4. Attachment C - Covered Benefits and Services.pdf

Covered Service Unit Your Cost (Copayment)

Physician Services (including maternity care) Primary Care: Office visit/ telehealth for services provided by your primary care physician during regular office hours

Per Visit $10

Specialty Care: Office visit/ telehealth for services provided by a participating provider when authorized by your primary care

Per Visit $25

Urgent Care:

Office Visit/Telehealth – Urgent care services provided by your primary care physician, or other Capital Health Plan personnel or participating providers including after regular office hours.

Telehealth- Amwell urgent care services provided by network physicians through remote access technology including the web and other mobile devices.

Per Visit

Per visit

$20

$0

Preventive services covered under Original Medicare Per Visit $0 Acupuncture- For chronic low back pain under certain circumstances Per Visit $25 Chiropractic Care- if medically necessary under certain circumstances

Per Visit $20

Mental health and Substance Use Disorder outpatient care when medically necessary and authorized by the primary care physician Per Visit $25

Outpatient procedures, surgical services, and other medical care provided by the primary care physician or by a participating provider when authorized by the primary care physician

Per Visit $25

Hospital Services (including maternity care) Room and board in a semiprivate room, or private when medically necessary, and all services covered under this agreement Per Admission $150 per day, days 1-10 Outpatient procedures performed in a hospital Per Visit $200 Mental health inpatient hospital care Per Admission $150 per day, days 1-10 Emergency Services

Emergency room visit Per Visit $120 (waived if admitted)

Medically necessary ambulance service Per Transport $250

Other Benefits Home health services Per Occurrence $0

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State of Florida Retiree Classic (HMO) Schedule of Copayments

Attachment C - Covered Benefits and Services

Covered Service Unit Your Cost (Copayment)

Hospice care Per

Occurrence $0 Skilled nursing facility services limited to 100 days of confinement per benefit period

Per Confinement

$0 days 1-20 $75 days 21-100

Outpatient procedures performed in an ambulatory surgical Per Visit $100 Durable medical equipment Per Device 20% Orthotic and Prosthetic medical appliances Per Appliance 20% Diagnostic Imaging including MRI, PET, CT, and Thallium Per Visit $100 Vision/routine eye exams (one every 12 months) Per Visit $10 or $25 Visits for physical therapy, occupational therapy, and speech language therapy Per Visit $25

Visits for cardiac and intensive cardiac rehabilitation services Per Visit $25 Visits for pulmonary rehabilitation services Per Visit $20 Diabetic testing supplies Of the Cost 20% Part B Drugs Of the Cost $50 Outpatient Prescription Drugs

30 day supply 60 day supply 90 day supply Retail Tier 1 $7 $7 $7

Tier 2 $7 $14 $21 Tier 3 $45 $90 $135 Tier 4 $95 $190 $285 Tier 5 $95 N/A N/A Tier 6 $0 $0 $0

Mail order

Tier 1 Tier 2

$7 $7

$45 $95 N/A $0

$7 $14 $90

$190 N/A $0

$7 $14 $90 $190 N/A $0

Tier 3 Tier 4

*100 day Tier 5 supply Tier 6*

Exclusions Services not specifically listed in the Evidence of Coverage; service, which in our opinion was, or is, not medically necessary; hearing aids and devices; cosmetic surgery; nonprescription drugs and vitamins; and custodial care.

• You are responsible for the payment of charges for health care services that are not covered and for the payment of charges in excess of any maximum benefit limitation set forth in the Evidence of Coverage or Schedule of Copayments.

• Your maximum out-of-pocket amount for medical services in the calendar year is $2,500 per member.

• Prescription maximum out of pocket is $2000.

• The Medicare Prescription Payment Plan is a new payment option that works with your current drug coverage, and it can help you manage your drug costs by spreading them across monthly payments that vary throughout the year (January – December).

• See the Capital Health Plan Retiree Advantage Evidence of Coverage or the Capital Health Plan Retiree Advantage Summary of Benefits for additional information.

• Annual diabetic eye exams for members with diabetes is a $0 copay at CHP’s eye care center.

