AttachmentA.pdf

Large Group HMO Health Benefit Plan TD8

TD8 – 1/21

LGHMOSOB1.21

Amount Member Pays Schedule of Benefits for Covered Services In-Network Out-of-Network Financial Features Medical Benefits Deductible (EM DED1) (PCP2) $3,000 per person N/A (DED is the amount the member is responsible for before FHCP pays) $9,000 per family Prescription Drug Benefits Deductible (EM DED1) (PCP2) (DED is the amount the member is responsible for before FHCP pays)

$0 per person $0 per family

N/A

Coinsurance (Coinsurance is the percentage the member pays for services)

20% of Allowed Amount N/A

Out-of-Pocket Maximum (EM OOPM3) (PCP2) $6,350 per person N/A (OOPM includes DED, Coinsurance, Copayments and Prescription Drugs) $12,700 per family Office Services Physician Office Services (per visit)

Primary Care Office $40 Copay N/A Specialist $65 Copay N/A

Maternity (Office Cost Share for initial visit only. Delivery charges are separate) Primary Care Physician $40 Copay N/A Specialist $65 Copay N/A

Allergy Injections (per visit) Primary Care Physician 20% Coinsurance N/A Specialist 20% Coinsurance N/A

Medical Pharmacy: Medications administered by a health care provider in an office or outpatient setting. Includes chemotherapy, infusions, therapeutic injections and other medications ordered and administered by a provider. Prior authorization is required.

Preferred Medications 15% Coinsurance N/A Non-Preferred Medications 25% Coinsurance N/A

Important: The Cost Share for Medical Pharmacy Services applies to the Prescription Drug only and is in addition to the Office Services and/or Outpatient Facility Cost Share. Medical Pharmacy does not include immunizations, allergy injections or Services covered through the pharmacy program. Please refer to your Certificate of Coverage for a description of Medical Pharmacy.

Preventive Care Routine Adult & Child Preventive Services, Wellness Services, Blood Work and Immunizations

$0 N/A

Mammogram Screening

Bone Density Screening $0 N/A

Colonoscopy (Routine for age 50+ then frequency schedule applies)

Emergency Medical Care Urgent Care Centers (per visit)

$100 Copay $100 Copay

Hospital Emergency Room or Stand-Alone Emergency Facility Services (per visit) (waived if admitted)

$400 Copay $400 Copay

Ambulance Services

Deductible + 20% Deductible + 20%

EM DED1 = Deductible is Embedded: A covered member’s family deductible costs are capped at the individual deductible amount on the family plan

PCP2 = Per Coverage Period (Not Benefit Period/Calendar Year) EM OOPM3 = Out-of-Pocket Maximum is Embedded: A covered family member’s out-of-pocket costs are capped at the individual out-of-pocket maximum amount on the family plan.

Florida Health Care Plans is an Independent Licensee of the Blue Cross and Blue Shield Association.

LGHMOSOB1.21

Amount Member Pays Schedule of Benefits for Covered Services In-Network Out-of-Network Outpatient Diagnostic and Therapeutic Services - services with an asterisk * require prior authorization. Charges are per visit/test.

Independent Diagnostic Testing Facility/Provider’s Office

Allergy Testing

$0

N/A

X-rays and Ultrasounds $50 Copay N/A Diagnostic Services (except AIS) $50 Copay N/A *Advanced Imaging Services (AIS) (MRI, MRA, PET, CT, Nuclear Med.) $200 Copay N/A *Radiation Therapy $65 Copay N/A

Independent Clinical Lab (diagnostic testing of blood and specimens) $0 N/A Outpatient Hospital Facility Services (per visit)

X-rays and Ultrasounds Deductible + 20% N/A Diagnostic Services (except AIS) Deductible + 20% N/A *Advanced Imaging Services (AIS) (MRI, MRA, PET, CT, Nuclear Med.)

*Radiation Therapy

Deductible + 20% Deductible + 20%

N/A N/A

Important: Diagnostic or therapeutic services rendered in physician offices, testing centers or other outpatient locations that are owned and operated by a hospital system are considered by the hospital system to be departments of the hospital. As a result, FHCP will be billed by the hospital for such services, and the member’s outpatient hospital benefit will be applied to these claims. FHCP’s Provider Directories and online Provider Search application provides information regarding which provider offices are actually hospital outpatient departments. Members should contact FHCP’s cost estimation center to determine if having the diagnostic test or service performed in a hospital or hospital owned facility will result in higher cost sharing.

