BlueSelect 1835 - Health Insurance for Florida

1 BlueSelect 1835 Coverage Period: 01/01/2018 - 12/31/2018 GoldSummary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage for: Individual and/or Family | Plan Type: PPO/EPO 1 of 7 SBCID: 1470529 The Summary of Benefits and Coverage (SBC) document will help you choose a Health plan. The SBC shows you how you and the plan would share the cost for covered Health care services. NOTE: Information about the cost of this plan (called the premium) will be provided is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at or call 1-800-352-2583 to request a QuestionsAnswersWhy This Matters:What is the overall deductible?

2 In-Network: $2,000 Per Person/$4,000 Family. Out-of-Network: $4,000 Per Person/$8,000 Family. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family there services covered before you meet your deductible?Yes. Preventive plan covers some items and services even if you haven t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at Are there otherdeductibles for specific services? don t have to meet deductibles for specific is the out-of-pocket limit for this plan?

3 Yes. In-Network: $5,500 Per Person/$11,000 Family. Out-Of-Network: $12,500 Per Person/$25,000 out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been is not included inthe out-of-pocket limit?Premium, balance-billed charges, and Health care this plan doesn't though you pay these expenses, they don t count toward the out of pocket you pay less if you use a network provider?Yes. See or call 1-800-352-2583 for a list of network plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing).

4 Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get you need a referral to see a specialist?No. You can see the specialist you choose without a referral. 2 of 7 For more information about limitations and exceptions, see the plan or policy document at : 1470529 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible You Will PayCommon Medical EventServices You May NeedNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most) Limitations, Exceptions, & Other Important InformationPrimary care visit to treat an injury or illness$40 Copay per VisitDeductible + 50% CoinsurancePhysician administered drugs may have higher cost visit$75 Copay per VisitDeductible + 50% CoinsurancePhysician administered drugs may have higher cost you visit a Health care provider s office or clinicPreventive care/screening/immunizationNo Charge50% CoinsurancePhysician administered drugs may have higher cost shares.

5 You may have to pay for services that aren t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay test (x-ray, blood work)Independent Clinical Lab: $20 Copay per Visit/ Independent Diagnostic Testing Center: $175 Copay per VisitIndependent Clinical Lab: Not Covered/ Independent Diagnostic Testing Center: Deductible + 50% CoinsuranceTests performed in hospitals may have higher you have a testImaging (CT/PET scans, MRIs) $325 Copay per VisitDeductible + 50% CoinsurancePrior Authorization may be required. Your benefits/services may be denied. Tests performed in hospitals may have higher cost-share. 3 of 7 For more information about limitations and exceptions, see the plan or policy document at : 1470529 Common Medical EventServices You May NeedWhat You Will PayLimitations, Exceptions, & Other Important InformationNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most) Generic drugsPreventive: No Charge (retail)/ Condition Care Rx: $4 Copay per Prescription (retail)/ All Other Generic: $20 Copay per Prescription (retail)Not CoveredUp to 30 day supply for retail, 90 day supply for mail order at 2 times the retail amount.

6 Responsible Rx programs such as Prior Authorization may apply. See Medication guide for more brand drugsCondition Care Rx: $33 Copay per Prescription (retail)/ All Other Preferred Brand: $65 Copay per Prescription (retail)Not CoveredUp to 30 day supply for retail, 90 day supply for mail order at 2 times the retail brand drugs50% Coinsurance (retail)Not CoveredUp to 30 day supply for retail, 90 day supply for mail order at 2 times the retail you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at drugs50% CoinsuranceNot CoveredUp to 30 day supply for retail. Not covered through Mail Order. Facility fee ( , ambulatory surgery center)Deductible + 20% CoinsuranceDeductible + 50% Coinsurance none If you have outpatient surgeryPhysician/surgeon feesNo ChargeNo Charge none Emergency room care$450 Copay per Visit$450 Copay per Visit none Emergency medical transportationDeductible + 20% CoinsuranceIn-Network Deductible + 20% Coinsurance none If you need immediate medical attentionUrgent care$85 Copay per VisitDeductible + $85 Copay per Visit none Facility fee ( , hospital room)Deductible + 20% CoinsuranceDeductible + 50% CoinsuranceInpatient Rehab Services limited to 30 days.

7 Inpatient Habilitation Services limited to 30 you have a hospital stayPhysician/surgeon feesNo ChargeNo Charge none 4 of 7 For more information about limitations and exceptions, see the plan or policy document at : 1470529 Common Medical EventServices You May NeedWhat You Will PayLimitations, Exceptions, & Other Important InformationNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most) Outpatient servicesPhysician Office: $75 Copay per Visit / Hospital: Deductible + 20% CoinsuranceDeductible + 50% Coinsurance none If you need mental Health , behavioral Health , or substance abuse servicesInpatient servicesPhysician Services: No Charge / Hospital: Deductible + 20% CoinsurancePhysician Services: No Charge/ Hospital: DeductiblePrior Authorization may be required. Your benefits/services may be visits$75 Copay per VisitDeductible + 50% CoinsuranceMaternity care may include tests and services described elsewhere in the SBC ( ultrasound.)

8 Childbirth/delivery professional servicesNo ChargeNo Charge none If you are pregnantChildbirth/delivery facility servicesDeductible + 20% CoinsuranceDeductible + 50% Coinsurance none Home Health careNo ChargeNot CoveredCoverage limited to 30 visits. Rehabilitation services$75 Copay per VisitDeductible + 50% CoinsuranceCoverage limited to 35 visits, including 35 manipulations. Services performed in hospital may have higher cost-share. Prior Authorization may be required. Your benefits/services may be services$75 Copay per VisitDeductible + 50% CoinsuranceServices performed in hospital may have higher cost share. Prior Authorization may be required. Your benefits/services may be nursing careDeductible + 20% CoinsuranceDeductible + 50% CoinsuranceCoverage limited to 60 days. Durable medical equipmentMotorized Wheelchairs: $500 Copay per Visit/ All Other: No ChargeNot CoveredExcludes vehicle modifications, home modifications, exercise, bathroom equipment and replacement of DME due to you need help recovering or have other special Health needsHospice servicesNo ChargeDeductible + 50% Coinsurance none Children s eye examNo ChargeNot CoveredOne exam per calendar your child needs dental or eye careChildren s glassesNo ChargeNot CoveredOne pair per calendar year.

9 Additional cost 5 of 7 For more information about limitations and exceptions, see the plan or policy document at : 1470529 Common Medical EventServices You May NeedWhat You Will PayLimitations, Exceptions, & Other Important InformationNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most) shares may apply for Non-Collection Frame. Children s dental check-upNot CoveredNot CoveredNot CoveredExcluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture Bariatric surgery Cosmetic surgery Dental care (Adult) Hearing aids Infertility treatment Long-term care Non-excepted abortions ( , not medically necessary) Pediatric dental check-up Private-duty nursing Routine eye care (Adult) Routine foot care unless for treatment of diabetes Weight loss programs Other Covered Services (Limitations may apply to these services.)

10 This isn t a complete list. Please see your plan document.) Chiropractic care - Limited to 35 visits Most coverage provided outside the United States. See Non-emergency care when traveling outside the Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or , State consumer assistance program , Office of Personnel Management Multi State Plan Program: Or or call 1-800-318-2596 OR state Health Insurance marketplace or SHOP. Other coverage options may be available to you too, including buying individual Insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit or call Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim.