The School Board of Broward County, FL

Transcription

1 The School Board of Broward County, FL Open Enrollment 2014 Your Choices. Your Benefits. Your Health.

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3 Table of Contents Biometric Screenings...1 How to Complete Your HRA...2 Preferred Pharmacy Network Hour Nurse Line...4 Preventive Care Coverage...5 Save on Heatlh Care Cost...6 Coventry WellBeing...7 My Online Services SM...8 Coventry Mobile App...9 Dependent Passport Program...10 Premier Plus Option Plan Premier Option Plan Consumer Driven Plan Basic Kids Plan Kids Enhanced Plan sbbc.chcflorida.com

4 Your Choices. Your Benefits. Your Health. Completeing Your Biometric Screenings New for 2014, employees are required to complete an on-line HRA & biometric screening prior to enrolling into the Premier Plus Plan. There is no pass or fail on the HRA or biometric screening. Results are private and will only be shared with you. Biometric Screenings are provided at no cost to you. It s as easy as 1-2-3! For your convenience, on-site biometric testing will be available during working hours at designated School Board locations beginning September 23 - November 15, 2013, or you may schedule your screening at a LabCorp Service Center outside of working hours. Step 1 Complete a confidential on-line Health Risk Assessment (HRA). The HRA is easy to complete and only takes about 20 minutes. Be sure to print a copy of your assessment report to verify that you have completed your HRA. Go to My Online Services at sbbc.chcflorida.com. Step 2 To take advantage of a convenient onsite biometric screening you MUST make an appointment, bring a copy of your HRA assessment report and present it to the site registrar. To make an appointment and to find a location near you, go to sbbc.chcflorida.com Step 3 Your final step is to complete an on-site biometric screening at a designated School Board location or at a LabCorp center near you. To make an appointment at a LabCorp Service center, log onto LabCorp.com. Don t delay, register today! Biometric screenings are provided at no cost to you. To make an appointment, visit sbbc.chcflorida.com for a biometric screening site near you or go to LabCorp.com to make an appointment. *In 2014, employees that choose to enroll in the Premier Plus Plan must complete a confidential on-line Health Risk Assessment (HRA) and biometric screening. This HRA and biometric screening must be completed between September 23 - November 15, sbbc.chcflorida.com

5 Your Choices. Your Benefits. Your Health. Completing Your HRA Once you complete the required HRA and biometric screening, you are now eligible to enroll in the Premier Plus Plan for 2014 and you re on your way to a healthier you! There is no pass or fail on the HRA or biometric screening. Results are private and will only be shared with you. All journeys have a beginning. The first step to your successful wellness journey begins at sbbc.chcflorida.com. Login or register at My Online Services, and click on Take Your Personal Health Risk Assessment (HRA) today. The HRA is a completely confidential, online questionnaire. It is designed to provide you a better understanding of your current health status and engagement levels. After completing the questionnaire, you will receive an assessment report. Be sure to print your assessment report and bring it with you to your on-site biometric screening appointment. For those employees that choose to complete their biometric screening at a LabCorp Service Center, please a copy of your HRA assessment report to sbbchra@cvty.com to receive credit for completing your on-line HRA. If you are considering enrolling in the Premier Plus Plan but do not complete your on-line HRA and biometric screening between September 23 - November 15, 2013, you will be defaulted to the lower option Premier Plan for It s simple: Visit sbbc.chcflorida.com and login or register at My Online Services Here s wishing you all the best on the road to better health. Enjoy your journey and its many rewards. zz sbbc.chcflorida.com 2

6 Your Choices. Your Benefits. Your Health. New for 2014, Preferred Pharmacy Network & Lower Copayments for Tier 1 Generic Drugs Maximize your benefits by utilizing the School Board s Preferred Pharmacy Network. This network is offered exclusively on the Premier Plus Plan and Premier Plans. The Preferred Pharmacy Network is a select network of retail pharmacies that rely on four key retail locations, as well as a broad selection of local independent pharmacies. We refer to these pharmacies as preferred. Included in the network are Walgreens, Publix, Costco, Navarro and 243 retail independent pharmacies. However, you may choose to utilize other pharmacies (non-preferred) within Coventry s Network at an additional $10. For a detailed list of preferred and non-preferred pharmacies, go to sbbc.chcflorida.com Premier Plus Plan Premier Plan Preferred $3/5/35/50 Preferred $3/5/45/60 Non-Preferred $13/15/45/60 Non-Preferred $13/15/55/70 3 sbbc.chcflorida.com

7 Your Choices. Your Benefits. Your Health. Transfer your Rx How to Easily Transfer a Prescription From One Pharmacy to Another If you would like to transfer your prescription to a preferred pharmacy, you do not need to contact your old pharmacy. Most pharmacies have a prescription transferring process that only requires a request and a small amount of information from you. The new pharmacy will contact your old pharmacy and request all the required information. You can easily transfer your prescription on-line, over the phone or in the store without any hassles or stress. Contact your preferred pharmacy and transfer your prescription today! Preferred Pharmacies include Walgreens, Publix, Costco, Navarro and 243 retails independent pharmacies. For a detailed list of preferred pharmacies go to sbbc.chcflorida.com. sbbc.chcflorida.com 4