Delivery / Hospital / Surgical - * all services require prior authorization

*Ambulatory Surgical Center Facility (ASC) $350 Copay N/A

*Birthing Center Deductible + 20% N/A

*Outpatient Hospital Facility Services (surgical) (per visit) Deductible + 20% N/A

*Inpatient Hospital Facility (per admit) Deductible + 20% N/A

Mental Health / Substance Dependency - services with an asterisk * require prior authorization

*Inpatient Hospitalization Facility Services (per admit) Deductible + 20% N/A

Outpatient Facility Service (per visit) $65 Copay N/A

*Partial Hospitalization (per admit) Deductible + 20% N/A

*Residential/Rehabilitation Facility (per day) Deductible + 20% N/A

Hospital Emergency Room or Stand-Alone Emergency Facility Services (per visit) (waived if admitted)

$400 Copay $400 Copay

Provider Services at Hospital/Crisis Unit

Primary Care Physician / Specialist Deductible + 20% N/A

Provider Services at Locations other than Office, Hospital and ER

Primary Care Physician / Specialist Deductible + 20% N/A

Outpatient Office Visit

Primary Care Physician Specialist

$40 Copay $65 Copay

N/A N/A

Other Provider Services Provider Services at ER $0 $0

Provider Services at Hospital / Birthing Center Inpatient /Outpatient

Deductible + 20%

Provider Services at an Ambulatory Surgical Center (ASC) $0 N/A

LGHMOSOB1.21

Amount Member Pays

Schedule of Benefits for Covered Services In-Network Out-of-Network Other Special Services - services with an asterisk * require prior authorization Combined Limit for Outpatient Occupational, Physical and Speech Therapy (per visit) Deductible + 20% N/A Combined Limit for Outpatient Cardiac and Pulmonary Rehabilitation Therapy (per visit) Deductible + 20% N/A Chiropractic Care (per visit) Deductible + 20% N/A *Durable Medical Equipment Deductible + 20% N/A *Prosthetics and Orthotics Deductible + 20% N/A *Home Health Care (per visit) Deductible + 20% N/A *Skilled Nursing Facility Deductible + 20% N/A Hospice Deductible + 20% N/A Hearing Exam (Audiologist/Specialist) $65 Copay N/A Telehealth Services

Medical Visit $10 Copay N/A Mental Health/Behavioral Health Visit $30 Copay N/A

Diabetes Care Management

Diabetes Outpatient Self-Management Education $0 N/A Glucometer (2 per year) $0 N/A Annual Complete Diabetic Eye Exam (Optometrist/Ophthalmologist) $40 / $65 Copay N/A 50 Test Strips (per box) $10 Copay N/A Lancets (per box) $4 Copay N/A

*Prior Authorization is Required: There are certain medical services, supplies and medications for which members are required to obtain Prior Authorization before receiving. If you don’t obtain prior authorization from FHCP, you will have to pay the entire cost of the service, supply or medication. Before receiving a service, supply or medication you should visit www.fhcp.com or call toll-free 1-877- 615-4022 to see if prior authorization is required.

Schedule of Benefits for Covered Services Amount Member Pays Prescription Drug Program Network Provider Services: A Network Provider pharmacy must be used when a member needs to have a prescription filled or the member will have to pay the full cost of the drug (except in certain situations such as emergencies). Members should log into their member account at www.fhcp.com and click Find a Pharmacy to locate a Network Provider pharmacy. Mail Order is only available through FHCP Pharmacy.

Network Pharmacy

(1 month supply) Mail Order

(3 month supply) FHCP Walgreens FHCP Only

Generic Drugs Preventive (e.g., oral contraceptives) $0 Not Covered $0 Preferred Generic $3 Copay $15 Copay $6 Copay Non Preferred Generic $10 Copay $15 Copay $27 Copay

Preferred Brand Drugs $30 Copay $35 Copay $87 Copay Non-Preferred Brand Drugs $55 Copay $60 Copay $162 Copay Specialty Drugs (Prior authorization is required) Preferred Specialty 15% Coinsurance Not Covered Not Covered Non Preferred Specialty 25% Coinsurance Not Covered Not Covered If a Brand Name Prescription Drug is requested when there is a Generic Prescription Drug available, the member will be responsible for paying the Usual and Customary cash price for that prescription.

FHCP Pharmacy benefit provides coverage for Generic contraceptive medications or devices (e.g., oral contraceptives, emergency contraceptive, and diaphragms) at no cost when obtained from a pharmacy owned and operated by FHCP. FHCP’s Pharmacy Benefit also covers certain preventive medications at no cost in accordance with the United States Preventative Task Force (USPSTF) Affordable Care Act A and B recommendations as long as all criteria are met and the medication is obtained from a FHCP owned and operated pharmacy.

LGHMOSOB1.21

Schedule of Benefits for Covered Services Amount Member Pays - Network Provider Pediatric Vision Network Provider Services: The services listed below must be received from a Network Provider or the member will have to pay the full cost of the service (except in certain situations such as emergencies). Members should log onto www.fhcp.com and click Find a Provider/Facility to locate a Network Provider near them.

