PPO_Attachment G - Benefit Document_2023.pdf

DRAFT

www.myBenefits.myFlorida.com

Group Health Insurance Plan Booklet and Benefits Document

State Employees’ PPO Plan

Effective January 1, 2023

State of Florida Department of Management Services

Division of State Group Insurance P.O. Box 5450

Tallahassee, FL 32314-5450

This Plan Booklet and Benefits Document replaces any other brochure or booklet printed prior to January 1, 2023, relative to the Plan and shall remain in effect until further notice. The State Employees’ PPO Plan is further subject to federal and State of Florida laws and rules promulgated pursuant to law, including, but not limited to, Chapter 60P of the Florida Administrative Code.

In any instance of conflict, the provisions of this Plan Booklet and Benefits Document shall take precedence over provisions of law, so far as legally permitted. Any clause, section or part of this Plan Booklet and Benefits Document that is held or declared invalid for any reason shall be eliminated, and the remaining portion or portions shall remain in full force and be valid, as if such invalid clause or section had not been incorporated herein.

This Plan contains a deductible provision. Details on deductible dollar amounts and when deductibles may be applied can be found in sections 1 and 2, depending on the Plan you choose.

WARNING: LIMITED BENEFITS WILL BE PAID WHEN NONPARTICIPATING PROVIDERS ARE USED. You should be aware that when you elect to utilize the services of a nonparticipating provider for a covered non-emergency service, benefit payments to the provider are not based upon the amount the provider charges.

The basis of the payment will be determined according to your policy’s out-of-network reimbursement benefit. Non-participating providers may bill insureds for any difference in the amount. YOU MAY BE REQUIRED TO PAY MORE THAN THE COINSURANCE OR COPAYMENT AMOUNT. Participating providers have agreed to accept discounted payments for services with no additional billing to you other than coinsurance, copayment, and deductible amounts. You may obtain further information about the providers who have contracted with your insurance plan by consulting your insurer’s website or contacting your insurer or agent directly.

If you and/or your dependents have Medicare or will become eligible for Medicare in the next 12 months, a federal law gives you more choices about your prescription drug coverage. Please see page 16-7 for more details.

State Employees’ PPO Plan Group Health Insurance

Plan Booklet and Benefits Document Effective January 1, 2023

I

[Back to Table of Contents]

Important Information About the Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV

Who to Call for Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .V

Section 1: Standard PPO Option Summary of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . 1-1

Section 2: PPO High Deductible Health Plan Option Summary of Benefits . . . . . . . . . 2-1

Section 3: Covered Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-1

Section 4: Pre-existing Condition Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-1

Section 5: Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-1

Section 6: About the Provider Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-1

Section 7: Additional Required Provisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-1

Section 8: Special Plan Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-1

Section 9: Prescription Drug Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-1

Section 10: Eligibility and Enrollment Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10-1

Section 11: How to File a Claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11-1

Section 12: Appealing a Denied Claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-1

Section 13: Coordinating Benefits with Other Coverage . . . . . . . . . . . . . . . . . . . . . . . . 13-1

Section 14: Plan’s Right to Recover and Sue for Losses . . . . . . . . . . . . . . . . . . . . . . . . . . 14-1

Section 15: Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15-1

Section 16: Notices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16-1

-State of Florida Employees’ Group Health Insurance Privacy Notice

-Special Notice about the Women’s Health and Cancer Rights Act

-Special Notice about the Medicare Part D Drug Program

-Your Rights and Protections Against Surprise Medical Bills Notice

Section 17: Shared Savings Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17-1

Table of Contents

II

III

Important Information About the Plan Plan Administrator

Division of State Group Insurance P .O . Box 5450 Tallahassee, FL 32314-5450

(850) 921-4600; (800) 226-3734

The Division of State Group Insurance (DSGI), within the Department of Management Services, has been designated by the Florida Legislature as the entity responsible for administering state employee benefits, including the State Employees’ PPO Plan (PPO Plan or Plan) .

DSGI is authorized to provide health insurance coverage through fully insured or self-insured plans .

This preferred provider organization (PPO) Plan is a self-insured plan . This means that claims are paid from a fund established by the State of Florida (State) . Because this Plan is self-insured, the Plan does not have to pay typical insurance company fees, such as retention, reinsurance, premium taxes and other insurance-related charges .

DSGI has full and final decision-making authority concerning eligibility, coverage, benefits, claims, and interpretation of the Plan’s Benefits Document .

Final decisions concerning the existence of coverage or benefits under the Plan shall not be delegated or deemed to have been delegated by DSGI . DSGI and the Medical and Prescription Drug Program Third Party Administrators hired by DSGI are responsible for processing claims in accordance with the terms of the Benefits Document .

Medical Claim Administrator

Florida Blue P .O . Box 2896 Jacksonville, FL 32232-0079

(800) 825-2583 www.floridablue.com or www.floridablue.com/state-employees

Florida Blue is a trade name for Blue Cross and Blue Shield of Florida, Inc . (BCBSF) . Florida Blue provides claim processing services, customer service, provider network access, medical coverage guidelines, and utilization and benefit management services . Benefits are available through Florida Blue’s Preferred Patient CareSM PPO, which is a network of preferred providers established by Florida Blue .

Florida Blue does not assume any financial risk or obligation with respect to claims .

Prescription Drug Program Claim Administrator

CVS Caremark

(888) 766-5490 www.Caremark.com

CVS Caremark provides prescription drug utilization and benefit management services . CVS Caremark also provides prescription drug claims payment services, retail pharmacy access, mail order services and clinical management services .