8 Your Choices. Your Benefits. Your Health. Preventive Care Coverage Preventive Care Helps Keep Members Healthy At Coventry Health Care, we encourage members to receive preventive care items and services. The Affordable Care Act (ACA) requires specific preventive services and drugs to be covered at 100 percent when they are received through participating providers. Members who use our network providers will receive preventive care services paid at 100 percent. Coverage for Preventive Services Here are some examples of the preventive services that are covered with no copay, coinsurance or deductible. Child Preventive Exams: Preventive office visits including well child care Immunizations: (vaccines for children, birth to age 18- doses, recommended ages and populations vary): Influenza (flu) Pneumonia Hepatitis A Hepatitis B Diphtheria, Tetanus, Pertussis (Td/Tdap) Varicella (chicken pox) Measles, Mumps, Rubella (MMR) Polio Rotavirus Meningococcal Human Papillomavirus (HPV) Screening Tests: hearing, vision, phenylketonuria (newborns), sickle cell disease (newborns) Newborn Preventive Treatment: ocular medication against gonorrhea for all newborns Adult Preventive Exams: Preventive office visits including well woman exam Immunizations: (vaccines for adults - doses, recommended ages and populations vary): Influenza (flu) Pneumonia Hepatitis A Hepatitis B Diphtheria, Tetanus, Pertussis (Td/Tdap) Varicella (chicken pox) Measles, Mumps, Rubella (MMR) Meningococcal Zoster Human Papillomavirus (HPV) Screening Tests: breast cancer, cervical cancer, colorectal cancer, prostate cancer, HIV, routine blood and urine, cholesterol, osteoporosis The list is subject to change as federal guidance is issued. The full list of covered preventive services issued with the Interim Final Rules can be found at Talking with Your Provider about Preventive Care We process claims based on your provider s clinical assessment of the office visit. If a preventive item or service is billed separately, cost-sharing may apply to the office visit. If the primary reason for your visit is seeking treatment for an illness or condition, and preventive care is administered during the same visit, cost-sharing may apply. This means your provider may ask you to pay your appropriate health plan copay, deductible or coinsurance. identified through a preventive screening, any subsequent testing, diagnosis, analysis or treatment are not considered preventive services and are subject to the appropriate cost-sharing. If you have questions about a claim or provider visit, please call the customer service number on your Member ID card or speak with your provider. Please regularly check our website for new information about preventive care coverage as the government agencies refine guidance and requirements. Certain screening services, such as a colonoscopy or mammogram, may identify health conditions that require further testing or treatment. If a condition is 5 sbbc.chcflorida.com

9 Your Choices. Your Benefits. Your Health. Knowing where to go can help you save on health care costs Your Primary Care Physician (PCP) should be your first source for health care. He or she knows you best and can guide you to other services as needed. If you can t get to see your PCP right away, you have other choices including an urgent care center, a convenient care center and the emergency room. The following table can help you decide where to go. Convenient Care Center Urgent Care Center (UCC) Emergency Room (ER) Illustrative Copays and Savings (HMO High Plan) $10 Copay Savings vs ER $240 $10 Copay Savings vs ER $240 $250 Copay What is it Health centers, located in pharmacies, grocery stores and other retail stores, which treat common illnesses and are usually open evenings and weekends Facilities that offer quality medical care for illnesses and injuries and are often open evenings and weekends A group of rooms in a hospital created to treat emergency conditions, usually open 24 hours a day, seven days a week When to go, in general For small problems when you can t see your family doctor right away When you can t get in to see your doctor and you need care for an unexpected illness or injury that does not pose a serious danger to your health When a sudden accident or medical condition causes severe symptoms or pain and not receiving immediate medical attention places your health in serious jeopardy. Examples of when to go Minor sicknesses, such as rashes, ear aches, sore throats, stomach aches and other problems Flu shots, vaccinations and other shots An injury, and it s after your doctor s office hours Need stitches for a non-critical injury Have a chronic problem, such as a sore throat or back pain, that isn t improving and can t wait until your doctor is available Away from home but need medical care in the area you re visiting Poisoning or drug overdose Difficulty breathing or shortness of breath Chest or upper abdominal pain or pressure Fainting, sudden dizziness, weakness, loss of consciousness Changes in vision Confusion or changes in mental status or difficulty speaking Uncontrolled bleeding or severe pain Coughing or vomiting blood Suicidal feelings Advantages Convenience when you can t get in to see your doctor for a small problem Save time and money compared to visiting the ER The ER is the only place to go for treatment in a true emergency In case of emergency If you find yourself in need of emergency care, dial 911 or go to the nearest emergency room. sbbc.chcflorida.com 6

10 Coventry Health Care of Florida believes member health and wellbeing is our top priority. As part of our commitment, we offer discount programs and online tools designed to promote healthy living. WellBeing Online Members have access to Coventry's WellBeing online health and wellness portal, including a Health Risk Assessment questionnaire, online coaching programs such as tobacco cessation, blood pressure management, cholesterol management and others. To help members with their program and track progress, we offer additional tools such as a step tracker, a restaurant guide, and BMI calculator. WellBeing Discount Fitness Program* Most of us know that regular physical activity can improve your health and well-being. This program is designed to empower our members to take a more active role in improving their personal health. Members can choose from participating centers and receive a discount toward membership fees. To find a participating fitness center visit chcflorida.com or call * The fitness centers are not credentialed or contracted through Coventry. Healthways, Inc. is the exclusive vendor contracted by Coventry to administer covered fitness services. WellBeing Complementary Alternative Medicine (CAM) Program With Coventry WellBeing CAM Program, our members can make meaningful lifestyle changes to improve their diet, fitness level, emotional wellbeing, and more. With the CAM Program, members and their covered dependents have access to discounts of up to 30% for various alternative therapies through American WholeHealth Network (AWHN) including: Guided Imagery, Massage, Tai Chi, Pilates, Acupuncture, Yoga and Nutrition. WellBeing Weight Loss Discount Program Jenny Craig is all about eating well, moving more and living life! Jenny Craig offers Coventry members a FREE 30-Day Trial Program and a 25% discount off a Premium Program.* * Plans do not include a weekly food discount. Weight Watchers Online discount program offers Coventry members a savings of $10 off a 3-month subscription. Members have access to Weight Watchers Online for only $55 - less than $5 per week. QualSight LASIK Savings Coventry members have access to savings on the nation s most popular and successful elective procedure - LASIK eye surgery! Coventry has partnered with QualSight LASIK to bring members savings of 40% to 50% off the national average price for Traditional LASIK. QualSight s network of the nation s most experienced LASIK surgeons has collectively performed over 2.5 million procedures. Choose from over 800 locations nationwide for your free LASIK consultation to find out if you are a candidate for this life changing procedure. Hearing Exam & Hearing Aid Discount Program Through HearUSA, our members receive a 20% discount on a variety of products and services, including hearing aids, exams and educational classes at convenient locations across Florida. Your Choices. Your Benefits. Your Health. 7 sbbc.chcflorida.com

