St. Lucie County Schools FLEXIBLE BENEFITS PLAN. COBRA & Retiree Participants

Transcription

1 2014 St. Lucie County Schools FLEXIBLE BENEFITS PLAN R E F E R E N C E G U I D E COBRA & Retiree Participants

2 2014 St. Lucie County Schools Table of Contents 4 Enrollment at a Glance 6 COBRA Eligibility Requirements 7 Florida Blue Health Benefits Summary 10 Group Health Plan Premiums 13 Medicare Information 23 Dental Plan 25 Vision Care 26 Group Hospital Indemnity Insurance 27 Group Term Life Insurance 28 Group Cancer Insurance Plan 29 Creditable Coverage Letter Back Benefits Directory PayFlex FBMC s COBRA Outsource Provider COBRA benefits communication is being supported by FBMC Benefits Management s outsource provider, PayFlex. Please note that all PayFlex correspondence you receive is approved for distribution by the St. Lucie County Schools and FBMC Benefits Management, Inc. For COBRA questions about your Benefits Open Enrollment and throughout the year, please contact PayFlex Systems at or FBMC s Service Center at LUCIE4U ( ). 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 29 for more details. 2

3 2014 St. Lucie County Schools What s New This year is a mandatory enrollment. All COBRA Participants and Retirees of St. Lucie County Schools must complete an enrollment form by November 1, BlueOptions 3748, 3769 and BlueChoice 706 are no longer available, effective January 1, If you are currently enrolled in one of these plans, you must choose from one of the two other BlueOptions plans available for the 2014 Plan Year. SLCS is offering the BlueOptions Plan and BlueOptions Plans 05180/ BlueMedicare Group PPO Plans 1 and 2 are available to all Medicareeligible retirees and their dependents. SLCS has changed dental carriers. If you are currently enrolled in FCL Dental and wish to continue dental coverage, you must select the Delta Dental, Low or High PPO plan. Important Enrollment Information You must complete and mail an enrollment form by November 1, COBRA Participants: At Open Enrollment, a Qualified Beneficiary under COBRA will be given the same opportunity as similarly-situated active participants and beneficiaries, to change his or her group health plans, to drop dependents or to add eligible dependents who are not already covered under COBRA. FBMC Benefits Management, Inc. has contracted with Payflex Systems USA, Inc. to administer COBRA services as required by law. COBRA Participants must complete and mail an enrollment form by November 1, 2013 to continue COBRA benefits to PayFlex Systems USA, Inc. Benefits Billing Department P.O. Box 2239 Omaha, NE Forms may be faxed to or ed to cobramail@payflex.com. You may also call PayFlex Systems at or call LUCIE4U ( ). Retiree Participants: At Open Enrollment, a retiree may continue, cancel or decrease coverage. A Retiree may not add or increase coverage, or add or increase dependent coverage. Retiree Participants: If you currently do not have your premiums deducted from your Florida Retirement System (FRS) monthly benefit check, and would like to, please complete the enclosed FRS Deduction Authorization Form and return it with your Enrollment Form. Your deductions will start as soon as possible. Please be aware that you must make your payments via personal check or money order until the FRS deductions begin. Retirees must complete and mail an enrollment form by November 1, 2013 to FBMC Benefits Management Direct Bill Department P.O. Box Tallahassee, FL Dependents: If you are enrolling in coverage for your dependents, please record your dependent s Social Security numbers and dates of birth on your Enrollment Form. 3

4 Enrollment at a Glance Important Dates to Remember Your Open Enrollment dates are: October 7, 2013, through November 1, Your Period of Coverage dates are: January 1, 2014, through December 31, Medicare Advantage Plans SLCS offers two Medicare Advantage Plans for eligible Retirees who are age 65 or older and are eligible for Medicare. If you are currently eligible for Medicare and would like to enroll in either plan, please complete the enclosed application along with the FloridaBlue BlueMedicare enrollment form. The effective date of your Medicare Advantage Plan will be January 1, If you will become eligible for Medicare during the 2014 Plan Year and would like to participate in the Medicare Advantage Plan, please contact St. Lucie County Schools Risk Management Office to request an application. The effective date of your Medicare Advantage Plan will be the same date your Medicare becomes effective, usually the first day of the month in which you turn 65. For a summary of the benefits this plan offers, please refer to Page 13. COBRA Open Enrollment At Open Enrollment, a qualified beneficiary is given the same opportunity as similarly-situated active participants and beneficiaries, to change his or her group health plans, drop dependents and/or to add eligible dependents who are not already on COBRA. Please refer to the information contained on your current Benefit Statement and in this book when making your COBRA selections for the 2014 Plan Year. You can cover your dependents under every benefit that shows a premium amount for dependent coverage (refer to the rates in this book) provided you participate in the same benefit. You must fully complete, sign and return the enclosed enrollment form to PayFlex Systems USA, Inc. Benefits Billing Department P.O. Box 2239 Omaha, NE You may also call PayFlex Systems at or call LUCIE4U ( ). Forms may be faxed to or ed to cobramail@payflex.com. If you do complete an enrollment form, please assure you have noted all benefits you want to continue in the new plan year. Late forms will not be accepted and the benefits shown on your current Benefit Statement will be terminated as of December 31, For more information, contact FBMC Service Center at LUCIE4U ( ), Monday - Friday, 7 a.m. - 8 p.m. ET. Retiree Open Enrollment At Open Enrollment, retirees may not add or increase coverage, or add or increase dependent coverage. Once a coverage is cancelled, it may not be reinstated or added at a later date. Please refer to the information contained on your current Benefit Statement and in this guide when making selections for the 2014 Plan Year. All Retirees must complete a 2014 enrollment form. If you are Medicareeligible and you elect to enroll in either BlueMedicare Group PPO plan, you must also complete a Florida Blue BlueMedicare enrollment form. Please assure you have noted all benefits you want to continue in the new plan year. Late forms will not be accepted and the benefits shown on your current Benefit Statement will be terminated as of December 31, For more information, contact FBMC Service Center at LUCIE4U ( ), Monday - Friday, 7 a.m. - 8 p.m. ET. Any changes to your retiree benefits will require your written authorization. Premium changes required because of such written authorization will be initiated as soon as possible after receipt of your written request. If you are having FRS deductions for premium payments, any required refunds will be completed as soon as it has been verified that FRS has changed your deduction. Retirees are encouraged to submit their enrollment form(s) early to ensure that deductions are made by FRS in a timely manner. Any coverage you elect to cancel cannot be reinstated. Please send your written requests to: FBMC Benefits Management Direct Bill Department P.O. Box Tallahassee, FL

