Ambulatory Surgical Center Facility (ASC)

50%

Not covered

Outpatient Hospital Facility Services (per visit) Therapy Services All other Services

50% after Deductible 50% after Deductible

Not covered Not covered

Inpatient Hospital Facility and Rehabilitation Services (per admit) Mental Health / Substance Dependency

50% after Deductible

Not covered

Inpatient Hospitalization Facility Services (per admit)

$0

Not covered

Outpatient Hospitalization Facility Service (per visit)

$0

Not covered

Emergency Room Facility Services (per visit) Provider Services at Hospital Primary Care Physician / Specialist

$0

$0

$0

Not covered

Provider Services at ER Primary Care Physician / Specialist

$0

$0

Provider Services at Locations other than Office, Hospital and ER Primary Care Physician / Specialist

5

Outpatient Diagnostic Services Independent Diagnostic Testing Facility Services (per visit) (e.g. X-rays) (Includes Provider Services) Diagnostic Services (except AIS) Advanced Imaging Services (AIS) (MRI, MRA, PET, CT, Nuclear Med.)

$0

Not covered

Outpatient Office Visit Primary Care Physician / Specialist Other Provider Services

$0

Not covered

Provider Services at Hospital Provider Services at ER

50% after Deductible 50% after Deductible

Not covered 50% after In-Network Deductible

Radiology, Pathology and Anesthesiology Provider Services at an Ambulatory Surgical Center (ASC) Provider Services at Locations other than Office, Hospital and ER Primary Care Physician Specialist

50% after Deductible

Not covered

$50 Copay $100 Copay

Not covered Not covered

Page 2 of 6

89300-0720R (Bronze)

For Small Groups Everyday Health Benefit Plan 18852

Amount Member Pays In-Network Out-of-Network

Summary of Benefits for Covered Services Other Special Services Combined Outpatient Cardiac Rehabilitation and Occupational, Physical, Speech and Massage Therapies and Spinal Manipulations Outpatient Rehabilitation Therapy Center Outpatient Hospital Facility Services (per visit)

$100 Copay 50% after Deductible

Not covered Not covered

Durable Medical Equipment, Prosthetics and Orthotics Motorized Wheelchair All Other

50% after Deductible $0

Not covered Not covered

Home Health Care Skilled Nursing Facility

$0 50% after Deductible

Not covered Not covered

Hospice

50% after Deductible

Not covered

Page 3 of 6

89300-0720R (Bronze)

Preferred Pharmacy Network When you use a pharmacy in the Preferred Pharmacy Network, such as Walgreens, Walmart, Publix, WinnDixie and FHCP you’ll pay a lower cost share or copay for your prescriptions.

If you choose to fill a prescription outside the Preferred Pharmacy Network, you may pay higher out-of-pocket costs.

To find a preferred pharmacy, follow these steps: • Log in to your member website.

• Click on Tools, then Find a Doctor & More.

• In the Search Within box, make a selection from the drop-down menu.

• Select Pharmacy from the drop-down menu in the Provider Type box.

• Preferred pharmacies feature an orange “preferred pharmacy” designation in the search returns. Use these pharmacies to get the lowest out-of-pocket costs.

Here is an example of how the Preferred Pharmacy Network will work.

ValueScript – SimplyBlue Tier 1

Tier 2

Tier 3

Tier 4

Tier 5

Tier 6

Preventive Prescription Drugs and Supplies (USPSTF)

Condition Care Generic Prescription Drugs and Supplies

Low Cost Generic Prescription Drugs and Supplies

Condition Care Brand Name Prescription Drugs and Supplies

High Cost Generic, Preferred Brand Name Prescription Drugs and Supplies

Specialty Generic and Brand Name Prescription Drugs; Non-Preferred Prescription Drugs and Supplies

Preferred Pharmacy

Standard Pharmacy

$0

$10 (Generic) $20 (Brand)

Preferred Pharmacy

$4

Standard Pharmacy

$14

Preferred Pharmacy

$25

Standard Pharmacy

Preferred Pharmacy

$35

$75

Standard Pharmacy

$95

Preferred Pharmacy

Standard Pharmacy

Preferred Pharmacy

Standard Pharmacy

$150

$160 (Generic) $170 (Brand)

**$300 $200

**300 $220 (NonPreferred Brand)

Preferred Pharmacy Network only applies to Retail and Extended Supply Network (cost shares are based on 30-day supply) *Home delivery is excluded from the Preferred Pharmacy Network **Specialty Drugs are not included in the Preferred Pharmacy Network ***Pharmacy plan cost share examples are only for illustrative purposes only

Page 4 of 6

89300-0720R (Bronze)

For Small Groups Everyday Health Benefit Plan 18852

Amount Member Pays In-Network Out-of-Network

Summary of Benefits for Covered Services Prescription Drug Program (ValueScript Rx®)

Low Cost Generic Drugs: Tier 1 – 3 Preventive6 (e.g., oral contraceptives) Condition Care Generic Rx6 (high blood pressure, high cholesterol, diabetes, asthma) Low Cost Generics

*Prescriptions filled outside the Preferred Pharmacy Network may have higher out-ofpocket costs. Please refer to Preferred Pharmacy Network Flier above for details.

High Cost Generic / Brand Drugs: Tier 4 – 5 Condition Care Brand Rx6 (high blood pressure, high cholesterol, diabetes, asthma) High Cost Generic and Preferred Brand

*Prescriptions filled outside the Preferred Pharmacy Network may have higher out-ofpocket costs. Please refer to Preferred Pharmacy Network Flier above for details.

Specialty Generic / Brand Drugs; Non-Preferred Drugs: Tier 6 Specialty Generic, Brand and Non-preferred *Prescriptions filled outside the Preferred Pharmacy Network may have higher out-ofpocket costs. Please refer to Preferred Pharmacy Network Flier above for details.

In-Network Retail Pharmacy (1 month supply)

In-Network Mail Order (3 month supply)

$0, no Deductible $4 Copay, no Deductible $25 Copay, no Deductible

$0, no Deductible $10 Copay, no Deductible $63 Copay, no Deductible

$75 Copay, no Deductible $150 Copay, after Deductible

$188 Copay, no Deductible $375 Copay, after Deductible

$250 Copay, after Deductible

$625 Copay, after Deductible

$10 Copay

$25 Copay*

Oral Chemotherapy Drugs * Specialty Drugs are not available through Mail Order

Out-of-Network

Not Covered Not Covered

Not Covered Not Covered Not Covered

Not Covered Not Covered

Inform the member that if a Brand Name Prescription Drug is requested when there is a Generic Prescription Drug available, the member will be responsible for: 1) the Copayment applicable to Brand Name Prescription Drugs; and 2) the difference in cost between the Generic Prescription Drug and the Brand Name Prescription Drug, as indicated in the ValueScript Rx Pharmacy Program Schedule of Benefits.

ValueScript Rx Pharmacy benefit also provides coverage for Generic contraceptive medications or devices (e.g., oral contraceptives, emergency contraceptive, and diaphragms) at no cost. Additionally, certain vaccines which are covered under the Wellness Benefits can be administered by Pharmacists who are certified.

Pediatric Vision (under age 197) Exam Eyeglass Lenses

$0 $0

Not Covered Not Covered

Frames

Pediatric Selection: $0 Non-Selection: Amount over standard $150 allowance, minus a 20% discount (No discount at Sam’s/Walmart)

Not Covered

Contact Lenses (Instead of eyeglasses) Includes contact lenses, evaluation, fitting and follow up care.

Pediatric Selection: $0 Non-Selection: Amount over standard $150 allowance, minus a 15% discount (No discount at Sam’s/Walmart)

Not Covered

Note: Anything over the allowance will not go toward your out-of-pocket maximum.