11 24-Hour Nurse Line Answers when you need them Professional advice, anytime you need it. The nurse line is part of our member resource system that provides members with direct access to a registered nurse 24 hours a day, 365 days a year. This value added benefit is designed to support you during an urgent situation. When you need answers to your health-related questions call our 24-Hour Nurse Line. The Nurse Line has registered nurses available to offer friendly, helpful advice on topics like fever, back and muscle pain, medication questions, minor burns, dizziness, headaches, colds and viruses, swelling or cuts and stomach pain. The nurse will ask you some questions about your problem and help you decide if you need to go to the hospital, see a physician or care for yourself at home. Take advantage of the 24-Hour Nurse Line anytime. Call anytime Your Choices. Your Benefits. Your Health. sbbc.chcflorida.com 8

12 My Online Services sbbc.chcflorida.com SM Coventry offers online resources designed to help members get the information they need. Coventry members can register on our website and access their health benefits information in a safe and secure environment. The following capabilities and many more are just a click away. n n n n n n View or print detailed benefit information Search for participating providers Access the Provider Comparison Tool, which offers quality ratings for hospitals, pricing information for procedures and detailed profiles on doctors and hospitals Search for prescription drug pricing and research drugs by generic or brand names Learn about costs, uses, precautions and side effects Access educational resources through the National Institutes of Health Print ID cards Going Places? Take Coventry along. Download Coventry s Mobile App Stay connected to your benefit information while on the go. With Coventry Mobile, you have secure access to the following: n Medical claims status with detailed summaries n Allergy & immunization details n Benefit usage details n Family history n ID cards n Surgery and procedure history n Current medications n Authorized dependents accounts n Emergency contact information Plus, use the provider search feature to obtain a list of participating network doctors, hospitals and urgent care centers within a few easy steps and without having to log in. Coventry Mobile is compatible with smartphones such as Android, BlackBerry iphone, and devices such as ipod touch and tablets. TM and Provider search is not available for Blackberry smartphones. Your Choices. Your Benefits. Your Health. 9 sbbc.chcflorida.com

13 Dependent Passport Program Peace of mind while they re away With the Passport Program, dependents who are enrolled in one of our health plans and live outside the service area will now receive out-of-area coverage at the highest level of benefits for services that are obtained from providers that are in the Coventry National Network.* Using the Passport Program Always present your Coventry member ID card so that providers can contact Coventry to verify coverage. Just like your in-network benefit, certain services require pre-authorization. Failure to obtain necessary pre-authorization will result in a reduction of benefits. Find a Provider To find a participating provider, call Customer Service at the number listed on your Member ID Card. How to Participate Please contact your on-site representative to find out how your dependents can participate in the Dependent Passport Program. Your dependent may be able to participate in the Passport Program if: n n Eligible for dependent coverage as explained in your Group Agreement. Resides outside your plan s designated service area to live with a parent or attend school. * Certain covered services, including Behavioral Health Services may not be provided through the Coventry National Network, therefore members may be required to return to the service area to obtain care. sbbc.chcflorida.com 10

14 Referrals are not required for Covered Services Copayment Maximums: Individual / Family (maximum amount of Copayments a Member will pay excluding prescription drugs) Lifetime Maximum Benefit Major Copayment Provisions PCP (Primary Care Physician) Office Visits includes Dermatology, Podiatry, OB/GYN & Chiropractic Services Specialist Office Visits Hospital Admission Emergency Room (waived if admitted) Convenience Care clinic Visits Urgent Care Center Visits Prescription Drugs: 30-day supply at participating pharmacy* Preferred Pharmacy Mail Order (MO): 90-day supply Non-Preferred Pharmacy Mail Order (MO): 90-day supply Self-Injectables Inpatient Hospital Services Inpatient Hospital Facility Services (Room and Board) Inpatient X-Rays Diagnostic Tests & Lab Operating and Recovery Room, Intensive and Special Care Units, General Nursing Care, Prescribed Drugs, Anesthesia In-Hospital Maternity Care (labor and delivery) Rehabilitative Services; Radiation Therapy and Chemotherapy Pre-Admission Testing Human Organ Transplants Inpatient Physician Services Surgeon Services (including Asst. Surgeon) Anesthesiologist Services Specialist Consultation in Hospital Other Physician Visits in Hospital Outpatient Medical Care PCP Office Visits Specialist Office Visits Routine Lab Tests, Radiology, Mammograms and Diagnostics Procedures and/or their interpretation ordered by the physician but performed at a separate lab or drawing station Adult Preventive Care, including annual physical exams, annual well-woman exams, prenatal care, Pap smears, prostate cancer screening, colon cancer screening, eye exams, health education and counseling and immunizations and elective sterilization for women. Child Preventive Care, including well child and well baby exams and immunizations Bone Density Screenings Outpatient Diagnostic Services (e.g., MRI, CT Scan, PET scan) at the Hospital at a Freestanding Facility Radiation and Chemotherapy Maternity Postnatal Care Coventry Health Care of Florida, Inc. Schedule of Benefits School Board of Broward County Premier Plus HMO Plan 2014 $1,264 / $2,528 Unlimited $10 copay per visit $30 copay per visit $150 copay per admission $250 copay per visit $10 copay per visit $10 copay per visit Tier 1A - $3; MO: $3 Tier 1B - $5; MO: $5 Tier 2 - $35 MO: $70 Tier 3 - $50; MO: $100 Tier 1A - $13; MO: $3 Tier 1B - $15; MO: $5 Tier 2 - $45 MO: $70 Tier 3 - $60; MO: $100 Applicable Tier copay $150 copay per admission No Additional Copay; Included in Inpatient Hospital admission No Additional Copay; Included in Inpatient Hospital admission No Additional Copay; Included in Inpatient Hospital admission No Additional Copay; Included in Inpatient Hospital admission No Additional Copay; Included in Inpatient Hospital admission No Additional Copay; Included in Inpatient Hospital admission $10 copay per visit $30 copay per visit $150 copay $30 copay One time $30 copay 11 sbbc.chcflorida.com