• Eyewear Benefit $200 each year/Fitness reimbursement $150 each year.

Covered services In-network

Annual medical deductible $0

Inpatient hospital care 100% after $100 copayment per admission

Outpatient hospital services $0 - $10 copayment

Provider office visits $0 copayment for primary care provider (PCP);

$10 copayment for specialist

Preventive services 100% coverage for many preventive services and no plan deductible

Emergency room care 100% after $65 copayment; waived if admitted within 24 hours

Transportation $0 copay for plan approved location up to 50 one-way trip(s) per year by car, van or wheelchair accessible vehicle

Dental $0 preventive, 20% basic and 50% major services;

annual maximum limit $1,000

Prescription drug schedule Covered prescription drugs are assigned to one of four different tiers with corresponding cost-share amounts. The tiers are described in the chart below:

$0 plan deductible Network pharmacy cost (30-day supply)

Network pharmacy cost (61-90 day supply)

Tier 1 Generic or preferred generic $7 $14

Tier 2 Preferred brand $30 $60

Tier 3 Non-preferred brand $50 $100

Tier 4 Specialty $50 N/A*

* You cannot order a 90-day supply of specialty drugs. Specialty drugs can only be ordered as a 30-day supply.

Attention State of Florida Medicare-eligible retirees!

Keep more money in your pocket with a Humana Group Medicare HMO plan You and your Medicare-eligible dependents are able to enroll in the Humana Group Medicare Advantage Prescription Drug HMO plan offered through the Division of State Group Insurance at anytime.

If it isn’t everything you expected, you can go back to the plan you had before.

2025 monthly plan premium is $75.09

Extra benefits, at no additional cost to you This custom plan includes all the benefits of Original Medicare and provides coverage for both medical and prescription drug benefits, as well as extra benefits like:

MyHumana Your secure online account at Humana.com where you can keep track of your claims and benefits, find providers, view important plan documents and more.

Humana Well Dine® meal program After your overnight inpatient stay in a hospital or nursing facility, you’re eligible to receive up to 28 nutritious meals (2 meals per day for 14 days). The meals will be delivered to your door at no additional cost to you. For more information, please contact the number on the back of your Humana member ID card or visit Humana.com/home-care/well-dine.

SilverSneakers®

SilverSneakers is a health and fitness program designed for senior adults that offers fun and engaging classes and activities. The program has online and in-person sessions at any pace—sit, stand, walk or run. Visit SilverSneakers.com/StartHere to get your SilverSneakers ID number and find a location near you, or call SilverSneakers at 888-423-4632 (TTY: 711).

Go365 by Humana®

Go365 is a wellness program that rewards you for completing eligible healthy activities like working out, getting your Annual Wellness Visit or volunteering. You can earn rewards* to redeem for gift cards in the Go365 Mall. If you have a MyHumana account, you can use the same information to log in to Go365.com. If not, activate your profile at MyHumana.com. Once you log into Go365, you’ll see eligible activities you can complete to earn rewards and details on how to track your activities.

* Rewards have no cash value and can only be redeemed in the Go365 Mall. Rewards must be earned and redeemed within the same program year. Gift cards cannot be used to purchase prescription drugs or medical services that are covered by Medicare, Medicaid or other federal healthcare programs, alcohol, tobacco, e-cigarettes, or firearms. Gift cards must not be converted to cash.

Ask your questions, get answers Please call Humana’s State of Florida Customer Care team at 800-555-7997 (TTY: 711).

Representatives are available Monday – Friday, 8 a.m. – 9 p.m., Eastern time. Outside of work hours, leave your name and number; we’ll call you back by the end of the next business day. Or visit your.Humana.com/sof for more information about the Humana plan.

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Important _________________________________________ At Humana, it is important you are treated fairly.

Humana Inc. and its subsidiaries comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, ancestry, ethnicity, sex, sexual orientation, gender, gender identity, disability, age, marital status, religion, or language in their programs and activities, including in admission or access to, or treatment or employment in, their programs and activities.