Pediatric Dental (under age 197) Preventive, basic and major $0 6Preventive Medication and Condition Care Rx Lists are available in the Medication Guide.

7 Pediatric Dental and Vision Benefits end on the last day of the month of the member’s 19th birthday.

Page 5 of 6

Not Covered

89300-0720R (Bronze)

For Small Groups Everyday Health Benefit Plan 18852 Benefit Maximums Home Health Care

30 Visits PBP

Inpatient Rehabilitation Therapy Inpatient Habilitation Therapy

30 Days PBP 30 Days PBP

Outpatient Rehabilitation Therapy

35 Visits PBP

Outpatient Habilitation Therapy

35 Visits PBP

Spinal Manipulations Skilled Nursing Facility

35 PBP (accumulates towards the Outpatient Rehabilitation Therapy maximum) 60 Days PBP

Preauthorization for select services: Members don’t need a referral to see a participating specialist, however authorizations are required for certain services such as CT/MRI scans and select injectables, as well as other medical services like hospitalization, rehabilitation services, home health care, and select durable medical equipment. Ensure members know that before an appointment they should visit floridablue.com/Authorization or call the toll-free number on their member ID card to see if a prior authorization is required.

Additional Benefits and Features • Encourage our members to call the care consultants team at 1-888-476-2227 to find out more about their benefits and/or treatment options. This can help them save time and money.

• Let our members know that there is online access to about everything on their health benefit plan as well as all of our self-service tools.

• Let our members know they can go to floridablue.com, click on Find a Doctor and follow the on-screen directions to easily find a doctor in the plan’s network and they don’t need a referral to see a participating provider.

• In addition to virtual visit coverage at a Primary Care Physician and Specialist, we now cover Behavioral Health Services at $0 when rendered by an In-Network designated provider

This Benefit Summary is only a partial description of the many benefits and services provided or authorized by Florida Blue HMO. This does not constitute a contract. For a complete description of benefits and exclusions, please see the Florida Blue HMO SimplyBlue Benefit Booklet and Schedule of Benefits; its terms prevail.

Page 6 of 6

89300-0720R (Bronze)

For Small Groups All Copay Health Benefit Plan 20751 Amount M ember Pays In-Network Out-of-Network

Summary of Benefits for Covered Services

Financial Features Deductible (DED1) (PBP2) $0 Not covered (DED is the amount the member is responsible for before Florida Blue HMO pays) Coinsurance 0% Not covered (Coinsurance is the percentage the member pays for services) Out-of-Pocket Maximum (PBP) $7,900 per person Not covered (Out-of-Pocket Maximum includes DED, Coinsurance, Copayments and $15,800 per family Prescription Drugs) Office Services Physician Office Services Value Choice Provider/Specialist 5 (available in select counties) $0 Copay/ $20 Copay Not covered Primary Care Physician $40 Copay Not covered In Network Specialist $90 Copay Not covered Virtual Visits(designated providers only) Primary Care Physician/Specialist $0 Copay/$90 Copay Not covered Behavioral Health Services $0 Copay Not covered Maternity (Cost Share for initial visit only) Primary Care Physician $40 Copay Not covered Specialist $90 Copay Not covered Allergy Injections (per visit) Primary Care Physician $10 Copay Not covered Specialist $10 Copay Not covered Advanced Imaging Services (AIS) (MRI, MRA, PET, CT, Nuclear Med.) $90 Copay Not covered Medical Pharmacy - Physician-Administered Medications (applies to Office Setting and Specialty Pharmacy Vendors) In-Network Monthly Out-of-Pocket (OOP) Maximum3 Low: $100 Standard: $200 In Office Health Care Professional Administered Medications Low: 10% Not covered Standard: 20% Not covered Physician-Administered Medications – These medications require the administration to be performed by a health care provider. The medications are ordered by a provider and administered in an office or outpatient setting. Physician-Administered medications are covered under the medical benefit. Please refer to the Physician-Administered medication list in the Medication Guide for a list of drugs covered under this benefit.

Preventive Care Routine Adult & Child Preventive Services, Wellness Services, and $0 Not covered Immunizations Mammograms $0 Not covered Colonoscopy (Routine for age 50+ then frequency schedule applies) $0 Not covered Emergency Medical Care 5 Value Choice Urgent Care Provider (available in select counties) $0 Copay Visits 1-2 PBP Not covered Urgent Care Centers $95 Copay Not covered Emergency Room Facility Services (per visit) (copayment waived if admitted) $600 Copay $600 Copay Ambulance Services $600 Copay $600 Copay 1 DED = Deductible / 2 PBP = Per Benefit Period. 3 In-Network Medical Pharmacy will be paid at 100% for the remainder of the calendar month once OOP max is met. 5See Agent Toolkit for a full list of counties where Value Choice Providers are available.

Page 1 of 5

96315-0720R (Gold)

For Small Groups All Copay Health Benefit Plan 20751 Amount M ember Pays In-Network Out-of-Network

Summary of Benefits for Covered Services Outpatient Diagnostic Services Independent Diagnostic Testing Facility Services (per visit) (e.g. X-rays) (Includes Provider Services) Diagnostic Services (except AIS) Advanced Imaging Services (AIS) (MRI, MRA, PET, CT, Nuclear Med.) Independent Clinical Lab (e.g., Blood Work) Outpatient Hospital Facility Services (per visit) (e.g., Blood Work and X-rays) Hospital / Surgical Ambulatory Surgical Center Facility (ASC) Outpatient Hospital Facility Services (per visit) Therapy Services All other Services Inpatient Hospital Facility and Rehabilitation Services (per admit) Mental Health / Substance Dependency Inpatient Hospitalization Facility Services (per admit) Outpatient Hospitalization Facility Service (per visit) Emergency Room Facility Services (per visit) Provider Services at Hospital Primary Care Physician / Specialist Provider Services at ER Primary Care Physician / Specialist Provider Services at Locations other than Office, Hospital and ER Primary Care Physician / Specialist Outpatient Office Visit Primary Care Physician / Specialist Other Provider Services Provider Services at Hospital Provider Services at ER Radiology, Pathology and Anesthesiology Provider Services at an Ambulatory Surgical Center (ASC) Provider Services at Locations other than Office, Hospital and ER Primary Care Physician Specialist Other Special Services Combined Outpatient Cardiac Rehabilitation and Occupational, Physical, Speech and Massage Therapies and Spinal Manipulations Outpatient Rehabilitation Therapy Center Outpatient Hospital Facility Services (per visit) Durable Medical Equipment, Prosthetics and Orthotics Motorized Wheelchair All Other Home Health Care Skilled Nursing Facility Hospice Page 2 of 5

$0 $600 Copay $0 $800 Copay

Not covered Not covered Not covered Not covered

$500 Copay

Not covered

$800 Copay $1,000 Copay $2,000 Copay per day ($6,000 max)

Not covered Not covered Not covered

$0 $0 $0

Not covered Not covered $0

$0

Not covered

$0

$0

$0

Not covered

$0

Not covered

$0 $0

Not covered $0

$0

Not covered

$40 Copay $90 Copay

Not covered Not covered

$90 Copay $800 Copay

Not covered Not covered

Deductible $0 $0 Deductible Deductible

Not covered Not covered Not covered Not covered Not covered 96315-0720R (Gold)

Preferred Pharmacy Network When you use a pharmacy in the Preferred Pharmacy Network, such as Walgreens, Walmart, Publix, Winn-Dixie and FHCP you’ll pay a lower cost share or copay for your prescriptions.

If you choose to fill a prescription outside the Preferred Pharmacy Network, you may pay higher out-of-pocket costs.

To find a preferred pharmacy, follow these steps: • Log in to your member website.

• Click on Tools, then Find a Doctor & More.

• In the Search Within box, make a selection from the drop-down menu.