15 Outpatient Hospital Surgery including physician and facility services at the Hospital at an Ambulatory Surgical Center Second Medical and Surgical Opinion Participating Provider Non-Participating Provider Special Kinds of Care $250 copay $50 copay 40% of Allowed Amount Mental Health Care Inpatient $150 copay per admission Outpatient $10 copay per visit Alcohol and Substance Abuse Care Inpatient Rehabilitation and Detoxification Treatment $150 copay per admission Outpatient Rehabilitation Treatment $10 copay per visit Emergency and Urgent Care Hospital Emergency Room In Service Area (waived if admitted) $250 copay per visit Hospital Emergency Room Outside Service Area (waived if admitted) $250 copay per visit In an Urgent Care Facility $10 copay per visit In a Physician s Office $10 PCP; $30 Specialist Ambulance Service to hospital Skilled Nursing Facility Care Limitation: Up to 100 days per calendar year Home Health Care (Unlimited visits) $10 copay per visit Hospice Care Limitation: 210 days lifetime maximum Dialysis Treatment Insulin Diabetic Supplies: Outpatient Physical, Speech and Occupational Therapy Outpatient Cardiac and Respiratory Therapy Durable Medical Equipment Breast Prosthetics; Other External Orthotics and Prosthetics Smoking Cessation Limitation: Prescriptions are for a 90-day supply once per calendar year, twice per lifetime Hearing Aids $300 allowance per calendar year Infertility Services Limitation: Coventry will pay 100% of first $2,000 reasonable cost and 50% of reasonable cost thereafter up to a maximum of 3 cycles per member per lifetime Voluntary Counseling Infertility Diagnosis Testing Infertility Treatment - Artificial Insemination & In-Vitro Fertilization Injectable Drugs administered in the office Family Planning Elective Abortion (Outpatient Hospital or Office) Not covered Elective Sterilization $200 copay Intrauterine Devices (IUD) (device, insertion, removal) *If you or your physician requests a brand name medication when a generic is available, you must pay 100% of the difference in price between the generic and brand name medication, plus the applicable brand copayment. Tier 1A drugs are a select group of drugs available for a reduced copayment. A listing of Tier 1A ($3 Generic) drugs can be found on the Coventry website. For Tier 1B drugs, refer to all other Tier 1 drugs not listed on Tier 1A. PCP referrals are not required to obtain Covered Services, however certain Covered Services require Prior Authorization including Hospital and Skilled Nursing Facility confinements, Non-emergent transportation, Non-emergent Outpatient Hospital services, MRIs, CAT Scans, PET Scans, Hospice, Pain Management and Non-emergent Wound care procedures. Please refer to the Summary Plan Description for further details on Prior Authorization requirements. Services must be rendered within the Coventry network. Coventry participating physicians and providers have contracted with Coventry to provide care to our members. This schedule is provided for information only; it does not contain complete details of the Plan which are available only in the Summary Plan Description and it does not constitute an Agreement. This plan has exclusions and limitations and terms under which the plan may be continued in force or discontinued. Self-insured and administered by Coventry Health Care of Florida, Inc. sbbc.chcflorida.com 12