5 Enrollment at a Glance Dependent Eligibility for Group Health and Dental Plan: An individual who meets the eligibility criteria specified below is an Eligible Dependent and is eligible to apply for coverage under this Booklet: 1. The Covered Employee s spouse under a legally valid existing marriage; 2. The Covered Employee s natural, newborn, adopted, foster, or step child(ren) (or a child for whom the Covered Employee has been courtappointed as legal guardian or legal custodian) who: a) has reached the end of the calendar year in which he or she becomes 26, but has not reached the end of the calendar year in which he or she becomes 30 and who: i. is unmarried and does not have a dependent; ii. is a Florida resident or a full-time or part-time student; iii. is not enrolled in any other health coverage policy or plan; iv. is not entitled to benefits under Title XVIII of the Social Security Act unless the child is a handicapped dependent child. b) in the case of a handicapped dependent child, such child is eligible to continue coverage beyond the limiting age of 30, as a Covered Dependent if the dependent child is: i. otherwise eligible for coverage under the Group Master Policy; ii. incapable of self-sustaining employment by reason of mental or physical handicap; and iii. chiefly dependent upon the Covered Employee for support and maintenance provided that the symptoms or causes of the child s handicap existed prior to the child s 30th birthday. This eligibility shall terminate on the last day of the month in which the dependent child no longer meets the requirements for extended eligibility as a handicapped child. or 3. The newborn child of a Covered Dependent child who has not reached the end of the calendar year in which he or she becomes 26. Coverage for such newborn child will automatically terminate 18 months after the birth of the newborn child. Note: If a Covered Dependent child who has reached the end of the calendar year in which he or she becomes 26 obtains a dependent of their own (e.g., through birth or adoption), such newborn child will not be eligible for this coverage. It is your sole responsibility as the Covered Employee to establish that a child meets the applicable requirements for eligibility. Eligibility will terminate on the last day of the month in which the child no longer meets the eligibility criteria required to be an Eligible Dependent. Dependent Eligibility For Other Plans Refer to the benefit description pages in this reference guide for information on each benefit. You may cover your eligible dependents under every benefit that shows a premium amount for dependent coverage (refer to the rate charts that appear with each benefit description) provided you participate in the same benefit. An eligible dependent is: your legal spouse; an unmarried dependent child of either you or your legal spouse (including a stepchild, a legally adopted child, a child placed and approved for adoption in your home or a child for whom you have been appointed legal guardian), provided they reside in your household and primarily depend on you for support. Until the following conditions are reached, eligible dependents will be covered from birth, adoption or time of guardianship: Group Cancer Insurance and Hospital Indemnity Insurance coverage will cease at the end of the calendar year in which the child reaches age 25 if the child lives in your home and depends on you for support, or attends school full or part time. Vision - coverage will cease at the end of the calendar year in which the child reaches age 19 (or 25 if the child lives in your home and depends on you for support or attends school full or part time). Unmarried insured children who are physically or mentally handicapped and fully incapable of self-care, will be covered until disablement becomes other than total. Proof of disability must be submitted to your insurance provider following the child s 19th birthday. Please refer to the specific dependent eligibility information on the individual benefit information pages of this reference guide. 5

6 COBRA Eligibility Requirements What is continuation coverage? Federal law requires that most group health plans, give employees and their families the opportunity to continue their health care coverage when there is a qualifying event that would result in a loss of coverage under an employer s plan. For more information, please contact the FBMC Service Center at LUCIE4U ( ), Monday - Friday, 7 a.m. - 8 p.m. ET. COBRA Coverage A Qualified Beneficiary's (QB) period of coverage is January 1, 2014, through December 31, 2014, unless a QB's scheduled COBRA expiration date is sooner. QBs who have elected to continue eligible group health plans under COBRA will be given the same opportunity to change their coverage options or add or drop eligible dependents at Open Enrollment as similarly situated active employees and beneficiaries. A QB's Medical Expense FSA coverage will not be continued beyond the Plan Year in which the qualifying COBRA event occurs. HIPAA's special enrollment rights may apply to those who have elected COBRA. HIPAA, a federal law, gives a person already on COBRA certain rights to add dependents if such person acquires a new dependent, or if an eligible dependent declines coverage because of alternative coverage and later loses such coverage due to certain qualifying reasons. Spouse or dependents who are added under this law do not become Qualified Beneficiaries and their coverage will end at the same time coverage ends for the person who elected COBRA and later added them. If there s a loss of coverage for a group health plan, due to one of the triggering events below, then COBRA rights may have been created: For Covered Employees upon: termination of employment (other than for gross misconduct), including retirement, or a reduction in hours of employment For Spouses or Dependent Child(ren) upon: a covered employee s termination of employment (other than for gross misconduct), including retirement a covered employee s reduction in hours of employment a covered employee s death a divorce or legal separation (if recognized by state law) of a spouse from a covered employee a covered employee s entitlement to Medicare, or a child s loss of dependent status Method of Payment A COBRA Participant s initial payment including all back premiums is due within 45 days of COBRA continuation election. Subsequent monthly premium payments are due on the first of every month. COBRA law allows for a 30-day grace period after the due date for monthly payments. If a full premium payment is not received from a COBRA Participant by 30 days after the due date, COBRA coverage will be canceled retroactive to the first day of the month for which the full premium payment is due. A cancellation notice will be sent to the COBRA Participant if his or her full premium payment is not received. 6