• Select Pharmacy from the drop-down menu in the Provider Type box.

• Preferred pharmacies feature an orange “preferred pharmacy” designation in the search returns. Use these pharmacies to get the lowest out-of-pocket costs.

Here is an example of how the Preferred Pharmacy Network will work.

ValueScript – SimplyBlue Tier 1 Preventive Prescription Drugs and Supplies (USPSTF) Preferred Pharmacy

Standard Pharmacy

$0

$10 (Generic) $20 (Brand)

Tier 2

Tier 3

Condition Care Generic Prescription Drugs and Supplies Preferred Pharmacy

$4

Standard Pharmacy

$14

Tier 4

Low Cost Generic Prescription Drugs and Supplies Preferred Pharmacy

$25

Standard Pharmacy

Condition Care Brand Name Prescription Drugs and Supplies Preferred Pharmacy

$35

$75

Standard Pharmacy

$95

Tier 5

Tier 6

High Cost Generic, Preferred Brand Name Prescription Drugs and Supplies

Specialty Generic and Brand Name Prescription Drugs; Non-Preferred Prescription Drugs and Supplies

Preferred Pharmacy

Standard Pharmacy

Preferred Pharmacy

Standard Pharmacy

$150

$160 (Generic) $170 (Brand)

**$300 **$200

**$300 $220 (NonPreferred Brand)

Preferred Pharmacy Network only applies to Retail and Extended Supply Network (cost shares are based on 30 -day supply) *Home deliv ery is ex cluded from the Preferred Pharmacy Netw ork **Specialty Drugs and Non-Preferred Prescription Drugs are not included in the Preferred Pharmacy Netw ork ***Pharmacy plan cost share ex amples are only for illustrativ e purposes only

Page 3 of 5

96315-0720R (Gold)

For Small Groups All Copay Health Benefit Plan 20751 Amount M ember Pays In-Network Out-of-Network

Summary of Benefits for Covered Services Prescription Drug Program (ValueScript Rx®)

Low Cost Generic Drugs: Tier 1 – 3 Preventive6 (e.g., oral contraceptives) Condition Care Generic Rx 6 (high blood pressure, high cholesterol, diabetes, asthma) Low Cost Generics *Pr escriptions filled outside the Preferred Pharmacy Network may have higher out-ofpocket costs. Please refer to Preferred Pharmacy Network Flier above for details.

High Cost Generic / Brand Drugs: Tier 4 – 5 Condition Care Brand Rx 6 (high blood pressure, high cholesterol, diabetes, asthma) High Cost Generic and Preferred Brand *Pr escriptions filled outside the Preferred Pharmacy Network may have higher out-ofpocket costs. Please refer to Preferred Pharmacy Network Flier above for details.

Specialty Generic / Brand Drugs; Non-Preferred Drugs: Tier 6 Specialty Generic, Brand and Non-preferred

In-Network Retail Pharmacy (1 month supply)

In-Network Mail Order (3 month supply)

$0, no Deductible $4 Copay, no Deductible $20 Copay, no Deductible

$0, no Deductible $10 Copay, no Deductible $50 Copay, no Deductible

$25 Copay, no Deductible $50 Copay, no Deductible

$62 Copay, no Deductible $125 Copay, no Deductible

$500 Copay, no Deductible

$1,250 Copay, no Deductible

*Pr escriptions filled outside the Preferred Pharmacy Network may have higher out-ofpocket costs. Please refer to Preferred Pharmacy Network Flier above for details.

Out-of-Network

Not Covered Not Covered Not Covered

Not Covered Not Covered

Not Covered

Oral Chemotherapy Drugs * Specialty Drugs are not available through Mail Order $10 Copay $25 Copay* Not Covered Inform the member that if a Brand Name Prescription Drug is requested when there is a Generic Prescription Drug available, the member will be responsible for: 1) the Copayment applicable to Brand Name Prescription Drugs; and 2) the difference in cost between the Generic Prescription Drug and the Brand Name Prescription Drug, as indicated in the ValueScript Rx Pharmacy Program Schedule of Benefits.

ValueScript Rx Pharmacy benefit also provides coverage for Generic contraceptive medications or devices (e.g., oral contraceptives, emergency contraceptive, and diaphragms) at no cost. Additionally, certain vaccines which are covered under the Wellness Benefits can be administered by Pharmacists who are certified.

Pediatric Vision (under age 197) Exam $0 Not Covered Eyeglass Lenses $0 Not Covered Frames Pediatric Selection: $0 Not Covered Non-Selection: Amount over standard $150 allowance, minus a 20% discount (No discount at Sam’s/Walmart) Pediatric Selection: $0 Not Cov ered Contact Lenses (Instead of eyeglasses) Includes contact lenses, ev aluation, fitting and follow up care.

Non-Selection: Amount ov er standard $150 allow ance, minus a 15% discount (No discount at Sam’s/Walmart)

Note: Anything over the allowance will not go toward your out-of-pocket maximum.

Pediatric Dental (under age 197) Preventive, basic and major $0 4 Pediatric Dental and Vision Benefits end on the last day of the month of the member’s 19th birthday.

7 Preventive Medication and Condition Care Rx Lists are available in the Medication Guide.

Page 4 of 5

Not Covered

96315-0720R (Gold)

For Small Groups All Copay Health Benefit Plan 20751 Benefit Maximums Home Health Care Inpatient Rehabilitation Therapy Inpatient Habilitation Therapy Outpatient Rehabilitation Therapy Outpatient Habilitation Therapy Spinal Manipulations Skilled Nursing Facility

30 Visits PBP 30 Days PBP 30 Days PBP 35 Visits PBP 35 Visits PBP 35 PBP (accumulates towards the Outpatient Rehabilitation Therapy maximum) 60 Days PBP

Preauthorization for select services: Members don’t need a referral to see a participating specialist, however authorizations are required for certain services such as CT/MRI scans and select injectables, as well as other medical services like hospitalization, rehabilitation services, home health care, and select durable medical equipment. Ensure members know that before an appointment they should visit floridablue.com/Authorization or call the toll-free number on their member ID card to see if a prior authorization is required.

Additional Benefits and Features  Encourage our members to call the care consultants team at 1-888-476-2227 to find out more about their benefits and/or treatment options.

This can help them save time and money.  Let our members know that there is online access to about everything on their health benefit plan as well as all of our self-service tools.  Let our members know they can go to floridablue.com, click on Find a Doctor and follow the on-screen directions to easily find a doctor in the plan’s network and they don’t need a referral to see a participating provider.  In addition to virtual visit coverage at a Primary Care Physician and Specialist, we now cover Behavioral Health Services at $0 when rendered by an In-Network designated provider

This Benefit Summary is only a partial description of the many benefits and services provided or authorized by Florida Blue HMO. This does not constitute a contract. For a complete description of benefits and exclusions, please see the Florida Blue HMO SimplyBlue Benefit Booklet and Schedule of Benefits; its terms prevail.

