myBlue Silver 1604 - Florida Blue

1 myBlue Silver 1604 Schedule of Benefits This Schedule of Benefits is part of your Contract, where more detailed information about your benefits can be found. Review this Schedule of Benefits carefully; it contains important information concerning your share of the expenses for Covered Services you receive. Amounts listed in this schedule are the Cost Share amount you pay. When a Covered Service is subject to more than one type of Cost Share, the Cost Shares are listed in the order in which they apply to the Covered Service. 0515 0515 1 FINANCIAL FEATURES YOU PAY Calendar Year Deductibles (DED) - Embedded Individual Deductible $6,100 Family Deductible $12,200 Coinsurance (The percentage of the Allowed Amount you pay for Covered Services) 30% Out-of-Pocket Maximums - Embedded Individual Out-of-Pocket Maximum $6,850 Family Out-of-Pocket Maximum $13,700 Medical Pharmacy per person, per month $240 What applies to the out-of-pocket maximum?

2 All Copayments (including Pharmacy) Coinsurance (including Pharmacy) DED What does not apply to out-of-pocket maximums? Non-covered charges Benefit penalties MEDICAL BENEFITS 0515 0515 2 You should always verify a Provider s participation status before you receive Health care Services. To verify a Provider s specialty or participation status, you may contact our local office or access the most recent myBlue provider directory at Unless indicated otherwise, Copays listed in the charts that follow, apply per visit. IMPORTANT: ALL Services must be rendered by your PCP or Provider on referral from your PCP in order to be considered Covered Services, except as indicated in the COVERAGE ACCESS RULES section of your Contract. PREVENTIVE SERVICES YOU PAY Adult Wellness Services (at all locations) $0 Child Wellness Services (at all locations) $0 Mammograms $0 Routine Colonoscopies (Ages 50+) $0 OFFICE SERVICES YOU PAY Office Visits rendered by blue Physician Recognition ( Florida only) and Primary care Physicians visit 1 $0 Copay** thereafter $65 Copay Specialist Physicians and other health care professionals licensed to perform such Services $90 Copay after DED Allergy Injections and Allergy Testing rendered by blue Physician Recognition ( Florida only) and Primary care Physicians $10 Copay Specialist Physicians and other health care professionals licensed to perform such Services $10 Copay E-Visits rendered by blue Physician Recognition ( Florida only)

3 And Primary care Physicians $10 Copay Specialist Physicians and other health care professionals licensed to perform such Services $10 Copay 0515 0515 3 OFFICE SERVICESYOU PAYA dvanced Imaging Services (CT/CAT Scans, MRAs, MRIs, PET Scans and nuclear medicine) rendered by blue Physician Recognition ( Florida only) and Primary care Physicians visit 1 $0 Copay** thereafter $65 Copay Specialist Physicians and other health care professionals licensed to perform such Services $90 Copay after DED Outpatient Therapies and Spinal Manipulation rendered by blue Physician Recognition ( Florida only) and Primary care Physicians visit 1 $0 Copay** thereafter $65 Copay Specialist Physicians and other health care professionals licensed to perform such Services $90 Copay after DED Medical Pharmacy Prescription Drugs administered in a Physician s office $60 Copay per Drug Important: The Cost Share for Medical Pharmacy Services applies to the Prescription Drug only and is in addition to the office Services Cost Share.

4 Medical Pharmacy does not include immunizations, allergy injections or Services covered through the pharmacy program. Please refer to your Contract for a description of Medical Pharmacy. ** blue Physician Recognition ( Florida only) and Primary care Physician Visits: Each Covered Person each Calendar Year is eligible for one (1) visit at no Cost Share for office visits rendered by blue Physician Recognition ( Florida only) or Primary care Physicians, including behavioral health and outpatient therapies and spinal manipulation Services. This reduced Cost Share applies to the first covered visit in the Calendar Year. Thereafter, office visits are covered at the blue Physician Recognition ( Florida only) and Primary care Physicians Cost Share shown above. OUTPATIENT DIAGNOSTIC SERVICES YOU PAY Independent Clinical Lab $0 Copay Independent Diagnostic Testing Center Advanced Imaging Services (CT/CAT Scans, MRAs, MRIs, PET Scans and nuclear medicine) 30% after DED All other diagnostic Services ( , X-rays) $4 Copay Outpatient Hospital Facility Advanced Imaging Services (CT/CAT Scans, MRAs, MRIs, PET Scans and nuclear medicine) 30% after DED All other diagnostic Services ( , X-rays) 30% after DED 0515 0515 4 EMERGENCY AND URGENT care SERVICES YOU PAY Ambulance Services 30% after DED Convenient care Center $140 Copay Emergency Room Visits (Copay waived if admitted)

5 In-Network Facility $600 Copay after DED Out-of-Network Facility $600 Copay after DED Physician Services $0 Copay Urgent care Center $250 Copay after DED HOSPITAL AND SURGICAL SERVICES YOU PAY Ambulatory Surgical Center Facility 30% after DED Physician Services $0 Copay InpatientHospitalFacility 30% after DED Physician Services $0 Copay Outpatient Hospital Facility 30% after DED Physician Services $0 Copay 0515 0515 5 OTHER SERVICES YOU PAY Birth Center 30% after DED Dialysis Center 30% after DED Durable Medical Equipment Motorized wheelchairs $500 Copay All other Durable Medical Equipment $0 Copay Enteral Formula 30% after DED Home Health care $0 Copay Outpatient Hab/Rehab Facility 30% after DED Prosthetic and Orthotic Devices $0 Copay Second Medical Opinion In-Network Provider 30% after DED Out-of-Network Provider 40% after DED Skilled Nursing Facility 30% after DED BENEFIT MAXIMUMS All benefit maximums apply per person and are based on the Calendar Year.