16 Referrals are not required for Covered Services Copayment Maximums: Individual / Family (maximum amount of Copayments a Member will pay excluding prescription drugs) Lifetime Maximum Benefit Major Copayment Provisions PCP (Primary Care Physician) Office Visits includes Dermatology, Podiatry, OB/GYN & Chiropractic Services Specialist Office Visits Hospital Admission Emergency Room (waived if admitted) Convenience Care clinic Visits Urgent Care Center Visits Prescription Drugs: 30-day supply at participating pharmacy* Preferred Pharmacy Mail Order (MO): 90-day supply Non-Preferred Pharmacy Mail Order (MO): 90-day supply Self-Injectables Inpatient Hospital Services Inpatient Hospital Facility Services (Room and Board) Inpatient X-Rays Diagnostic Tests & Lab Operating and Recovery Room, Intensive and Special Care Units, General Nursing Care, Prescribed Drugs, Anesthesia In-Hospital Maternity Care (labor and delivery) Rehabilitative Services; Radiation Therapy and Chemotherapy Pre-Admission Testing Human Organ Transplants Inpatient Physician Services Surgeon Services (including Asst. Surgeon) Anesthesiologist Services Specialist Consultation in Hospital Other Physician Visits in Hospital Outpatient Medical Care PCP Office Visits Specialist Office Visits Routine Lab Tests, Radiology, Mammograms and Diagnostics Procedures and/or their interpretation ordered by the physician but performed at a separate lab or drawing station Adult Preventive Care, including annual physical exams, annual well-woman exams, prenatal care, Pap smears, prostate cancer screening, colon cancer screening, eye exams, health education and counseling and immunizations, and elective sterilization for women. Child Preventive Care including well child and well baby exams and immunizations Non-Preventive Bone Density Screenings at Hospital at Freestanding Facility Outpatient Diagnostic Services (e.g., MRI, CT Scan, PET scan) at Hospital at Freestanding Facility Radiation and Chemotherapy Coventry Health Care of Florida, Inc. Schedule of Benefits School Board of Broward County Premier HMO Plan $1,500 / $3,000 Unlimited $20 copay per visit $40 copay per visit $150/day for the first 5 days $250 copay per visit $20 copay per visit $20 copay per visit Tier 1A - $3; MO: $3 Tier 1B - $5; MO: $5 Tier 2 - $45 MO: $90 Tier 3 - $60; MO: $120 Tier 1A - $13; MO: $3 Tier 1B - $15; MO: $5 Tier 2 - $55 MO: $90 Tier 3 - $70; MO: $120 Applicable Tier copay $150/day for the first 5 days No Additional Copay; Included in Inpatient Hospital admission No Additional Copay; Included in Inpatient Hospital admission $200 copay No Additional Copay; Included in Inpatient Hospital admission No Additional Copay; Included in Inpatient Hospital admission No Additional Copay; Included in Inpatient Hospital admission $20 copay per visit $40 copay per visit $100 copay $20 copay $175 copay $50 copay $20 copay per visit 13 sbbc.chcflorida.com

17 Maternity Postnatal Care Outpatient Hospital Surgery including physician and facility services at Hospital at an Ambulatory Surgical Center Second Medical and Surgical Opinion Participating Provider Non-Participating Provider Special Kinds of Care $40 copay per visit $300 copay $75 copay $20 copay per visit 40% of Allowed Amount Mental Health Care Inpatient $150/day for the first 5 days Outpatient $20 copay per visit Alcohol and Substance Abuse Care Inpatient Rehabilitation and Detoxification Treatment $150/day for the first 5 days Outpatient Rehabilitation Treatment $20 copay per visit Emergency and Urgent Care Hospital Emergency Room In Service Area (waived if admitted) $250 copay per visit Hospital Emergency Room Outside Service Area (waived if admitted) $250 copay per visit In an Urgent Care Facility $20 copay per visit In a Physician s Office $20 copay PCP; $40 copay Specialist Ambulance Service to hospital Skilled Nursing Facility Care Limitation: Up to 100 days per calendar year Home Health Care (Unlimited visits) $10 copay per visit Hospice Care Limitation: 210 days lifetime maximum Dialysis Treatment $20 copay per visit Insulin / Diabetic supplies Outpatient Physical, Speech and Occupational Therapy (Therapy must be completed within 90 days of first visit per episode of care) Limitation: 60 visits per calendar year combined Outpatient Cardiac and Respiratory Therapy Durable Medical Equipment Breast Prosthetics; Other External Orthotics and Prosthetics Smoking Cessation Limitation: Prescriptions are for a 90-day supply once per calendar year, twice per lifetime Hearing Aids Infertility Services Limitation: $6,000 lifetime maximum. Up to a maximum of 3 cycles per member per lifetime. Voluntary Counseling Infertility Diagnosis Testing Artificial Insemination & In-Vitro Fertilization Injectable Drugs administered in the office (subject to lifetime maximum) Family Planning Elective Abortion (Outpatient Hospital or Office) Elective Sterilization Intrauterine Devices (IUD) (device, insertion, removal) $20 copay per visit $20 copay per visit $300 allowance per calendar year $40 copay per visit $40 copay per visit Not covered $200 copay *If you or your physician requests a brand name medication when a generic is available, you must pay 100% of the difference in price between the generic and brand name medication, plus the applicable brand copayment. Tier 1A drugs are a select group of drugs available for a reduced copayment. A listing of Tier 1A ($3 Generic) drugs can be found on the Coventry website. For Tier 1B drugs, refer to all other Tier 1 drugs not listed on Tier 1A. PCP referrals are not required to obtain Covered Services, however certain Covered Services require Prior Authorization including Hospital and Skilled Nursing Facility confinements, Non-emergent transportation, Non-emergent Outpatient Hospital services, MRIs, CAT Scans, PET Scans, Hospice, Pain Management and Non-emergent Wound care procedures. Please refer to the Summary Plan Description for further details on Prior Authorization requirements. Services must be rendered within the Coventry network. Coventry participating physicians and providers have contracted with Coventry to provide care to our members. This schedule is provided for information only; it does not contain complete details of the Plan which are available only in the Summary Plan Description and it does not constitute an Agreement. This plan has exclusions and limitations and terms under which the plan may be continued in force or discontinued. Self in d d d inist d b C t H lth C f Flo id I sbbc.chcflorida.com 14