Exam Not Covered Eyeglass Lenses Not Covered Frames Pediatric Selection: Not Covered

Non-Selection: Not Covered Contact Lenses (Instead of eyeglasses)

Includes contact lenses, evaluation, fitting and follow up care.

Pediatric Selection: Not Covered Non-Selection: Not Covered

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

Pediatric Dental Preventive, Basic and Major Services Not Covered

Benefit Maximums Home Health Care 60 Visits PCP OT, PT, ST Outpatient Rehabilitation Therapy 20 Visits PCP Cardiac and Pulmonary Therapy 20 Visits PCP Chiropractic Care 20 Visits PCP Skilled Nursing/Rehabilitation Facility 20 Days PCP Behavioral Health Residential Facility 20 Days PCP

Additional Benefits and Features

• To find out more about their benefits and/or treatment options, members are encouraged to call the Member Services Department at

1-877-615-4022. This can help them save time and money.

• Members have online access to view their health benefit plan information as well as self-service tools through the Member Portal at www.fhcp.com.

This is not an insurance contract or Benefit Booklet. This Benefit Schedule is only a partial description of the many benefits and services provided or authorized by Florida Health Care Plans. This does not constitute a contract. For a complete descript ion of benefits and exclusions, please see the Florida Health Care Plans Certificate of Coverage; its terms prevail.

http://www.fhcp.com/

Discrimination is Against the Law Florida Health Care Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Florida Health Care Plans does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Florida Health Care Plans:

• Provides 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)

• Provides free language services to people whose primary language is not English, such as:

o Qualified Interpreters o Information written in other languages

If you need these services, contact:

• Florida Health Care Plans : 1-877-615-4022

If you believe that Florida Health Care Plans 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:

Florida Health Care Plans Civil Rights Coordinator

PO Box 9910, Daytona Beach, FL 32120-0910.

Phone: 1-844-219-6137, TTY: 1-800-955-8770

Fax: 386-676-7149, Email: rights@fhcp.com.

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW

Room 509F, HHH Building Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

10103-U65 0920R1 https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

Florida Health Care Plan, Inc. d/b/a Florida Health Care Plans (“FHCP”) offers health insurance coverage products. FHCP is an affiliate of Blue Cross and Blue Shield of Florida, Inc. d/b/a Florida Blue. Both companies are Independent Licensees of the Blue Cross and Blue Shield Association.

10104-U65 0718

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-

877-615-4022. (TTY: 1-800-955-8770)

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-

877-615-4022 (TTY: 1-800-955-8770).

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-877-

615-4022 (TTY: 1-800-955-8770).

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-615-4022

(TTY: 1-800-955-8770).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-877-615-

4022 (TTY: 1-800-955-8770).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-877-615-4022

（TTY：1-800-955-8770）

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement.

Appelez le 1-877-615-4022 (ATS : 1-800-955-8770).

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-615-4022 (TTY: 1-800-955-8770).

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.

Звоните 1-877-615-4022 (телетайп: 1-800-955-8770).

(رقم ھاتف 4022-615-877-1تتوافر لك بالمجان. اتصل برقم ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة ).8770-955-800-1الصم والبكم:

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti.

Chiamare il numero 1-877-615-4022 (TTY: 1-800-955-8770).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-615-4022 (TTY: 1-800-955-8770).

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-877-615-4022

(TTY: 1-800-955-8770)번으로 전화해 주십시오.

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-

877-615-4022 (TTY: 1-800-955-8770).

�ચુના: જો તમે �જુરાતી બોલતા હો, તો િન:�લુ્ક ભાષા સહાય સેવાઓ તમારા માટ� ઉપલબ્ધ છે. ફોન

કરો 1-877-615-4022 (TTY: 1-800-955-8770).

เรียน: ถา้คุณพดูภาษาไทยคุณสามารถใชบ้ริการช่วยเหลือทางภาษาไดฟ้รี โทร 1-877-615-4022 (TTY: 1-800-955-8770).

Health Benefit Plan TD7

TD7 – 1/21

LGHMOSOB1.21 Page 1 of 4

Amount Member Pays Schedule of Benefits for Covered Services In-Network Out-of-Network Financial Features Medical Benefits Deductible (EM DED1) (PCP2) $500 per person N/A (DED is the amount the member is responsible for before FHCP pays) $1,500 per family Prescription Drug Benefits Deductible (EM DED1) (PCP2) (DED is the amount the member is responsible for before FHCP pays)

$0 per person $0 per family

N/A

Coinsurance (Coinsurance is the percentage the member pays for services)

10% of Allowed Amount N/A

Out-of-Pocket Maximum (EM OOPM3) (PCP2) $2,000 per person N/A (OOPM includes DED, Coinsurance, Copayments and Prescription Drugs) $4,000 per family Office Services Physician Office Services (per visit)

Primary Care Office $20 Copay N/A Specialist $35 Copay N/A

Maternity (Office Cost Share for initial visit only. Delivery charges are separate) Primary Care Physician $20 Copay N/A Specialist $35 Copay N/A

Allergy Injections (per visit) Primary Care Physician $0 N/A Specialist $0 N/A

Medical Pharmacy: Medications administered by a health care provider in an office or outpatient setting. Includes chemotherapy, infusions, therapeutic injections and other medications ordered and administered by a provider. Prior authorization is required.