6 Home Health care Visits .. 30 Inpatient Habilitative and Rehabilitative Days (combined) .. 30 Outpatient Therapies and Spinal Manipulation Visits .. 35 Note: Spinal Manipulations are limited to 35 per Calendar Year and accumulate towards the Outpatient Therapies and Spinal Manipulation combined visit maximum. Skilled Nursing Facility Days .. 60 PRESCRIPTION DRUG PROGRAM 0515 0515 6 ValueScript Rx Pharmacy Program For a list of In-Network Pharmacies, you may contact our local office or access the most recent provider directory at COST SHARE TIER Retail Pharmacy (for each One-Month Supply*) Mail Order Pharmacy (up to a Three-Month Supply) Tier 1: Lowest cost Generic Drugs and Brand Name Drugs and Supplies $30 Copay after DED $75 Copay after DED Tier 2: Low cost Generic Drugs and Brand Name Drugs and Supplies** $45 Copay after DED $113 Copay after DED Tier 3.

7 High cost Generic Drugs and Brand Name Drugs and Supplies** 30% after DED 30% after DED Preventive Prescription Drugs and Supplies included on the Preventive Drugs List $0 Copay $0 Copay Condition care Rx Prescription Drugs and Supplies Generic Prescription Drugs and Supplies included on the Condition care Rx Value List $4 Copay $0 Copay Brand Name Prescription Drugs and Supplies included on the Condition care Rx Value List $30 Copay $75 Copay Oral Chemotherapy Medications** $10 Copay $25 Copay Other Important Information affecting the amount you will pay: * You can get up to a Three-Month Supply of a Covered Prescription Drug or Covered Prescription Supply (except Specialty Drugs) from a retail Pharmacy, if the Prescription is written for a Three-Month Supply. ** Specialty Drugs are only covered when purchased from the Specialty Pharmacy and only up to a One-Month Supply.

8 Some Specialty Drugs may be dispensed in lesser quantities due to manufacturer package size or course of therapy and certain Specialty Pharmacy products may have additional quantity limits. ** Please refer to the Oral Chemotherapy Drug List contained in the Medication Guide. PEDIATRIC VISION BENEFITS 0515 0515 7 Pediatric Vision Benefits end on the last day of the calendar month of the Covered Person s 19th birthday. COVERED SERVICE YOU PAY Eye exam one per Calendar Year .. $0 including dilation (when professionally indicated) Spectacle Lenses one pair per Calendar Year .. $0 Clear plastic single vision, lined bifocal, trifocal or lenticular lenses (any Rx) Oversize lenses Scratch-resistant coating Standard progressive lenses Plastic photosensitive lenses Polycarbonate lenses (for monocular patients and patients with prescriptions +/- diopters or greater) Tinting of plastic lenses Ultraviolet coating Frames one per Calendar Year from the Pediatric Frame Selection*.

9 $0 * If you choose a frame that is not in the Pediatric Frame Selection you will be responsible for the difference in cost between the price of the frame selected and those available in the Pediatric Frame Selection. Any such amounts will not apply to any Deductibles or Out-of-Pocket maximums. Contact Lenses (instead of eye glasses) once per Calendar Year from the Pediatric Contact Lens Selection** including the evaluation, fitting and follow-up care .. $0 ** If you do not select contact lenses from the Pediatric Contact Lens Selection you will be responsible for the difference in cost between the contact lenses selected and those available in the Pediatric Contact Lens Selection. Any such amounts will not apply to any Deductibles or Out-of-Pocket maximums. Medically Necessary Contact Lenses (prior authorization is required).

10 $0 Including the evaluation, fitting and follow-up care myBlue For Individuals Non-Group Contract Florida blue HMO is a trade name of Health Options, Inc., an HMO affiliate of blue Cross and blue Shield of Florida , Inc., D/B/A Florida blue . These companies are Independent Licensees of the blue Cross and blue Shield Association. 0515 0515 This Contract contains a deductible provision myBlue For Individuals Non-Group Contract Florida blue HMO is a trade name of Health Options, Inc., an HMO affiliate of blue Cross and blue Shield of Florida , Inc., D/B/A Florida blue . These companies are Independent Licensees of the blue Cross and blue Shield Association. 0515 0515 Prakash Patel President and Chairman of the Board For Customer Service Assistance: Log in at Contractholder Name: [Inserted Here] Contract Number: [ Inserted Here] Group Number: [ Inserted Here] Contract Type: [ Inserted Here] Effective Date: [ Inserted Here] Monthly Rate: [Inserted Here] 4800 Deerwood Campus Parkway Jacksonville, Florida 32246 IMPORTANT NOTICE In deciding to issue this Contract to you, we relied on the truthfulness and accuracy of the information provided on the application.