2016
BENEFITS
MADE
SIMPLE
St. Lucie County Schools
Flexible Benefits Plan
Reference Guide
COBRA & Retiree Participants
2016 St. Lucie County Schools
PayFlex – FBMC’s COBRA
Outsource Provider
Table of Contents
3
Plan Highlights
4
Enrollment at a Glance
6
COBRA Eligibility Requirements
7
Florida Blue Health Benefits Summary
10
Group Health Plan Premiums
11
Medicare Health Plan Summary PPO Plan 1
17
Medicare Group Rx Option 1
18
Medicare Health Plan Summary PPO Plan 2
24
Medicare Group Rx Option 3
25
Dental Plan
27
Vision Plan
28
Group Hospital Indemnity Insurance
29
Group Term Life Insurance
30
Group Cancer Insurance Plan
31
Creditable Coverage Notice
COBRA benefits communication is being supported
by FBMC Benefits Management’s outsource
provider, PayFlex Systems USA, Inc. 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 at 1-855-LUCIE4U (1-855-582-4348).
Back Benefits Directory
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 31 for more details.
www.myFBMC.com
2
Enrollment Information
Plan Highlights
Important Enrollment Information
• If you wish to make changes to your existing coverage, you must
complete and mail an enrollment form by November 13, 2015.
• 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 13, 2015 to continue COBRA benefits to PayFlex Systems
USA, Inc. Benefits Billing Department P.O. Box 2239 Omaha, NE
68103-2239. Forms may be faxed to 1-402-231-4302 or e-mailed
to cobramail@payflex.com. You may also call PayFlex Systems at 1-855-LUCIE4U (1-855-582-4348).
• 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.
• If you are making changes to your benefits, you must complete and
mail an enrollment form by November 13, 2015 to:
FBMC Benefits Management, Inc.
Retiree and Direct Bill Department
P.O. Box 10789
Tallahassee, FL 32302-2789
• Dependents: If you are enrolling in coverage for your dependents,
please record your dependents’ Social Security numbers and dates
of birth on your enrollment form.
• This year is a changes only enrollment. All COBRA participants and
retirees of St. Lucie County Schools may complete an enrollment
form to make changes to your coverage. If you do not complete an
enrollment form, your current benefits will continue.
• SLCS will continue to offer the BlueOptions Plan 05771 and
BlueOptions Plans 05180/05181 to COBRA participants and retirees.
• BlueMedicare Group PPO Plans 1 and 2 are available to all Medicareeligible retirees and their dependents.
• Effective January 1, 2016, your dental provider will be changing from
Delta Dental to Florida Combined Life.
3
www.myFBMC.com
Enrollment at a Glance
Retiree Open Enrollment
Important Dates to Remember
Your Open Enrollment dates are:
October 26, 2015 through November 13, 2015.
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.
Your Period of Coverage dates are:
January 1, 2016 through December 31, 2016.
Please refer to the information contained on your current Benefit Statement
and in this guide when making selections for the 2016 Plan Year.
If you are making changes to your benefits, you must complete a 2016
enrollment form. If you are Medicare-eligible and you elect to enroll in
either BlueMedicare Group PPO plan, you must also complete a Florida
Blue BlueMedicare enrollment form.
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 Florida Blue BlueMedicare
enrollment form. The effective date of your Medicare Advantage Plan
will be January 1, 2016.
Please assure you have noted all benefits you want to continue in the
new plan year. Late forms will not be accepted. For more information,
contact FBMC Service Center at 1-855-LUCIE4U (1-855-582-4348),
Monday - Friday, 7 a.m. - 7 p.m. ET.
If you will become eligible for Medicare during the 2016 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 can
be the same date your Medicare becomes effective. For a summary of
the benefits this plan offers, please refer to Page 11.
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.
COBRA Open Enrollment
Retirees are encouraged to submit their enrollment form(s) early
during Open Enrollment to ensure that deductions are made by FRS
in a timely manner.
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.
Any coverage you elect to cancel cannot be reinstated. Please send
your enrollment form, marking cancel to cancel selected coverage during
Open Enrollment, to: FBMC Benefits Management, Inc., Retiree and
Direct Bill Department, P.O. Box 10789, Tallahassee, FL 32302-2789.
Please refer to the information contained on your current Benefit
Statement and in this book when making your COBRA selections for
the 2016 Plan Year.
Insurance Coverage after Retirement
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. Refer to page 6 for more
details on COBRA and HIPAA exclusions.
Under section 112.0801, Florida Statutes, your FRS employer is required
to offer you or your eligible dependents the option of continued
participation in any employer-sponsored group insurance plans in which
you were participating at your retirement or at your DROP termination
date.
If you are making changes to your benefits, 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 68103-2239. You may also call PayFlex Systems at 1-855-LUCIE4U (1-855-582-4348).
Forms may be faxed to 1-402-231-4302 or e-mailed 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, 2015. For more
information, contact FBMC Service Center at 1-855-LUCIE4U (1-855582-4348), Monday - Friday, 7 a.m. - 7 p.m. ET.
As a retiree, your premium cost for health and hospitalization insurance
coverage may not exceed the total employee and employer premium
cost applicable to active employees. You may lose your eligibility to
participate if you choose not to continue participating in your employer’s
group plan at retirement, initially choose to continue but subsequently
stop participating, defer your retirement to a future date, or otherwise
do not meet your employer’s group plan requirements. Before you
terminate employment, contact your FRS employer about continuing
your employer-sponsored group insurance coverage. The division has
no authority over or responsibility for employer group health and
hospitalization plans.
Income Taxes on Your Retirement Benefit
Each year at the end of January, the division provides you an IRS Form
1099-R. Your annual taxable income is shown in the taxable amount box
(Box 2a). You should use this form when you file your income tax return.
www.myFBMC.com
4
Enrollment at a Glance
Dependent Eligibility for Group Health
and Dental Plan:
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.
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.
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.
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.
5
www.myFBMC.com
COBRA Eligibility Requirements
What is continuation coverage?
Method of Payment
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 1-855-LUCIE4U (1-855-582-4348), Monday
- Friday, 7 a.m. - 7 p.m. ET.
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.
COBRA Coverage
A Qualified Beneficiary's (QB) period of coverage is January 1, 2016,
through December 31, 2016, 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. Spouses
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
www.myFBMC.com
6
Florida Blue Health Benefits Summary
Summary of Health Benefits for
St. Lucie County School Board 01-01-16 thru 12-31-16
COST SHARING
Maximums shown are Per Benefit Period
(BPM) unless noted
Deductible (DED) (Per Person/Family Agg)
In-Network
Out-of-Network
Coinsurance (Member Responsibility)
In-Network
Out-of-Network
Out of Pocket Maximum (Per Person/Family
Agg)
In-Network
Out-of-Network
Lifetime Maximum
PROFESSIONAL PROVIDER SERVICES
Allergy Injections
In-Network Primary/Family Care Physician
In-Network Specialist
Out-of-Network
E-Office Visit Services
In-Network Primary/Family Care Physician
In-Network Specialist
Out-of-Network
Office Services
In-Network Primary/Family Care Physician
In-Network Specialist
Out-of-Network
Provider Services at Hospital and ER
In-Network Primary/Family Care Physician
In-Network Specialist
Out-of-Network
Provider Services at Other Locations