Page 5 of 5

96315-0720R (Gold)

For Small Groups Everyday Health Benefit Plan 14353 Amount M ember Pays In-Network Out-of-Network

Summary of Benefits for Covered Services

Financial Features Deductible (DED1) (PBP2) $2,000 per person Not covered (DED is the amount the member is responsible for before Florida Blue HMO pays) $4,000 per family Coinsurance 20% of the allowed amount Not covered (Coinsurance is the percentage the member pays for services) Out-of-Pocket Maximum (PBP) $4,200 per person Not covered (Out-of-Pocket Maximum includes DED, Coinsurance, Copayments and $8,400 per family Prescription Drugs) Office Services Physician Office Services Value Choice Provider/Specialist 5 (available in select counties) $0 Copay/$20 Copay Not covered Primary Care Physician $30 Copay Not covered In-Network Specialist $60 Copay Not covered Virtual Visits Primary Care Physician /Specialist $0 Copay / $60 Copay Not covered Behavioral Health Services $0 Copay Not covered Maternity (Cost Share for initial visit only) Primary Care Physician $30 Copay Not covered Specialist $60 Copay Not covered Allergy Injections (per visit) Primary Care Physician $10 Copay Not covered Specialist $10 Copay Not covered Advanced Imaging Services (AIS) (MRI, MRA, PET, CT, Nuclear Med.) $60 Copay Not covered Medical Pharmacy - Physician-Administered Medications (applies to Office Setting and Specialty Pharmacy Vendors) In-Network Monthly Out-of-Pocket (OOP) Maximum3 Low: $100 Standard: $200 In Office Health Care Professional Administered Medications Low: 10% Not covered Standard: 20% Not covered Physician-Administered Medications – These medications require the administration to be performed by a health care provider. The medications are ordered by a provider and administered in an office or outpatient setting. Physician-Administered medications are covered under the medical benefit. Please refer to the Physician-Administered medication list in the Medication Guide for a list of drugs covered under this benefit.

Preventive Care Routine Adult & Child Preventive Services, Wellness Services, and $0 Not covered Immunizations Mammograms $0 Not covered Colonoscopy (Routine for age 50+ then frequency schedule applies) $0 Not covered 1 DED

= Deductible = Per Benefit Period 3 In-Netw ork Medical Pharmacy w ill be paid at 100% for the remainder of the calendar month once OOP max is met.

5 See Agent Toolkit for a full list of counties where Value Choice Providers are available.

2 PBP

Page 1 of 6

76839-0720R E (Gold)

For Small Groups Everyday Health Benefit Plan 14353 Amount M ember Pays In-Network Out-of-Network

Summary of Benefits for Covered Services Emergency Medical Care Value Choice Urgent Care Provider5 (available in select counties) Urgent Care Centers Emergency Room Facility Services (per visit)

$0 Copay Visits 1-2 PBP $65 Copay 20% after Deductible

Ambulance Services

20% after Deductible

Outpatient Diagnostic Services Independent Diagnostic Testing Facility Services (per visit) (e.g. X-rays) (Includes Provider Services) Diagnostic Services (except AIS) Advanced Imaging Services (AIS) (MRI, MRA, PET, CT, Nuclear Med.) Independent Clinical Lab (e.g., Blood Work) Outpatient Hospital Facility Services (per visit) (e.g., Blood Work and X-rays) Hospital / Surgical Ambulatory Surgical Center Facility (ASC) Outpatient Hospital Facility Services (per visit) Therapy Services All other Services Inpatient Hospital Facility and Rehabilitation Services (per admit) Mental Health / Substance Dependency Inpatient Hospitalization Facility Services (per admit) Outpatient Hospitalization Facility Service (per visit) Emergency Room Facility Services (per visit) Provider Services at Hospital Primary Care Physician / Specialist Provider Services at ER Primary Care Physician / Specialist Provider Services at Locations other than Office, Hospital and ER Primary Care Physician / Specialist Outpatient Office Visit Primary Care Physician / Specialist Other Provider Services Provider Services at Hospital Provider Services at ER

Not covered Not covered 20% after In-Network Deductible 20% after In-Network Deductible

20% after Deductible 20% after Deductible $50 Copay 20% after Deductible

Not covered Not covered Not covered Not covered

20%

Not covered

20% after Deductible 20% after Deductible 20% after Deductible

Not covered Not covered Not covered

$0 $0 $0

Not covered Not covered $0

$0

Not covered

$0

$0

$0

Not covered

$0

Not covered

$100 Copay $100 Copay

Not covered $100 Copay

Radiology, Pathology and Anesthesiology Provider Services at an $100 Copay Ambulatory Surgical Center (ASC) Provider Services at Locations other than Office, Hospital and ER Primary Care Physician $30 Copay Specialist $60 Copay 5 See Agent Toolkit for a full list of counties where Value Choice Providers are available.

Not covered

Page 2 of 6

Not covered Not covered

76839-0720R E (Gold)

For Small Groups Everyday Health Benefit Plan 14353 Other Special Services Combined Outpatient Cardiac Rehabilitation and Occupational, Physical, Speech and Massage Therapies and Spinal Manipulations Outpatient Rehabilitation Therapy Center Outpatient Hospital Facility Services (per visit) Durable Medical Equipment, Prosthetics and Orthotics Motorized Wheelchair All Other Home Health Care Skilled Nursing Facility Hospice

Page 3 of 6

$60 Copay 20% after Deductible

Not covered Not covered

20% after Deductible $0 $0 20% after Deductible 20% after Deductible

Not covered Not covered Not covered Not covered Not covered

76839-0720R E (Gold)

Preferred Pharmacy Network When you use a pharmacy in the Preferred Pharmacy Network, such as Walgreens, Walmart, Publix, Winn-Dixie and FHCP you’ll pay a lower cost share or copay for your prescriptions.

If you choose to fill a prescription outside the Preferred Pharmacy Network, you may pay higher out-of-pocket costs.

To find a preferred pharmacy, follow these steps: • Log in to your member website.

• Click on Tools, then Find a Doctor & More.

• In the Search Within box, make a selection from the drop-down menu.

• Select Pharmacy from the drop-down menu in the Provider Type box.

• Preferred pharmacies feature an orange “preferred pharmacy” designation in the search returns. Use these pharmacies to get the lowest out-of-pocket costs.

Here is an example of how the Preferred Pharmacy Network will work.

CareChoices - BlueCare Rx Tier 1

Tier 2

Tier 3

Tier 4

Tier 5

Tier 6

Tier 7

Preventive Prescription Drugs and Supplies (USPSTF)

Condition Care Generic Prescription Drugs and Supplies

All Other Generic Prescription Drugs and Supplies

Condition Care Brand Name Prescription Drugs and Supplies

Preferred Brand Name Prescription Drugs and Supplies

Non-Preferred Brand Name Prescription Drugs and Supplies

Specialty Generic and Brand Name Prescription Drugs and Supplies

Pr efer r ed Phar macy

Standar d Phar macy

Pr efer r ed Phar macy

Standar d Phar macy

Pr efer r ed Phar macy

Standar d Phar macy

Pr efer r ed Phar macy

Standar d Phar macy

Pr efer r ed Phar macy

Standar d Phar macy

Pr efer r ed Phar macy

Standar d Phar macy

Pr efer r ed Phar macy

Standar d Phar macy

$0

$10 (Generic) $20 (Brand)

$4

$14

$25

$35

$75

$95

$150

$170

$250

$270

**$350

**$350

Preferred Pharmacy Network only applies to Retail and Extended Supply Network (cost shares are based on 30 -day supply)

*Home deliv ery is ex cluded from the Preferred Pharmacy Netw ork **Specialty Drugs are not included in the Preferred Pharmacy Netw ork ***Pharmacy plan cost share ex amples are only for illustrativ e purposes only

Page 4 of 6

76839-0720R E (Gold)

For Small Groups Everyday Health Benefit Plan 14353 Prescription Drug Program (BlueCare Rx ®) In-Network In-Network Retail Pharmacy Home Delivery (1 month supply) (3 month supply)

Out-of-Network

Generic Drugs: Tier 1 – 3 Preventive6 (e.g., oral contraceptives) Condition Care Rx 6 (high blood pressure, high cholesterol, diabetes, depression, asthma) All other Generics

$0 $4 Copay $10 Copay

$0 $8 Copay $20 Copay

Not Covered Not Covered Not Covered

Brand Drugs: Tier 4 – 5 Condition Care Rx 6 (high blood pressure, high cholesterol, diabetes, depression, asthma) All other Preferred Brand Drugs

$15 Copay $30 Copay

$30 Copay $60 Copay

Not Covered Not Covered

Non-preferred Brand Drugs: Tier 6 Non-preferred Brand Drugs

$50 Copay

$100 Copay

Not Covered

*Prescriptions filled outside the Preferred Pharmacy Network may have higher out-ofpocket costs. Please refer to Preferred Pharmacy Network Flier above for details.