7 Summary of Benefits for St. Lucie County School Board thru Florida Blue Summary of Benefits for COST SHARING BlueOptions St. Maximums Lucie shown County are Per School Benefit Period Board thru BlueOptions BlueOptions HSA-Compatible HSA-Compatible (BPM) unless noted Network Blue (Single Coverage) (Family Coverage) Only Available Network Blue Network Blue COST SHARING BlueOptions BlueOptions BlueOptions to Employees hired Maximums shown are Per Benefit Period HSA-Compatible HSA-Compatible (BPM) unless noted Network prior to Blue 1/1/14 (Single Coverage) (Family Coverage) Deductible (DED) (Per Person/Family Agg) Only Available Network Blue Network Blue In-Network to Employees $1,500 / $4,500 hired $1,500 / Not Applicable $3,000 / $3,000 Out-of-Network prior $4,500 to 1/1/14 / $13,500 $3,000 / Not Applicable $6,000 / $6,000 Deductible Coinsurance (DED) (Member (Per Person/Family Responsibility) Agg) In-Network $1,500 / $4,500 20% $1,500 / Not Applicable 10% $3,000 / $3,000 10% Out-of-Network 50% $4,500 of Allowed / $13,500 Amount + $3,000 40% / of Not Allowed Applicable Amount + $6,000 40% of / Allowed $6,000 Amount + Coinsurance (Member Responsibility) Subject to Balance Billing Subject to Balance Billing Subject to Balance Billing In-Network 20% Charges 10% Charges 10% Charges Out Out-of-Network Pocket Maximum (Per Person/Family 50% Includes of Allowed DED, Amount Coins, + & 40% of Includes Allowed DED, Amount Coins, + & 40% of Includes Allowed DED, Amount Coins, + & Agg) Subject to Balance Copays Billing Subject to Balance Copays Billing Subject to Balance Copays Billing In-Network $4,500 Charges/ $9,000 $3,000 Charges / Not Applicable Charges $6,000 /$6,000 Out Out-of-Network Pocket Maximum (Per Person/Family Includes $9,000 DED, / Coins, $18,000 & Includes $6,000 DED, / Not Coins, Applicable & Includes $12,000 DED, Coins, / $12,000 & Agg) Lifetime Maximum Copays No Maximum Copays No Maximum Copays No Maximum PROFESSIONAL In-Network PROVIDER SERVICES $4,500 / $9,000 $3,000 / Not Applicable $6,000 /$6,000 Out-of-Network $9,000 / $18,000 $6,000 / Not Applicable $12,000 / $12,000 Lifetime Allergy Maximum Injections No Maximum No Maximum No Maximum In-Network Primary/Family Care Physician $10 DED + 10% DED + 10% PROFESSIONAL PROVIDER SERVICES In-Network Specialist $10 DED + 10% DED + 10% Allergy Out-of-Network Injections DED + 50% DED + 40% DED + 40% E-Office In-Network Visit Primary/Family Services Care Physician $10 DED + 10% DED + 10% In-Network Specialist $10 DED + 10% DED + 10% In-Network Primary/Family Care Physician $10 DED + 10% DED + 10% Out-of-Network DED + 50% DED + 40% DED + 40% In-Network Specialist $10 DED + 10% DED + 10% E-Office Visit Services Out-of-Network DED + 50% DED + 40% DED + 40% In-Network Primary/Family Care Physician $10 DED + 10% DED + 10% Office Services In-Network Specialist $10 DED + 10% DED + 10% Out-of-Network In-Network Primary/Family Care Physician DED + 50% $30 DED DED + 40% + 10% DED + DED 40% + 10% Office In-Network ServicesSpecialist $55 DED + 10% DED + 10% In-Network Out-of-Network Primary/Family Care Physician DED $ % DED DED + 10% + 40% DED + DED 10% + 40% Provider In-Network Services Specialist at Hospital and ER $55 DED + 10% DED + 10% Out-of-Network In-Network Primary/Family Care Physician DED DED + 50% + 20% DED DED + 40% + 10% DED + DED 40% + 10% Provider In-Network Services Specialist at Hospital and ER DED + 20% DED + 10% DED + 10% In-Network Out-of-Network Primary/Family Care Physician In-Ntwk DED + 20% DED + 20% DED In-Ntwk + 10% DED + 10% DED In-Ntwk + 10% DED + 10% Provider In-Network Services Specialist at Other Locations DED + 20% DED + 10% DED + 10% Out-of-Network In-Network Primary/Family Care Physician In-Ntwk DED $ % In-Ntwk DED + 10% In-Ntwk DED % 10% Provider In-Network Services Specialist at Other Locations $55 DED + 10% DED + 10% In-Network Out-of-Network Primary/Family Care Physician DED $ % DED DED + 10% + 40% DED + DED 10% + 40% Radiology, In-Network Pathology Specialist and Anesthesiology $55 DED + 10% DED + 10% Provider Out-of-Network Services at Ambulatory Surgical DED + 50% DED + 40% DED + 40% Radiology, Center Pathology and Anesthesiology Provider In-Network Services Specialist at Ambulatory Surgical ASC: $55 DED + 10% DED + 10% Center Hospital: DED + 20% In-Network Out-of-Network Specialist ASC: ASC: $55 $55 DED In-Ntwk + 10% DED + 10% DED In-Ntwk + 10% DED + 10% Hospital: DED In-Ntwk + 20% DED + Out-of-Network ASC: $55 20% In-Ntwk DED + 10% In-Ntwk DED + 10% Hospital: In-Ntwk DED + PREVENTIVE CARE 20% PREVENTIVE Adult Wellness CARE Office Services In-Network Primary/Family Care Physician $0 $0 $0 Adult Wellness Office Services In-Network Specialist $0 $0 $0 In-Network Primary/Family Care Physician $0 $0 $0 In-Network Out-of-Network Specialist 50% $0 (No DED) 40% $0 (No DED) 40% $0 (No DED) Colonoscopies Out-of-Network (Routine) Age 50% 50+ (No then DED) Frequency Age 40% 50+ (No then DED) Frequency 40% Age (No 50+ DED) then Frequency Colonoscopies (Routine) Age 50+ Schedule then Frequency Applies Age 50+ Schedule then Frequency Applies Age 50+ then Schedule Frequency Applies In-Network Schedule Applies $0 Schedule Applies $0 Schedule Applies $0 In-Network Out-of-Network $0 $0 $0 $0 $0 $0 Mammograms Out-of-Network (Routine) $0 $0 $0 Mammograms In-Network (Routine) $0 $0 $0 In-Network Out-of-Network $0 $0 $0 $0 $0 $0 Well Out-of-Network Child Office Visits (No BPM) $0 $0 $0 Well In-Network Child Office Primary/Family Visits (No Care BPM) Physician $0 $0 $0 In-Network Primary/Family Specialist Care Physician $0 $0 $0 $0 $0 $0 In-Network Out-of-Network Specialist 50% $0 (No DED) 40% $0 (No DED) 40% $0 (No DED) Out-of-Network 50% (No DED) 40% (No DED) 40% (No DED) 7