Plan Documents

The descriptions contained in this document are intended to provide a summary explanation of your benefits . Easy-to-read language has been used as much as possible to help you understand the terms of the Plan .

Your insurance coverage is limited to the express written terms of this Benefits Document . Your coverage cannot be changed based upon statements or representations made to you by anyone, including employees of DSGI, Florida Blue, CVS Caremark, People First or your employer .

Rights to Employment

The existence of this Plan does not affect the employment rights of any employee or the rights of the State to discharge an employee .

Rights to Amend or Terminate the Plan

The State has arranged to sponsor this Plan indefinitely, but reserves the right to amend, suspend, or terminate it for any reason . Plan fee schedules, allowed amounts, allowances, Physician and pharmacy network participation status, medical policy guidelines, prescription Preferred Drug List (PDL), maintenance medication list, Specialty (drug) Management Program guidelines and premium rates are subject to change at any time without the consent of Plan participants . You will be given notice of any changes that affect your benefit levels as soon as administratively possible .

[Back to Table of Contents] http://www.floridablue.com http://www.FloridaBlue.com/state-employees http://www.caremark.com

NOTICE: As prohibited by the terms of the Plan, the following acts will be treated as fraud or misrepresentation of material fact:

• Falsifying dependent information;

• Falsely certifying ineligible persons as eligible;

• Falsifying dependent documentation;

• Falsely enrolling ineligible persons in Coverage;

• Falsifying the occurrence of QSC Events;

• Falsifying QSC Event documentation .

Such acts will require you to reimburse the Plan for any fraudulent claims incurred or, if still within the COBRA election window, for paying COBRA premiums for any months ineligible persons were covered .

Introduction This booklet describes the coverage and benefits available to employees, retirees, COBRA participants, the surviving spouses of active State employees or retirees, and eligible covered dependents, under the State Employees’ PPO Plan . In this booklet, the PPO Plan may also be referred to as “this Plan” or “the Plan .” If you have questions about your coverage after reading this booklet, you may call any of the telephone numbers listed on page VI and talk with a member service representative .

The PPO Plan is designed to cover most major medical expenses for a covered Illness or injury, including Hospital and Physician services . However, you will be responsible for any:

1 . deductibles;

2 . Copayments;

3 . Coinsurance (as applicable, a percentage of the Network Allowed Amount or Non-Network Allowance for the service provided);

4 . admission fees;

5 . non-covered services;

6 . amounts above the Plan’s allowance for non-network services, except when provided in an emergency or an in-network facility;

7 . amounts above the Plan’s limitations; and

8 . penalties for not certifying most Hospital admissions or stays in a non-network Hospital .

This booklet describes enrollment and eligibility, covered services, what the Plan pays, amounts that are your responsibility, and services that are not covered .

This Plan contains a deductible provision . Details on deductible dollar amounts and when deductibles may be applied can be found in sections 1 and 2, depending on the Plan you chose .

Important enrollment and eligibility information can be found in section 10 of this booklet, including information on:

1 . who is eligible to participate in this Plan;

2 . how to enroll for coverage;

3 . when coverage begins and ends; and

4 . when coverage may be continued, including continuation coverage through COBRA .

Medical Necessity In order to be covered under this Plan Document, the service, prescription drug, or supply must meet all of the requirements of a Covered Service and Supply, including being Medically Necessary, as defined by this Plan Document .

It is important to remember that any time we review whether services, prescription drugs, or supplies are Medically Necessary, it is solely for the purpose of determining coverage, benefits, or payment under the terms of this Plan Document and not for the purpose of recommending or providing medical care . When we review whether services, prescription drugs, or supplies are Medically Necessary, we may review specific medical facts or information about you . Any such review, however, is strictly for the purpose of determining, whether the service, prescription drug, or supply provided or proposed is Medically Necessary as defined in this Plan Document . In applying the definition of Medically Necessary to a specific service, prescription drug, or supply we may apply our coverage and payment guidelines then in effect .

All decisions that require or pertain to independent professional medical/clinical judgment or training, or the need for medical services, prescription drug, or supplies are solely your responsibility and that of your treating providers . You and your providers are responsible for deciding what medical care you should have and when that care should be provided .

Florida Blue, CVS Caremark, and DSGI are solely responsible for determining whether expenses

IV

incurred for that medical care are Covered Services and Supplies under this Plan Document . In making coverage decisions, Florida Blue, CVS Caremark, and DSGI will not be deemed to participate in or override your decisions concerning your health or the medical decisions of your health care providers .

Whether or not a service, prescription drug, or supply is specifically listed as an exclusion, the fact that a provider may prescribe, recommend, approve, or furnish a service, prescription drug, or supply does not mean that the service, prescription drug, or supply is Medically Necessary (as determined by Florida Blue, CVS Caremark, and DSGI and as defined in this Plan Document) or a Covered Service and Supply . You are free to obtain a service, prescription drug, or supply even if we deny coverage because the service, prescription drug, or supply is not Medically Necessary; however, you will be solely responsible for paying for the service, prescription drug, or supply . Please refer to Section 15 for the definition of “Medically Necessary” .

Medical Policies (Medical Coverage Guidelines) Florida Blue develops medical policies in consultation with expert physicians from various medical specialties, clinical studies published in respected scientific journals, and various medical specialty organizations . These medical policies which consist of medical guidelines are used when making clinical determinations . A link to medical policies (medical coverage guidelines) are available at www.FloridaBlue.com/state-employees .”