*Prescriptions filled outside the Preferred Pharmacy Network may have higher out-ofpocket costs. Please refer to Preferred Pharmacy Network Flier above for details.

*Prescriptions filled outside the Preferred Pharmacy Network may have higher out-ofpocket costs. Please refer to Preferred Pharmacy Network Flier above for details.

Specialty Drugs: Tier 7 Specialty Drugs purchased from a Specialty Pharmacy $150 Copay Not Covered Not Covered Oral Chemotherapy Drugs * Specialty Drugs are not available through Mail Order $10 Copay $20 Copay* Not Covered Inform the member that if a Brand Name Prescription Drug is requested when there is a Generic Prescription Drug available, the member will be responsible for: 1) the Copayment applicable to Brand Name Prescription Drugs; and 2) the difference in cost between the Generic Prescription Drug and the Brand Name Prescription Drug, as indicated in the BlueCare Rx Pharmacy Program Schedule of Benefits.

BlueCare Rx Pharmacy benefit also provides coverage for Generic contraceptive medications or devices (e.g., oral contraceptives, emergency contraceptive, and diaphragms) at no cost. Additionally, certain vaccines which are covered under the Wellness Benefits can be administered by Pharmacists who are certified.

Summary of Benefits for Covered Services Pediatric Vision (under age 194) Exam Eyeglass Lenses Frames

Contact Lenses (Instead of eyeglasses) Includes contact lenses, evaluation, fitting and follow up care.

Amount M ember Pays In-Network Out-of-Network $0 $0 Pediatric Selection: $0 Non-Selection: Amount over standard $150 allowance, minus a 20% discount (No discount at Sam’s/Walmart) Pediatric Selection: $0 Non-Selection: Amount over standard $150 allowance, minus a 15% discount (No discount at Sam’s/Walmart)

Note: Anything over the allowance will not go toward your out-of-pocket maximum.

Pediatric Dental (under age 194) Preventive, basic and major $0 4 Pediatric Dental and Vision Benefits end on the last day of the month of the member’s 19th birthday.

6 Preventive Medication and Condition Care Rx Lists are available in the Medication Guide.

Page 5 of 6

Not Covered Not Covered Not Covered

Not Covered

Not Covered

76839-0720R E (Gold)

For Small Groups Everyday Health Benefit Plan 14353 Benefit Maximums Home Health Care Inpatient Rehabilitation Therapy Inpatient Habilitation Therapy Outpatient Rehabilitation Therapy Outpatient Habilitation Therapy Spinal Manipulations Skilled Nursing Facility

30 Visits PBP 30 Days PBP 30 Days PBP 35 Visits PBP 35 Visits PBP 35 PBP (accumulates towards the Outpatient Rehabilitation Therapy maximum) 60 Days PBP

Preauthorization for select services: Members don’t need a referral to see a participating specialist, however authorizations are required for certain services such as CT/MRI scans and select injectables, as well as other medical services like hospitalization, rehabilitation services, home health care, and select durable medical equipment. Ensure members know that before an appointment they should visit floridablue.com/Authorization or call the toll-free number on their member ID card to see if a prior authorization is required.

Additional Benefits and Features  Encourage our members to call the care consultants team at 1-888-476-2227 to find out more about their benefits and/or treatment options. This can help them save time and money.  Let our members know that there is online access to about everything on their health benefit plan as well as all of our self-service tools.  Let our members know they can go to floridablue.com, click on Find a Doctor and follow the on-screen directions to easily find a doctor in the plan’s network and they don’t need a referral to see a participating provider.  In addition to virtual visit coverage at a Primary Care Physician and Specialist, we now cover Behavioral Health Services at $0 when rendered by an In-Network designated provider

This Benefit Summary is only a partial description of the many benefits and services provided or authorized by Florida Blue HMO. This does not constitute a contract. For a complete description of benefits and exclusions, please see the Florida Blue HMO BlueCare Benefit Booklet and Schedule of Benefits; its terms prevail.

Page 6 of 6

76839-0720R E (Gold)

BlueVision Benefit Summary for Group Vision Plan 4 Provider Network: You can locate an in-network provider by visiting floridablue.com and clicking on Find a Doctor. Choose the BlueVision network and add your zip code to find a vision provider near you. If you do not receive care from an in-network provider for the services listed below, you will have to pay the full cost of the service (except in certain situations such as emergencies) and may be reimbursed up to the amount listed if you file a claim.

Additional Benefits and Features: • Additional Allowance: Receive an additional $50 allowance towards frames purchased at Visionworks.

• Additional Discounts: Receive 50% off of additional pairs of eyeglasses at Visionworks retail locations nationally. At most other participating network offices, member will receive a 20% courtesy discount on items not covered by the /1 benefit (e.g., second pairs, sunglasses, etc).

• Scratch Protection Plan: Standard scratch-resistant coating is available free of charge for plastic lenses.

• Free One-Year Breakage Warranty: All eyeglasses come with a breakage warranty for repair/replacement of the frame/lenses for a period of one year from the date of delivery.

In-Network Benefits Benefit Frequency

Once Every

Eye Examination inclusive of Dilation (when professionally indicated)

12 Months

Spectacle Lenses

12 Months

Frame

12 Months

Contact Lens Evaluation, Fitting & Follow-Up Care

12 Months

Contact Lenses (in lieu of eyeglasses)

12 Months

Copayments

In-Network Benefit

Eye Examination

$10 Copayment

Spectacle Lenses

$20 Copayment

Contact Lens Evaluation, Fitting & Follow-Up Care

$20 Copayment

Eyeglass Benefit - Frame

/4

In-Network Benefit Plan covers up to $130 /1 plus a 20% discount on any overage

Non-Collection Frame Allowance (Retail): /3

Exclusive Frame Collection (in lieu of Allowance): Fashion level

Included

Designer level

Included

Premier level

$25

1

Additional discounts not applicable at Walmart or Sam’s Club locations.

Collection is available at most participating independent provider offices. Collection is subject to change. Collection is inclusive of select torics and ‘multifocal.

4 Copayment applies to Collection Contact Lenses only.

3

Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc., an Independent Licensee of the Blue Cross and Blue Shield Association.

80736-0818 0320V

1

Additional Lens Options

In-Network Benefit (Member Cost)

Standard Clear Plastic Lenses (any size or Rx)

Included

Tinting of Plastic Lenses

Included /2

Polycarbonate Lenses (Children / Adults)

Included

Intermediate-Vision Lenses

$30

High-Index Lenses

$55

Polarized Lenses

$75

Plastic Photosensitive Lenses

$65

Scratch-Resistant Coating

Included

Ultraviolet Coating

$12

Anti-Reflective (AR) Coating (Standard / Premium / Ultra)

$35 / $48 / $60

Progressives Lenses (Standard / Premium / Ultra)

$50 / $90 / $140

Scratch Protection Plan: Single Vision / Multifocal Lenses

$20 / $40

One-Year Breakage Warranty

Included

Contact Lens Benefit (in lieu of eyeglasses)

In-Network Benefit

Non-Collection Contact Lenses: Materials Allowance

Plan covers up to $130 /1 plus a 15% discount on any overage

Evaluation, Fitting & Follow-Up Care – Standard Lens Types

15% Discount

Evaluation, Fitting & Follow-Up Care – Specialty Lens Types

15% Discount

/3

Collection Contact Lenses (in lieu of Allowance) : Materials Allowance

Included (up to 4 boxes)

Evaluation, Fitting & Follow-Up Care – Standard Lens Types

Included

Evaluation, Fitting & Follow-Up Care – Specialty Lens Types Medically Necessary Contact Lenses (with prior approval): Materials, Evaluation, Fitting & Follow-Up Care

Included

Out-of-Network Reimbursement Schedule

Included Amount Member Reimbursed

Eye Examination

Up to $40

Frame

Up to $50

Single Vision Lenses

Up to $40

Bifocal/Progressive Lenses

Up to $60

Trifocal Lenses

Up to $80

Lenticular Lenses

Up to $100

Elective Contact Lenses

Up to $105

Medically Necessary Contact Lenses

Up to $225

1

Additional discounts not applicable at Walmart or Sam’s Club locations.

Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with prescriptions +/- 6.00 diopters 2or greater.

3 Collection is available at most participating independent provider offices. Collection is subject to change. Collection is inclusive of select torics and ‘multifocals.

2

Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc., an Independent Licensee of the Blue Cross and Blue Shield Association.

2

80736-0818 0320V

Nondiscrimination and Accessibility Notice (ACA §1557) Florida Blue and Florida Blue HMO comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. Florida Blue and Florida Blue HMO does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

Florida Blue and Florida Blue HMO 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) o Provides free language services to people whose primary language is not English, such as:  Qualified interpreters  Information written in other languages If you need these services, contact 1-800-352-2583.

If you believe that Florida Blue and Florida Blue HMO has 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: Senior Manager of Business Ethics 4800 Deerwood Campus Parkway, DC1-7 Jacksonville, FL 32246 Phone 800-477-3736 x29070 (TTY: 800-955-8770) Fax 904-301-1580 Email section1557coordinator@floridablue.com You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, our Senior Manager of Business Ethics 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, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, DC 20201 1-800-368-1019, 800–537–7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc., an Independent Licensee of the Blue Cross and Blue Shield Association.

3

80736-0818 0320V

Florida Blue and Florida Blue HMO: [1-800-352-2583] TTY: 800-955-8770 Have a disability? Speak a language other than English? Call to get help for free. ¿Habla español? ¿Tiene alguna discapacidad? Llame para obtener ayuda de forma gratuita. Èske w pale kreyòl ayisyen? Èske w andikape? Rele nou pou w jwenn èd gratis.

Quý vị nói tiếng Việt? Quý vị bị khuyết tật? Hãy gọi trợ giúp miễn phí.

Você fala potuguês? Tem alguma deficiência? Telefone para obter assistência.

您会讲中文吗？是否为伤残人士？如需帮助，请拨打我们的免费电话： Vous parlez français ? Vous avez une incapacité ? Appelez pour recevoir une assistance gratuite.

Nagsasalita ng Tagalog o Filipino? May kapansanan? Tumawag para sa libreng tulong. Вы говорите по-русски? Вы являетесь инвалидом? Свяжитесь с нами для получения бесплатной помощи по телефону

.‫ھل ﺗﺗﺣدث )اﻟﻌرﺑﯾﺔ(؟ ﺗﻌﺎﻧﻲ ﻣن إﻋﺎﻗﺔ؟ اﺗﺻل ﻟﻠﺣﺻول ﻋﻠﻰ ﻣﺳﺎﻋدة ﻣﺟﺎﻧﯾﺔ‬ Parli italiano? Hai una disabilità? Chiama per un'assistenza gratuita.

Sprechen Sie deutsch? Haben Sie eine Behinderung? Rufen Sie an, um kostenlos Hilfe zu erhalten. 한국어 통역이 필요하세요? 장애가 있나요? 전화하시면 무료로 도와드립니다.

Mówisz po polsku? Jesteś osobą niepełnosprawną? Zadzwoń po bezpłatną pomoc.

�ુજરાતી બોલો છો? અક્ષમતા ધરાવો છો? મફત સહાયતા મેળવવા ફોન કરો.

พูดภาษาไทยได้? เป็ นผูพ้ ิการใช่หรื อไม่? โทรศัพท์ขอรับคําปรึ กษาได้ฟรี

日本語をご希望ですか？障害をお持ちですか？無料の電話サービスをご利用ください。 ‫ﺑﮫ زﺑﺎن ﻓﺎرﺳﯽ ﺻﺣﺑت ﻣﯽ ﮐﻧﯾد؟ دارای ﻣﻌﻠوﻟﯾت ھﺳﺗﯾد؟ ﺑرای درﯾﺎﻓت ﮐﻣﮏ راﯾﮕﺎن ﺗﻣﺎس ﺑﮕﯾرﯾد‬

Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc., an Independent Licensee of the Blue Cross and Blue Shield Association.

4

80736-0818 0320V

Group Proposal For: SOLOMON SEARCH Quote Number: I-230630

Proposal Expiration Date: 01/01/2021 Coverage Effective Date: 01/01/2021

Dental Benefits and Rates Summary Single/Dual Option:

Single

Plan

BlueDental Choice Copayment CR Plan 213

Deductible No Deductible for Preventive Services Per Person Per Plan Year Per Family Per Plan Year

Benefits Periodic Oral Evaluation (0120) Comprehensive Oral Evaluation (0150) Bitewing X-rays, two films (0272) Cleanings - Adult/Child (1110, 1120) Fluoride Treatment - Child (1206,1208) Office Visits (9430) X-rays - Intraoral/Complete Series (0210) Sealant – per tooth (1351) Amalgam Restorations (Silver Fillings) (2140) Resin-Based Restorations - Anterior (2330) Extractions - Routine and Surgical (7140) Root Canal Molar (3330) Periodontal Scaling & Root Planing-per quad (4341) Crowns - Porcelain fused to noble metal (2752) Complete Dentures (5110, 5120) Pontic - Porcelain fused to noble metal (6242) Partial Dentures (5213, 5214) Surgical placement of implant body: endosteal implant (6010) Implant supported porcelain fused to metal crown (titanium, high noble metal) (6066) Orthodontia Services BlueDental Coverage Waiting Periods Major Service Benefits Orthodontia Benefits Maximum Benefits Plan Year (per person) Lifetime Orthodontia (per person) Dental Rollover OON Reimbursement Procedures Performed by Specialist

In-Network/Out-of-Network $0 / $50 $0 / $150 Copayment**/ Services Coinsurance* Preventive Preventive Preventive Preventive Preventive Preventive Basic Basic Basic Basic Basic Major

$0 / 80% $0 / 80% $0 / 80% $10 / 80% $0 / 80% $0 / 80% $17 / 60% $6 / 60% $15 / 60% $20 / 60% $17 / 60% $305 / 40%

Major

$61 / 40%

Major Major Major Major

$302 / 40% $382 / 40% $302 / 40% $420 / 40%

Major

$512 / 40%

Major

$282 / 40% None NA# 12 Months NA $1000 NA Opt In Fee Schedule Covered

Group Proposal For: SOLOMON SEARCH Quote Number: I-230630

Proposal Expiration Date: 01/01/2021 Coverage Effective Date: 01/01/2021

Single/Dual Option:

Single

Coverage Tier

Members Quoted

BlueDental Choice Copayment CR Plan 213

Employee Only

6

$16.04

Employee + Spouse

1

$34.86

Employee + Children

0

$34.09

Family

0

$54.84

Total Monthly Premium:

* ** #

$131.10

Of allowable expenses established by contract for the participating dentists.

Copayment fees will not apply toward the satisfaction of any deductible or coinsurance requirements under this contract.

Value-added benefits include a 20% discount on orthodontia and cosmetic procedures. Certain dentists have voluntarily agreed to offer a 20% discount off their usual charge for non-covered cosmetic or orthodontic services. These dentists are identified by an affiliation to either the Cosmetic Dental Discount Program or Orthodontic Discount Program. Because these dentists are neither contractually nor legally bound to offer these discounts, we recommend that members contact the provider to inquire about the continued availability of any discount prior to scheduling an appointment.