Preferred Medications 15% Coinsurance N/A Non-Preferred Medications 25% Coinsurance N/A

Important: The Cost Share for Medical Pharmacy Services applies to the Prescription Drug only and is in addition to the Office Services and/or Outpatient Facility Cost Share. Medical Pharmacy does not include immunizations, allergy injections or Services covered through the pharmacy program. Please refer to your Certificate of Coverage for a description of Medical Pharmacy.

Preventive Care Routine Adult & Child Preventive Services, Wellness Services, Blood Work and Immunizations

Bone Density Screening $0 N/A

$50 Copay $50 Copay

Deductible + 10% Deductible + 10%

EM DED1 = Deductible is Embedded: A covered member’s family deductible costs are capped at the individual deductible amount on the family plan

PCP2 = Per Coverage Period (Not Benefit Period/Calendar Year) EM OOPM3 = Out-of-Pocket Maximum is Embedded: A covered family member’s out-of-pocket costs are capped at the individual out-of-pocket maximum amount on the family plan.

Florida Health Care Plans is an Independent Licensee of the Blue Cross and Blue Shield Association.

LGHMOSOB1.21 Page 2 of 4

Amount Member Pays Schedule of Benefits for Covered Services In-Network Out-of-Network Outpatient Diagnostic and Therapeutic Services - services with an asterisk * require prior authorization. Charges are per visit/test.

Independent Diagnostic Testing Facility/Provider’s Office

Deductible + 10%

X-rays and Ultrasounds $35 Copay N/A Diagnostic Services (except AIS) $35 Copay N/A *Advanced Imaging Services (AIS) (MRI, MRA, PET, CT, Nuclear Med.) $75 Copay N/A *Radiation Therapy $35 Copay N/A

Independent Clinical Lab (diagnostic testing of blood and specimens) $0 N/A Outpatient Hospital Facility Services (per visit)

X-rays and Ultrasounds Diagnostic Services (except AIS) *Advanced Imaging Services (AIS) (MRI, MRA, PET, CT, Nuclear Med.)

*Radiation Therapy

Deductible + 10% Deductible + 10% Deductible + 10% Deductible + 10%

N/A N/A N/A N/A

Important: Diagnostic or therapeutic services rendered in physician offices, testing centers or other outpatient locations that are owned and operated by a hospital system are considered by the hospital system to be departments of the hospital. As a result, FHCP will be billed by the hospital for such services, and the member’s outpatient hospital benefit will be applied to these claims. FHCP’s Provider Directories and online Provider Search application provides information regarding which provider offices are actually hospital outpatient departments. Members should contact FHCP’s cost estimation center to determine if having the diagnostic test or service performed in a hospital or hospital owned facility will result in higher cost sharing.

*Ambulatory Surgical Center Facility (ASC) Deductible + 10% N/A

*Birthing Center Deductible + 10% N/A

*Outpatient Hospital Facility Services (surgical) (per visit) Deductible + 10% N/A

*Inpatient Hospital Facility (per admit) Deductible + 10% N/A Mental Health / Substance Dependency - services with an asterisk * require prior authorization

*Inpatient Hospitalization Facility Services (per admit) Deductible + 10% N/A

Outpatient Facility Service (per visit) $35 Copay N/A

*Partial Hospitalization (per admit) Deductible + 10% N/A

*Residential/Rehabilitation Facility (per day) Deductible + 10% N/A

Hospital Emergency Room or Stand-Alone Emergency Facility Services (per visit) (waived if admitted)

$100 Copay $100 Copay

Provider Services at Hospital/Crisis Unit Primary Care Physician / Specialist Deductible + 10% N/A

Provider Services at Locations other than Office, Hospital and ER Primary Care Physician / Specialist Deductible + 10% N/A

Outpatient Office Visit Primary Care Physician Specialist

$20 Copay $35 Copay

N/A N/A

Other Provider Services Provider Services at ER $0 $0

Provider Services at Hospital / Birthing Center Inpatient/Outpatient

Deductible + 10%

Provider Services at an Ambulatory Surgical Center (ASC) Deductible + 10% N/A

LGHMOSOB1.21 Page 3 of 4

Amount Member Pays Schedule of Benefits for Covered Services In-Network Out-of-Network Other Special Services - services with an asterisk * require prior authorization