V https://www.floridablue.com/state-employees

VI

Who to Call for Information

If you need information about… Contact…

Medical benefits or claims under the PPO Plan, or finding a medical Network Provider within the State of Florida

Florida Blue P .O . Box 2896 Jacksonville, FL 32232-0079

(800) 825-2583 www.floridablue.com or www.floridablue.com/state-employees

Finding Florida Blue Medical Coverage Guidelines www.floridablue.com/state-employees Click on link under Medical Policies (Medical Coverage Guidelines)

PPO Plan Pre-Admission Hospital Certification (800) 955-5692

Finding a PPO Network Provider outside the state of Florida, Puerto Rico or the U .S . Virgin Islands – BlueCard® PPO Program

(800) 810-2583 or www.bluecares.com

Finding a provider outside the U .S . - BlueCard® Worldwide

(877) 547-2903 if calling within the U .S ., or (collect) at (804) 673-1177, if calling outside the U .S .

Healthy Addition® Prenatal Program

(800) 955-7635, option 6, or www.floridablue.com or www.floridablue.com/state-employees

Health Dialog One-on-one nurse support 24/7

(877) 789-2583 (TTY (877) 900-4304)

Prescription drug program information CVS Caremark www.Caremark.com or www.Caremark.com/sofrxplan Customer Care Team

(888) 766-5490

For paper claims only:

CVS Caremark P .O . Box 52010 MC003 Phoenix, AZ 85072-2010

General correspondence, Customer Care Correspondence:

P .O . Box 7074 Lee’s Summit, MO 64064-7074

Enrollment, eligibility, or changing coverage People First

(866) 663-4735 https://peoplefirst.myflorida.com

Medicare eligibility and enrollment The Social Security Administration office in your area

[Back to Table of Contents] http://www.floridablue.com http://www.FloridaBlue.com/state-employees http://www.bluecares.com http://www.floridablue.com http://www.FloridaBlue.com/state-employees http://www.FloridaBlue.com/state-employees http://www.caremark.com https://peoplefirst.myflorida.com

Standard PPO Option Summary of Benefits

Section 1: Standard PPO Option Summary of Benefits This summary provides an overview of the Standard PPO Option . For further information on the coverage and benefits of this Plan, as well as applicable limitations and exclusions, please refer to sections 3 (Covered Services), 5 (Exclusions), 7 (Additional Required Provisions) and 15 (Definitions) of this booklet . If you are enrolled in the PPO High Deductible Health Plan Option, please refer to section 2, entitled “PPO High Deductible Health Plan Option Summary of Benefits.”

Benefit Description Network Non-Network*

Calendar Year Deductible/Copays/Limits Calendar Year Deductible (CYD) Per person Family aggregate

$250 $500

$750 $1,500

Coinsurance Maximum (OOP) Per person Family aggregate

$2,500 $5,000

Global Network (OOP) Maximum Per Person Family Aggregate

$9,100 $18,200 N/A

Emergency Room (ER) Facility Services Copay (per visit) $100 copay (waived if admitted) $100 copay (waived if admitted)

Urgent Care Center $25 PVF $25 PVF

Per Admission Deductible (PAD) Inpatient Hospital $250 per admission $500 per admission

Physician Office Per Visit Fee (PVF) Primary Care Physician (PCP) Specialist Convenient Care Center

$15 PVF

$25 PVF

$15 PVF

Coinsurance only; no CYD or PVF

Teladoc $0 PVF N/A

Virtual Visits:

Primary Care Physician (PCP) Specialist

$15 PVF

$25 PVF

Coinsurance Only;

No CYD or PVF

Hospital Services

Room and Board (R&B) (semi-private) Admission Certification/ Hospital Stay Certification (AC/ HSC) required

80% of Allowed Amt after PAD 60% of Allowance after PAD

Intensive/Progressive Care AC/HSC required 80% of Allowed Amt after PAD 60% of Allowance after PAD

Emergency Room 100% of Allowed Amt after ER copay

100% of Allowance after ER copay

Inpatient Ancillaries (x-ray, lab, drugs, oxygen, operating room, etc .)

80% of Allowed Amt after PAD 60% of Allowance after PAD

Outpatient Services 80% of Allowed Amt after CYD 60% of Allowance after CYD

Partial Hospitalization 80% of Allowed Amt after CYD 60% of Allowance after CYD

Physician Services

Emergency Room 80% of Allowed Amt after CYD 80% of Allowance after CYD

Hospital Visit 80% of Allowed Amt after CYD 60% of Allowance after CYD

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Benefit Description Network Non-Network*

Office Visit 100% of Allowed Amt after applicable PVF 60% of Allowance (no PVF/CYD)

Teladoc 100% of Allowed Amount N/A

Virtual Visit 100% of Allowed Amount After applicable PVF

60% of the Allowance No CYD or PVF

After applicable PVF 60% of the Allowance 60% of Allowance after CYD

No CYD or PVF 80% of Allowed Amt after CYD 60% of Allowance after CYD

Preventive Care-Adult (Screening mammograms are included in Preventive Adult Care)

100% of Allowed Amt 100% of Allowance

Preventive Care-Children 100% of Allowed Amt 100% of Allowance

Surgery (Inpatient/Outpatient) 80% of Allowed Amt after CYD 60% of Allowance after CYD

Urgent Care Center 100% of Allowed Amt after $25 PVF 100% of Allowance after $25 PVF

Other Covered Facility Services

Ambulatory Surgical Center 80% of Allowed Amt after CYD 60% of Allowance after CYD

Birthing Center 80% of Allowed Amt after CYD 60% of Allowance after CYD

Osteopathic Hospital (Inpatient)