8 COST SHARING Maximums shown are Per Benefit Period (BPM) unless noted EMERGENCY/URGENT/CONVENIENT CARE BlueOptions BlueOptions Florida Blue HSA-Compatible (Single Coverage) BlueOptions HSA-Compatible (Family Coverage) Ambulance Maximum (per day) No Maximum No Maximum No Maximum COST SHARING BlueOptions BlueOptions BlueOptions In-Network DED + 20% DED + 10% DED + 10% Maximums Out-of-Network shown are Per Benefit Period HSA-Compatible HSA-Compatible In-Ntwk DED + 20% In-Ntwk DED + 10% In-Ntwk DED + 10% (BPM) Convenient unless Care noted (Single Coverage) (Family Coverage) Centers (CCC) EMERGENCY/URGENT/CONVENIENT In-Network $30 DED + 10% DED + 10% CARE Out-of-Network DED + 50% DED + 40% DED + 40% Ambulance Emergency Maximum Room Facility (per day) No Maximum No Maximum No Maximum Services In-Network (also see Professional Provider Services) Out-of-Network In-Network DED + 20% In-Ntwk DED $ % DED + 10% In-Ntwk DED + 10% DED + 10% In-Ntwk DED DED + 10% + 10% Convenient Out-of-Network Care Centers (CCC) $250 In-Ntwk DED + 10% In-Ntwk DED + 10% Urgent In-Network Care Centers (UCC) $30 DED + 10% DED + 10% Out-of-Network In-Network DED + 50% $60 DED DED + 40% + 10% DED + DED 40% + 10% Emergency Out-of-Network Room Facility Services DED + 50% DED + 40% DED + 40% (also see Professional Provider Services) FACILITY SERVICES - HOSP/SURG/ICL/IDTF In-Network $250 DED + 10% DED + 10% Unless Out-of-Network otherwise noted, physician services are $250 In-Ntwk DED + 10% In-Ntwk DED + 10% Urgent in addition Care to Centers facility services. (UCC) See Professional Provider In-Network Services. $60 DED + 10% DED + 10% Ambulatory Out-of-Network Surgical Center FACILITY In-Network SERVICES - HOSP/SURG/ICL/IDTF DED + 50% $200 DED + 40% DED + 10% DED + 40% DED + 10% Unless Out-of-Network otherwise noted, physician services are DED + 50% DED + 40% DED + 40% in Independent addition to facility Clinical services. Lab See Professional Provider In-Network Services. (Quest Diagnostics) $0 DED DED Ambulatory Out-of-Network Surgical Center DED + 50% DED + 40% DED + 40% Independent In-Network Diagnostic Testing Facility - $200 DED + 10% DED + 10% Xrays Out-of-Network and AIS (Includes Physician Services) DED + 50% DED + 40% DED + 40% Independent In-Network Clinical - Advanced Lab Imaging Services $250 DED + 10% DED + 10% In-Network (AIS) (Quest Diagnostics) $0 DED DED Out-of-Network In-Network - Other Diagnostic Services DED + 50% $50 DED DED + 40% + 10% DED + DED 40% + 10% Independent Out-of-Network Diagnostic Testing Facility - DED + 50% DED + 40% DED + 40% Xrays Inpatient and AIS Hospital (Includes (per Physician admit) Services) In-Network - Advanced Imaging Services (AIS) Option $ DED + 20% Option 2 - DED + 20% Option DED + 110% - DED + 10% Option 2 - DED + 10% DED Option + 10% 1 - DED + 10% Option 2 - DED + 10% In-Network Out-of-Network - Other Diagnostic Services $500 PAD $50 + DED + 50% DED DED + 10% + 40% DED + DED 10% + 40% Inpatient Out-of-Network Rehab Maximum (PBP) DED % Days DED % Days DED + 40% 21 Days Inpatient Outpatient Hospital Hospital (per (per admit) visit) In-Network Option Option 1 - DED 1 - DED + 20% + 20% Option Option 1 - DED 1 - DED + 10% + 10% Option Option 1 - DED 1 -+ DED 10% + 10% Option Option 2 - DED 2 - DED + 20% + 20% Option Option 2 - DED 2 - DED + 10% + 10% Option Option 2 - DED 2 -+ DED 10% + 10% Out-of-Network $500 PAD DED + DED + 50% + 50% DED DED + 40% + 40% DED + DED 40% + 40% Inpatient Therapy Rehab at Outpatient Maximum Hospital (PBP) 21 Days 21 Days 21 Days Outpatient In-Network Hospital (per visit) Option 1 - $55 Option 1 - DED + 10% Option 1 - DED + 10% In-Network Option 1 Option - DED % $80 Option Option 1 - DED 2 - DED + 10% + 10% Option Option 1 - DED 2 -+ DED 10% + 10% Out-of-Network Option 2 DED - DED % 20% Option 2 - DED DED + 40% 10% Option 2 - DED DED % 40% Out-of-Network DED + 50% DED + 40% DED + 40% Therapy OTHER at SPECIAL Outpatient SERVICES Hospital AND LOCATIONS In-Network Option 1 - $55 Option 1 - DED + 10% Option 1 - DED + 10% Advanced Imaging Services in Physician's Office Out-of-Network OTHER In-Network SPECIAL Primary/Family SERVICES AND Care Physician Option 2 - $80 DED + 50% $250 Option 2 - DED + 10% DED + 40% DED + 10% Option 2 - DED + 10% DED + 40% DED + 10% LOCATIONS In-Network Specialist $250 DED + 10% DED + 10% Advanced Out-of-Network Imaging Services in Physician's DED + 50% DED + 40% DED + 40% Office Birthing Center In-Network Primary/Family Care Physician $250 DED + 20% DED DED + 10% + 10% DED + DED 10% + 10% In-Network Out-of-Network Specialist $250 DED + 50% DED DED + 10% + 40% DED + DED 10% + 40% Durable Out-of-Network Medical Equipment, Prosthetics, DED No + Maximum 50% DED No + 40% Maximum DED No + 40% Maximum Birthing Orthotics Center BPM In-Network (Carecentrix) DED DED + 20% + 20% DED DED + 10% + 10% DED + DED 10% + 10% Out-of-Network DED DED + 50% + 50% DED DED + 40% + 40% DED + DED 40% + 40% Durable Home Health Medical Care Equipment, BPM Prosthetics, No Maximum 20 Visits No Maximum 20 Visits No Maximum 20 Visits Orthotics In-Network BPM (Carecentrix) DED + 20% DED + 10% DED + 10% In-Network Out-of-Network (Carecentrix) DED DED + 20% + 50% DED DED + 10% + 40% DED + DED 10% + 40% Out-of-Network DED + 50% DED + 40% DED + 40% Home Health Care BPM 20 Visits 20 Visits 20 Visits In-Network (Carecentrix) DED + 20% DED + 10% DED + 10% Out-of-Network DED + 50% DED + 40% DED + 40% 8