Combined Limit for Outpatient Occupational, Physical and Speech Therapy (per visit) Deductible + 10% N/A Combined Limit for Outpatient Cardiac and Pulmonary Rehabilitation Therapy (per visit) Deductible + 10% N/A Chiropractic Care (per visit) $15 Copay N/A *Durable Medical Equipment Deductible + 10% N/A *Prosthetics and Medical Brace Device Deductible + 10% N/A *Home Health Care (per visit) Deductible + 10% N/A *Skilled Nursing Facility Deductible + 10% N/A Hospice Deductible + 10% N/A Hearing Exam (Audiologist/Specialist) $35 Copay N/A Telehealth Services

Medical Visit $10 Copay N/A Mental Health/Behavioral Health Visit $30 Copay N/A

Diabetes Outpatient Self-Management Education $0 N/A Glucometer (2 per year) $0 N/A Annual Complete Diabetic Eye Exam (Optometrist/Ophthalmologist) $20 / $35 Copay N/A 50 Test Strips (per box) $10 Copay N/A Lancets (per box) $4 Copay N/A

*Prior Authorization is Required: There are certain medical services, supplies and medications for which members are required to obtain Prior Authorization before receiving. If you don’t obtain prior authorization from FHCP, you will have to pay the entire cost of the service, supply or medication. Before receiving a service, supply or medication you should visit www.fhcp.com or call toll-free 1-877- 615-4022 to see if prior authorization is required.

Schedule of Benefits for Covered Services Amount Member Pays Prescription Drug Program Network Provider Services: A Network Provider pharmacy must be used when a member needs to have a prescription filled or the member will have to pay the full cost of the drug (except in certain situations such as emergencies). Members should log into their member account at www.fhcp.com and click Find a Pharmacy to locate a Network Provider pharmacy. Mail Order is only available through FHCP Pharmacy.

Network Pharmacy

(1 month supply) Mail Order

(3 month supply) FHCP Walgreens FHCP Only

Generic Drugs Preventive (e.g., oral contraceptives) $0 Not Covered $0 Preferred Generic $3 Copay $15 Copay $6 Copay Non Preferred Generic $10 Copay $15 Copay $27 Copay

Preferred Brand Drugs $30 Copay $35 Copay $87 Copay Non-Preferred Brand Drugs $55 Copay $60 Copay $162 Copay Specialty Drugs (Prior authorization is required) Preferred Specialty 15% Coinsurance Not Covered Not Covered Non Preferred Specialty 25% Coinsurance Not Covered Not Covered If a Brand Name Prescription Drug is requested when there is a Generic Prescription Drug available, the member will be responsible for paying the Usual and Customary cash price for that prescription.

FHCP Pharmacy benefit provides coverage for Generic contraceptive medications or devices (e.g., oral contraceptives, emergency contraceptive, and diaphragms) at no cost when obtained from a pharmacy owned and operated by FHCP. FHCP’s Pharmacy Benefit also covers certain preventive medications at no cost in accordance with the United States Preventative Task Force (USPSTF) Affordable Care Act A and B recommendations as long as all criteria are met and the medication is obtained from a FHCP owned and operated pharmacy.

LGHMOSOB1.21 Page 4 of 4

Schedule of Benefits for Covered Services Amount Member Pays - Network Provider

Network Provider Services: The services listed below must be received from a Network Provider or the member will have to pay the full cost of the service (except in certain situations such as emergencies). Members should log onto www.fhcp.com and click Find a Provider/Facility to locate a Network Provider near them.

Exam Not Covered Eyeglass Lenses Not Covered Frames Pediatric Selection: Not Covered

Non-Selection: Not Covered Contact Lenses (Instead of eyeglasses)

Includes contact lenses, evaluation, fitting and follow up care.

Pediatric Selection: Not Covered Non-Selection: Not Covered

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

Benefit Maximums

OT, PT, ST Outpatient Rehabilitation Therapy 20 Visits PCP Cardiac and Pulmonary Therapy 20 Visits PCP Chiropractic Care 20 Visits PCP

• To find out more about their benefits and/or treatment options, members are encouraged to call the Member Services Department at

1-877-615-4022. This can help them save time and money.

• Members have online access to view their health benefit plan information as well as self-service tools through the Member Portal at

This is not an insurance contract or Benefit Booklet. This Benefit Schedule is only a partial description of the many benefits and services provided or authorized by Florida Health Care Plans. This does not constitute a contract. For a complete descript ion of benefits and exclusions, http://www.fhcp.com/

Florida Health Care Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Florida Health Care Plans does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Florida Health Care Plans:

• Provides 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)

• Provides free language services to people whose primary language is not English, such as:

o Qualified Interpreters o Information written in other languages

If you need these services, contact:

• Florida Health Care Plans : 1-877-615-4022

If you believe that Florida Health Care Plans 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:

Florida Health Care Plans Civil Rights Coordinator

PO Box 9910, Daytona Beach, FL 32120-0910.

Phone: 1-844-219-6137, TTY: 1-800-955-8770

Fax: 386-676-7149, Email: rights@fhcp.com.