AC/HSC required except for physical rehab admissions

80% of Allowed Amt after PAD 60% of Allowance after PAD

Outpatient Facility 80% of Allowed Amt after CYD 60% of Allowance after CYD

Rehab Hospital (Inpatient) AC/HSC not required

80% of Allowed Amt after PAD 60% of Allowance after PAD

Rehab Hospital (Outpatient) 80% of Allowed Amt after CYD 60% of Allowance after CYD

Skilled Nursing Facility

Not subject to PAD; AC/HSC not required

70% of Allowed Amt 70% of Allowance

Specialty Facility (Inpatient) AC/HSC required

80% of Allowed Amt after PAD 60% of Allowance after PAD

Specialty Facility (Outpatient) 80% of Allowed Amt after CYD 60% of Allowance after CYD

Home Health Care 80% of Allowed Amt after CYD 60% of Allowance after CYD

Residential Treatment Services 80% of Allowed Amt after PAD 60% Allowance after PAD

Other Covered Services

Acupuncture 80% of Allowed Amt after CYD 60% of Allowance after CYD

Ambulance 100% of Allowed Amt 100% of Covered Charge

Autism 80% of Allowed Amt after CYD 60% of Allowance after CYD

Cleft Lip and Cleft Palate 80% of Allowed Amt after CYD 60% of Allowance after CYD

Contraceptives, supplies and related services

Paid according to the type of service rendered as noted above for Preventive Adult Care, Physician office visits, other Physician services, Durable Medical Equipment, and prescription drugs .

Dental Services 80% of Allowed Amt after CYD 60% of Allowance after CYD

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Notes: Certain categories of Network Providers may not currently be available in all geographic regions.

Additionally, certain providers (e.g., radiologists, anesthesiologists, pathologists, emergency room Physicians, Hospitalists) rendering care at network facilities may not be Network Providers and are, therefore, subject to non-network benefits unless under applicable law the Non-Network Provider is under a duty to accept the applicable Non-Network Allowance plus applicable deductibles, Copays and Coinsurance as payment in full for Covered Services and Supplies.

These are the benefits provided the coverage is active (i.e., in effect) when the services are rendered.

Oral and written statements cannot modify the coverage or benefits described in this Plan Booklet and Benefits Document.

* The Non-Network Allowance is not the provider’s billed charges and could be significantly less than the provider’s billed charges. The patient is responsible for 100 percent of the difference between the billed charges and the Non-Network Allowance, except when provided in an emergency or an in-network facility within the state of Florida.

Benefit Description Network Non-Network*

Durable Medical Equipment (DME)/Supplies

80% of Allowed Amt after CYD 60% of Allowance after CYD

Eye Glasses or Contacts 80% of Allowed Amt after CYD 60% of Allowance after CYD

Limited Fertility Testing and Treatment

80% of Allowed Amt after CYD 60% of Allowance after CYD

Hearing Tests 80% of Allowed Amt after CYD 60% of Allowance after CYD

Mammograms (diagnostic and/ or medical)

80% of Allowed Amt after CYD 60% of Allowance after CYD

Manipulative Services 80% of Allowed Amt after CYD 60% of Allowance after CYD

Mastectomy and Reconstructive Surgery

80% of Allowed Amt after CYD 60% of Allowance after CYD

Maternity Care 80% of Allowed Amt after CYD 60% of Allowance after CYD

Midwife Services 80% of Allowed Amt after CYD 60% of Allowance after CYD

Physical/Massage/Occupational Therapy

80% of Allowed Amt after CYD 60% of Allowance after CYD

Prescription Drugs (CVS Caremark) Participating Retail Pharmacy (30-day supply) Participating Retail Pharmacy (90-day supply) Mail Order Pharmacy (90-day supply)

Generic/Preferred Brand/ Non-Preferred Brand

$7 / $30 / $50

$14 / $60 / $100

$14 / $60 / $100

You pay in full and file claim

(see section 9 for reimbursement information)

Prostheses 80% of Allowed Amt after CYD 60% of Allowance after CYD

Surgical Sterilization 80% of Allowed Amt after CYD 60% of Allowance after CYD

Transplants 80% of Allowed Amt after CYD 60% of Allowance after CYD

Weight Loss Services 80% of Allowed Amt after CYD 60% of Allowance after CYD

Wigs 80% of Allowed Amt after CYD 60% of Allowance after CYD

Hospice Care

Hospice Inpatient 70% of Allowed Amt 70% of Allowance

Hospice Outpatient/Home 80% of Allowed Amt 80% of Allowance

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Plan Maximums

Hospice Care days per person per lifetime

Lifetime Benefit Maximum per person per lifetime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Not Applicable

Manipulative Services per person per calendar year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 treatments

Massage and/or Physical Therapy (excluding physical therapy for the treatment of Autism Spectrum Disorder and Down syndrome)

Treatments per day; and Days per 6-month period

Occupational Therapy (excluding occupational therapy for the treatment of Autism Spectrum Disorder, Down Syndrome, and under hospice and home health care services)

Days per 6-month period

Skilled Nursing Facility days per person per calendar year

Weight Loss Services (non-surgical) per person per 12-month period; refer to page 3-8 . . . . . . . . . . . . . . $150

Wigs one wig and fitting in the 12 months following treatment or surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40

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Understanding Your Share of Health Care Expenses

How the Plan Pays Benefits

Office Visits

For office visits, the amount you pay depends on whether you use a network or non-network physician or other health care provider . You pay a set copayment per visit for network Physicians or other health care providers, while Coinsurance applies for most office visits to non-network physicians or other health care providers .