18 Up-Front Benefit Allowance Applies to medical services received from participating providers only. Does not apply to member copays, mental and nervous benefits, alcohol and chemical benefits or Rx benefit Annual Deductible (Individual / Family) Copayments do not apply. Annual Out-of-Pocket Maximum (Individual / Family) (maximum amount of Deductible, Coinsurance and Copayments a Member will pay excluding prescription drugs) Lifetime Maximum Individual Benefit Benefit Provisions Schedule of Benefits School Board of Broward County Consumer Driven Plan 2014 In-Network Out-of-Network $500 N/A $2,500 / $7,500 $5,000 / $15,000 $6,350 / $12,700 $9,000 / $27,000 Unlimited Plan Pays Physician s Office Visits (includes maternity care, all radiology, lab, diagnostic tests, 100% after $20 copay PCP; $35 copay 70% after deductible x-rays, MRI and surgery inside physician s office) Specialist Adult Preventive Care, including annual physical exams, annual well-woman exams, 100%, NO deductible 70% after deductible prenatal care, Pap smears, prostate cancer screening, colon cancer screening, eye exams, health education and counseling and immunizations and elective sterilizations for women. Child Preventive Care, including well child and well baby exams and immunizations 100%, NO deductible 70% after deductible All Radiology, Lab, Diagnostic Tests, X-Rays, MRIs, etc Outside Physician s office 100% after deductible 70% after deductible (Freestanding Facility) Hospital admission $100 copay per day for the first 5 days per admission after deductible 70% after deductible Inpatient Hospital / Physician Services Inpatient Hospital Facility Services (includes room and board, diagnostic tests, x- rays, operating & recovery room, intensive & special care units, general nursing care, anesthesia, prescribed drugs, radiation therapy & chemotherapy, surgeon services, anesthesiologist services, specialist consultation, physician visits, human organ transplants, maternity care, rehabilitative services) Plan Pays $100 copay per day for the first 5 days per admission after deductible 70% after deductible Pre-Admission Testing 100% after deductible 70% after deductible Outpatient Medical Services Plan Pays Convenience Care Clinic Visits 100% after $20 copay per visit 70% after deductible Bone Density Screenings 100% after deductible 70% after deductible Routine Mammography (based on established guidelines) 100%, NO deductible 100%, NO deductible Allergy Injections 100% after $5 copay 70% after deductible Maternity Postnatal Services 100% after one time office visit copay 70% after deductible Outpatient Surgery (includes physician and facility services) $50 copay after deductible 70% after deductible Outpatient Non-Surgical Care 100% after deductible 70% after deductible Outpatient Physical, Speech and Occupational Therapy 100% after deductible 70% after deductible (Therapy must be completed within 90 days of first visit per episode of care) Limitation: 20 visits each therapy type Outpatient Cardiac and Respiratory Therapy 100% after deductible 70% after deductible Outpatient Radiation and Chemotherapy in a hospital or freestanding facility in a physician s office 100% after deductible Included in office visit 70% after deductible 70% after deductible Outpatient Dialysis Treatment 100% after deductible 70% after deductible Non-surgical Spine and Back Treatment 100% after deductible 70% after deductible Limitation: 20 visits per calendar year Second Medical and Surgical Opinion 100% after deductible 70% after deductible Emergency and Urgent Care in hospital emergency room (waived if admitted) 100% after $250 copay 70% after $250 copay in urgent care facility 100% after $35 copay 70% after deductible in physician's office 100% after $20 copay PCP; $35 copay 70% after deductible Specialist Ambulance service to hospital 100% after deductible 100% after deductible 15 sbbc.chcflorida.com

19 Schedule of Benefits School Board of Broward County Consumer Driven Plan 2014 Family Planning Voluntary counseling Not Covered Infertility diagnosis and treatment Not Covered Elective Abortion Not Covered Elective sterilization $50 copay after deductible 70% after deductible Intrauterine Devices (IUD) (device, insertion, removal) 100%, NO deductible 70% after deductible Mental Health, Alcohol & Substance Abuse Services Plan Pays Mental Health Care Inpatient Treatment 100% after $100/day for the first 5 days 70% after deductible per admission Outpatient Treatment 100% after $35 copay 70% after deductible Alcohol and Substance Abuse Care Inpatient Detoxification Treatment 100% after $100/day for the first 5 days 70% after deductible per admission Outpatient Detoxification Treatment 100% after $35 copay 70% after deductible Other Covered Services Plan Pays Home Health Care 100% after deductible 70% after deductible Limitation: 40 visits per calendar year Hospice Care 100% after deductible 70% after deductible Limitation: Unlimited Skilled Nursing Facility Care 100% after deductible 70% after deductible Limitation: 30 days per calendar year Insulin / Diabetic supplies (includes glucose monitors, test strips, lancets, etc.) Tier 1 - $15 70% after deductible Tier 2 - $30 Tier 3 - $55 Durable Medical Equipment 100% after deductible 70% after deductible External orthotics, prosthetics and breast prosthetics 100% after deductible 70% after deductible Hearing Aids $300 allowance per calendar year Not Covered Smoking Cessation Program Not Covered Not Covered Services Provided by Rider or Endorsement Prescription drugs: 30-day supply at a pharmacy* Tier 1 - $15 Tier 2 - $30 Tier 3 - $55 Mail Order: 90-day supply at a participating pharmacy Tier 1 - $15 Tier 2 - $30 Tier 3 - $55 Plan Pays 70% after deductible plus $15/$30/$55 Not Covered *If a brand name medication is requested when a generic is available, you must pay 100% of the difference in price between the generic and brand name medication, plus the applicable brand copayment. Certain Covered Services require Prior Authorization, including Hospital and Skilled Nursing Facility confinements, Non-emergent transportation, Non-emergent Outpatient Hospital services, MRIs, CAT Scans, PET Scans, Hospice, Pain Management and N0n-emergent Wound care procedures. If you do not obtain authorization for services which require a Prior Authorization, the benefit otherwise payable by Coventry is reduced by $400. This additional out-of-pocket amount will not be used to satisfy Deductible, Coinsurance or Out-of-Pocket Maximum requirements. Please refer to the Summary Plan Description for further details on Prior Authorization requirements. All Out-of-Network services are subject to the Out-of-Network Deductible and applicable Coinsurance. In addition to the applicable Deductible and Coinsurance, Covered Persons who receive services from Non-Participating Providers shall be responsible for the difference between the Non- Participating Provider s bill and the Out-of-Network Rate. This schedule is provided for information only; it does not contain complete details of the Plan which are available only in the Summary Plan Description and it does not constitute and Agreement. This plan has exclusions and limitations and terms under which the plan may be continued in force or discontinued. Self-insured and administered by Coventry Health Care of Florida, Inc. sbbc.chcflorida.com 16