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW

Room 509F, HHH Building Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

10103-U65 0920R1

Florida Health Care Plan, Inc. d/b/a Florida Health Care Plans (“FHCP”) offers health insurance coverage products. FHCP is an affiliate of Blue Cross and Blue Shield of Florida, Inc. d/b/a Florida Blue. Both companies are Independent Licensees of

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-

877-615-4022 (TTY: 1-800-955-8770).

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-877-

615-4022 (TTY: 1-800-955-8770).

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-615-4022

(TTY: 1-800-955-8770).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-877-615-

4022 (TTY: 1-800-955-8770).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-877-615-4022

（TTY：1-800-955-8770）

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement.

Appelez le 1-877-615-4022 (ATS : 1-800-955-8770).

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-615-4022 (TTY: 1-800-955-8770).

(رقم ھاتف 4022-615-877-1تتوافر لك بالمجان. اتصل برقم ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti.

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-615-4022 (TTY: 1-800-955-8770).

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-877-615-4022

(TTY: 1-800-955-8770)번으로 전화해 주십시오.

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-

877-615-4022 (TTY: 1-800-955-8770).

�ચુના: જો તમે �જુરાતી બોલતા હો, તો િન:�લુ્ક ભાષા સહાય સેવાઓ તમારા માટ� ઉપલબ્ધ છે. ફોન

เรียน: ถา้คุณพดูภาษาไทยคุณสามารถใชบ้ริการช่วยเหลือทางภาษาไดฟ้รี โทร 1-877-615-4022 (TTY: 1-800-955-8770).

Large Group POS Health Benefit Plan T08

T08 – 1/21 1 of 4

LGTOSOB1.21

Amount Member Pays Schedule of Benefits for Covered Services In-Network Out-of-Network Financial Features Medical Benefits Deductible (EM DED1) (PCP2) $0 per person $2,000 per person (DED is the amount the member is responsible for before FHCP pays) $0 per family $4,000 per family Prescription Drug Benefits Deductible (EM DED1) (PCP2) (DED is the amount the member is responsible for before FHCP pays)

$0 per person $0 per family

Not Covered

Coinsurance (Coinsurance is the percentage the member pays for services)

15% of the Allowed Amount 50% of the Allowed Amount

Out-of-Pocket Maximum (EM OOPM3) (PCP2) $2,000 per person $6,000 per person (OOPM includes DED, Coinsurance, Copayments and Prescription Drugs) $4,000 per family $12,000 per family Office Services Physician Office Services (per visit)

Primary Care Office $20 Copay Deductible + 50% Specialist $35 Copay Deductible + 50%

Maternity (Office Cost Share for initial visit only. Delivery charges are separate) Primary Care Physician $20 Copay Deductible + 50% Specialist $35 Copay Deductible + 50%

Allergy Injections (per visit) Primary Care Physician $0 Deductible + 50% Specialist $0 Deductible + 50%

Medical Pharmacy: Medications administered by a health care provider in an office or outpatient setting. Includes chemotherapy, infusions, therapeutic injections and other medications ordered and administered by a provider. Prior authorization is required.

Preferred Medications 15% Coinsurance Deductible + 50% Non-Preferred Medications 25% Coinsurance Deductible + 50%

Important: The Cost Share for Medical Pharmacy Services applies to the Prescription Drug only and is in addition to the Office Services and/or Outpatient Facility Cost Share. Medical Pharmacy does not include immunizations, allergy injections or Services covered through the pharmacy program. Please refer to your Certificate of Coverage for a description of Medical Pharmacy.

Preventive Care Routine Adult & Child Preventive Services, Wellness Services, Blood Work and Immunizations

$0 Deductible + 50%

Bone Density Screening $0 Deductible + 50%

$60 Copay $60 Copay

EM DED1 = Deductible is Embedded: A covered member’s family deductible costs are capped at the individual deductible amount on the family plan

PCP2 = Per Coverage Period (Not Benefit Period/Calendar Year) EM OOPM3 = Out-of-Pocket Maximum is Embedded: A covered family member’s out-of-pocket costs are capped at the individual out-of-pocket maximum amount on the family plan.

Note: Out-of-Network services may be subject to balance billing.

Florida Health Care Plans is an Independent Licensee of the Blue Cross and Blue Shield Association

T08 – 1/21 2 of 4

Amount Member Pays Schedule of Benefits for Covered Services In-Network Out-of-Network Outpatient Diagnostic and Therapeutic Services - services with an asterisk * require prior authorization. Charges are per visit/test.

Independent Diagnostic Testing Facility/Provider’s Office

$0

Deductible + 50%

X-rays and Ultrasounds $0 Deductible + 50% Diagnostic Services (except AIS) $0 Deductible + 50% *Advanced Imaging Services (AIS) (MRI, MRA, PET, CT, Nuclear Med.)