If you use non-network physicians or other health care providers, you will be under an obligation to pay any amount above the Non-Network Allowance unless under applicable law the Non-Network Provider is under a duty to accept the applicable Non-Network Allowance plus applicable deductibles, Copays and Coinsurance as payment in full for Covered Services and Supplies . See page 1-7 for more information about the Network Allowed Amount and the Non-Network Allowance .

Copayments for office visits do not count toward meeting the Plan’s calendar year deductible or the calendar year coinsurance maximum . An office visit includes all services provided on the same day as the office visit, by the same health care provider .

Therefore, the copayment you pay for the office visit applies to all covered services rendered in that office visit and does not count toward meeting the calendar year deductible .

Emergency Room Visits

For emergency room (ER) visits, the amount you pay depends on whether you use a network or non-network facility:

1 . Facility You pay a set Copayment per visit for the facility charges . This Copayment is waived if you are admitted to the Hospital directly from the emergency room . The per visit ER Copayment does not count toward meeting the Plan’s calendar year deductible or the calendar year coinsurance maximum .

2 . ER Physician or Other Health Care Provider You pay a percentage of the Network Allowed Amount or Non-Network Allowance after you meet the calendar year deductible . It is not uncommon to receive ER Physician or other health care provider services from a Non-Network Provider within a network facility .

Deductible for Hospital Stays (Per Admission Deductible)

The calendar year deductible does not apply to covered facility services for inpatient Hospital stays, but there is a separate Hospital stay deductible that applies to each Hospital stay . This means that you must meet the Hospital stay deductible each time you are admitted as an inpatient before the Plan pays benefits for covered facility services . The calendar year deductible does apply to Physician or other professional services provided during your inpatient Hospital stay .

Deductible for Most Other Covered Care

You must meet a calendar year deductible before this Plan pays benefits for most covered expenses . Please refer to the summary of benefits chart on pages 1-1 through 1-3 for information on services that are not subject to the calendar year deductible (e .g ., services requiring a Copayment or per admission deductible) . The calendar year deductible applies each January 1 to December 31 . The deductible will not roll over to the following year .

Once the calendar year deductible is met, this Plan pays a percentage of the Network Allowed Amount for Network Providers and a percentage of the Non-Network Allowance for Non-Network Providers . Please refer to page 1-7 for more information regarding your share of expenses for Non-Network Providers .

The amount of the calendar year deductible depends on whether you use Network or Non- Network Providers . Amounts applied to the deductible for network-covered services will count toward satisfying the non-network deductible, and vice versa .

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If you have individual coverage, this Plan begins paying a percentage of your eligible expenses after you meet your individual deductible .

If you have family coverage, you can meet the family deductible in one of two ways:

1 . two family members can each meet the individual calendar year deductible; or

2 . all family members can combine their covered expenses to meet the family deductible .

How the Deductible Works

Assume Joe and his family had the following covered medical expenses during the first three months in a calendar year . All the expenses are for care from Network Providers and are not office visits .

Joe $ 200

Wife $ 125

Daughter $ 100

Son + $ 75 network family deductible $ 500

In this example, the family members’ combined covered expenses meet the network family deductible .

Once your family satisfies the family deductible, this Plan begins paying a percentage of covered expenses for you and all your covered dependents for the rest of the calendar year . If one person in your family meets the individual deductible, the Plan begins paying a percentage of covered expenses for that person for the rest of the calendar year .

Calendar Year Coinsurance Maximum

There is a limit on the amount of Coinsurance you pay out of your pocket toward covered expenses in any one calendar year for network and non-network care combined . Once your share of out-of-pocket Coinsurance expenses reaches the annual limit, this Plan begins paying 100 percent of the Network Allowed Amount for care from Network Providers and 100 percent of the Non-Network Allowance for care from Non-Network Providers, after any required Copayments or deductibles, for the rest of the calendar year . You meet the family out-of-pocket Coinsurance maximum (if applicable) when the Coinsurance expenses of two of your covered family members or a combination of covered family members adds up to the family Coinsurance maximum .

Both your network and non-network covered expenses count toward the out-of-pocket Coinsurance maximum . The following expenses, however, do not count toward the out-of-pocket Coinsurance maximum:

1 . calendar year and inpatient Hospital deductibles;

2 . Copayments for office visits, urgent care visits and emergency room visits;

3 . charges for services and supplies that are not covered by this Plan;

4 . charges greater than the Non-Network Allowance for Non-Network Providers;

5 . charges greater than Plan limits on dollar amounts, number of treatments, or number of days of treatment; and

6 . pre-admission certification or other penalties .

Global Network Out-Of-Pocket Maximum

There is a limit on the amount you will pay out-of-pocket toward covered expenses during any calendar year for network Covered Services and Supplies and prescription drugs . Under individual coverage, once your share of network out-of-pocket expenses reaches the global network out-of-pocket maximum, this Plan begins paying 100 percent of the Network Allowed Amount for network Covered Services and Supplies and prescription drugs for the remainder of the calendar year for you . You meet the family global network out-of-pocket maximum when two covered family members or a combination of covered family members meet the family global network out-of-pocket maximum . Only expenses for network Covered Services and Supplies and prescription drugs count toward the global network out-of-pocket maximum; expenses that apply to this maximum include:

1 . Network expenses that applied to the annual calendar year deductible;

2 . Network expenses that applied to the annual Coinsurance out-of-pocket maximum;

3 . Network emergency room Copays;

4 . Network hospital per admission deductibles;

5 . Network office visit Copays; and

6 . Network prescription drug Copays .