In-Network Primary/Family Care Physician
In-Network Specialist
Out-of-Network
Radiology, Pathology and Anesthesiology
Provider Services at Ambulatory Surgical
Center
In-Network Specialist
Out-of-Network
PREVENTIVE CARE
Adult Wellness Office Services
In-Network Primary/Family Care Physician
In-Network Specialist
Out-of-Network
Colonoscopies (Routine-1 every 10 years)
In-Network
Out-of-Network
Mammograms (Routine)
In-Network
Out-of-Network
Well Child Office Visits (No BPM)
In-Network Primary/Family Care Physician
In-Network Specialist
Out-of-Network
BlueOptions
BlueOptions
BlueOptions
HSA-Compatible 05180
(Single Coverage)
“Network Blue”
HSA-Compatible 05181
(Family Coverage)
“Network Blue”
05771
“Network Blue”
Only Available
To Employees Hired
Prior to 1/1/14
$1,500 / Not Applicable
$3,000 / Not Applicable
$3,000 / $3,000
$6,000 / $6,000
$1,500 / $4,500
$4,500 / $13,500
10%
40% of Allowed Amount +
Subject to Balance Billing
Charges
Includes DED, Coins, &
Copays
$3,000 / Not Applicable
$6,000 / Not Applicable
No Maximum
10%
40% of Allowed Amount +
Subject to Balance Billing
Charges
Includes DED, Coins, &
Copays
$6,000 /$6,000
$12,000 / $12,000
No Maximum
20%
50% of Allowed Amount +
Subject to Balance Billing
Charges
Includes DED, Coins, &
Copays
$4,500 / $9,000
$9,000 / $18,000
No Maximum
DED + 10%
DED + 10%
DED + 40%
DED + 10%
DED + 10%
DED + 40%
$10
$10
DED + 50%
DED + 10%
DED + 10%
DED + 40%
DED + 10%
DED + 10%
DED + 40%
$10
$10
DED + 50%
DED + 10%
DED + 10%
DED + 40%
DED + 10%
DED + 10%
DED + 40%
$30
$55
DED + 50%
DED + 10%
DED + 10%
In-Ntwk DED + 10%
DED + 10%
DED + 10%
In-Ntwk DED + 10%
DED + 20%
DED + 20%
In-Ntwk DED + 20%
DED + 10%
DED + 10%
DED + 40%
DED + 10%
DED + 10%
DED + 40%
$30
$55
DED + 50%
DED + 10%
DED + 10%
In-Ntwk DED + 10%
In-Ntwk DED + 10%
ASC: $55
Hospital: DED + 20%
ASC: $55
Hospital: In-Ntwk DED +
20%
$0
$0
40% (No DED)
Age 50+ then Frequency
Schedule Applies
$0
$0
$0
$0
40% (No DED)
Age 50+ then Frequency
Schedule Applies
$0
$0
$0
$0
50% (No DED)
Age 50+ then Frequency
Schedule Applies
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
40% (No DED)
$0
$0
40% (No DED)
$0
$0
50% (No DED)
7
www.myFBMC.com
Florida Blue Health Benefits Summary
COST SHARING
Maximums shown are Per Benefit Period
(BPM) unless noted
EMERGENCY / URGENT /
CONVENIENT CARE
Ambulance Maximum (per day)
In-Network
Out-of-Network
Convenient Care Centers (CCC)
In-Network
Out-of-Network
Emergency Room Facility Services
(also see Professional Provider Services)
In-Network
Out-of-Network
Urgent Care Centers (UCC)
In-Network
Out-of-Network
FACILITY SERVICES –
HOSPITAL/SURGICAL/ICL/IDTF
BlueOptions
BlueOptions
BlueOptions
HSA-Compatible 05180
(Single Coverage)
HSA-Compatible 05181
(Family Coverage)
05771
(Only Available
To Employees Hired
Prior to 1/1/14)
No Maximum
No Maximum
No Maximum
DED + 10%
In-Ntwk DED + 10%
DED + 10%
In-Ntwk DED + 10%
DED + 20%
In-Ntwk DED + 20%
DED + 10%
DED + 40%
DED + 10%
DED + 40%
$30
DED + 50%
DED + 10%
In-Ntwk DED + 10%
DED + 10%
In-Ntwk DED + 10%
$250
$250
DED + 10%
DED + 40%
DED + 10%
DED + 40%
$60
DED + 50%
Unless otherwise noted, physician services are in addition to facility services. See Professional Provider Services.
Ambulatory Surgical Center
In-Network
Out-of-Network
Independent Clinical Lab
In-Network (Quest Diagnostics)
Out-of-Network
Independent Diagnostic Testing Facility Xrays and AIS (Includes Physician Services)
In-Network - Advanced Imaging Services
(AIS)
In-Network - Other Diagnostic Services
Out-of-Network
Inpatient Hospital (per admit)
In-Network
Out-of-Network
Inpatient Rehab Maximum (PBP)
Outpatient Hospital (per visit)
In-Network
Out-of-Network
Therapy at Outpatient Hospital
In-Network
Out-of-Network ER SVIES AD
DED + 10%
DED + 40%
DED + 10%
DED + 40%
$200
DED + 50%
DED
DED + 40%
DED
DED + 40%
$0
DED + 50%
DED + 10%
DED + 10%
$250
DED + 10%
DED + 40%
DED + 10%
DED + 40%
$50
DED + 50%
Option 1 - DED + 10%
Option 2 - DED + 10%
DED + 40%
30 Days
Option 1 - DED + 10%
Option 2 - DED + 10%
DED + 40%
30 Days
Option 1 - DED + 20%
Option 2 - DED + 20%
$500 PAD + DED + 50%
30 Days
Option 1 - DED + 10%
Option 2 - DED + 10%
DED + 40%
Option 1 - DED + 10%
Option 2 - DED + 10%
DED + 40%
Option 1 - DED + 20%
Option 2 - DED + 20%
DED + 50%
Option 1 - DED + 10%
Option 2 - DED + 10%
DED + 40%
Option 1 - DED + 10%
Option 2 - DED + 10%
DED + 40%
Option 1 - $55
Option 2 - $80
DED + 50%
DED + 10%
DED + 10%
DED + 40%
DED + 10%
DED + 10%
DED + 40%
$250
$250
DED + 50%
DED + 10%
DED + 40%
No Maximum
DED + 10%
DED + 40%
No Maximum
DED + 20%
DED + 50%
No Maximum
DED + 10%
DED + 40%
20 Visits
DED + 10%
DED + 40%
No Maximum
DED + 10%
DED + 40%
60 Days
DED + 10%
DED + 40%
DED + 10%
DED + 40%
20 Visits
DED + 10%
DED + 40%
No Maximum
DED + 10%
DED + 40%
60 Days
DED + 10%
DED + 40%
DED + 20%
DED + 50%
20 Visits
DED + 20%
DED + 50%
No Maximum
DED + 20%
DED + 50%
60 Days
DED + 20%
DED + 50%
OTHER SPECIAL SERVICES AND
LOCATIONS
Advanced Imaging Services in Physician's
Office
In-Network Primary/Family Care Physician
In-Network Specialist
Out-of-Network
Birthing Center
In-Network
Out-of-Network
Durable Medical Equipment, Prosthetics,
Orthotics BPM
In-Network (Carecentrix)
Out-of-Network
Home Health Care BPM
In-Network (Carecentrix)
Out-of-Network
Hospice LTM
In-Network
Out-of-Network
Skilled Nursing Facility BPM
In-Network
Out-of-Network
www.myFBMC.com
8
Florida Blue Health Benefits Summary
COST SHARING
Maximums shown are Per Benefit Period
(BPM) unless noted
BlueOptions
BlueOptions
BlueOptions
HSA-Compatible 05180
(Single Coverage)
HSA-Compatible 05181
(Family Coverage)
05771
(Only Available
To Employees Hired
Prior to 1/1/14)
Option 1- DED + 10%
Option 2 - DED + 10%
DED + 40%
Option 1- DED + 10%
Option 2 - DED + 10%
DED + 40%
Option 1- $0
Option 2 - $0
50% (No DED)
Option 1 - DED + 10%
Option 2 - DED + 10%
DED + 40%
Option 1 - DED + 10%
Option 2 - DED + 10%
DED + 40%
Option 1 - $0
Option 2 - $0
50% (No DED)
Provider Services at Hospital and ER
In-Network Family Physician or Specialist
Out-of-Network Provider
DED + 10%
In-Ntwk DED + 10%
DED + 10%
In-Ntwk DED + 10%
$0
$0
Physician Office Visit
In-Network Family Physician or Specialist
Out-of Network Provider
DED + 10%
DED + 40%
DED + 10%
DED + 40%
$0
50% (No DED)
DED + 10%
In-Ntwk DED + 10%
DED + 10%
In-Ntwk DED + 10%
$0
$0
DED + 10%
DED + 10%
DED + 40%
DED + 10%
DED + 10%
DED + 40%
$0
$0
50% (No DED)
$1500
In-Network Plan
Deductible Applies
$3000
In-Network Plan
Deductible Applies
$0
$10 / $30 / $50
$10 / $30 / $50
$10 / $30 / $50
$20 / $60 / $100
$20 / $60 / $100
$20 / $60 / $100
MENTAL HEALTH AND SUBSTANCE ABUSE
Inpatient Hospitalization-Facility
In-Network
Out-of-Network
Outpatient Hospitalization- Facility (per visit)
In-Network
Out-of-Network
Emergency Room Facility Services
(per visit)
In-Network
Out-of-Network
Provider Services at Locations other than
Hospital and ER
In-Network Family Physician
In-Network Specialist
Out-of-Network Provider
PRESCRIPTION DRUGS
Deductible
In-Network (Mandatory Generic Program)
Retail (30 days)
Generic/Preferred Brand/Non-Preferred
Mail Order/Retail (90 days)
Generic/Preferred Brand/Non-Preferred
This is not an insurance contract or Benefit Booklet. The above Benefit Summary is only a partial description of the many benefits and services
covered by Blue Cross and Blue Shield of Florida, Inc., an independent licensee of the Blue Cross and Blue Shield Association. For a complete
description of benefits and exclusions, please see Blue Cross and Blue Shield of Florida’s Benefit Booklet and Schedule of Benefits; their terms prevail.
The information contained in this proposal includes benefit changes required as a result of the Patient Protection And Affordable Care Act (PPACA),
otherwise known as Health Care Reform (HCR). Please note that plan benefits are subject to change and may be revised based on guidance and
regulations issued by the Secretary of Health and Human Services (HHS) or other applicable federal agency. In addition, the rates quoted within
this proposal are based on the plan benefits at the time the proposal is issued and may change before the plan effective date if additional plan changes
become necessary.