*Radiation Therapy

$0 $35 Copay

Deductible + 50% Deductible + 50%

Independent Clinical Lab (diagnostic testing of blood and specimens) $0 Deductible + 50%

Outpatient Hospital Facility Services (per visit) X-rays and Ultrasounds $0 Deductible + 50% Diagnostic Services (except AIS) $0 Deductible + 50% *Advanced Imaging Services (AIS) (MRI, MRA, PET, CT, Nuclear Med.)

*Radiation Therapy

$0 $0

Deductible + 50% Deductible + 50%

Important: Diagnostic or therapeutic services rendered in physician offices, testing centers or other outpatient locations that are owned and operated by a hospital system are considered by the hospital system to be departments of the hospital. As a result, FHCP will be billed by the hospital for such services, and the member’s outpatient hospital benefit will be applied to these claims. FHCP’s Provider Directories and online Provider Search application provides information regarding which provider offices are actually hospital outpatient departments. Members should contact FHCP’s cost estimation center to determine if having the diagnostic test or service performed in a hospital or hospital owned facility will result in higher cost sharing.

*Ambulatory Surgical Center Facility (ASC) $100 Copay Deductible + 50%

*Birthing Center $100 Copay Deductible + 50%

*Outpatient Hospital Facility Services (surgical) (per visit) $100 Copay Deductible + 50%

*Inpatient Hospital Facility (per admit) $250 Copay/Day ($1,250 Maximum , Days 1-5) Deductible + 50%

Mental Health / Substance Dependency - services with an asterisk * require prior authorization

*Inpatient Hospitalization Facility Services (per admit) $250 Copay/Day ($1,250 Maximum, Days 1-5) Deductible + 50%

Outpatient Facility Service (per visit) $35 Copay Deductible + 50%

*Partial Hospitalization (per admit) $125 Copay/Day ($625 Maximum, Days 1-5) Deductible + 50%

*Residential/Rehabilitation Facility (per day) $50 Copay Deductible + 50%

Hospital Emergency Room or Stand-Alone Emergency Facility Services (per visit) (waived if admitted) $100 Copay $100 Copay

Provider Services at Hospital/Crisis Unit

Primary Care Physician / Specialist $0 Deductible + 50%

Provider Services at Locations other than Office, Hospital and ER

Primary Care Physician / Specialist $0 Deductible + 50%

Outpatient Office Visit

Primary Care Physician Specialist

$20 Copay $35 Copay

Deductible + 50% Deductible + 50%

Other Provider Services Provider Services at ER $0 $0 Provider Services at Hospital / Birthing Center

Inpatient/Outpatient $0 Deductible + 50%

Provider Services at an Ambulatory Surgical Center (ASC) $0 Deductible + 50%

T08 – 1/21 3 of 4

Amount Member Pays Schedule of Benefits for Covered Services In-Network Out-of-Network Other Special Services - services with an asterisk * require prior authorization Combined Limit for Outpatient Occupational, Physical and Speech Therapy (per visit) $15 Copay Deductible + 50% Combined Limit for Outpatient Cardiac and Pulmonary Rehabilitation Therapy (per visit) $15 Copay Deductible + 50% Chiropractic Care (per visit) $15 Copay Deductible + 50% *Durable Medical Equipment 15% Coinsurance Deductible + 50% *Prosthetics and Medical Brace Device $0 Deductible + 50% *Home Health Care (per visit) $15 Copay Deductible + 50% *Skilled Nursing Facility (per day) $50 Copay Deductible + 50% Hospice $0 Deductible + 50% Hearing Exam Audiologist/Specialist $35 Copay Deductible + 50% Telehealth Services

Medical Visit $10 Copay Not Covered Mental Health/Behavioral Health Visit $30 Copay Not Covered

Diabetes Outpatient Self-Management Education $0 Not Covered Glucometer (2 per year) $0 Not Covered Annual Complete Diabetic Eye Exam (Optometrist/Ophthalmologist) $20 / $35 Copay Deductible + 50% 50 Test Strips (per box) $10 Copay Not Covered Lancets (per box) $4 Copay Not Covered

*Prior Authorization is Required: There are certain medical services, supplies and medications for which members are required to obtain Prior Authorization before receiving. If you don’t obtain prior authorization from FHCP, you will have to pay the entire cost of the service, supply or medication. Before receiving a service, supply or medication you should visit www.fhcp.com or call toll-free 1-877- 615-4022 to see if prior authorization is required.

Schedule of Benefits for Covered Services Amount Member Pays Prescription Drug Program Network Provider Services: A Network Provider pharmacy must be used when a member needs to have a prescription filled or the member will have to pay the full cost of the drug (except in certain situations such as emergencies). Members should log into their member account at www.fhcp.com and click Find a Pharmacy to locate a Network Provider pharmacy. Mail Order is only available through FHCP Pharmacy.