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Expenses that do not apply to the global network out-of-pocket maximum include:

1 . Non-Network expenses that applied to the annual calendar year deductible;

2 . Non-Network expenses that applied to the annual coinsurance out-of-pocket maximum;

3 . Non-Network emergency room Copays;

4 . Non-Network hospital per admission deductibles;

5 . Non-Network office visit Coinsurance;

6 . Charges for services, supplies and prescription drugs that are not covered by this Plan;

7 . Charges for Covered Services and Supplies and prescription drugs that are greater than Plan limits for dollar amounts, number of treatments, or number of days of treatment;

8 . Charges and/or penalties for not obtaining pre admission certification and/or exceeding approved days of hospital stay certification;

9 . Non-Network prescription drugs;

10 . Specialty drugs that are denied by the Specialty Guideline Management Program;

11 . Specialty drugs that would have been denied or would have been outside clinical treatment guidelines by the Specialty Guideline Management Program if you had tried to get the drug approved but did not go through the proper approval process; and, 12 . The difference between the cost of a generic drug and a brand name drug when the prescribing physician does not indicate “dispense as written” or “brand name medically necessary” and you request the brand name drug .

The Plan Pays a Share of Covered Expenses

Benefits are paid at two different levels . The level you receive depends on whether your care is provided by Network Providers or Non-Network Providers .

This Plan pays benefits for covered services based on the Network Allowed Amount for network care and the Non-Network Allowance for non-network care .

The Network Allowed Amounts are preferred rates Florida Blue has negotiated with Network Providers, and NetworkProviders are not allowed to charge you for any amounts above the Network Allowed Amounts . When you use Network Providers, you take advantage of the preferred rates of the Network

Allowed Amounts and the Plan pays the highest level of benefits, keeping your cost down .

When you receive services from Non-Network Providers by choice or even if you have no choice in the selection of the Non-Network Provider, this Plan pays benefits based on the Non-Network Allowance, not the providers’ billed charges . If your provider charges more than the Non-Network Allowance, you are responsible for any amounts above the Non- Network Allowance unless under applicable law the Non-Network Provider is under a duty to accept the applicable Non-Network Allowance plus applicable deductibles, Copays and Coinsurance as payment in full for Covered Services and Supplies . In addition, because the Plan often pays a lower benefit level for non-network care, you pay more out-of-pocket for non-network care unless under applicable law the Non-Network Provider is under a duty to accept the applicable Non-Network Allowance plus applicable deductibles, Copays and Coinsurance as payment in full for Covered Services and Supplies .

In selecting Florida Blue as the Medical Claim Administrator for the State Employees’ PPO Plan, DSGI agreed to accept the Non-Network Allowance schedule used by Florida Blue to make payment for specific health care services submitted by Non- Network Providers .

In the case of a Non-Network Provider that has not entered into an agreement with Florida Blue to provide access to a discount from the billed amount of that Non-Network Provider for the specific Covered Services provided to you, the Non-Network Allowance will be the lesser of that Non-Network Provider’s actual billed amount for the specific Covered Services or an amount established by Florida Blue that may be based on several factors, including but not limited to:

• payment for such Covered Services under the Medicare and/or Medicaid programs;

• payment often accepted for such Covered Services by that Non-Network Provider and/ or by other providers, either in Florida or in other comparable market(s), that Florida Blue determines are comparable to the Non-Network Provider that rendered the specific Covered Services (which may include payment accepted by such Non-Network Provider and/or by other providers as participating providers in other provider networks of third-party payers which may include, for example, other insurance companies and/or health maintenance organizations);

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• payment amounts which are consistent, as determined by Florida Blue, with our provider network strategies (e .g ., does not result in payment that encourages providers participating in a Florida Blue network to become non-participating); and/or,

• the cost of providing the specific Covered Services .

In the case of a Non-Network Provider that has not entered into an agreement with another Blue Cross and/or Blue Shield organization to provide access to discounts from the billed amount for the specific Covered Services under the BlueCard® Program, the Non-Network Allowance for the specific Covered Services provided to you may be based upon the amount provided to Florida Blue by the other Blue Cross and/or Blue Shield organization where the services were provided at the amount such organization would pay Non-Network Providers in its geographic area for such services .

In no event will the Non-Network Allowance be greater than the amount the Non-Network Provider actually charges .

If a particular Covered Service is not available from any provider that is in PPCSM, as determined by Florida Blue, the Non-Network Allowance, whenever Florida Statute 627 .6471 applies, means the usual and customary charge(s) of similar providers in a geographical area established by Florida Blue .

You may get an estimate of the Non-Network Allowance or the Network Allowed Amount for particular services by calling Florida Blue Customer Service toll-free at (800) 825-2583 . The procedure code, diagnosis code, and the provider’s charge are required to provide an estimate of the Non- Network Allowance or Network Allowed Amount .

The fact that Florida Blue or DSGI may provide you with such information does not mean that the particular service is a Covered Service . All terms and conditions included in this Plan Booklet and Benefits Document apply . Please refer to Section 1 (Standard PPO Option Summary of Benefits), Section 2 (PPO High Deductible Health Plan Option Summary of Benefits), Section 3 (Covered Services), and Section 5 (Exclusions) for more detailed information on the Plan and member cost share amounts, covered services, and exclusions .

Keep in mind that you will receive benefits at the non-network level whenever you use Non-Network Providers .

See section 6 for more information about the PPCSM network .

The Non-Network Allowance is not the provider’s billed charges and could be significantly less than the provider’s billed charges. The patient is responsible for 100 percent of the difference between the billed charges and the Non-Network Allowance unless under applicable law the Non-Network Provider is under a duty to accept the applicable Non- Network Allowance plus applicable deductibles, Copays and Coinsurance as payment in full for Covered Services and Supplies.