Additionally, Interim rules released by the Federal Government February 2, 2010 require BCBSF to test all benefit plans to ensure compliance with the
Mental Health Parity and Addiction Equity Act (MHPAE). Benefits and rates reflected in the proposal are subject to change based on the outcomes of the test.
9
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Group Health Plan Premiums
Florida Blue
2016 COBRA Participant and Retiree Monthly Contributions
Blue Options - Plan 05180 (Single)/05181 (Family)
Retiree
COBRA
Participant Only
$572.41
$583.87
Spouse Only (Retiree is enrolled in BlueMed Plan)
$710.03
Participant & 1 Dependent
$1,282.44
$1,308.09
Participant & Family
$1,629.46
$1,662.05
Blue Options - Plan 05771
Retiree
COBRA
Participant Only
$611.03
$623.26
Spouse Only (Retiree is enrolled in BlueMed Plan)
$757.95
Participant & 1 Dependent
$1,368.98
$1,396.36
Participant & Family
$1,740.66
$1,775.47
BlueMedicare Group PPO Plan 1
Premiums for Medicare Eligible Retirees and Medicare-Eligible Dependents (age 65 and older)
Retiree
Retiree Only
$308.49
Retiree & Spouse
$616.98
BlueMedicare Group PPO Plan 2
Premiums for Medicare Eligible Retirees and Medicare-Eligible Dependents (age 65 and older)
Retiree
Retiree Only
$183.53
Retiree & Spouse
$367.06
www.myFBMC.com
10
Medicare Health Plan Summary - PPO Plan 1
St. Lucie County School District #24936
Florida Blue
2016 BlueMedicare Group PPO (Employer PPO) Health Benefits
Benefits
BlueMedicare Group PPO Plan 1
Premium (per member, per month)
$308.49 for PPO1Rx1
Annual Deductible (DED)
$0 In-Network / $1,000 Out-of-Network
Out-of Pocket Maximum (based on plan
year)
$1,000 In-Network / $3,000 Out-of-Network
In-Network out-of-pocket maximum accumulates
toward Out-of-Network out-of-pocket maximum
Physician Office
Primary Care (per visit)
In-Network $10 Copayment
Out-of-Network DED & 20% Coinsurance
Specialist Care (per visit)
In-Network $30 Copayment
Out-of-Network DED & 20% Coinsurance
e-Visit
In-Network $5 Copayment
Out-of-Network DED & 20% Coinsurance
Convenient Care Center
In-Network / Out-of-Network $30 Copayment
Podiatry Services (per visit)
(routine foot care up to 6 visits per year)
In-Network $30 Copayment
Out-of-Network DED & 20% Coinsurance
Chiropractic Services (per visit)
For each Medicare-covered visit (manual
manipulation of the spine to correct
subluxation)
In-Network $20 Copayment
Out-of-Network DED & 20% Coinsurance
Outpatient Mental Health Care (per visit)
For individual or group therapy
(including partial hospitalization)
In-Network $35 Copayment
Out-of-Network DED & 20% Coinsurance
Outpatient Substance Abuse Care (per visit)
In-Network $35 Copayment
Out-of-Network DED & 20% Coinsurance
Part B Drugs (including chemotherapy)
In-Network 20% Coinsurance
Out-of-Network DED & 20% Coinsurance
Allergy Injections
In-Network $5 Copayment
Out-of-Network DED & 20% Coinsurance
Y0011_31874 0815 EGWP C: 08/2015
1
11
www.myFBMC.com
Medicare Health Plan Summary - PPO Plan 1
Florida Blue
Benefits
BlueMedicare Group PPO Plan 1
Other Services
Outpatient Surgery
In-Network
 $150 Copayment for each outpatient
hospital facility visit
 $100 Copayment for each visit to an
ambulatory surgical center
Out-of-Network DED & 20% Coinsurance
In-Network / Out-of-Network
 $0 Copayment for physician services
Diagnostic Tests, X-Rays
Office
IDTF
Lab Services
Independent Clinical Lab
Outpatient Hospital
All Locations
Advanced Imaging (MRI, MRA, CT Scan,
PET Scan and Nuclear Medicine):
Office
In-Network
 PCP $10 Copayment
 Specialist $30 Copayment
Out-of-Network DED & 20% Coinsurance
In-Network $50 Copayment
Out-of-Network DED & 20% Coinsurance
In-Network $0 Copayment
In-Network $15 Copayment
Out-of-Network DED & 20% Coinsurance
In-Network $125 Copayment
Out-of-Network DED & 20% Coinsurance
IDTF
In-Network $125 Copayment
Out-of-Network DED & 20% Coinsurance
Outpatient Hospital
In-Network $150 Copayment
Out-of-Network DED & 20% Coinsurance
www.myFBMC.com
Y0011_31874 0815 EGWP C: 08/2015
12
2
Medicare Health Plan Summary - PPO Plan 1
Florida Blue
Benefits
Outpatient Hospital Services (per visit):
Occupational Therapy, Physical Therapy,
Speech & Language Therapy, Cardiac and
Pulmonary Rehab (including intensive
cardiac rehab)
BlueMedicare Group PPO Plan 1
In-Network $30 Copayment
Out-of-Network DED & 20% Coinsurance
$1,940 Physical and Speech Therapy Annual
Benefit Maximum
$1,940 Occupational Therapy Annual Benefit
Maximum
Radiation Therapy
In-Network $50 Copayment
Out-of-Network DED & 20% Coinsurance
Dialysis
In-Network / Out-of-Network 20% Coinsurance
Lab Only
In-Network $15 Copayment
Out-of-Network DED & 20% Coinsurance
All Other Diagnostic Tests, X-Rays,
Advanced Imaging, etc.
In-Network $150 Copayment
Out-of-Network DED & 20% Coinsurance
Urgently Needed Care
(This is not emergency care, and in most
cases is out-of-the-service area.)
In-Network / Out-of-Network $30 Copayment
Emergency Services
In-Network / Out-of-Network $75 Copayment
Worldwide Coverage
Dental, Hearing and Vision (MedicareCovered)
In-Network $30 Copayment
Out-of-Network DED & 20% Coinsurance
Home Health
In-Network / Out-of-Network $0 Copayment
Ambulance
In-Network / Out-of-Network $150 Copayment for
Medicare-covered ambulance services
13
www.myFBMC.com
Medicare Health Plan Summary - PPO Plan 1
Florida Blue
Benefits
BlueMedicare Group PPO Plan 1
Outpatient Medical Services and Supplies
Durable Medical Equipment/Diabetic
Supplies
Diabetic Supplies (glucose meters, test strips
and lancets)
Note: needles, syringes and insulin for selfinjection are covered under your Part D
benefit
In-Network $0 Copayment
Out-of-Network DED & 20% Coinsurance
Equipment: Plan-Approved Electric
Customized Wheelchairs, Electric Scooters
In-Network 20% Coinsurance
Out-of-Network DED & 20% Coinsurance
All Other Medicare-Covered Durable Medical
Equipment
In-Network $0 Copayment
Out-of-Network DED & 20% Coinsurance
Prosthetic Devices
In-Network $0 Copayment for Medicare-covered
items
Out-of-Network DED & 20% Coinsurance
Outpatient Rehabilitation
Occupational Therapy, Physical Therapy,
Speech & Language Therapy, Cardiac and
Pulmonary Rehab (including intensive
cardiac rehab)
Office or Freestanding Facility
Services
Outpatient Hospital Services
Dialysis
$1,940 Physical and Speech Therapy Annual
Benefit Maximum
$1,940 Occupational Therapy Annual Benefit
Maximum
In-Network $30 Copayment for each visit
Out-of-Network DED & 20% Coinsurance
In-Network $30 Copayment for each visit
Out-of-Network DED & 20% Coinsurance
In-Network/Out-of-Network 20% Coinsurance
Inpatient Care
Inpatient Hospital Care
(including substance abuse treatment)
www.myFBMC.com
Y0011_31874 0815 EGWP C: 08/2015
In-Network
 $150 Copayment each day for day(s) 1-7
for a Medicare-covered stay in a network
hospital
 After the 7th day, the plan pays 100% of
covered expenses per stay
Out-of-Network DED & 20% Coinsurance
14
4
Medicare Health Plan Summary - PPO Plan 1
Florida Blue
Benefits
BlueMedicare Group PPO Plan 1
Inpatient Mental Health Care
In-Network
 $200 Copayment each day for day(s) 1-7
for a Medicare-covered stay in a network
hospital
 $0 Copayment for day(s) 8-90 for a
Medicare-covered stay in a network hospital
 190-day lifetime limit in a psychiatric
hospital
Out-of-Network DED & 20% Coinsurance
Skilled Nursing Facility
(in a Medicare-certified skilled nursing
facility)
In-Network
 $0 Copayment each day for days 1-20 per
benefit period
 $75 Copayment each day for days 21-100
per benefit period
 There is a limit of 100 days for each benefit
period
 3-day prior hospital stay is not required
Out-of-Network DED & 20% Coinsurance
Hospice
Member must receive care from a Medicarecertified hospice
Preventive Services
Annual Screening Mammograms
(for women with Medicare, age 40 and older)
In-Network $0 Copayment for Medicare-covered
screening mammograms
Out-of-Network 20% Coinsurance
Pap Smears and Pelvic Exams
(for women with Medicare)
In-Network
 $0 Copayment per Pap smear
 $0 Copayment per pelvic exam
Out-of-Network 20% Coinsurance
Bone Mass Measurement
(for people with Medicare who are at risk)
In-Network $0 Copayment for each Medicarecovered bone mass measurement
Out-of-Network 20% Coinsurance
Colorectal Screening Exams
(for people with Medicare age 50 and older)
In-Network $0 Copayment for Medicare-covered
colorectal screening exams
Out-of-Network 20% Coinsurance
Prostate Cancer Screening Exams
(for men with Medicare age 50 and older)
In-Network $0 Copayment for Medicare-covered
prostate cancer screening exams
Out-of-Network 20% Coinsurance
15
Y0011_31874 0815 EGWP C: 08/2015
www.myFBMC.com
5
Medicare Health Plan Summary - PPO Plan 1
Florida Blue
Benefits
BlueMedicare Group PPO Plan 1
Vaccines (Medicare-covered)
In-Network / Out-of-Network
 $0 Copayment for influenza vaccine
 $0 Copayment for pneumococcal vaccine
 $0 Copayment for hepatitis B vaccine
Health & Wellness Benefit
Fitness
Free membership through SilverSneakers
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 Medicare Advantage organization with a Medicare contract. Enrollment in Florida
Blue depends on contract renewal.