Network Pharmacy

(1 month supply) Mail Order

(3 month supply) FHCP Walgreens FHCP Only

Generic Drugs Preventive (e.g., oral contraceptives) $0 Not Covered $0 Preferred Generic $3 Copay $15 Copay $6 Copay Non Preferred Generic $10 Copay $15 Copay $27 Copay

Preferred Brand Drugs $30 Copay $35 Copay $87 Copay Non-Preferred Brand Drugs $55 Copay $60 Copay $162 Copay Specialty Drugs (Prior authorization is required) Preferred Specialty 15% Coinsurance Not Covered Not Covered Non Preferred Specialty 25% Coinsurance Not Covered Not Covered If a Brand Name Prescription Drug is requested when there is a Generic Prescription Drug available, the member will be responsible for paying the Usual and Customary cash price for that prescription.

FHCP Pharmacy benefit provides coverage for Generic contraceptive medications or devices (e.g., oral contraceptives, emergency contraceptive, and diaphragms) at no cost when obtained from a pharmacy owned and operated by FHCP. FHCP’s Pharmacy Benefit also covers certain preventive medications at no cost in accordance with the United States Preventative Task Force (USPSTF) Affordable Care Act A and B recommendations as long as all criteria are met and the medication is obtained from a FHCP owned and operated pharmacy.

T08 – 1/21 4 of 4

Schedule of Benefits for Covered Services

Amount Member Pays - Network Provider

Network Provider Services: The services listed below must be received from a Network Provider or the member will have to pay the full cost of the service (except in certain situations such as emergencies). Members should log onto www.fhcp.com and click Find a Provider/Facility to locate a Network Provider near them.

Exam Not Covered Eyeglass Lenses Not Covered Frames Pediatric Selection: Not Covered

Non-Selection: Not Covered Contact Lenses (Instead of eyeglasses)

Includes contact lenses, evaluation, fitting and follow up care.

Pediatric Selection: Not Covered Non-Selection: Not Covered

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

Benefit Maximums – Combined Limit In-Network and Out-of-Network

OT, PT, ST Outpatient Rehabilitation Therapy 20 Visits PCP Cardiac and Pulmonary Therapy 20 Visits PCP Chiropractic Care 20 Visits PCP

• To find out more about their benefits and/or treatment options, members are encouraged to call the Member Services Department at

1-877-615-4022. This can help them save time and money.

• Members have online access to view their health benefit plan information as well as self-service tools through the Member Portal at

This is not an insurance contract or Benefit Booklet. This Benefit Schedule is only a partial description of the many benefits and services provided or authorized by Florida Health Care Plans. This does not constitute a contract. For a complete descript ion of benefits and exclusions, Florida Health Care Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Florida Health Care Plans does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Florida Health Care Plans:

• Provides 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)

• Provides free language services to people whose primary language is not English, such as:

o Qualified Interpreters o Information written in other languages

If you need these services, contact:

• Florida Health Care Plans : 1-877-615-4022

If you believe that Florida Health Care Plans 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:

Florida Health Care Plans Civil Rights Coordinator

PO Box 9910, Daytona Beach, FL 32120-0910.

Phone: 1-844-219-6137, TTY: 1-800-955-8770

Fax: 386-676-7149, Email: rights@fhcp.com.

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW

Room 509F, HHH Building Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

10103-U65 0920R1

Florida Health Care Plan, Inc. d/b/a Florida Health Care Plans (“FHCP”) offers health insurance coverage products. FHCP is an affiliate of Blue Cross and Blue Shield of Florida, Inc. d/b/a Florida Blue. Both companies are Independent Licensees of

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-

877-615-4022 (TTY: 1-800-955-8770).

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-877-

615-4022 (TTY: 1-800-955-8770).

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-615-4022

(TTY: 1-800-955-8770).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-877-615-

4022 (TTY: 1-800-955-8770).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-877-615-4022

（TTY：1-800-955-8770）

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement.

Appelez le 1-877-615-4022 (ATS : 1-800-955-8770).

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-615-4022 (TTY: 1-800-955-8770).

(رقم ھاتف 4022-615-877-1تتوافر لك بالمجان. اتصل برقم ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti.

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-615-4022 (TTY: 1-800-955-8770).

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-877-615-4022

(TTY: 1-800-955-8770)번으로 전화해 주십시오.

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-

877-615-4022 (TTY: 1-800-955-8770).

�ચુના: જો તમે �જુરાતી બોલતા હો, તો િન:�લુ્ક ભાષા સહાય સેવાઓ તમારા માટ� ઉપલબ્ધ છે. ફોન

เรียน: ถา้คุณพดูภาษาไทยคุณสามารถใชบ้ริการช่วยเหลือทางภาษาไดฟ้รี โทร 1-877-615-4022 (TTY: 1-800-955-8770).