How To Determine Your Cost Share

After claims are processed by Florida Blue for ser-vices received by you or your covered dependent, Florida Blue will send you a Monthly Health State-ment (MHS); the MHS will detail how the claim(s) processed including any amount you owe for copay-ments, deductibles, coinsurance, balance billing for non-network provider claims, and costs for noncov-ered services .

It is important to compare the MHS to the bill you receive from your provider to ensure that you pay the provider the correct amount shown on the MHS .

If Medicare is the primary coverage for you or your de-pendent, you will receive a MHS from Florida Blue as well as an Explanation of Medicare Benefits (EOMB) .

You will need to review both the MHS and the EOMB to determine your correct member cost share, if any, after both this Plan and Medicare have processed the claim(s) . You should subtract the amount paid to the provider shown on the MHS from the amount on the EOMB that Medicare shows as your responsibility; any difference is your cost share to pay the provider .

If Medicare is your primary coverage, any provider that accepts Medicare and Medicare Assignment of Benefits is deemed a Network provider; any pro-vider that does not accept Medicare Assignment of Benefits is deemed a Non-Network provider . When using providers outside the state of Florida, you should verify if the provider accepts Medicare Assign-ment of Benefits . If so, remind the provider to mark on the claim, that the provider submits to Medicare, that Assignment of Benefits is accepted; if accepting Assignment of Benefits is not marked, the claims will be processed as Non-Network which may result in a larger out-of-pocket cost share for you .

Please refer to Section 13: Coordinating Benefits with Other Coverage for examples of how this Plan coordinates benefits .

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PPO High Deductible Health Plan Option Summary of Benefits2-12-1

Section 2: PPO High Deductible Health Plan Option Summary of Benefits This summary provides an overview of the PPO High Deductible Health Plan Option . For further information on the coverage and benefits of this Plan, as well as applicable limitations and exclusions, please refer to sections 3 (Covered Services), 5 (Exclusions), 7 (Additional Required Provisions) and 15 (Definitions) of this booklet . If you are enrolled in the Standard PPO Option, please refer to section 1, entitled “Standard PPO Option Summary of Benefits.”

Benefit Description Network Non-Network*

Calendar Year Deductible/Copays/Limits Calendar Year Deductible (CYD) Individual Purchaser Family Purchaser

CYD

$1,500 $3,000

$2,500 $5,000

Coinsurance Maximum (OOP) Individual Purchaser Family Purchaser

$3,000 $6,000

$7,500 $15,000

Global Network (OOP) Maximum Individual Purchaser Family Purchaser

$4,500 $9,000 (no one person shall exceed $7,500) N/A

Emergency Room (ER) Facility Services Copay (per visit) No copay, subject to CYD

Per Admission Deductible (PAD) Inpatient Hospital No PAD; subject to CYD $1,000 after CYD

Physician Office Convenient Care Center Urgent Care Center

Subject to Coinsurance and CYD

Teladoc CYD N/A

Virtual Visit Coinsurance and CYD

Hospital Services

Room and Board (R&B) (semi-private)

Admission Certification/ Hospital Stay Certification (AC/ HSC) required

80% of Allowed Amt after CYD 60% of Allowance after PAD and CYD

Intensive/Progressive Care AC/HSC required 80% of Allowed Amt after CYD 60% of Allowance after PAD and CYD

Emergency Room 80% of Allowed Amt after CYD 80% of Allowance after CYD

Inpatient Ancillaries (x-ray, lab, drugs, oxygen, operating room, etc .)

80% of Allowed Amt after CYD 60% of Allowance after PAD and CYD

Outpatient Services 80% of Allowed Amt after CYD 60% of Allowance after CYD

Partial Hospitalization 80% of Allowed Amt after CYD 60% of Allowance after CYD

Physician Services

Emergency Room 80% of Allowed Amt after CYD 80% of Allowance after CYD

Hospital Visit 80% of Allowed Amt after CYD 60% of Allowance after CYD

PPO High Deductible Health Plan Option Summary of Benefits2-22-2

Benefit Description Network Non-Network*

Office Visit 80% of Allowed Amt after CYD 60% of Allowance after CYD

Teladoc 100% of Allowed Amt after CYD N/A

Virtual Visit 80% of Allowed Amt after CYD 60% of Allowance after CYD Outpatient Services (outpatient visits, consultations, maternity care, etc .)

80% of Allowed Amt after CYD 60% of Allowance after CYD

Pathology/Radiology/ Anesthesiology 80% of Allowed Amt after CYD 60% of Allowance after CYD

Preventive Care-Adult (Screening mammograms are included in Preventive Adult Care)

100% of Allowed Amt 100% of Allowance

Preventive Care-Children 100% of Allowed Amt 100% of Allowance

Surgery (Inpatient/Outpatient) 80% of Allowed Amt after CYD 60% of Allowance after CYD

Urgent Care Center 80% of Allowed Amt after CYD 80% of Allowance after CYD

Other Covered Facility Services

Ambulatory Surgical Center 80% of Allowed Amt after CYD 60% of Allowance after CYD

Birthing Center 80% of Allowed Amt after CYD 60% of Allowance after CYD

Osteopathic Hospital (Inpatient)

AC/HSC required except for physical rehab admissions

80% of Allowed Amt after CYD 60% of Allowance after PAD and CYD

Outpatient Facility 80% of Allowed Amt after CYD 60% of Allowance after CYD

Rehab Hospital (Inpatient) AC/HSC not required

80% of Allowed Amt after CYD 60% of Allowance after PAD and CYD Rehab Hospital (Outpatient) 80% of Allowed Amt after CYD 60% of Allowance after CYD Skilled Nursing Facility