www.myFBMC.com
Y0011_31874 0815 EGWP C: 08/2015
16
6
Medicare Group Rx Option 1
St. Lucie County School District #24936
Florida Blue
2016 BlueMedicare Group Rx (Employer PDP)
Benefits
BlueMedicare Group Rx Option 1
Premium
Included with PPO1Rx1
Annual Deductible
$0
Retail
31-day Supply
Tier 1 - Preferred Generics
$10 Copayment
Tier 2 - Generics
$10 Copayment
Tier 3 - Preferred Brand
$40 Copayment
Tier 4 - Non-Preferred Brand
$70 Copayment
Tier 5 - Specialty Drugs
25% Coinsurance
Mail Order
90-day Supply with PRIME Mail Order
Tier 1 - Preferred Generics
$0 Copayment
Tier 2 - Generics
$0 Copayment
Tier 3 - Preferred Brand
$80 Copayment
Tier 4 - Non-Preferred Brand
$140 Copayment
Tier 5 - Specialty Drugs
25% Coinsurance (31-day supply only)
Gap
31-day Supply
Tier 1 - Preferred Generics
$10 Copayment
Tier 2 - Generics
$10 Copayment
Tier 3 - Preferred Brand
$40 Copayment
Tier 4 - Non-Preferred Brand
$70 Copayment
Tier 5 - Specialty Drugs
25% Coinsurance
Catastrophic
$2.95 Copayment for generic drugs
$7.40 Copayment for brand drugs
Florida Blue is an Rx (PDP) Plan with a Medicare contract. Enrollment in Florida Blue depends on
contract renewal.
Prescription drug copays do not accumulate towards the health plan annual 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_31876 0815 EGWP C: 08/2015
17
www.myFBMC.com
Medical Health Plan Summary - PPO Plan 2
St. Lucie County School District #24936
Florida Blue
2016 BlueMedicare Group PPO (Employer PPO) Health Benefits
Benefits
BlueMedicare Group PPO Plan 2
Premium (per member, per month)
$183.53 for PPO2Rx3
Annual Deductible (DED)
$0 In-Network / $2,000 Out-of-Network
Out-of Pocket Maximum (based on plan
year)
$2,000 In-Network / $4,000 Out-of-Network
In-Network out-of-pocket maximum accumulates
toward Out-of-Network out-of-pocket maximum
Physician Office
Primary Care (per visit)
In-Network $35 Copayment
Out-of-Network DED & 40% Coinsurance
Specialist Care (per visit)
In-Network $50 Copayment
Out-of-Network DED & 40% Coinsurance
e-Visit
In-Network $5 Copayment
Out-of-Network DED & 40% Coinsurance
Convenient Care Center
In-Network / Out-of-Network $50 Copayment
Podiatry Services (per visit)
(routine foot care up to 6 visits per year)
In-Network $50 Copayment
Out-of-Network DED & 40% Coinsurance
Chiropractic Services (per visit)
For each Medicare-covered visit (manual
manipulation of the spine to correct
subluxation)
In-Network $20 Copayment
Out-of-Network DED & 40% Coinsurance
Outpatient Mental Health Care (per visit)
For individual or group therapy
(including partial hospitalization)
In-Network $40 Copayment
Out-of-Network DED & 40% Coinsurance
Outpatient Substance Abuse Care (per visit)
In-Network $40 Copayment
Out-of-Network DED & 40% Coinsurance
Part B drugs (including chemotherapy)
In-Network 20% coinsurance
Out-of-Network DED & 40% Coinsurance
Allergy Injections
In-Network $10 Copayment
Out-of-Network DED & 40% Coinsurance
Y0011_31875 0815 EGWP C: 08/2015
www.myFBMC.com
1
18
Medical Health Plan Summary - PPO Plan 2
Florida Blue
Benefits
BlueMedicare Group PPO Plan 2
Other Services
Outpatient Surgery
In-Network
 $250 Copayment for each outpatient hospital
facility visit
 $175 Copayment for each visit to an
ambulatory surgical center
Out-of-Network DED & 40% Coinsurance
In-Network / Out-of-Network
 $0 Copayment for physician services
Diagnostic Tests, X-Rays
Office
IDTF
Lab Services
Independent Clinical Lab
Outpatient Hospital
All Locations
Advanced Imaging (MRI, MRA, CT Scan,
PET Scan and Nuclear Medicine):
Office
In-Network $50 Copayment
Out-of-Network DED & 40% Coinsurance
In-Network $100 Copayment
Out-of-Network DED & 40% Coinsurance
In-Network $0 Copayment
In-Network $30 Copayment
Out-of-Network DED & 40% Coinsurance
In-Network $175 Copayment
Out-of-Network DED & 40% Coinsurance
IDTF
In-Network $175 Copayment
Out-of-Network DED & 40% Coinsurance
Outpatient Hospital
In-Network $250 Copayment
Out-of-Network DED & 40% Coinsurance
19
Y0011_31875 0815 EGWP C: 08/2015
www.myFBMC.com
2
Medical Health Plan Summary - PPO Plan 2
Florida Blue
Benefits
Outpatient Hospital Services (per visit):
Occupational Therapy, Physical Therapy,
Speech & Language Therapy, Cardiac and
Pulmonary Rehab (including intensive
cardiac rehab)
BlueMedicare Group PPO Plan 2
In-Network $40 Copayment
Out-of-Network DED & 40% Coinsurance
$1,940 Physical and Speech Therapy Annual Benefit
Maximum
$1,940 Occupational Therapy Annual Benefit
Maximum
Radiation Therapy
In-Network $50 Copayment
Out-of-Network DED & 40% Coinsurance
Dialysis
In-Network / Out-of-Network 20% Coinsurance
Lab Only
In-Network $30 Copayment
Out-of-Network DED & 40% Coinsurance
All Other Diagnostic Tests, X-Rays,
Advanced Imaging, etc.
In-Network $250 Copayment
Out-of-Network DED & 40% Coinsurance
Urgently Needed Care
(This is not emergency care, and in most
cases is out-of-the-service area.)