Employee Enrollment Application

Please type or write clearly in black or blue ink.

Section A: Current Information Group Name:

Division #:

Group #:

Effective Date of Coverage: Date of Hire:

Location #:

Employee #:

Package #:

Job Title:

Work Status: c Actively at Work c Cobra c Retired Retirement Date:

Paid: c Hourly c Salary c Open Enrollment

Section B: Employee Information Social Security #:

Last Name:

First Name:

Street Address:

M.I.: Birth Date:

Apt. #: City:

County:

Phone:

Physician Name / ID # HMO only:

Sex: c Mc F

State: Zip:

Marital Status: Legally c Single c Married c Divorced c Widowed c Separated

Existing Patient: Language of Preference: optional - for data collection purposes only c Yes c No c English c Spanish c Other c Prefer not to answer _

Ethnicity optional c Asian/Pacific Islander c Black/African American c Caribbean Islander c Hispanic c Native American c White Check all that apply: Section C: Health Coverage Level and Plan Information Employee Health Coverage: c Employee c *Employee & Spouse c *Employee & One Dependent c *Employee & Child(ren) c Family * When available BlueOptions Plan #

BlueChoice (PPO) Plan #

BlueSelect Plan #

Other Plan #

BlueCare (HMO) Plan #

I am Refusing all Health Coverage at this time. I understand that if I decide to apply later coverage may not be available until the next open or special enrollment period.

Signature: Date:

Section D: Vision Coverage Level and Plan Information Employee Vision Coverage: c Employee c *Employee & Spouse c *Employee & One Dependent c *Employee & Child(ren) c Family Vision Plan Choice:

I am Refusing all Vision Coverage at this time. I understand that if I decide to apply later coverage may not be available until the next open or special enrollment period. Signature: Date:

Physician Name/ID HMO only

Existing Patient (Y/N) You Support Lives With You Is a Student

Vision Sex (M or F) Check if Disabled

Other (O)* Health

Birth Date:

Domestic Part. Child (DPC)

Social Security Number:

Spouse (S)

Last Name: (if different than employee) First Name, M.I.

Child (C) Domestic Partner (DP)

Section E: Dependent Information Attach separate sheet, if additional space is needed, with dependent information, sign & date.

Relation to You Plan Ethnicity optional Dependent Circle all that apply.

Type A) Asian/Pacific Islander B) Black/African American C) Caribbean Islander H) Hispanic N) Native American W) White

A B C H N W A B C H N W A B C H N W A B C H N W List the name of each dependent listed above that is married or has dependent child(ren) or lives outside of Florida.

* If you indicated “O” in “Relation to You” above for any dependents, please explain here:

22095 0914R SR

Section F: Other Health Insurance Information This section must be completed for claims processing and Prior Coverage Information In addition to this policy, do you or your dependents have any other insurance coverage (including Florida Blue plans) that will be in effect after this coverage begins? c Yes c No Florida Blue Contract # Medicare # Pharmacy /Medicare D # Complete the following only if this is the first time you or your dependents: (1) are enrolling for health insurance with this employer; (2) currently have health coverage; and/or (3) have any health coverage in the past 12 months that this coverage replaces OR you can attach a Certificate of Creditable Coverage.

Prior Heath Carrier Name: Prior Employee Hire Date:

Contract #: Cancel Date:

Effective Date:

List names of all family members that were covered, including yourself:

I understand that any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Signature:

Date:

Section G: Acceptance of Coverage Plan Coverage Terms I hereby apply for the coverage/membership that is selected on this form. My employer has selected health and/or vision coverage through Florida Blue and/or HMO coverage through Florida Blue HMO. I authorize my employer to deduct from my earnings my premium contribution, if any. I understand all of the following: 1. If my coverage/membership is to be issued and continued, I must meet all the group contract’s requirements; 2. If my dependents’ coverage/membership, if any, is to be issued and continued, my dependents must meet all the group contract’s requirements; 3. If I must pay part or all of the premium, coverage/membership shall not become effective until Florida Blue and/or Florida Blue HMO accepts this application and assigns an effective date.

I understand that membership granted to persons herein shall be subject to all provisions and limitations of the group contract.

I am aware that a change in coverage of dependents may affect the amount deducted from any wages (if any) for coverage/ membership, and I hereby authorize such a change.

If I am enrolling in a high-deductible health plan designated for use with a Health Savings Account (HSA) under Internal Revenue Service Code section 223, I recognize and authorize Florida Blue to exchange certain limited information obtained from this application with its preferred financial partner(s) for the purposes of initial enrollment in, and administration of, HSAs. I understand that if I am enrolling in an HSA qualified High Deductible Health Plan and I elect to receive Prior Carrier Credit under Florida law, my plan may no longer qualify as an HSA compatible plan.

General Terms I AGREE that in the event of any controversy or dispute between Florida Blue and/or Florida Blue HMO, I and my dependents must exhaust the appeal and/or grievance processes in the benefit/member handbook issued to me.

I understand that my employer is not an agent of Florida Blue and/or Florida Blue HMO. I also understand that my employer is responsible for notifying all employees of: 1. Effective dates; 2. All termination dates; 3. Any conversion, COBRA or ERISA rights or responsibilities; and 4. All other matters pertaining to coverage/membership under the group contract.

When an overpayment is made, I authorize Florida Blue and/or Florida Blue HMO to recover the excess from any person or entity that received it.

I acknowledge that Florida Blue and/or Florida Blue HMO coverage/membership is contingent upon the complete, accurate disclosure of the information requested on this form.

I acknowledge that, if I apply for Florida Blue and/or Florida Blue HMO coverage/membership later, coverage/membership may not be available until the next annual open enrollment or special enrollment period. I acknowledge that any applicable credit toward a health care Pre-existing Condition Exclusion Period is contingent upon the complete and accurate disclosure of information.

I represent that the statements on this application are true and complete to the best of my knowledge and belief.

I understand and agree that misrepresentations, omissions, concealment of facts, or incorrect statements may result in denial of benefits and/or termination of coverage/membership. I agree to be bound by the group contract’s terms and conditions.

Signature:

Date:

Health and vision insurance is offered by Blue Cross and Blue Shield of Florida, Inc., D/B/A Florida Blue. HMO coverage is offered by Health Options, Inc., D/B/A Florida Blue HMO, an HMO affiliate of Florida Blue. These companies are Independent Licensees of the Blue Cross and Blue Shield Association.

22095 0914R SR

Get Started With

Florida Blue With Florida Blue, you have a community that cares about your health. Whether it’s by phone, our mobile app, online or in person, we have a host of people to give the support and tools to help you when you need medical care.

• Know what’s covered. Your plan benefits can help you save money on health care, so read up on what’s included in your plan.

• Find the lowest prices. Easily compare medications online or from your smartphone.

• Get personal attention. Visit your local Florida Blue Center to chat with an on-site nurse, check out the latest health gadgets and ask questions about your health plan.

• Get online. With your online account at floridablue.com or on the Florida Blue app, you can quickly see benefits, find the cost of medical care, find in-network doctors or pharmacies and even make appointments online.

Let’s get started.

Thanks for choosing Florida Blue HMO. Take a few minutes to review all the benefits and services your health plan has to offer.

Register online.

Once your plan starts, set up your online member account at floridablue.com or download the Florida Blue mobile app to register for 24/7 access to your ID cards, benefit coverage, claims information, cost estimators and health resources.

Choose a doctor.

It’s smart to build a relationship with a family doctor who’ll get to know you and your health history. You have a designated primary care doctor. To see your doctor’s name or find another primary care doctor in your plan’s network, log in to floridablue.com or our mobile app. You can find the name of your plan in the upper right corner of your member ID card.