9 COST SHARING Maximums shown are Per Benefit Period (BPM) unless noted EMERGENCY/URGENT/CONVENIENT CARE BlueOptions Florida Blue BlueOptions HSA-Compatible (Single Coverage) BlueOptions HSA-Compatible (Family Coverage) Ambulance Maximum (per day) No Maximum No Maximum No Maximum COST SHARING BlueOptions BlueOptions BlueOptions In-Network DED + 20% DED + 10% DED + 10% Maximums Out-of-Network shown are Per Benefit Period HSA-Compatible HSA-Compatible In-Ntwk DED + 20% In-Ntwk DED + 10% In-Ntwk DED + 10% (BPM) Convenient unless noted (Single Coverage) (Family Coverage) Care Centers (CCC) Hospice In-Network LTM No Maximum $30 No Maximum DED + 10% No Maximum DED + 10% In-Network Out-of-Network DED DED + 20% + 50% DED DED + 10% + 40% DED + DED 10% + 40% Emergency Out-of-Network Room Facility Services DED + 50% DED + 40% DED + 40% Skilled Nursing Facility BPM 60 Days 60 Days 60 Days (also see Professional Provider Services) In-Network DED + 20% DED + 10% DED + 10% In-Network $250 DED + 10% DED + 10% Out-of-Network DED + 50% DED + 40% DED + 40% Out-of-Network $250 In-Ntwk DED + 10% In-Ntwk DED + 10% PRESCRIPTION Urgent Care Centers DRUGS(UCC) Deductible In-Network $0 $60 In-Network DED Plan + 10% In-Network DED Plan + 10% Out-of-Network DED + 50% Deductible DED Applies + 40% Deductible DED Applies + 40% In-Network (Mandatory Generic Program) FACILITY SERVICES - HOSP/SURG/ICL/IDTF Retail (30 days) Unless Generic/Preferred otherwise noted, Brand/Non-Preferred physician services are $10 / $30 / $50 $10 / $30 / $50 $10 / $30 / $50 Mail in addition Order/Retail to facility (90 days) services. See Professional Provider Generic/Preferred Services. Brand/Non-Preferred $20 / $60 / $100 $25 / $75 / $125 $25 / $75 / $125 Ambulatory Surgical Center This is In-Network not an insurance contract or Benefit Booklet. The above $200 Benefit Summary is only DED a partial + 10% description of the many DED benefits + 10% and services Out-of-Network covered by Blue Cross and Blue Shield of Florida, Inc., DED an independent + 50% licensee of the DED Blue + Cross 40% and Blue Shield Association. DED + 40% For a complete Independent description Clinical of Lab benefits and exclusions, please see Blue Cross and Blue Shield of Florida s Benefit Booklet and Schedule of Benefits; In-Network their terms (Quest prevail. Diagnostics) $0 DED DED Out-of-Network DED + 50% DED + 40% DED + 40% The Independent information contained Diagnostic in this Testing proposal Facility includes - benefit changes required as a result of the Patient Protection And Affordable Care Act (PPACA), Xrays otherwise and AIS (Includes known as Physician Health Care Services) Reform (HCR). Please note that plan benefits are subject to change and may be revised based on In-Network - Advanced Imaging Services $250 DED + 10% DED + 10% guidance (AIS) and regulations issued by the Secretary of Health and Human Services (HHS) or other applicable federal agency. In addition, the rates quoted In-Network within - Other this proposal Diagnostic are Services based on the plan benefits at the $50time the proposal is issued DED and + 10% may change before the DED plan + effective 10% Out-of-Network DED + 50% DED + 40% DED + 40% date if additional plan changes become necessary. Inpatient Hospital (per admit) In-Network Option 1 - DED + 20% Option 1 - DED + 10% Option 1 - DED + 10% Additionally, Interim rules released by the Federal Government Option February 2 - DED 2, % require BCBSF Option to 2 -test DED all + benefit 10% plans to Option ensure 2 compliance - DED + 10% Out-of-Network $500 PAD + DED + 50% DED + 40% DED + 40% with Inpatient the Mental Rehab Health Maximum Parity and (PBP) Addiction Equity Act (MHPAE). 21 Benefits Days and rates reflected in the 21 Days proposal are subject to change 21 Days based on the Outpatient outcomes of Hospital the test. (per visit) In-Network Option 2 - DED + 20% Option 1 - DED + 20% Option 2 - DED + 10% Option 1 - DED + 10% Option 2 - DED + 10% Option 1 - DED + 10% Out-of-Network DED + 50% DED + 40% DED + 40% Therapy at Outpatient Hospital In-Network Option 1 - $55 Option 2 - $80 Option 1 - DED + 10% Option 2 - DED + 10% Option 1 - DED + 10% Option 2 - DED + 10% Out-of-Network DED + 50% DED + 40% DED + 40% OTHER SPECIAL SERVICES AND LOCATIONS Advanced Imaging Services in Physician's Office In-Network Primary/Family Care Physician $250 DED + 10% DED + 10% In-Network Specialist $250 DED + 10% DED + 10% Out-of-Network DED + 50% DED + 40% DED + 40% Birthing Center In-Network DED + 20% DED + 10% DED + 10% Out-of-Network DED + 50% DED + 40% DED + 40% Durable Medical Equipment, Prosthetics, No Maximum No Maximum No Maximum Orthotics BPM In-Network (Carecentrix) DED + 20% DED + 10% DED + 10% Out-of-Network DED + 50% DED + 40% DED + 40% Home Health Care BPM 20 Visits 20 Visits 20 Visits In-Network (Carecentrix) DED + 20% DED + 10% DED + 10% Out-of-Network DED + 50% DED + 40% DED + 40% 9

10 Florida Blue Group Health Plan Premiums 2014 COBRA Participant and Retiree Monthly Contributions Blue Options - Plan (Single)/05181 (Family) Retiree COBRA Participant Only $ $ Participant & 1 Dependent $1, $1, Participant & Family $1, $1, Blue Options - Plan Retiree COBRA Participant Only $ $ Participant & 1 Dependent $1, $1, Participant & Family $1, $1, BlueMedicare Group PPO Plan 1 New Plan - Premiums for Medicare Eligible Retirees and Medicare-Eligible Dependents (age 65 and older) Retiree Retiree Only $ Retiree & Spouse $ BlueMedicare Group PPO Plan 2 New Plan - Premiums for Medicare Eligible Retirees and Medicare-Eligible Dependents (age 65 and older) Retiree Retiree Only $ Retiree & Spouse $