• The following department has been designated to handle inquiries regarding Humana’s non-discrimination policies: Discrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618.

800-555-7997 (TTY: 711).

Auxiliary aids and services, free of charge, are available to you.

800-555-7997 (TTY: 711).

Humana provides free auxiliary aids and services, such as qualified sign language interpreters, video remote interpretation, and written information in other formats to people with disabilities when such auxiliary aids and services are necessary to ensure an equal opportunity to participate.

This information is available for free in other languages. Please call our customer service number at 877-320-1235 (TTY: 711). Hours of operation:

8 a.m. – 8 p.m. Eastern time.

Español (Spanish): Llame al número indicado para recibir servicios gratuitos de asistencia lingüística.

877-320-1235 (TTY: 711). Horas de operación: 8 a.m. a 8 p.m. hora del este.

繁體中文 (Chinese): 本資訊也有其他語言版本可供免費索取。請致電客戶服務部：877-320-1235 ( 聽障專線：711)。辦公時間：東部時間上午 8 時至晚上 8 時。

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Humana is a Medicare Advantage HMO plan with a Medicare contract. Enrollment in this Humana plan depends on contract renewal. Call 800-555-7997 (TTY: 711) for more information.

All product names, logos, brands and trademarks are property of their respective owners, and any use does not imply endorsement.

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MyFlorida Group Medicare Advantage (PPO) plan benefits

Division of State Group Insurance

Department of

A plan to explore more benefits made just for you

What is the MyFlorida Group Medicare Advantage (PPO) plan?

As a Medicare-eligible retiree of the State of Florida, you have the opportunity to enroll in the MyFlorida Group Medicare Advantage (PPO) plan, one of the offerings by the Division of State Group Insurance (DSGI).

The MyFlorida Group Medicare Advantage (PPO) plan is insured by UnitedHealthcare® and provides health care and prescription drug coverage.

This is a custom plan offered only to Medicare-eligible retirees of the State of Florida, and it includes extra benefits and programs beyond Original Medicare, such as hearing, dental, vision and more

This is a MA-PD plan. It includes Part A hospitalization coverage, Part B medical coverage and Part D prescription drug coverage

This is a Preferred Provider Organization (PPO) plan that allows you to see any Medicare-participating provider (in-network or out-of-network) at the same cost share, as long as the provider accepts the plan

UnitedHealthcare has a large network of doctors and specialists within the United States, including the District of Columbia and U.S. Territories

This plan covers nearly all Medicare Part D eligible drugs, plus additional drugs determined by the State Group Insurance Program

Take a look through this brochure to learn more about the plan and the extra benefits and programs.

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Let’s get started

What is the MyFlorida Group Medicare Advantage (PPO) plan?

Medical benefit summary

Prescription drug benefit summary

Additional programs and services

Medical benefit summary This is a short description of the current year plan benefits. Limitations, exclusions and restrictions may apply. For more information on coverage and benefits, please scan the QR code.

Prescription drug benefit summary This is a short description of the current year prescription drug benefits. For more information please scan the QR code.

How to scan QR codes

Open your phone camera

Aim your phone camera at the code

Tap the banner that appears on your phone

Benefit feature In-network

Annual out-of-pocket maximum (medical) (amount the retiree pays before the Plan pays 100% of charges) Individual: $500

Primary care provider office visits $5 copay

Specialist office visits $10 copay

Urgent care $10 copay

Emergency room care $65 copay (waived if admitted)

Inpatient hospital stay $100 copay per stay

Outpatient surgery $0 copay

Mental health care/substance abuse treatment Inpatient

Outpatient

$100 copay per stay

$5 copay (group)

$10 copay (individual)

Diagnostic labs and X-rays high cost testing (MRI, CAT etc.) $10 copay

Lab services/outpatient X-rays $5 copay

Routine eye exam (1 exam every 12 months) $0 copay

Routine dental (preventive dental care including exams, cleanings, X-rays and fluoride) $0 copay

Hearing aids* (1 set every 3 years) Plan pays a $500 allowance (combined for both ears)

Routine foot care (6 visits per plan year**) $10 copay

* Hearing aid coverage under this plan is only available through UnitedHealthcare Hearing. Other hearing exam providers are available in our network.