In-Network / Out-of-Network $50 Copayment
Emergency Services
In-Network / Out-of-Network $75 Copayment
Worldwide Coverage
Dental, Hearing and Vision (MedicareCovered)
In-Network $50 Copayment
Out-of-Network DED & 40% Coinsurance
Home Health
In-Network / Out-of-Network $0 Copayment
Ambulance
In-Network / Out-of-Network $150 Copayment for
Medicare-covered ambulance services
www.myFBMC.com
Y0011_31875 0815 EGWP C: 08/2015
20
3
Medical Health Plan Summary - PPO Plan 2
Florida Blue
Benefits
BlueMedicare Group PPO Plan 2
Outpatient Medical Services and Supplies
Durable Medical Equipment/Diabetic
Supplies
Diabetic Supplies (glucose meters, test
strips and lancets)
Note: needles, syringes and insulin for selfinjection are covered under your Part D
benefit
In-Network $0 Copayment
Out-of-Network DED & 40% Coinsurance
Equipment: Plan-Approved Electric
Customized Wheelchairs, Electric Scooters
In-Network 20% Coinsurance
Out-of-Network DED & 40% Coinsurance
All Other Medicare-Covered Durable
Medical Equipment
In-Network $0 Copayment
Out-of-Network DED & 40% Coinsurance
Prosthetic Devices
In-Network $0 Copayment for Medicare-covered
items
Out-of-Network DED & 40% Coinsurance
Outpatient Rehabilitation
Occupational Therapy, Physical Therapy,
Speech & Language Therapy, Cardiac and
Pulmonary Rehab (including intensive
cardiac rehab)
Office or Freestanding Facility
Services
Outpatient Hospital Services
Dialysis
$1,940 Physical and Speech Therapy Annual Benefit
Maximum
$1,940 Occupational Therapy Annual Benefit
Maximum
In-Network $40 Copayment for each visit
Out-of-Network DED & 40% Coinsurance
In-Network $40 Copayment for each visit
Out-of-Network DED & 40% Coinsurance
In-Network/Out-of-Network 20% Coinsurance
Inpatient Care
Inpatient Hospital Care
(including substance abuse treatment)
In-Network
 $250 Copayment each day for day(s) 1-7 for
a Medicare-covered stay in a network
hospital
 After the 7th day, the plan pays 100% of
covered expenses per stay
Out-of-Network DED & 40% Coinsurance
21
Y0011_31875 0815 EGWP C: 08/2015
www.myFBMC.com
4
Medical Health Plan Summary - PPO Plan 2
Florida Blue
Benefits
BlueMedicare Group PPO Plan 2
Inpatient Mental Health Care
In-Network
 $250 Copayment each day for day(s) 1-7 for
a Medicare-covered stay in a network
hospital
 $0 Copayment for day(s) 8-90 for a
Medicare-covered stay in a network hospital
 190-day lifetime limit in a psychiatric hospital
Out-of-Network DED & 40% Coinsurance
Skilled Nursing Facility
(in a Medicare-certified skilled nursing
facility)
In-Network
 $0 Copayment each day for days 1-20 per
benefit period
 $100 Copayment each day for days 21-100
per benefit period
 There is a limit of 100 days for each benefit
period
 3-day prior hospital stay is not required
Out-of-Network DED & 40% Coinsurance
Hospice
Member must receive care from a Medicare-certified
hospice
Preventive Services
Annual Screening Mammograms
(for women with Medicare, age 40 and older)
In-Network $0 Copayment for Medicare-covered
screening mammograms
Out-of-Network 40% Coinsurance
Pap Smears and Pelvic Exams
(for women with Medicare)
In-Network
 $0 Copayment per Pap smear
 $0 Copayment per pelvic exam
Out-of-Network 40% Coinsurance
Bone Mass Measurement
(for people with Medicare who are at risk)
In-Network $0 Copayment for each Medicarecovered bone mass measurement
Out-of-Network 40% Coinsurance
Colorectal Screening Exams
(for people with Medicare age 50 and older)
In-Network $0 Copayment for Medicare-covered
colorectal screening exams
Out-of-Network 40% Coinsurance
Prostate Cancer Screening Exams
(for men with Medicare age 50 and older)
In-Network $0 Copayment for Medicare-covered
prostate cancer screening exams
Out-of-Network 40% Coinsurance
www.myFBMC.com
Y0011_31875 0815 EGWP C: 08/2015
22
5
Medical Health Plan Summary - PPO Plan 2
Florida Blue
Benefits
BlueMedicare Group PPO Plan 2
Vaccines (Medicare-covered)
In-Network / Out-of-Network
 $0 Copayment for influenza vaccine
 $0 Copayment for pneumococcal vaccine
 $0 Copayment for hepatitis B vaccine
Supplemental Benefit
Fitness
Free membership through SilverSneakers
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. Enrollment in Florida Blue depends on contract
renewal.
23
Y0011_31875 0815 EGWP C: 08/2015
www.myFBMC.com
6
Medicare
Group Rx Option 3
St. Lucie County School District #24936
Florida
Blue
2016 BlueMedicare
Group
Rx (Employer PDP)
Benefits
BlueMedicare Group Rx Option 3
Premium
Included with PPO2Rx3
Annual Deductible
$75 for Brand Drugs Only
Retail
31-day Supply
Tier 1 - Preferred Generics
$10 Copayment
Tier 2 - Generics
$10 Copayment
Tier 3 - Preferred Brand
$45 Copayment
Tier 4 - Non-Preferred Brand
$95 Copayment
Tier 5 - Specialty Drugs
33% Coinsurance
Mail Order
90-day Supply with PRIME Mail Order
Tier 1 - Preferred Generics
$10 Copayment
Tier 2 - Generics
$10 Copayment
Tier 3 - Preferred Brand
$135 Copayment
Tier 4 - Non-Preferred Brand
$285 Copayment
Tier 5 - Specialty Drugs
33% Coinsurance (31-day supply only)
Gap
31-day Supply
Tier 1 - Preferred Generics
$10 Copayment
Tier 2 - Generics
$10 Copayment
Tier 3 - Preferred Brand
45% Coinsurance
Tier 4 - Non-Preferred Brand
45% Coinsurance
Tier 5 - Specialty Drugs
58% Coinsurance (Generic) / 45% Coinsurance (Brand)
Catastrophic
Greater of $2.95 Copayment or 5% Coinsurance for generic drugs
Greater of $7.40 Copayment or 5% Coinsurance for brand drugs
Florida Blue is an Rx (PDP) Plan with a Medicare contract. Enrollment in Florida Blue depends on
contract renewal.
Prescription drug copays do not accumulate towards the health plan calendar year out-of-pocket
maximum.
After your total Plan Year drug costs reach $3,310 you enter the Coverage Gap. During the Coverage
Gap, coverage for generic drugs remains the same as during the Initial Coverage Period. For brand
drugs, you will pay 45% on the negotiated manufacturer’s plan cost for the drugs.
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_31878 0815 EGWP C: 08/2015
www.myFBMC.com
24
Dental Plan
2016
Dental
Benefits
2016
Dental
Benefits
for for
St. Lucie
County
School
Board
-COBRA
Retirees
COBRA
Dental
PPO
for
both
and
Retiree
St. Lucie
County
School
Board
- Retirees
andand
COBRA
BlueDental Choice
BlueDental Choice
Low
Low
Financial Features
Financial Features
Deductible (Basic & Major Services Only)
Deductible
(BasicPer
& Major
Services Only)
Per Person
Plan Year
Per Person
Per Plan
Per Family
PerYear
Plan Year
Per Family
Per Plan
Year credits apply to Out-of-Network
In-Network
deductible
BlueDental Choice
BlueDental Choice
High
High
In-Network
In-Network
Out-of-Network
Out-of-Network
In-Network
In-Network
Out-of-Network
Out-of-Network
$50
$50 $150
$150
$50
$50 $150
$150
$50
$50 $150
$150
$50
$50 $150
$150
In-Network
deductible
credits apply to Out-of-Network
deductible
and Out-of-Network
deductible credits apply to Indeductible
and Out-of-Network
deductible credits apply to InNetwork
deductible.
Network deductible.
