myBlue 1601 - Health Insurance for Florida

1 myBlue 1601 Coverage Period: 01/01/2018 - 12/31/2018 BronzeSummary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage for: Individual and/or Family | Plan Type: HMO 1 of 7 SBCID: 1470132 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.

2 You can view the Glossary at or call 1-855-692-5830 to request a QuestionsAnswersWhy This Matters:What is the overall deductible?In-Network: $6,400 Per Person/$12,800 Family. Out-of-Network: Not , 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.

3 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?Yes. In-Network: $6,900 Per Person/$13,800 Family. Out-Of-Network: Not 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?

4 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 1-855-692-5830 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). Be aware your network provider might use an out-of-network provider for some services (such as lab work).

5 Check with your provider before you get you need a referral to see a specialist? plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. 2 of 7 For more information about limitations and exceptions, see the plan or policy document at : 1470132 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$0 Copay - Visits 1-3$35 Copay for remaining VisitsNot CoveredPhysician administered drugs may have higher cost visit$65 Copay per VisitNot CoveredPhysician administered drugs may have higher cost you visit a Health care provider s office or clinicPreventive care/screening/immunizationNo ChargeNot CoveredPhysician administered drugs may have higher cost shares.

6 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: Deductible + 50% CoinsuranceNot CoveredTests performed in hospitals may have higher cost-share. Prior Authorization may be required. Your benefits/services may be you have a testImaging (CT/PET scans, MRIs) Deductible + 50% CoinsuranceNot CoveredPrior Authorization may be required. Your benefits/services may be denied. Tests performed in hospitals may have higher cost-share.

7 3 of 7 For more information about limitations and exceptions, see the plan or policy document at : 1470132 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 Visit (retail)/ Low Cost Generic: $25 Copay per Visit (retail)/ High Cost Generic: Deductible + 50% Coinsurance (retail)Not CoveredUp to 30 day supply for retail, 90 day supply for mail order at 2 times the retail amount.

8 Responsible Rx programs such as Prior Authorization may apply. See Medication guide for more brand drugsCondition Care Rx: $30 Copay per Visit (retail)/ All Other Preferred Brand: Deductible + 50% Coinsurance (retail)Not CoveredUp to 30 day supply for retail, 90 day supply for mail order at 2 times the retail brand drugsDeductible + 50% 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 drugsDeductible + 50% CoinsuranceNot CoveredUp to 30 day supply for retail.

9 Not covered through Mail Order. Facility fee ( , ambulatory surgery center)Deductible + 50% CoinsuranceNot CoveredPrior Authorization may be required. Your benefits/services may be you have outpatient surgeryPhysician/surgeon feesDeductibleNot Covered none Emergency room careDeductible + 50% CoinsuranceIn-Network Deductible + 50% Coinsurance none Emergency medical transportationDeductible + 50% CoinsuranceIn-Network Deductible + 50% CoinsuranceOut-of-Network only covered for emergencies. If you need immediate medical attentionUrgent care$75 Copay per VisitNot Covered none Facility fee ( , hospital room)Deductible + $100 Copay per AdmissionNot CoveredInpatient Rehab Services limited to 30 days.

10 Inpatient Habilitation Services limited to 30 days. Prior Authorization may be required. Your benefits/services may be you have a hospital stayPhysician/surgeon feesDeductibleNot Covered none 4 of 7 For more information about limitations and exceptions, see the plan or policy document at : 1470132 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: $65 Copay per Visit / Hospital: Deductible + 50% CoinsuranceNot CoveredPrior Authorization may be required.