11 St. Lucie County School Board 2014 BlueMedicare Group PPO* Health Benefits Benefits BlueMedicare Group PPO* Plan 1 Premium (per member, per month) $ Deductible Out-of Pocket Max $0 In-Network / $1,000 Out-of-Network $1,000 In-Network / $3,000 Out-of-Network. Physician Office Primary Care (per visit) Specialist Care (per visit) e-visit Convenient Care Center Podiatry Services (per visit) (Routine foot care up to 6 visits per year) Chiropractic Services (per visit) For each Medicare covered visit (manual manipulation of the spine to correct subluxation) Outpatient Mental Health Care (per visit) For individual or group therapy Outpatient Substance Abuse Care (per visit) Part B drugs (including Chemotherapy) Allergy Injections Other Services Outpatient Surgery In-Network out-of-pocket max accumulates toward Out-of-Network out-of-pocket max. In-Network $10 copay In-Network $30 copay In-Network $5 copay In-Network $30 copay In-Network $30 copay In-Network $20 copay In-Network $35 copay In-Network $35 copay In-Network 20% coinsurance Office visit or facility copay may apply coinsurance Office visit or facility charges may apply In-Network $5 copay In-Network $150 copay for each outpatient hospital facility visit $100 copay for each visit to an ambulatory surgical center Y0011_ R1 EGWP C: 08/

12 Benefits BlueMedicare Group PPO* Plan 1 Diagnostic Tests, X-Rays Office IDTF In-Network / Out-of-Network $0 copay for Physician Services In-Network PCP $10 copay Specialist $30 copay Office visit copay may apply In-Network $50 copay Lab Services Independent Clinical Lab Outpatient Hospital Advanced Imaging (MRI, MRA, Cat Scan, Pet Scan & Nuclear Med): Office IDTF Outpatient Hospital Outpatient Hospital Services (per visit): Occupational Therapy, Physical Therapy, Speech & Language Therapy, Cardiac and Pulmonary Rehab Radiation Dialysis Lab only All other Diagnostic Tests, X-Rays Advanced Imaging, etc. Urgently Needed Care (This is not emergency care, and in most cases is out of the service area.) Emergency Services Dental - Medicare approved (No Preventive) In-Network $0 copay In-Network $15 copay Office visit or facility copay may apply In-Network $150 copay In-Network $125 copay In-Network $150 copay In-Network Out-of-Network $30 CYD & 20% $50 CYD & 20% 20% 20% $15 CYD & 20% $150 CYD & 20% In-Network / Out-of-Network $30 copay In-Network / Out-of-Network $50 copay Worldwide coverage In-Network $30 copay Y0011_ R1 EGWP C: 08/

13 Benefits BlueMedicare Group PPO* Plan 1 Home Health In-Network / Out-of-Network $0 copay Ambulance Outpatient Medical Services and Supplies Durable Medical Equipment/Diabetic Supplies Diabetic Supplies (glucose meters, test strips and Lancets) needles, syringes and insulin for self-injection is covered under your Part D benefit Equipment: Electric customized wheelchairs, electric scooters All other Medicare-covered durable medical equipment Prosthetic Devices Outpatient Rehabilitation - Office or Free Standing Facility Services: Occupational Therapy Physical Therapy Speech and Language Therapy Cardiac and Pulmonary Rehab Dialysis Outpatient Rehabilitation Outpatient Hospital Services: Occupational Therapy Physical Therapy Speech and Language Therapy Cardiac and Pulmonary Rehab Inpatient Care In-Network / Out-of-Network $150 copay for Medicare-covered ambulance services In-Network $0 copay In-Network 20% coinsurance In-Network $0 copay In-Network $0 copay for Medicare-covered items In-Network $30 copay for each visit In-Network/Out-of-Network 20% coinsurance In-Network $30 copay for each visit Inpatient Hospital Care (includes Substance Abuse) Inpatient Mental Health Care (may also include Substance Abuse) In-Network $150 copay each day for day(s) 1-7 for a Medicare-covered stay in a network hospital After the 7 th day, the plan pays 100% of covered expenses per stay. In-Network $200 copay each day for day(s) 1-7 for a Medicare-covered stay in a network psychiatric hospital For day(s) 8-90, $0 copay for Y0011_ R1 EGWP C: 08/

14 Benefits BlueMedicare Group PPO* Plan 1 Skilled Nursing Facility (in a Medicare-certified skilled nursing facility) Hospice Preventive Services Annual Screening Mammograms (for women with Medicare age 40 and older) Pap Smears and Pelvic Exams (for women with Medicare) Bone Mass Measurement (for people with Medicare who are at risk) Colorectal Screening Exams (for people with Medicare age 50 and older) Prostate Cancer Screening Exams (for men with Medicare age 50 and older) Vaccines Medicare covered Health & Wellness Benefit Fitness Medicare-covered stay in a network psychiatric hospital 190-day lifetime limit in a psychiatric hospital In-Network $0 copay each day for days 1-20 per benefit period $75 copay each day for days per benefit period There is a limit of 100 days for each benefit period 3-day prior hospital stay is not required Member must receive care from a Medicarecertified hospice In-Network: $0 copay for Medicare-covered Screening Mammogram In-Network: $0 copay per Pap smear $0 copay per pelvic exam In-Network: $0 copay for each Medicare-covered Bone Mass Measurement In-Network: $0 copay for Medicare-covered Colorectal screening exam In-Network: $0 copay for Medicare-covered Prostate Cancer Screening exam In-Network / Out-of-Network $0 copay for Influenza vaccine $0 copay for Pneumococcal vaccine $0 copay for Hepatitis B vaccine Free membership through SilverSneakers Y0011_ R1 EGWP C: 08/

15 BlueMedicare Group PPO out-of-pocket maximum includes all covered health services member cost share rendered in/out of network on a calendar year basis. Supplemental services and Part D costs are not applied to out-of-pocket maximum. Medicare Part B - the premium provided under this plan excludes the Medicare Part B premium payments. (Members must continue to pay the Medicare Part B premium unless paid by Medicaid or another third party.) Florida Blue is a PPO Plan with a Medicare contract.. Y0011_ R1 EGWP C: 08/