Coinsurance *
Coinsurance *
Participants
We Pay You Pay We Pay You Pay We Pay You Pay We Pay You Pay
We Pay You Pay We Pay You Pay We Pay You Pay We Pay You Pay
PREVENTIVE **
PREVENTIVE **
100 %
100 %
0%
BASIC **
BASIC **
80%
80%
20%
80%
20%
90%
10%
80%
20%
20%
80%
20%
90%
10%
80%
20%
MAJOR **
MAJOR **
50%
50%
50%
50%
50%
60%
40%
50%
50%
50%
50%
50%
60%
40%
50%
50%
0%
100%
100%
0%
0%
100%
100%
0%
0%
90%
90%
10%
10%
Service Highlights
Service Highlights
Oral Evaluations (Exams)
Oral Evaluations
(Exams)
Bitewing X-ray
Bitewing
X-ray
Prophylaxis/Periodontal
Cleanings (4) – Adult/Child
Prophylaxis/Periodontal
– Adult/Child
Fluoride TreatmentCleanings
(No age (4)
limit)
Fluoride
Treatment
Office
Visits (No age limit)
Office X-rays
Visits – Intraoral/Complete Series/Panoramic
X-raysSealants
– Intraoral/Complete Series/Panoramic
Sealants
Amalgam Restorations (Silver Fillings)
Amalgam
Restorations
(Silver Fillings)
Resin-Based
Restorations
(Anterior and Posterior)
Resin-Based
Restorations (Anterior and Posterior)
Extractions
Extractions
Surgical Extractions
Surgical
Extractions
Root
Canal Therapy
Root Canal
Therapy
Periodontal
Treatment
Periodontal Treatment
Crowns
Crowns
Osseous Surgery
Osseous
SurgeryDentures
Complete
Complete
Dentures
Partial
Dentures
PartialFixed
Dentures
Partial Dentures (Bridges)
Fixed Partial
Dentures
(Bridges)
Surgical
Placement
of Implant Body
Surgical
Placement
of Implant
BodyFused to Metal Crown
Implant
Supported
Porcelain
Implant Supported Porcelain Fused to Metal Crown
Orthodontia Services (children to age 19)
Orthodontia
Services
(children
to age 19)
Orthodontia
Lifetime
Maximum
Orthodontia
Lifetime
Maximum
BlueDental
Pays
BlueDental
Pays
Benefit
Waiting Period
Benefit Waiting Period
Preventive
Preventive
Basic
Major
Preventive
Preventive
Basic
Basic
Major
Major
Basic
Major
Waiting Period: (Major Services)
Waiting Period: (Major Services)
$500
$500 50%
50% NONE
NONE
NONE
NONE
$1,000
$1,000 50%
50% NONE
NONE
NONE
NONE
Calendar Year Maximum Per Person
Calendar Year Maximum Per Person
$1,000
$1,000
$1,500
$1,500
Procedures Performed By Specialist
Procedures Performed By Specialist
Covered
Covered
Covered
Covered
Dental Rollover
Dental Rollover
TYPE OF COVERAGE
TYPE OF COVERAGE
Employee
Employee
Employee Plus 1
Employee Plus 1
Employee Plus 2 or more
Employee Plus 2 or more
Yes
RETIREE
RETIREE
$29.52
$29.52
$62.02
$62.02
$106.83
$106.83
Yes
Yes
MONTHLY PREMIUM
MONTHLY PREMIUM
COBRA
COBRA
$30.11
$30.11
$63.26
$63.26
$108.97
$108.97
RETIREE
RETIREE
$35.98
$35.98
$75.70
$75.70
$133.45
$133.45
Yes
COBRA
COBRA
$36.70
$36.70
$77.21
$77.21
$136.12
$136.12
The information provided above is a summary of benefits for the group Choice certificate. It is intended to highlight key points of the Dental Plan and is
The information
above as
is aan
summary
of benefits
for the
Choice
certificate.
It is intended
toinhighlight
points of the
is
provided toprovided
the employee
aid in deciding
whether
to group
enroll in
the Plan.
This summary
should
no way key
be construed
as Dental
a part ofPlan
the and
contract.
provided
to the employee
as an aidininno
deciding
whether
to enroll
in does
the Plan.
This summary
noplan.
way be construed as a part of the contract.
Possession
of this summary
way implies
coverage
nor
it guarantee
benefitsshould
under in
the
Possession of this summary in no way implies coverage nor does it guarantee benefits under the plan.
* Percentage of fee schedule
* Percentage
fee schedule
** Someoflimitations
may apply
** Some
may
apply
*** limitations
Percentage
of fee
schedule + balance of any charges; non-par dentists may charge fees in excess of our Fee Schedule and may bill you the
*** Percentage
of
fee
schedule
+ balance of any charges; non-par dentists may charge fees in excess of our Fee Schedule and may bill you the
difference.
difference.
25
www.myFBMC.com
Dental Plan
Dental PPO for both COBRA and Retiree Participants
Maximum Rollover - Maximum Rollover is a BlueDental Choice benefit
that rewards you just for visiting the dentist. Each year when you visit
the dentist and use less than the yearly claim payment threshold, you’ll
receive Rollover dollars to help cover future unexpected visits or higher
out-of-pocket costs for complex procedures.
BlueDental Choice
Did you know that dental health can have an influence on the
development of conditions such as diabetes, coronary artery disease
and low-birth-weight, premature babies? An undeniable relationship
exists between a healthy mouth and overall good health. That means it
is more important than ever for you to receive regular preventive dental
care that will help you maintain not only your good oral health, but
your good health in general.
It’s that easy. Maximum Rollover is applied automatically as long as:
• You receive at least one covered service during your plan year
• You are an active member of your plan on the last day of the plan year
• You don’t exceed the claim payment threshold in your plan year
BlueDental ChoiceSM is a flexible PPO plan designed to encourage
regular cleanings and preventive services that lead to good oral health
and better overall health.
Benefits
Our dental PPO network consists of a network of quality dentists who
have agreed to provide services based on a negotiated fee. When you
use a participating dentist in the BlueDental Choice network* for your
plan, you’ll receive maximum plan benefits and be protected against
balance billing (the difference between the BlueDental Choice fee
schedule and the dentist’s normal charges). You also have the option of
visiting a non-participating dentist although balance billing may occur.
Orthodontic Discount Program** – When you choose an orthodontist
in our orthodontic provider network, you’ll receive 20 percent off your
total case fee. This discount is only available to you when orthodontic
coverage is not part of your plan.
Cosmetic Dental Discount Program** – You can experience significant
savings on cosmetic dentistry procedures by visiting a dentist who
participates in our cosmetic dentistry network. As a BlueDental Choice
member, you’ll receive a 20-percent savings on the following procedures:
• Cosmetic Contouring
• Laminate Veneer (porcelain or composite)
• Whitening (in office or at-home system)
As a BlueDental Choice member you can look forward to:
• No referrals or authorizations to see a general dentist or specialist
• Access to one of the largest dental networks in Florida
• Access to a vast national network
The following example shows how your Maximum Rollover amount is determined.
If your annual benefit
maximum is:
AND your total claims
paid for the benefit
period do not exceed:
THEN we will rollover
Accumulated totals will be
capped at:
$1,000 - $1,249
$500
$350
$1,000
$1,250 - $1,499
$600
$450
$1,250
$1,500 - $1,999
$700
$500
$1,250
$2,000 - $2,499
$800
$600
$1,500
To see a list of the dentists in our network, visit www.floridabluedental.com. Don’t see your dentist in our network? Send an e-mail to
FCLProvidernomination@FCLife.com or fax your nomination to (904) 866-4846.
Questions? Need more information? Our Customer Service representatives can help. Just call (888) 223-4892 from 8 a.m. to 8 p.m. Monday through
Friday.
*Networks are comprised of independent contracted dentists.
**Certain dentists have voluntarily agreed to offer a 20% discount off their usual charge for non-covered cosmetic or orthodontic services. These dentists are identified by an affiliation to either the Cosmetic Dental
Discount Program or Orthodontic Discount Program. Because these dentists are neither contractually nor legally bound to offer these discounts, we recommend that you contact the provider to inquire about
the continued availability of any discount prior to scheduling an appointment.
www.myFBMC.com
26
Vision Plan
Vision Plan for both COBRA and Retiree Participants
There are two vision care options available, the In-Network Option and
the Out-of-Network Option.
• In-Network Option: You choose a doctor from the panel provider list.
Services are provided at predetermined rates.
• Out-of-Network Option: You can choose any eye doctor. You are
reimbursed a percentage of your costs.
In-Network Option and Out-of-Network
Option
Copayment/Credit Schedule
IN-NETWORK
EYE DOCTOR
(up to plan
maximums)
Vision Examination
Covered in full
Materials
Single Vision Lenses Covered in full
Bifocal Lenses
Covered in full
Trifocal Lenses
Covered in full
Lenticular Lenses
Covered in full
Frames
$30 retail allowance
Contact Lenses
Medically Necessary Covered in full
Elective
$85 allowance
(in lieu of exam, frames and lenses)
Plan Features
•
•
•
•
•
No deductible
Examination — Once every 12 months
Lenses — Once every 12 months, if necessary
Frames — Once every 12 months, if necessary
Contact Lenses — Once every 12 months (in place of exam, lenses
and frames)
• Refractive Care — Vision Care Plan (VCP) offers the LASIK procedure
for plan members who are nearsighted or have astigmatism and
wear glasses or contacts. You may also use independent Lasik
provider-network doctors to receive a ten percent discount from
usual and customary prices and pay no more than $1,800 per eye
for conventional Lasik and $2,300 per eye for custom Lasik, due to
SB632.
To utilize the Refractive Care program, members first contact VCP
to request a LASIK ID card and a list of network eye doctors for
initial screening to determine if the patient is a candidate for LASIK.
If the patient qualifies, the doctor can also make arrangements for
the procedure with one of the LASIK centers that participates in this
program. Plan members can also go directly to one of the participating
RefractiveCare ophthalmologists.
OUT-OF-NETWORK
EYE DOCTOR*
$35 reimbursement
$25 reimbursement
$40 reimbursement
$60 reimbursement
$100 reimbursement
$30 reimbursement
$210 reimbursement
$85 reimbursement (in lieu of exam, frames and lenses)
*Please note: Amounts shown above are maximums.
Plan Provider
Humana/CompBenefits underwrites the Vision plan. Call VisionCare Plan at
1-800-865-3676 to obtain your claim forms prior to going to the eye
doctor. For questions regarding your vision benefit, call VisionCare,
visit the VisionCare website at www.compbenefits.com or call
FBMC Service Center at 1-855-LUCIE4U (1-855-582-4348).