20 Referrals are required for Covered Services Individual Out-of-Pocket Maximum (maximum amount of Copayments a Member will pay excluding prescription drugs) Lifetime Maximum Benefit Major Copayment Provisions PCP (primary care physician) office visits Specialist office visits Hospital admission Emergency room (waived if admitted) Convenience Care Clinic Visits Prescription drugs*:30-day supply at participating pharmacy Mail Order (MO) 90 day supply Self-Injectables Inpatient Hospital / Physician Services Inpatient Hospital facility services (room and board) Inpatient x-rays, diagnostic tests & lab Operating and recovery room, intensive and special care units, general nursing care, prescribed drugs, anesthesia In-Hospital maternity care Short-term speech, physical, occupational and respiratory therapy Radiation therapy and chemotherapy Pre-admission testing Human organ transplants Inpatient detoxification Surgeon services (including Asst. Surgeon) Anesthesiologist services Specialist consultation and other physician visits in hospital Outpatient Medical Care Allergy Injections Routine lab tests, radiology, mammograms and diagnostic procedures and/or their interpretation ordered by the physician but performed at a separate lab or drawing station Preventive care, including annual physical exams, annual well-woman exams, prenatal care, Pap smears, eye exams, health education and counseling, hearing exams, immunizations and elective sterilization for women Child Preventive Care, including well child and well baby exams and immunizations and hearing and eye exams Outpatient diagnostic services (e.g., MRI, CT Scan, PET scan) Radiation and chemotherapy Postnatal care in physician s office Outpatient hospital surgery including physician and facility services Ambulatory surgery including physician and facility services Second medical and surgical opinion Non-Surgical spine and back services Coventry Health Care of Florida, Inc. Schedule of Benefits School Board of Broward County Kids Enhanced Plan 2014 $1,264 Unlimited $15 copay per visit $15 copay per visit $100 copay per day for the first 5 days $250 copay per visit $15 copay per visit Tier 1 - $5; MO: $5 Tier 2 - $5; MO: $5 Tier 3 - $25; MO: $25 Applicable Tier copay $100 copay per day for the first 5 days No additional copay; Included in Inpatient Hospital admission No additional copay; Included in Inpatient Hospital admission Not Covered No additional copay; Included in Inpatient Hospital admission No additional copay; Included in Inpatient Hospital admission No additional copay; Included in Inpatient Hospital admission No additional copay; Included in Inpatient Hospital admission No additional copay; Included in Inpatient Treatment $15 copay per visit per visit $20 copay per visit $15 copay per visit Not covered $50 copay per visit $50 copay per visit Participating Provider: $15 copay per visit; Non-Participating Provider: 40% of Allowed Amount $15 copay per visit 17 sbbc.chcflorida.com

21 Mental Health, Alcohol & Substance Abuse Mental Health Care Inpatient $100 copay per day for the first 5 days Outpatient $15 copay per visit Alcohol and Substance Abuse Care Inpatient rehabilitation treatment $100 copay per day for the first 5 days Outpatient rehabilitation treatment $15 copay per visit Special Kinds of Care Emergency and urgent care In hospital emergency room - In service area (waived if admitted) $250 copay per visit In urgent care facility $15 copay per visit In physician's office $15 copay per visit Ambulance service to hospital Home health care (20 visits per acute** episode) $15 copay per visit Hospice care Not covered Skilled nursing facility care (up to 45 days per calendar year) $20 copay per day Dialysis treatment $15 copay per visit Insulin Diabetic supplies Outpatient physical, speech or occupational therapy $ 5 copay per visit (Therapy must be completed within 90 days of first visit per episode of care) Outpatient cardiac and respiratory therapy $15 copay per visit Durable medical equipment $15 copay per item Breast Prosthetics $15 copay per item Other External Orthotics and Prosthetics $15 copay per item Smoking Cessation (Prescriptions are for a 90-day supply once per year, twice $15 copay per visit per lifetime) Hearing Aids $300 allowance per calendar year Family Planning Voluntary counseling, infertility diagnosis & treatment, elective abortion and elective sterilization Not covered Intrauterine Devices (IUD) (device, insertion, removal) Dental Care Preventive dental (Oral exam, cleaning & bitewing x-rays including fluoride treatment for children sixteen (16) and under once every 6 months) Vision Care Routine vision and hearing screenings by PCP only (once per year) Vision exam provided by a participating Optometrist (once per year) Eyeglasses 1 pair per year, single vision/bifocal, plastic or glass lenses, frames from the Coventry Classic Selection at a participating Vision provider. Member may receive discounts on other items. $0 copay $3 copay $10 copay *If you or your physician requests a brand name medication when a generic is available, you must pay 100% of the difference in price between the generic and brand name medication, plus the applicable brand copayment.. ** Sudden onset of illness or injury, severe symptoms and of short duration. Except for emergency care, services are covered only when provided or referred by a Coventry Health Care of Florida, Inc. (Coventry) primary care physician and/or approved in advance by the Coventry Medical Management. Certain Covered Services require Prior Authorization including Hospital and Skilled Nursing Facility confinements, Non-emergent transportation, Non-emergent Outpatient Hospital services, MRIs, CAT Scans, PET Scans, Pain Management and Non-emergent Wound care procedures. Please refer to the Summary Plan Description for further details on Prior Authorization requirements. Services must be rendered within the Coventry network. Coventry participating physicians and providers have contracted with Coventry to provide care to our members. This schedule is provided for information only; it does not contain complete details of the plan which are available only in the Summary Plan Description and it does not constitute an Agreement. This plan has exclusions and limitations and terms under which the plan may be continued in force or discontinued. Self-insured and administered by Coventry Health Care of Florida, Inc. sbbc.chcflorida.com 18