** Benefits are combined in and out-of-network.

Initial coverage stage Network retail pharmacy (up to a 30-day retail supply)

Preferred mail service pharmacy (up to a 90-day supply≠)

Tier 1 – preferred generic $7 copay $14 copay

Tier 2 – preferred brand $30 copay $60 copay

Tier 3 – Non-preferred drug $50 copay $100 copay

Tier 4 – specialty tier $50 copay $100 copay

Beginning in 2025, there are three payment stages the Yearly Deductible Stage, the Initial Coverage Stage, and the Catastrophic Stage. Under your plan there is no deductible stage and the Coverage Gap Stage and the Coverage Gap Discount Program will no longer exist in the Part D benefit. Once you have paid $2,000 out-of-pocket for Medicare-covered Part D drugs, you will move to the next stage (the Catastrophic Coverage stage). If you reach the Catastrophic Coverage stage, you pay nothing for your Medicare-covered Part D drugs for the remainder of the plan year.

≠ Reduced copay only available at Mail order.

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Additional programs and services As a member of the MyFlorida Group Medicare Advantage (PPO) plan, you will have an array of programs and services available. Below are some additional benefits, services and programs you can take advantage of once you become a member.

Annual Wellness Visit and preventive services at $0 copay An Annual Wellness Visit with a health care practitioner is one of the best ways retirees can stay on top of their health. Together, retirees can identify the preventive screenings they may need, review their medications and talk about any health concerns. They may also be eligible for rewards for completing their Annual Wellness Visit and other health and wellness-related activities.

Virtual Visits You are able to talk to a behavioral health specialist by phone or video from your computer, tablet or smartphone — 24/7, day or night. Services include initial evaluation, medication management and ongoing counseling.

Virtual visits may require video-enabled smartphone or other device. Not for use in emergencies.

UnitedHealthcare Hearing1

Hearing health is important to your overall well-being and can help you stay connected. Get access to thousands of name-brand and private-labeled hearing aids — available in person at any of our 6,500 UnitedHealthcare Hearing providers nationwide or delivered directly to your door.

Call toll-free 1-855-523-9355, TTY 711. Or visit uhchearing.com

Special programs for people with chronic or complex health needs UnitedHealthcare offers special programs to help members who are living with chronic disease, like diabetes or heart disease. You get personal attention and your provider gets up-to-date information to help you make decisions.

A dental plan worth smiling about2 The MyFlorida Group Medicare Advantage (PPO) plan gives you access to a large network of dentists.

Dental benefits include:

$0 copay for preventive care when you see a network dentist. This includes exams, 2 cleanings in a 12-month period and X-rays.

Fillings

Freedom to see out-of-network providers; you may pay more when going out-of-network

Large nationwide network of providers to serve your dental needs $0 deductible

Vision care3

Regular visits to an eye doctor can help keep your eyes healthy and improve your overall health. With the MyFlorida Group Medicare Advantage (PPO) plan, you have access to a nationwide network of providers with the freedom to see any participating vision provider, anywhere in the country.

Routine eye exam once every 12 months; copay may apply

Allowance toward eyeglasses (frames and lenses) or contact lenses

Freedom to see any participating vision provider

Nationwide network of providers to serve your vision needs

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UnitedHealthcare Healthy at Home You are eligible for the following benefits up to 30 days following all inpatient and skilled nursing facility discharges:

Receive 28 home-delivered meals

Receive up to 12 one-way rides to and from medically related appointments and the pharmacy

Receive up to 6 hours of non-medical personal care like companionship, meal prep, medication reminders, and more with a professional caregiver.

A referral is not required.

Health and wellness resource Our health and wellness experience helps you take charge of your well-being every day with a wide variety of resources and activities, including healthy recipes, fitness activities, education resources and more. All at no additional cost.