Exclusions
• Orthoptics or vision training, subnormal vision aids, aniseikonic
lenses or plan (non-prescription) lenses
• Medical or surgical treatment of the eyes
• Two pairs of glasses in lieu of bifocals
• Broken or lost frames or lens replacement, except at specified times
• Workers’ Compensation-provided services and materials; any
employer-required exam; other group plan-provided services or
materials and
• Services or materials not obtained in the prescribed procedure
For vision care questions, please contact VisionCare Plan Member
Services online at www.compbenefits.com or call 1-800-865-3676,
Mon - Fri, 8 a.m. - 5 p.m. ET.
Your Monthly VisionCare Rates
Coverage
Participant only
Participant & Family
Retiree
$6.00
$16.94
COBRA
$6.12
$17.28
27
www.myFBMC.com
Group Hospital Indemnity Insurance
For Retiree Participants Only
What’s Not Covered
Group Hospital Indemnity Insurance provides daily benefits if you or
your covered dependents are hospitalized for a covered sickness or
injury.
• Suicide attempts or intentionally self-inflicted injuries
• Injuries or sickness resulting from declared or undeclared war or any
act thereof, or sustained while serving in the armed forces of any
country
• Treatment for injuries or sicknesses covered by Workers’ Compensation
• Treatment for the prevention or cure of narcotic addiction or
alcoholism
• Injuries sustained in the commission of a felony or while in jail
The 19 levels of daily coverage are:
$10 $15 $20 $25 $30 $35 $40
$45 $50 $55 $60 $65 $70 $75
$80 $85 $90 $95 $100
Plan Features
• Benefits start on the first day of hospitalization.
• Benefits continue up to 365 days or until you are discharged,
whichever occurs first for each injury or sickness.
• You may continue this benefit if you retire from School Board
employment by submitting an Employee Change In Status Form to
FBMC Benefits Management, Inc., within the 60-day period preceding
your retirement.
• Your coverage will continue as long as the Group Master Policy
remains in effect, you pay your premiums and you remain eligible
for coverage under the plan.
Plan Provider
Fidelity Security Life Insurance Company underwrites this plan. Fidelity
Security Life Insurance Company has been rated “A-”, Excellent, based
on an analysis of financial position and operating performance by A.M.
Best Company, an independent analyst of the insurance industry.
Policy Form #M-00116
Policy No. HP-5
Your Group Hospital Indemnity Insurance Rates
24 PAY PERIODS - DAILY BENEFIT AMOUNT
Coverage
$10
$15
$20
$25
$30
$35
$40
$45
$50
Retiree Only
$1.60
$2.40
$3.20
$4.00
$4.80
$5.60
$6.40
$7.20
$8.00
Retiree & Family
$3.60
$5.40
$7.20
$9.00
$10.80
$12.60
$14.40
$16.20
$18.00
$55
$60 $65
$70
$75
$80
$85
$90
$95
$100
Retiree Only $8.80
$9.60 $13.60
$14.40
$15.20
$16.00
Retiree & Family
$19.80 $21.60 $23.40 $30.60
$32.40
$34.20
$36.00
Coverage
www.myFBMC.com
$10.40 $11.20 $12.00 $12.80
$25.20 $27.00 28
$28.80
Group Term Life Insurance
For Retiree Participants Only
If you’re like most people, you want to make sure that your loved ones
are adequately provided for if something happens to you.
Your Monthly Group Term Life Insurance
Rates Based on Your Age as of 1/1/2016
There are a number of levels of group term
life insurance: $10,000
$30,000
$50,000
Retirees under 65
$15,000 $20,000$25,000
$35,000
$40,000 $45,000
You may continue the life insurance level you had in force at the time
of your retirement. During Open Enrollment, you may decrease or
cancel your retiree life insurance. You may not increase your level of
coverage.
Premium Waiver
You can apply for a premium waiver if you have been totally disabled
for nine consecutive months while insured. Call FBMC Service Center at
1-855-LUCIE4U (1-855-582-4348) for a waiver of premium application.
Coverage Level At Ages 65 and 70
Your benefits decrease by 35 percent at age 65. All benefit amounts in
excess of $3,000 will reduce to $3,000 at age 70.
How to File a Claim:
1. The listed beneficiary must notify FBMC Service Center of the claim
to begin the process.
2. The listed beneficiary must provide the following
• The date of death
• Caller’s name and relationship to insured
• The name, address and phone number of the caller
3. The following forms and proofs will be required for submission,
including:
• A completed claim form by beneficiary (if more than one,
each beneficiary must complete a form)
• Certified copy of death certificate
• If an accidental death, an autopsy report and the police
accident or investigation report will be required.
4. If a claim process is started through FBMC Benefits Management,
letters will be sent to the beneficiary requesting all the forms needed
to process the claim. FBMC will forward the claim to FSL for final
processing.
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
$45,000
$50,000
under 30
$3.10
$3.65
$4.00
$4.75
$5.30
$5.85
$6.40
$6.95
$7.50
30-34
$3.10
$3.75
$4.40
$5.05
$5.70
$6.35
$7.00
$7.65
$8.30
35-39
$3.10
$3.95
$4.80
$5.65
$6.50
$7.35
$8.20
$9.05
$9.90
40-44
$3.10
$4.60
$6.10
$7.60
$9.10
$10.60
$12.10
$13.60
$15.10
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
$45,000
$50,000
45-49
$3.10
$5.50
$7.90
$10.30
$12.70
$15.10
$17.50
$19.90
$22.30
50-54
$3.10
$6.95
$10.80
$14.65
$18.50
$22.35
$26.20
$30.05
$33.90
55-59
$3.10
$8.85
$14.60
$20.35
$26.10
$31.85
$37.60
$43.35
$49.10
60-64
$3.10
$11.45
$19.80
$28.15
$36.50
$44.85
$53.20
$61.55
$69.90
Retiree age 65 and over, but under 70
$6,500
$9,750
$13,000
$16,250
$19,500
$22,750
$26,000
$29,750
$32,500
Plan Provider
Fidelity Security Life Insurance Company (FSL) underwrites this plan.
Fidelity Security Life Insurance Company has been rated “A-” (Excellent),
based on an analysis of financial position and operating performance by
A.M. Best Company, an independent analyst of the insurance industry.
For the latest rating, visit www.ambest.com.
65-69
$2.02
$3.02
$10.48
$18.48
$26.47
$34.47
$42.46
$50.46
$58.45
Retiree age 70 and over 70 +
$3,000
$0.93
Policy Form #ML-00072
Policy No. TL-30
29
www.myFBMC.com
Group Cancer Insurance Plan
For both COBRA and Retiree Participants
With improved medical technologies, your chances of surviving cancer
are better today than ever before. This plan helps cover the cost of
procedures and treatments for you and your covered dependents and
pays benefits in addition to any other medical coverage you have.
Your Monthly Cancer Protection Rates
Coverage
RetireeCOBRA
Participant $6.90
$7.04
Participant & Family
$10.86
$11.08
Plan Features:*
•  Benefits are paid directly to you
•  Pays regardless of other insurance
• $100 per day during the first 90 cumulative days that you are
hospitalized for cancer. After 91 cumulative days, hospital expenses
are fully covered up to $5,000 per month, in lieu of all other
benefits
• Up to $1,500 for radiation treatment, chemotherapy and X-rays, (does
not include diagnostic procedures)
• Up to $120 for anesthesiologist services ($40 for skin cancer)
• Up to $1,000 for surgery (per surgery schedule)
• Up to $1,200 for blood and plasma (no maximum for leukemia)
• Up to $30 per day for a private duty nurse ($750 maximum) and
• Up to $50 per ambulance service per confinement ($500
maximum).
• Cancer Screening Benefit for the insured/insured spouse that pays 50
percent up to $50 according to the baseline schedule (shown below)
per benefit period for a screening by low-dose mammography** for
the presence of occult breast cancer A diagnosis of cancer is not
necessary for this benefit to be payable.
Mammography Baseline Schedule
1 baseline - age 35 to 40
1 every two years - age 40 to 50
1 every year - age 50+
Eligibility
If you, your spouse or your unmarried dependent children under age 25
(must be dependent upon you for support and living in your household
or a full-time student) have received no medical treatment for any type
of cancer within 10 years of your plan’s effective date, you are eligible
for the Cancer Protection plan. Your coverage will continue for as long
as the Group Master Policy remains in effect, you pay your premiums,
and you remain eligible for coverage under the plan.
What’s Not Covered
• Cancer that materializes before you have been insured for 30
continuous days will not be covered until after 12 months of
coverage
• Illnesses or injuries other than cancer and
• Treatment received from a VA or other government hospital unless
you are legally required to pay in the absence of insurance.
How to File a Claim:
1. Contact the FBMC Service Center to obtain a “Statement of Cancer
Claim” form to begin the process; or, you may contact Fidelity Security
Life Insurance Company directly to obtain a form and file a claim.
2. Please complete the “Statement of Cancer Claim” form and forward
to the physician and request that the Attending Physician Statement
be completed.