16 St. Lucie County School Board 2014 BlueMedicare Group Rx * Benefits BlueMedicare Group Rx* Option 1 Premium Included with PP01 Plan Deductible $0 Retail 31-day Supply Tier 1 - Preferred Generics $10 Tier 2 - Non-Preferred Generics $10 Tier 3 - Preferred Brand $40 Tier 4 - Non-Preferred Brand $70 Tier 5 - Specialty Drugs 25% Mail Order 90-day Supply with PRIME Mail Order Tier 1 - Preferred Generics $0 Tier 2 - Non-Preferred Generics $0 Tier 3 - Preferred Brand $80 Tier 4 - Non-Preferred Brand $140 Tier 5 - Specialty Drugs 25% Formulary Type Added coverage for selected CMS excluded drugs. Generic & multi-source brand prescription drugs will be covered for the following categories: Cough Cold Gap 31-day Supply Tier 1 - Preferred Generics $10 Tier 2 - Non-Preferred Generics $10 Tier 3 - Preferred Brand $40 Tier 4 - Non-Preferred Brand $70 Tier 5 - Specialty Drugs 25% Catastrophic Greater of $2.55 or 5% / Greater of $6.35 or 5% Florida Blue is an Rx (PDP) Plan with a Medicare contract. Prescription drug copays do not accumulate towards the health plan calendar year out-of-pocket maximum. Part D Creditable Coverage The enrolling member may incur late enrollment penalties as defined and set by CMS in accordance with Part D guidelines if prior creditable coverage cannot be proven. Y0011_ EGWP C: 06/

17 St. Lucie County School Board 2014 BlueMedicare Group PPO* Health Benefits Benefits BlueMedicare Group PPO* Plan 2 Premium (per member, per month) $ Deductible Out-of Pocket Max $0 In-Network / $2,000 Out-of-Network $2,000 In-Network / $4,000 Out-of-Network. Physician Office Primary Care (per visit) Specialist Care (per visit) e-visit Convenient Care Center Podiatry Services (per visit) (Routine foot care up to 6 visits per year) Chiropractic Services (per visit) For each Medicare covered visit (manual manipulation of the spine to correct subluxation) Outpatient Mental Health Care (per visit) For individual or group therapy Outpatient Substance Abuse Care (per visit) Part B drugs (including Chemotherapy) Allergy Injections Other Services Outpatient Surgery In-Network out-of-pocket max accumulates toward Out-of-Network out-of-pocket max. In-Network $35 copay In-Network $50 copay In-Network $5 copay In-Network $50 copay In-Network $50 copay In-Network $20 copay In-Network $40 copay In-Network $40 copay In-Network 20% coinsurance Office visit or facility copay may apply Office visit or facility charges may apply In-Network $10 copay In-Network $250 copay for each outpatient hospital facility visit $175 copay for each visit to an ambulatory surgical center Y0011_ R1 EGWP C: 08/

18 Benefits BlueMedicare Group PPO* Plan 2 Diagnostic Tests, X-Rays Office IDTF In-Network / Out-of-Network $0 copay for Physician Services In-Network PCP $35 copay Specialist $50 copay Office visit copay may apply In-Network $100 copay Lab Services Independent Clinical Lab Outpatient Hospital In-Network $0 copay In-Network $30 copay Office visit or facility copay may apply Advanced Imaging (MRI, MRA, Cat Scan, Pet Scan & Nuclear Med): Office IDTF Outpatient Hospital Outpatient Hospital Services (per visit): Occupational Therapy, Physical Therapy, Speech & Language Therapy, Cardiac and Pulmonary Rehab Radiation Dialysis Lab only All other Diagnostic Tests, X-Rays Advanced Imaging, etc. Urgently Needed Care (This is not emergency care, and in most cases is out of the service area.) Emergency Services Dental - Medicare approved (No Preventive) In-Network $175 copay In-Network $175 copay In-Network $250 copay In-Network Out-of-Network $50 CYD & 40% $50 CYD & 40% 20% 20% $30 CYD & 40% $250 CYD & 40% In-Network / Out-of-Network $50 copay In-Network / Out-of-Network $65 copay Worldwide coverage In-Network $50 copay Y0011_ R1 EGWP C: 08/

19 Benefits BlueMedicare Group PPO* Plan 2 Home Health In-Network / Out-of-Network $0 copay Ambulance Outpatient Medical Services and Supplies Durable Medical Equipment/Diabetic Supplies Diabetic Supplies (glucose meters, test strips and Lancets) needles, syringes and insulin for self-injection is covered under your Part D benefit Equipment: Electric customized wheelchairs, electric scooters All other Medicare-covered durable medical equipment Prosthetic Devices Outpatient Rehabilitation - Office or Free Standing Facility Services: Occupational Therapy Physical Therapy Speech and Language Therapy Cardiac and Pulmonary Rehab Dialysis Outpatient Rehabilitation Outpatient Hospital Services: Occupational Therapy Physical Therapy Speech and Language Therapy Cardiac and Pulmonary Rehab Inpatient Care Inpatient Hospital Care (includes Substance Abuse) Inpatient Mental Health Care (may also include Substance Abuse) In-Network / Out-of-Network $150 copay for Medicare-covered ambulance services In-Network $0 copay In-Network 20% coinsurance In-Network $0 copay In-Network $0 copay for Medicare-covered items In-Network $40 copay for each visit In-Network/Out-of-Network 20% coinsurance In-Network $50 copay for each visit In-Network $250 copay each day for day(s) 1-7 for a Medicare-covered stay in a network hospital After the 7 th day, the plan pays 100% of covered expenses per stay. In-Network $250 copay each day for day(s) 1-7 for a Medicare-covered stay in a network psychiatric hospital For day(s) 8-90, $0 copay for Medicare- Y0011_ R1 EGWP C: 08/

20 Benefits BlueMedicare Group PPO* Plan 2 Skilled Nursing Facility (in a Medicare-certified skilled nursing facility) Hospice Preventive Services Annual Screening Mammograms (for women with Medicare age 40 and older) Pap Smears and Pelvic Exams (for women with Medicare) Bone Mass Measurement (for people with Medicare who are at risk) Colorectal Screening Exams (for people with Medicare age 50 and older) Prostate Cancer Screening Exams (for men with Medicare age 50 and older) Vaccines Medicare covered Health & Wellness Benefit Fitness covered stay in a network psychiatric hospital 190-day lifetime limit in a psychiatric hospital In-Network $0 copay each day for days 1-20 per benefit period $100 copay each day for days per benefit period There is a limit of 100 days for each benefit period 3-day prior hospital stay is not required Member must receive care from a Medicarecertified hospice In-Network: $0 copay for Medicare-covered Screening Mammogram In-Network: $0 copay per Pap smear $0 copay per pelvic exam In-Network: $0 copay for each Medicare-covered Bone Mass Measurement In-Network: $0 copay for Medicare-covered Colorectal screening exam In-Network: $0 copay for Medicare-covered Prostate Cancer Screening exam In-Network / Out-of-Network $0 copay for Influenza vaccine $0 copay for Pneumococcal vaccine $0 copay for Hepatitis B vaccine Free membership through SilverSneakers Y0011_ R1 EGWP C: 08/