If you’ll be traveling or need to explore longterm care options outside your service area, please call us at the number on the back of your member ID card.

Let us know.

Are you living with a health condition? Call us right away. We’ll help you transition to your new plan without skipping a beat.

You’ll also get personal support from nurses and health coaches to answer questions and help you get the care you need.

It’s important to know that your plan doesn’t include out-of-network coverage. This means if you see a doctor or fill a prescription outside your network, you’ll end up paying the entire cost (except in an emergency or if you’ve gotten preapproval).

For questions and personal support: Call: Talk to an advocate at 888-476-2227.

Click: Log in to floridablue.com or the Florida Blue mobile app.

Visit: Stop by a Florida Blue Center near you. Find one at floridablue.com/centers.

Stay on top of your health.

As soon as your health plan benefits start, schedule your yearly wellness exam. When you go, take a list of your medications and vitamins with you.

Remember, the more your doctor knows about your health, the better they can help with your care.

Your plan includes all these preventive services at no extra cost: • $0 routine physicals, immunizations, well-child visits and more • $0 lab tests and blood work at Quest Diagnostics • $0 Generic oral contraceptives and preventive medication • $0 eye exams, lenses and more for children under age 19 • $0 dental cleanings, fillings and more for children under age 19 Plus: • $4 generic drugs available at your local pharmacy • $0 virtual visits with a primary care doctor or behavioral health provider • Health programs1 for heart disease, diabetes, asthma and more • TIPS: Depending on your exam, your doctor may need to treat you for new conditions or change your treatment, which may not be covered by your annual wellness exam. In this case, the cost for your visit may be more.

See your preventive benefits for details.

Get care centered on YOU. Look into choosing a Value Choice Provider or a Patient-Centered Medical Home doctor as your primary care doctor (PCP). These kinds of doctors offer quality, coordinated care and may cost less for sick and wellness visits. Find one in the online provider directory by looking for Value Choice Providers or Patient-Centered Medical Home under the “Programs” column.

Virtual visits are available with primary care doctors, specialists and behavioral health providers in your network or through Teladoc2.

Download the Teladoc app from your app store or visit teladoc.com to register.

Save on medication.

When you use a pharmacy in the Preferred Pharmacy Network, you’ll pay a lower cost share or copay for your prescriptions. To find a preferred pharmacy, log in to your account at floridablue.com and click on Tools, then Find a Doctor. Preferred pharmacies feature an orange “preferred pharmacy” designation in the search returns.

If you choose to fill a prescription outside the Preferred Pharmacy Network, you may pay higher out-of-pocket costs. Also, talk to your pharmacist to be sure you’re getting the lowest price offered.

Even if it’s through a store program, it will still go toward meeting your deductible (if applicable).

Make sure any medicine you take regularly is covered by your plan. In some cases you might need preapproval or to try another drug first.

For medicine you take for 90 days or longer, switch to home delivery and save money—you can get three months of drugs for the cost of two.3 Florida Blue’s home delivery pharmacy can help you transfer your prescriptions. Give them a call at 888-230-7261.

Before you get a prescription filled, log in at floridablue.com or the Florida Blue mobile app to compare drug prices and get coverage details.

Save on medical costs.

The quality and price of medical services can vary depending on where you go for office visits, imaging services and surgery. For example, going to an urgent care usually saves time and costs less than an ER visit.

See how much you’ll pay for services in advance with our online cost estimator. Anytime you need care, we can help—online, in person or by phone.

Check first for preapproval.

You’ll need to get some medical services approved first so your plan can pay for them.

Some examples of these medical services include advanced imaging, spine care, heart screenings, hospital stays and durable medical equipment.

If your doctor performs any of these without checking with us first, you could be stuck paying your whole medical bill.

Here’s how preapproval works: Your doctor will: • Recommend services for your treatment • Call us to get approval We will: • Review your doctor’s request • Send you a letter letting you know whether we can or can’t approve the service (and why) Your next steps before a medical service: • Remind your doctor that you need approval for some services, including the ones listed above.

• If you haven’t heard from Florida Blue before your appointment for treatment, call us at the number on the back of your member ID card to check on the approval.

• Keep the approval letter from Florida Blue for your records.

For more information and the most up-todate list of services that need approval, please visit floridablue.com/checkfirst.

Thrive and be well.

Better You Strides creates a step-by-step guide to help you reach your health goals.

• Activities to help you move more, eat better and feel happier • Wellness challenges to make it fun • Mobile-based so you can get support when and where you need it

Important numbers Care Consultants can show you

how your benefits work to manage costs, and help you find the doctors, programs and community services you need to get well: 888-476-2227 For disease management and

extended care, help your treatment and recovery stay on the right path with our Care Coordination program: 844-730-BLUE (2583) Enjoy free classes along with

personal service at any of our Florida Blue Centers: 877-FL-BLUE-0 (352-5830) Our Healthy Addition® program designed to provide expecting is moms information for a healthy pregnancy and delivery: 800-955-7635, option 6 Looking for a doctor outside of

Florida?

BlueCard5 Access helps you locate providers worldwide: 800-810-BLUE (2583)

Other important numbers:

et more value—at no G extra cost.

Doctor: _____________________________

Blue365® is an online member-only discount program4 that provides savings on health and wellness products and services. Just log on to floridablue.com to find deals on:

Pharmacy: ___________________________

• • • • •

Gym memberships Weight loss management Vision care, glasses, contact lenses Hearing aids and care Family care and elder care services

Doctor: _____________________________

Member ID: __________________________ Group Number: ______________________ Member Number: ____________________

Get answers,

then get going Call: Talk to an advocate at 888-476-2227.

Click: Log in to floridablue.com.

Visit: Stop by a Florida Blue Center. Find one at floridablue.com/centers.

Download: Get the Florida Blue app at apps.floridablue.com.

Go paperless. Get your health statements online. Log in to your account and go paperless today.

For more details about your benefits or if you’d like us to mail you a benefit booklet, log in at floridablue.com or call us at the number on the back of your member ID card.

Connect with us:

Florida Blue has entered into an arrangement with Onlife to provide members with care decision support services, information and other services. Please remember that all decisions that require or pertain to independent professional medical/clinical judgment or training, or the need for medical services, are solely your responsibility and the responsibility of your Physicians and other health care Providers. The programs mentioned above are subject to change.

2 Teladoc is an independent company contracted by Florida Blue to provide physician visits via phone or online video to members with non-emergent medical issues.

Teladoc is only available in the U.S. Teladoc® is a trademark of Teladoc, Inc. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

3 Florida Blue contracts with Prime Therapeutics, LLC to provide pharmacy benefit management and mail order pharmacy services.

4 Blue365® offers access to savings on items that members may purchase directly from independent vendors. Blue365 does not include items covered under your policies with Florida Blue HMO or any applicable federal health care program. Blue Cross and Blue Shield Association (BCBSA) and local Blue companies may receive payments from Blue365 vendors. Neither BCBSA nor any local Blue company recommends, endorses, warrants or guarantees any specific Blue365 vendor or item. For more information about Blue365, go to floridablue.com.

5 The BlueCard Program is made available through the Blue Cross and Blue Shield Association (BCBSA). Neither Florida Blue nor BCBSA shall be liable for losses, damages, or uncovered charges as a result of using the Blue Cross and Blue Shield Global Service Center or receiving care from any provider listed on the Blue Cross and Blue Shield Global website.

HMO coverage is offered by Florida Blue HMO, an affiliate of Florida Blue. These companies are Independent Licensees of the Blue Cross and Blue Shield Association.

We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-352-2583 (TTY: 1-877-955-8773).

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-352-2583 (TTY: 1-800-955-8770).

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