3. After the Attending Physician Statement is completed, submit it and
the completed claim form along with a copy of the pathologist’s report
and any bills for covered expenses to Fidelity Security Life Insurance
Company.
4. If a claim process is started through FBMC Benefits Management,
letters will be sent to the insured requesting all the forms needed
to process the claim. FBMC will forward the claim to FSL for final
processing.
* Note: All benefits are maximums per illness period. An illness period begins when expenses are
first incurred. Following a period of at least 45 days during which no eligible expense is incurred,
any eligible expenses incurred thereafter will begin a new illness period. All benefits reduce by 50
percent at age 65.
** low-dose mammography means X-ray examinations of the breast using equipment dedicated
specifically for mammography.
Plan Provider
Fidelity Security Life Insurance Company underwrites this plan. Fidelity
Security Life Insurance Company has been rated “A-” (Excellent), based
on an analysis of financial position and operating performance by A.M.
Best Company, an independent analyst of the insurance industry. For
the latest rating, visit www.ambest.com.
Policy Form #M-7000-FL
Policy No. CA-54
www.myFBMC.com
30
Creditable Coverage Notice
Important Notice from St. Lucie County School Board
About Your Prescription Drug Coverage and Medicare
Please note that this notice only pertains to you if:
 You are Medicare eligible (over age 65 or considered disabled by the Social
Security Administration) and currently covered or eligible for coverage under the
health plan sponsored by St. Lucie County School Board for retired employees, or
 You have a dependent spouse/domestic partner or child who is covered by
Medicare or Medicaid and who is currently covered or eligible for coverage under
the health plan sponsored by St. Lucie County School Board for employees and
retired employees.
Please read this notice carefully and keep it where you can find it. This notice has
information about your current prescription drug coverage with St. Lucie County School
Board and about your options under Medicare’s prescription drug coverage. This
information can help you decide whether or not you want to join a Medicare drug plan. If
you are considering joining, you should compare your current coverage, including which
drugs are covered at what cost, with the coverage and costs of the plans offering
Medicare prescription drug coverage in your area. Information about where you can get
help to make decisions about your prescription drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and
Medicare’s prescription drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with
Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or
join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug
coverage. All Medicare drug plans provide at least a standard level of coverage set by
Medicare. Some plans may also offer more coverage for a higher monthly premium.
2. St. Lucie County School Board has determined that the prescription drug coverage
offered by the St. Lucie County School Board Prescription Drug Plan is, on average for
all plan participants, expected to pay out as much as standard Medicare prescription drug
coverage pays and is therefore considered Creditable Coverage. Because your existing
coverage is Creditable Coverage, you can keep this coverage and not pay a higher
premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each
year from October 15th to December 7th.
31
www.myFBMC.com
Creditable Coverage Notice
However, if you lose your current creditable prescription drug coverage, through no fault
of your own, you will also be eligible for a two (2) month Special Enrollment Period
(SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A
Medicare Drug Plan?
While you have Creditable Coverage, you can decline coverage under Medicare Part D
and if you decide to enroll in Medicare Part D in the future, you will not be assessed a
late payment charge by the Center for Medicare and Medicaid Services (CMS). This
letter serves as your “Notice of Creditable Coverage.” If you are covered under the St.
Lucie County School Board Prescription Drug Plan, you have Creditable Coverage.
 Enrollment for Medicare Part D for the 2016 calendar year begins October 15,
2015 and runs through December 7, 2015. If you elect the St. Lucie County
School Board Prescription Drug Plan for 2016, you will have Creditable Coverage
and you can choose to delay enrollment in Medicare Part D without paying a
Medicare Part D late enrollment penalty. As long as you maintain Creditable
Coverage, you will not be assessed a late enrollment penalty if you choose to
enroll in Medicare Part D at a later date. Individuals can enroll in a Medicare
prescription drug plan when they first become eligible for Medicare. If you leave
employment during the year, you may be eligible for a Special Enrollment Period
to sign up for a Medicare prescription drug plan.
 If you enroll or your dependent enrolls in Medicare Part D for the 2016 calendar
year, you or your dependent cannot maintain coverage in the St. Lucie County
School Board Prescription Drug Plan. If you or one of your dependents enrolls in
Medicare Part D, you must disenroll them from the St. Lucie County School
Board Prescription Drug Plan. To disenroll yourself or your dependent from
prescription coverage, please call Risk Management. You will be able to re-enroll
in the St. Lucie County School Board Prescription Drug Plan in the future during
each annual open enrollment.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare
Drug Plan?
You should also know that if you drop or lose your current coverage with St. Lucie
County School Board and don’t join a Medicare drug plan within 63 continuous days
after your current coverage ends, you may pay a higher premium (a penalty) to join a
Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage,
your monthly premium may go up by at least 1% of the Medicare base beneficiary
premium per month for every month that you did not have that coverage. For example, if
you go nineteen months without creditable coverage, your premium may consistently be
www.myFBMC.com
32
Creditable Coverage Notice
at least 19% higher than the Medicare base beneficiary premium. You may have to pay
this higher premium (a penalty) as long as you have Medicare prescription drug coverage.
In addition, you may have to wait until the following October to join.
For More Information About This Notice Or Your Current Prescription
Drug Coverage...
Contact the Risk Management Department for further information. NOTE: You’ll get
this notice each year. You will also get it before the next period you can join a Medicare
drug plan, and if this coverage through St. Lucie County School Board changes. You also
may request a copy of this notice at any time.
For More Information About Your Options Under Medicare
Prescription Drug Coverage...
More detailed information about Medicare plans that offer prescription drug coverage is
in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every
year from Medicare. You may also be contacted directly by Medicare drug plans.
For more information about Medicare prescription drug coverage:



Visit www.medicare.gov
Call your State Health Insurance Assistance Program (see the inside back cover of
your copy of the “Medicare & You” handbook for their telephone number) for
personalized help
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-4862048.
If you have limited income and resources, extra help paying for Medicare prescription
drug coverage is available. For information about this extra help, visit Social Security on
the web at www.socialsecurity.gov , or call them at 1-800-772-1213 (TTY 1-800-3250778).
Remember: Keep this Creditable Coverage notice. If you decide to join
one of the Medicare drug plans, you may be required to provide a copy
of this notice when you join to show whether or not you have
maintained creditable coverage and, therefore, whether or not you are
required to pay a higher premium (a penalty).
Date:
Name of Entity/Sender:
Contact--Position/Office:
Address:
Phone Number:
09/15/15
St. Lucie County School Board
Risk Management
4204 Okeechobee Road, Fort Pierce, FL 34947
(772) 429-5520
33
www.myFBMC.com
Benefits Directory
Florida Blue
Customer Service - Commercial Plans Retirees/COBRA
Mon - Fri, 8 a.m. - 6 p.m. ET
1-800-352-2583
www.floridablue.com
Florida Blue
BlueMedicare Group PPO Plans 1 & 2
Customer Service
Mon - Fri, 8 a.m. - 9 p.m. ET
1-800-926-6565
www.bluemedicarefl.com
Florida Combined Life Dental
Customer Service
1-888-223-4892
Mon – Fri, 8 a.m. – 5 p.m.
www.floridabluedental.com
VisionCare Plan (VCP),
A Humana/CompBenefits Company
(Vision)
Member Services
Mon - Fri, 8 a.m. - 5 p.m. ET
1-800-865-3676
Fidelity Security Life
Insurance Company
(Group Hospital Indemnity Insurance, Group Term Life
and Group Cancer Insurance)
FBMC Service Center
Mon - Fri, 7 a.m. - 7 p.m. ET
1-855-LUCIE4U (1-855-582-4348)
PayFlex Systems USA, Inc.
(COBRA Services)
Benefits Billing Department
P.O. Box 2239 Omaha, NE 68103-2239
1-855-LUCIE4U (1-855-582-4348)
Fax: 402-231-4302
E-mail: cobramail@payflex.com
www.healthhub.com
FBMC Benefits Management, Inc.
Retiree and Direct Bill Department
P.O. Box 10789
Tallahassee, FL 32302-2789
Service Center 1-855-LUCIE4U (1-855-582-4348)
www.myrsc.com
Health Equity
(Health Savings Account/Benk)
1-866-346-5800
www.healthequity.com
Transamerica
(Existing Universal Life and Long-term Care policies)
Universal Life
1-800-322-0426
Long-term Care
1-800-227-3740
Trustmark
(Existing Accident, Critical Illness, Life Events
and Universal Life policies)
1-800-918-8877
www.trustmarksolutions.com
Contract Administrator
FBMC Benefits Management, Inc.
P.O. Box 1878 • Tallahassee, Florida 32302-1878
Service Center 1-855-LUCIE4U (1-855-582-4348)
www.myrsc.com
Information contained herein does not constitute an insurance
certificate or policy. Certificates will be provided to participants
following the start of the plan year, if applicable.
© FBMC 2015
FBMC/SLCSB_CR/0915