UnitedHealthcare Fitness Program Renew Active® by UnitedHealthcare is the gold standard in Medicare fitness programs, offered at no additional cost to you. This includes a free gym membership at a fitness center from our large nationwide network, thousands of on-demand workout videos and live streamed fitness classes and social activities at local health and wellness classes and events.

Ways to save on prescription drugs With the MyFlorida Group Medicare Advantage (PPO) plan, you can choose from thousands of national chain, regional and independent local retail pharmacies.

Home Delivery — You may save on the medications you take regularly If you prefer the convenience of mail order, you could save time and money by receiving your maintenance medications through OptumRx® Home Delivery.4 You’ll get automatic refill reminders and access to licensed pharmacists if you have questions.

Get a 3-month supply at retail pharmacies In addition to OptumRx® Home Delivery, most retail pharmacies offer 3-month supplies for some prescription drugs. Check your UnitedHealthcare pharmacy directory to see if a retail pharmacy offers 3-month supplies.

HouseCalls – Enjoy a preventive care visit in the privacy of your own home With UnitedHealthcare® HouseCalls, you are eligible for an optional, yearly in-home visit from one of our health care practitioners at no extra cost. A HouseCalls visit is designed to support, but does not take the place of your regular doctor’s care.

HouseCalls may not be available in all areas.

Healthier habits, healthier lifestyle Real Appeal on Rally Coach™ is a proven weight management program designed to help you get healthier and stay healthier. It’s available to you and eligible family members at no additional cost as part of your benefits.

* Refer to your Evidence of Coverage for eligibility requirements.

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1 Other hearing exam providers are available in the UnitedHealthcare network. The plan only covers hearing aids from a UnitedHealthcare Hearing network provider. Network size varies by market

2 $0 cost-share for in-network dental care, specified services only. If your plan offers out-of-network dental coverage and you see an out-of-network dentist you might be billed more, even for services listed as $0 copay. Network size varies by market.

3 Allowance for contacts or frames with standard (single, bi-focal, tri-focal or standard Tier I progressive) lenses covered in full either annually or every two years.

4 $0 copay may be restricted to particular tiers, preferred medications, or home delivery prescriptions during the initial coverage phase and may not apply during the coverage gap or catastrophic stage. OptumRx is an affiliate of UnitedHealthcare Insurance Company. You are not required to use OptumRx home delivery for a 90-100 day supply of your maintenance medication.

Renew by UnitedHealthcare is not available in all plans. Resources may vary. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply.

The Formulary, pharmacy network, and/or provider network may change at any time. The retiree will receive notice when necessary.

Out-of-network/non-contracted providers are under no obligation to treat Plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information.

Benefits, features and/or devices vary by plan/area. Limitations and exclusions apply. Benefits, Premium and/or copayments/coinsurance may change on January 1 of each year. Refer to the Evidence of Coverage for eligibility requirements. Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a Medicare approved Part D sponsor. Enrollment in these plans depends on the plan’s contract renewal with Medicare.

© 2024 United HealthCare Services, Inc. All Rights Reserved.

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Virtual Education Center The Virtual Education Center is an online resource that was created because it’s not always possible to share information face to face. We’ve brought the resources together in one place wherever and whenever you need it.

Visit uhcvirtualretiree.com/MyFlorida Explore a library of flyers, brochures, videos and more. Learn about:

Questions about the plan?

Call Customer Service at 1-877-352-7794, TTY 711, 8 a.m.–8 p.m. local time, Monday–Friday.

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• The basics of Medicare Advantage (Part C)

• How the MyFlorida Group Medicare Advantage (PPO) plan works

• UnitedHealthcare® HouseCalls

• Telephonic and Virtual Visits

• UnitedHealthcare Hearing

• Fitness membership

• Health and wellness tools

• Clinical resources support to manage one-time health challenges or chronic conditions like diabetes or hypertension

Get more with the MyFlorida Group Medicare Advantage (PPO) plan

Call 1-877-352-7794, TTY 711 8 a.m.–8 p.m. local time, Monday–Friday

Visit retiree.uhc.com/MyFlorida