21 BlueMedicare Group PPO out-of-pocket maximum includes all covered health services member cost share rendered in/out of network on a calendar year basis. Supplemental services and Part D costs are not applied to out-of-pocket maximum. Medicare Part B - the premium provided under this plan excludes the Medicare Part B premium payments. (Members must continue to pay the Medicare Part B premium unless paid by Medicaid or another third party.) Florida Blue is a PPO Plan with a Medicare contract.. Y0011_ R1 EGWP C: 08/

22 St. Lucie County School Board 2014 BlueMedicare Group Rx * Benefits BlueMedicare Group Rx* Option 3 Premium Included with PP02 Plan Deductible $75 for Brand Drugs Only Retail 31-day Supply Tier 1 - Preferred Generics $10 Tier 2 - Non-Preferred Generics $10 Tier 3 - Preferred Brand $45 Tier 4 - Non-Preferred Brand $95 Tier 5 - Specialty Drugs 33% Mail Order 90-day Supply with PRIME Mail Order Tier 1 - Preferred Generics $10 Tier 2 - Non-Preferred Generics $10 Tier 3 - Preferred Brand $135 Tier 4 - Non-Preferred Brand $285 Tier 5 - Specialty Drugs 33% Formulary Type Added coverage for selected CMS excluded drugs. Generic & multi-source brand prescription drugs will be covered for the following categories: Cough Cold Gap 31-day Supply Tier 1 - Preferred Generics $10 Tier 2 - Non-Preferred Generics $10 Tier 3 - Preferred Brand 47.5% Tier 4 - Non-Preferred Brand 47.5% Tier 5 - Specialty Drugs 33% (Generic) / 47.5% (Brand) Catastrophic Greater of $2.55 or 5% / Greater of $6.35 or 5% Florida Blue is an Rx (PDP) Plan with a Medicare contract. Prescription drug copays do not accumulate towards the health plan calendar year out-of-pocket maximum. Part D Creditable Coverage The enrolling member may incur late enrollment penalties as defined and set by CMS in accordance with Part D guidelines if prior creditable coverage cannot be proven. Y0011_ R1 EGWP C: 08/

23 Dental Plan Delta Dental PPO for both COBRA and Retiree Participants St. Lucie County Schools is pleased to partner with Delta Dental to offer a PPO plan that makes it easy for you to find a dentist and control your costs when you visit a network dentist. Here are some of the great things you ll need to know about enrolling with Delta Dental: Save with a PPO dentist. Our PPO network dentists accept reduced fees for covered services, so you ll usually pay the least when you visit a PPO network dentist. Non-Delta Dental dentists may balance bill you the difference between the contracted fee and their usual fee. Large dentist network. Since Delta Dental offers access to some of the largest dentist networks in the U.S., chances are there s a wide choice of PPO dentists near your home or office. Use your desktop or mobile device to search for a dentist at deltadentalins.com. Visit the dentist of your choice. Want to visit a non-delta Dental dentist? No problem. You can visit any licensed dentist, but your costs are usually lowest with a PPO dentist. Log in to Online Services. Check benefits, eligibility and claims status, view or print an ID card and use our Fee Finder tool to check average costs in your area. You can also change your Profile preference to go paperless. Use your mobile device to access many of these tools on the go; show the dental office your ID card information instead of carrying a printed card. Visit the SmileWay Wellness section of our site for dental health articles, videos, quizzes and a risk assessment tool. You can also subscribe to our free dental health e-newsletter. In Texas, Delta Dental Insurance Company offers a Dental Provider Organization (DPO) plan. Netminder Dental Network Trend Report, March Your Saving with a PPO Dentist SAVE MORE Non PPO Dentist PPO Dentist 23

24 Dental Plan Plan Benefit Highlights for: St. Lucie County School Board Delta Dental Group PPO No: for both COBRA Effective and Date: Retiree 1/1/2014 Participants Eligibility Deductibles* Deductibles waived for D & P? Maximums* D & P counts toward maximum? Primary enrollee, spouse and eligible dependent children to age 26, or to age 30 if the specific conditions of eligibility are met. $50 per person / $150 per family each calendar year Yes Low Plan: $1,000 per person each calendar year High Plan: $1,500 per person each calendar year No RATES EFFECTIVE 1/1/2014 to 12/31/2015 RETIREE (Monthly) 24 COBRA ( Monthly) Low High Low High EE Only $23.49 $28.63 $23.96 $29.20 EE + One $49.35 $60.24 $50.34 $61.45 EE + Two or more $85.01 $ $86.71 $ Low Plan High Plan Benefits and Covered Services** Diagnostic & Preventive Services (D & P) Exams, cleanings, x-rays, sealants Basic Services Fillings, simple tooth extractions Endodontics (root canals) Covered Under Basic Services Non- Surgical Periodontics Covered Under Basic Services Surgical Periodontics Covered Under Major Services Oral Surgery Covered Under Basic Services Major Services Crowns, inlays, onlays and cast restorations, bridges and dentures, implants Orthodontic Benefits dependent children Orthodontic Maximums Lifetime Delta Dental PPO dentists Non-Delta Dental PPO dentists Delta Dental PPO dentists Non-Delta Dental PPO dentists 100 % 100 % 100 % 90 % 80 % 80 % 90 % 80 % 80 % 80 % 90 % 80 % 80 % 80 % 90 % 80 % 50 % 50 % 60 % 50 % 80 % 80 % 90 % 80 % 50 % 50 % 60 % 50 % 50 % 50 % 50 % 50 % $ 500 $ 500 $ 1,000 $ 1,000 * If you switch plans during the calendar year your Deductible and Annual Maximum may be adjusted accordingly. ** Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental contract allowances and not necessarily each dentist s actual fees. Fees are based on PPO contracted fees for PPO dentists, PPO contracted fees for Premier dentists and PPO contracted fees for non- Delta Dental dentists. Delta Dental Insurance Company 1130 Sanctuary Parkway, Suite 600 Alpharetta, GA Customer Service Claims Address P.O. Box 1809 Alpharetta, GA deltadentalins.com This benefit information is not intended or designed to replace or serve as the plan s Evidence of Coverage or Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your company s benefits representative. HLT_PPO_2COL_HILO_DDIC (Rev. 3 1/13)