Not subject to PAD; AC/HSC not required

70% of Allowed Amt after CYD 70% of Allowance after CYD

Specialty Facility (Inpatient) AC/HSC required

80% of Allowed Amt after CYD 60% of Allowance after PAD and CYD Specialty Facility (Outpatient) 80% of Allowed Amt after CYD 60% of Allowance after CYD

Home Health Care 80% of Allowed Amt after CYD 60% of Allowance after CYD

Residential Treatment Services 80% of Allowed Amt after PAD 60% Allowance after PAD and CYD

Other Covered Services

Acupuncture 80% of Allowed Amt after CYD 60% of Allowance after CYD

Ambulance 100% of Allowed Amt after CYD 100% of Covered Charge after CYD

Autism 80% of Allowed Amt after CYD 60% of Allowance after CYD

Cleft Lip and Cleft Palate 80% of Allowed Amt after CYD 60% of Allowance after CYD

Contraceptives, supplies and related services

Paid according to the type of service rendered as noted above for Preventive Adult Care, Physician office visits, other Physician services, Durable Medical Equipment, and prescription drugs .

Dental Services 80% of Allowed Amt after CYD 60% of Allowance after CYD

PPO High Deductible Health Plan Option Summary of Benefits2-32-3

Notes: Certain categories of Network Providers may not currently be available in all geographic regions.

Additionally, certain providers (e.g., radiologists, anesthesiologists, pathologists, emergency room Physicians, Hospitalists) rendering care at network facilities may not be Network Providers and are, therefore, subject to non-network benefits unless under applicable law the Non-Network Provider is under a duty to accept the applicable Non-Network Allowance plus applicable deductibles, Copays and Coinsurance as payment in full for Covered Services and Supplies.

These are the benefits provided the coverage is active (i.e., in effect) when the services are rendered.

Oral and written statements cannot modify the coverage or benefits described in this Plan Booklet and Benefits Document.

* The Non-Network Allowance is not the provider’s billed charges and could be significantly less than the provider’s billed charges. The patient is responsible for 100 percent of the difference between the billed charges and the Non-Network Allowance except when provided in an emergency or an in-network facility within the state of Florida.

Benefit Description Network Non-Network*

Durable Medical Equipment (DME)/Supplies

80% of Allowed Amt after CYD 60% of Allowance after CYD

Eye Glasses or Contacts 80% of Allowed Amt after CYD 60% of Allowance after CYD

Limited Fertility Testing and Treatment

80% of Allowed Amt after CYD 60% of Allowance after CYD

Hearing Tests 80% of Allowed Amt after CYD 60% of Allowance after CYD

Mammograms (diagnostic and/ or medical)

80% of Allowed Amt after CYD 60% of Allowance after CYD

Manipulative Services 80% of Allowed Amt after CYD 60% of Allowance after CYD

Mastectomy and Reconstructive Surgery

80% of Allowed Amt after CYD 60% of Allowance after CYD

Maternity Care 80% of Allowed Amt after CYD 60% of Allowance after CYD

Midwife Services 80% of Allowed Amt after CYD 60% of Allowance after CYD

Physical/Massage/Occupational Therapy

80% of Allowed Amt after CYD 60% of Allowance after CYD

Prescription Drugs (CVS Caremark) Participating Retail Pharmacy (30-day supply) Participating Retail Pharmacy (90-day supply) Mail Order Pharmacy (90-day supply)

Generic/Preferred Brand/ Non-Preferred Brand

30% / 30% / 50%

30% / 30% / 50%

30% / 30% / 50% (after In-Network CYD)

You pay in full and file claim

(see section 9 for reimbursement information)

Prostheses 80% of Allowed Amt after CYD 60% of Allowance after CYD

Surgical Sterilization 80% of Allowed Amt after CYD 60% of Allowance after CYD

Transplants 80% of Allowed Amt after CYD 60% of Allowance after CYD

Weight Loss Services 80% of Allowed Amt after CYD 60% of Allowance after CYD

Wigs 80% of Allowed Amt after CYD 60% of Allowance after CYD

Hospice Care

Hospice Inpatient 70% of Allowed Amt after CYD 70% of Allowance after CYD

Hospice Outpatient/Home 80% of Allowed Amt after CYD 80% of Allowance after CYD

PPO High Deductible Health Plan Option Summary of Benefits2-42-4

Plan Maximums

Hospice Care days per person per lifetime

Lifetime Benefit Maximum per person per lifetime (includes prescription drugs) . . . . . . . . . . . Not Applicable

Manipulative Services per person per calendar year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 treatments

Massage and/or Physical Therapy (excluding physical therapy for the treatment of Autism Spectrum Disorder, Down Syndrome)

Treatments per day; and Days per 6-month period

Occupational Therapy (excluding occupational therapy for the treatment of Autism Spectrum Disorder and Down syndrome and under hospice and home health care services)

Days per 6-month period

Skilled Nursing Facility days per person per calendar year

Weight Loss Services (non-surgical) per person per 12-month period; refer to page 3-8 . . . . . . . . . . . . . . $150

Wigs one wig and fitting in the 12 months following treatment or surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40

PPO High Deductible Health Plan Option Summary of Benefits2-52-5

Understanding Your Share of Health Care Expenses How the Plan Pays Benefits

Office Visits

For office visits, the amount you pay depends on whether you use a network or non-network physician or other health care provider .