22 Referrals are required for Covered Services Individual Out-of-Pocket Maximum (maximum amount of Deductible, Copayments and Coinsurance a Member will pay excluding prescription drugs) Lifetime Maximum Benefit Annual Hospital Deductible (per calendar year): applies to all inpatient and outpatient services at hospital Major Copayment Provisions Primary Care Physician (PCP) office visits Specialist office visits Hospital admission Emergency room (waived if admitted) Convenience Care Clinic Visits Prescription drugs:* 30-day supply at participating pharmacy Mail Order (MO) 90-say supply Self-injectables (except for diabetes) Inpatient Hospital / Physician Services Inpatient hospital facility services (room and board) Inpatient x-rays, diagnostic tests & lab Operating and recovery room, intensive and special care units, general nursing care, prescribed drugs, anesthesia In-Hospital maternity care Rehabilitative Services Limitation: 30 days per calendar year Radiation therapy and chemotherapy Pre-admission testing Surgeon services (including Asst. Surgeon) Anesthesiologist services Specialist consultation and other physician visits Human organ transplants Outpatient Medical Services Preventive Care, including annual physical exams, annual well-woman exams, prenatal care, Pap smears, eye exams, health education and counseling, hearing exams, immunizations and elective sterilization for women Child Preventive Care, including well child and well baby exams and immunizations Diagnostic procedures, tests, chest x-rays, blood tests, urinalysis, EKG s performed: in a physician s office at a separate facility Outpatient diagnostic services (MRI, CAT scans, etc) at Hospital at Freestanding Facility Outpatient Surgery (including physician and facility services) at Hospital at Ambulatory Surgical Center Postnatal care in physician s office Radiation and chemotherapy at Hospital at Freestanding Facility Second medical and surgical opinion Participating Provider Non-Participating Provider Coventry Health Care of Florida, Inc. Schedule of Benefits School Board of Broward County Basic Kids Plan 2014 $1,500 Unlimited $300 $15 copay per visit $30 copay per visit $250 copay per visit $15 copay per visit Tier 1 - $7; MO: $7 Tier 2 - $45; MO: $45 Not covered Not covered No additional copay $30 copay per visit $100 copay per visit Not covered $30 copay per visit $15 PCP/$30 Specialist 40% of Allowed Amount 19 sbbc.chcflorida.com

23 Non-Surgical Spine and Back services Limitation: 20 visits per calendar year Mental Health, Alcohol & Substance Abuse Services $15 PCP/$30 Specialist Mental health care Inpatient Outpatient $30 copay per visit Alcohol and substance abuse care Inpatient detoxification Outpatient rehabilitation treatment Not covered Special Kinds of Care Emergency and urgent care In hospital emergency room (waived if admitted) $250 copay per visit In urgent care facility $30 copay per visit In physician's office $15 PCP/$30 Specialist Ambulance service to hospital Home Health Care Limitation: 60 visits per calendar year Hospice Care Not covered Skilled Nursing Facility Care $25/day for the first 5 days per admission Limitation: 30 days per calendar year Dialysis treatment (outpatient) at Hospital at Freestanding Facility $30 copay per treatment Insulin Diabetic supplies (includes glucose monitors, test strips, lancets, etc.) Outpatient physical, speech and occupational therapy (therapy must be completed within 90 days of first visit per episode of care) Limitation: 60 visits per calendar year, combined for all therapies at Hospital at Freestanding Facility Outpatient cardiac and respiratory therapy at Hospital at Freestanding Facility Durable medical equipment; other external orthotics and prosthetics Hearing Aids Family Planning Voluntary counseling, infertility diagnosis & treatment, elective abortion and elective sterilization Intrauterine Devices (IUD) (device, insertion, removal) Dental care: Preventive dental (Oral exam, cleaning & bitewing x-rays including fluoride treatment for children sixteen (16) and under once every 6 months) $30 copay per visit $30 copay per visit $300 allowance per year Not covered Vision care - at a participating Optometrist Refractive eye exams $15 copay per visit Eyeglasses Negotiated fees available at participating providers *If you or your physician requests a brand name medication when a generic is available, you must pay 100% of the difference in price between the generic and brand name medication, plus the applicable brand copayment. Except for emergency care, services are covered only when provided or referred by a Coventry Health Care of Florida, Inc.(Coventry) primary care physician and/or approved in advance by Coventry Medical Management. Certain Covered Services require Prior Authorization including Hospital and Skilled Nursing Facility confinements, Non-emergent transportation, Non-emergent Outpatient Hospital services, MRIs, CAT Scans, PET Scans, Pain Management and Nonemergent Wound care procedures. Please refer to the Summary Plan Description further details on Prior Authorization requirements. Services must be rendered within the Coventry network. Coventry participating physicians and providers have contracted with Coventry to provide care to our members. This schedule is provided for information only; it does not contain complete details of the Plan which are available only in the Summary Plan Description and it does not constitute an Agreement. This plan has exclusions and limitations and terms under which the plan may be continued in force or discontinued. Self-insured and administered by Coventry Health Care of Florida, Inc. sbbc.chcflorida.com 20