13-SCBOCC SBC PLAN 03160 Florida Blue Medical 20251001.pdf

BlueOptions 03160 Coverage Period: 10/01/2025 - 09/30/2026

HSA Compatible with Rx $15/$30/$50 after In-network Deductible Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage for: Individual | Plan Type: PPO

SBCID: 2994669

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: $1,650 Per Person. Out-of- Network: $3,300 Per Person.

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 policy, the overall family deductible must be met before the plan begins to pay.7

Are there services covered before you meet your deductible?

Yes. Preventive care.

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/.

Are there other deductibles for specific services?

No. You don’t have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan?

In-Network: $5,100 Per Person. Out-Of- Network: $10,200 Per Person.

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, the overall family out-of-pocket limit must be met.

What is not included in the out-of-pocket limit?

Premium, balance-billed charges, and health care this plan doesn't cover.

Even though you pay these expenses, they don’t count toward the out–of–pocket limit.

Will you pay less if you use a network provider?

Yes. See https://providersearch.floridablue.com/pr ovidersearch/pub/index.htm or call 1- 800-352-2583 for a list of network providers.

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.

Do you need a referral to see a specialist?

No. You can see the specialist you choose without a referral.

http://www.floridablue.com/plancontracts/group http://www.floridablue.com/plancontracts/group http://www.healthcare.gov/coverage/preventive-care-benefits/ https://providersearch.floridablue.com/providersearch/pub/index.htm https://providersearch.floridablue.com/providersearch/pub/index.htm

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

What You Will Pay Limitations, Exceptions, & Other Important

Information Network Provider

(You will pay the least) Out-of-Network Provider (You will pay the most)

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

Value Choice Provider:

Deductible + 20% Coinsurance / Primary Care Visits: Deductible + 20% Coinsurance/ Virtual Visits: Deductible + 20% Coinsurance

Deductible + 40% Coinsurance/ Virtual Visits: Not Covered

Physician administered drugs may have higher cost share. Virtual Visit services are only covered for In-Network providers.

Specialist visit

Value Choice Specialist:

Deductible + 20% Coinsurance / Specialist: Deductible + 20% Coinsurance/ Virtual Visits:

Deductible + 20% Coinsurance

Deductible + 40% Coinsurance/ Virtual Visits: Not Covered

Physician administered drugs may have higher cost share. Virtual Visit services are only covered for In-Network providers.

Preventive care/screening/ immunization

No Charge, Deductible does not apply

40% Coinsurance

Physician administered drugs may have higher cost share. 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.

If you have a test

Diagnostic test (x-ray, blood work)

Value Choice Specialist:

Deductible + 20% Coinsurance / Independent Clinical Lab: No Charge after Deductible/ Independent Diagnostic Testing Center: Deductible + 20% Coinsurance

Deductible + 40% Coinsurance

Tests performed in hospitals may have higher cost share.

Imaging (CT/PET scans, MRIs)

Deductible + 20% Coinsurance Deductible + 40% Coinsurance

Tests performed in hospitals may have higher cost share. Prior Authorization may be required. Your benefits/services may be denied.

For more information about limitations and exceptions, see the plan or policy document at www.floridablue.com/plancontracts/group.

Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important

Information Network Provider

(You will pay the least) Out-of-Network Provider (You will pay the most)

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at https://www.floridabl ue.com/members/to ols-resources/pharmac y/medication-guide

Generic drugs

Deductible + $15 Copay per Prescription at retail, Deductible + $30 Copay per Prescription by mail

In-Network Deductible + 50% Coinsurance

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.

Preferred brand drugs

Deductible + $30 Copay per Prescription at retail, Deductible + $60 Copay per Prescription by mail

In-Network Deductible + 50% Coinsurance

Up to 30 day supply for retail, 90 day supply for mail order.

Non-preferred brand drugs

Deductible + $50 Copay per Prescription at retail, Deductible + $100 Copay per Prescription by mail

In-Network Deductible + 50% Coinsurance

Up to 30 day supply for retail, 90 day supply for mail order.

Specialty drugs Specialty drugs are subject to the cost share based on applicable drug tier.

Specialty drugs are subject to the cost share based on the applicable drug tier.

Up to 30 day supply for retail. Not covered through Mail Order.

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

Deductible + 20% Coinsurance Deductible + 40% Coinsurance

––––––––none––––––––

Physician/surgeon fees Deductible + 20% Coinsurance

Ambulatory Surgical Center: Deductible + 40% Coinsurance/ Hospital:

Not Covered

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If you need immediate medical attention

Emergency room care Deductible + 20% Coinsurance In-Network Deductible + 20% Coinsurance

––––––––none––––––––

Emergency medical transportation

Deductible + 20% Coinsurance In-Network Deductible + 20% Coinsurance

––––––––none––––––––

Urgent care

Value Choice Provider:

Deductible + 20% Coinsurance / Urgent Care Visits: Deductible + 20% Coinsurance

Deductible + 20% Coinsurance

––––––––none––––––––

If you have a hospital stay

Facility fee (e.g., hospital room)

Deductible + 20% Coinsurance Deductible + 40% Coinsurance

Inpatient Rehab Services limited to 30 days.

http://www.floridablue.com/plancontracts/group https://www.floridablue.com/members/tools-resources/pharmacy/medication-guide https://www.floridablue.com/members/tools-resources/pharmacy/medication-guide https://www.floridablue.com/members/tools-resources/pharmacy/medication-guide https://www.floridablue.com/members/tools-resources/pharmacy/medication-guide https://www.floridablue.com/members/tools-resources/pharmacy/medication-guide

For more information about limitations and exceptions, see the plan or policy document at www.floridablue.com/plancontracts/group.

Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important

Information Network Provider

(You will pay the least) Out-of-Network Provider (You will pay the most)

Physician/surgeon fees Deductible + 20% Coinsurance In-Network Deductible + 20% Coinsurance

––––––––none––––––––

If you need mental health, behavioral health, or substance abuse services

Outpatient services Deductible + 20% Coinsurance Deductible + 40% Coinsurance/ Specialist Virtual Visits: Not Covered

Virtual Visit services are only covered for In- Network providers.

Inpatient services Deductible + 20% Coinsurance

Physician Services: In- Network Deductible + 20% Coinsurance/ Hospital: Deductible + 40% Coinsurance

Prior Authorization may be required. Your benefits/services may be denied.

If you are pregnant

Office visits Deductible + 20% Coinsurance Deductible + 40% Coinsurance

Maternity care may include tests and services described elsewhere in the SBC (i.e.

ultrasound.)

Childbirth/delivery professional services

Deductible + 20% Coinsurance Not Covered ––––––––none––––––––

Childbirth/delivery facility services

Deductible + 20% Coinsurance Deductible + 40% Coinsurance

––––––––none––––––––

If you need help recovering or have other special health needs

Home health care Deductible + 20% Coinsurance Deductible + 40% Coinsurance

Coverage limited to 60 visits.

Rehabilitation services Deductible + 20% Coinsurance Deductible + 40% Coinsurance

Coverage limited to 35 visits, including 26 manipulations. Services performed in hospital may have higher cost share. Prior Authorization may be required. Your benefits/services may be denied.

Habilitation services Not Covered Not Covered Not Covered

Skilled nursing care Deductible + 20% Coinsurance Deductible + 40% Coinsurance

Coverage limited to 60 days.

Durable medical equipment Deductible + 20% Coinsurance Deductible + 40% Coinsurance

Excludes vehicle modifications, home modifications, exercise, bathroom equipment and replacement of DME due to use/age.

Hospice services Deductible + 20% Coinsurance Deductible + 40% Coinsurance

––––––––none––––––––

Children’s eye exam Not Covered Not Covered Not Covered http://www.floridablue.com/plancontracts/group

For more information about limitations and exceptions, see the plan or policy document at www.floridablue.com/plancontracts/group.

Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important

Information Network Provider

(You will pay the least) Out-of-Network Provider (You will pay the most)

If your child needs dental or eye care

Children’s glasses Not Covered Not Covered Not Covered

Children’s dental check-up 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

• Bariatric surgery

• Cosmetic surgery

• Dental care (Adult)

• Habilitation services

• Hearing aids

• Infertility treatment

• Long-term care

• Pediatric dental check-up

• Pediatric eye exam

• Pediatric glasses

• Private-duty nursing

• Routine eye care (Adult)

• Routine foot care unless for treatment of diabetes

• Weight loss programs

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 States. See www.floridablue.com.

• Non-emergency care when traveling outside the 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/agencies/ebsa 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/healthreform.

Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

https://www.dol.gov/agencies/ebsa http://www.cciio.cms.gov/ http://www.healthcare.gov/ http://www.dol.gov/ebsa/healthreform http://www.dol.gov/ebsa/healthreform

For more information about limitations and exceptions, see the plan or policy document at www.floridablue.com/plancontracts/group.

Does this plan meet the 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.––––––––––––––––––––––

Peg is Having a Baby

(9 months of in-network pre-natal care and a hospital delivery)

Mia’s Simple Fracture

(in-network emergency room visit and follow up care)

Managing Joe’s type 2 Diabetes

(a year of routine in-network care of a well-controlled condition)

◼ The plan’s overall deductible $1,600 ◼ Specialist Coinsurance 20% ◼ Hospital (facility) Coinsurance 20% ◼ Other No Charge $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 $12,700

In this example, Peg would pay:

Cost Sharing

Deductibles $1,600

Copayments $10

Coinsurance $2,000

What isn’t covered

Limits or exclusions $60

The total Peg would pay is $3,670

◼ Other Coinsurance 20%

Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

Total Example Cost $5,600

In this example, Joe would pay:

Deductibles $1,600

Copayments $800

Coinsurance $100

What isn’t covered

Limits or exclusions $20

The total Joe would pay is $2,520

◼ Other Coinsurance 20%

Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

Total Example Cost $2,800

In this example, Mia would pay:

Deductibles $1,600

Copayments $10

Coinsurance $200

What isn’t covered

Limits or exclusions $0

The total Mia would pay is $1,810

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.

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.

http://www.floridablue.com/

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.

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.

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.