2015
BENEFITS
MADE
SIMPLE
St. Lucie County Schools
Flexible Benefits Plan
Reference Guide
COBRA & Retiree Participants
2015 St. Lucie County Schools
Table of Contents
4
Enrollment at a Glance
6
COBRA Eligibility Requirements
7
Florida Blue Health Benefits Summary
10
Group Health Plan Premiums
11
Medicare PPO Health Summary
23
Dental Plan
25
Vision Care
26
Group Hospital Indemnity Insurance
27
Group Term Life Insurance
28
Group Cancer Insurance Plan
29
Creditable Coverage Notice
PayFlex – FBMC’s COBRA
Outsource Provider
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 30 for more details.
www.myFBMC.com
2
2015 St. Lucie County Schools
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 21, 2014.
• 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 21, 2014 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 21, 2014 to:
• 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.
FBMC Benefits Management 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.
3
www.myFBMC.com
Enrollment at a Glance
Retiree Open Enrollment
Important Dates to Remember
Your Open Enrollment dates are:
November 3, 2014, through November 21, 2014.
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, 2015, through December 31, 2015.
Please refer to the information contained on your current Benefit Statement
and in this guide when making selections for the 2015 Plan Year.
If you are making changes to your benefits, you must complete a 2015
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 at www.floridablue.com.
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, 2015.
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 2015 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 will
be the same date your Medicare becomes effective, usually the first day
of the month in which you turn 65. 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.
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.
COBRA Open Enrollment
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 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 2015 Plan Year.
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.
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, 2014. For more
information, contact FBMC Service Center at 1-855-LUCIE4U (1-855582-4348), Monday - Friday, 7 a.m. - 7 p.m. ET.
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, 2015,
through December 31, 2015, 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
Summary
Summary of
of Benefits
Benefits for
for
St.
St. Lucie
Lucie County
County School
School Board
Board 1-1-14
1-1-14 thru
thru 12-31-14
12-31-14
Florida Blue
COST
COSTSHARING
SHARING
Maximums
Maximumsshown
shownare
arePer
PerBenefit
BenefitPeriod
Period
(BPM)
(BPM)unless
unlessnoted
noted
Deductible
Deductible(DED)
(DED)(Per
(PerPerson/Family
Person/FamilyAgg)
Agg)
COST SHARING
In-Network
In-Network
Maximums shown are Per Benefit Period
Out-of-Network
Out-of-Network
(BPM) unless
noted Responsibility)
Coinsurance
(Member
Coinsurance
(Member
Responsibility)
In-Network
In-Network
Out-of-Network
Out-of-Network
BlueOptions
BlueOptions
05771
05771
“Network
“NetworkBlue”
Blue”
Only
OnlyAvailable
Available
to
toEmployees
Employeeshired
hired
prior
priorto
to1/1/14
1/1/14
BlueOptions
$1,500
$1,500/ /$4,500
$4,500
05771 / $13,500
$4,500
$4,500
/ $13,500
BlueOptions
BlueOptions
HSA-Compatible
HSA-Compatible05180
05180
(Single
(SingleCoverage)
Coverage)
“Network
“NetworkBlue”
Blue”
BlueOptions
BlueOptions
HSA-Compatible
HSA-Compatible05181
05181
(Family
(FamilyCoverage)
Coverage)
“Network
“NetworkBlue”
Blue”
BlueOptions
$1,500
$3,000
$1,500/ /Not
NotApplicable
ApplicableBlueOptions
$3,000/ /$3,000
$3,000
HSA-Compatible
05180
HSA-Compatible$6,000
05181 / $6,000
$3,000
$3,000/ /Not
NotApplicable
Applicable
$6,000
/ $6,000
(Single Coverage)
(Family Coverage)
“Network Blue”
“Network Blue”
“Network Blue”
Only Available
20%
20%
To Employees
hired
50%
ofofto
Allowed
50%
Allowed
Amount++
Prior
1/1/14 Amount
10%
10%
10%
10%
40%
40%
40%ofofAllowed
AllowedAmount
Amount++
40%ofofAllowed
AllowedAmount
Amount++
Deductible (DED) (Per Person/Family Agg)
Subject
Subject
Subject
Subjectto
toBalance
BalanceBilling
Billing
Subjectto
toBalance
BalanceBilling
Billing
Subjectto
toBalance
BalanceBilling
Billing
In-Network
$1,500 Charges
/ Charges
$4,500
$1,500 / Not Applicable
$3,000 / $3,000 Charges
Charges
Charges
Charges
Out-of-Network
$4,500
/ $13,500
/Includes
Not Applicable
/Includes
$6,000 DED,
Out
Pocket
Includes
DED,
DED,
Outof
of
PocketMaximum
Maximum(Per
(PerPerson/Family
Person/Family
Includes
DED,Coins,
Coins,&&$3,000Includes
DED,Coins,
Coins,&&$6,000 Includes
DED,Coins,
Coins,&&
Coinsurance (Member Responsibility)
Agg)
Copays
Copays
Copays
Agg)
Copays
Copays
Copays
In-Network
20%
10%
10%
In-Network
$4,500
/ /$9,000
$3,000
/ /Not
$6,000
/$6,000
In-Network
$4,500Amount
$9,000
$3,000Amount
NotApplicable
Applicable
$6,000
Out-of-Network
50% of Allowed
+
40% of Allowed
+
40% of Allowed Amount
+ /$6,000
Out-of-Network
$9,000
/
$18,000
$6,000
/
Not
Applicable
$12,000
/
Out-of-Network
$9,000
/
$18,000
$6,000
/
Not
Applicable
$12,000
$12,000
Subject to Balance Billing
Subject to Balance Billing
Subject to Balance Billing /$12,000
Lifetime
No
No
LifetimeMaximum
Maximum
NoMaximum
Maximum
NoMaximum
Maximum
NoMaximum
Maximum
Charges
Charges
Charges No
Out of Pocket Maximum
(PerSERVICES
Person/Family
Includes DED, Coins, &
Includes DED, Coins, &
Includes DED, Coins, &
PROFESSIONAL
PROVIDER
PROFESSIONAL
PROVIDER
SERVICES
Agg)
Copays
Copays
Copays
Allergy
Injections
Allergy
Injections
In-Network
$4,500 / $9,000
$3,000 / Not Applicable
$6,000 /$6,000
In-Network
Primary/Family
Care
Physician
$10
DED
+
10%
DED
In-Network
Primary/Family Care Physician
$10
DED + 10%
DED++10%
10%
Out-of-Network
$9,000 / $18,000
$6,000 / Not Applicable
$12,000 / $12,000
In-Network
Specialist
$10
DED
In-Network
Specialist
$10
DED++10%
10%
DED++10%
10%
Lifetime Maximum
No Maximum
No Maximum
No MaximumDED
Out-of-Network
DED
DED
DED
Out-of-Network
DED++50%
50%
DED++40%
40%
DED++40%
40%
E-Office
Visit
E-Office
VisitServices
Services
PROFESSIONAL
PROVIDER SERVICES
In-Network
Primary/Family
$10
DED
DED
In-Network
Primary/FamilyCare
CarePhysician
Physician
$10
DED++10%
10%
DED++10%
10%
Allergy Injections
In-Network
Specialist
DED
In-Network
Specialist
$10
DED++10%
10%
DED++10%
10%
In-Network
Primary/Family Care Physician
$10 $10
DED + 10%
DED + 10% DED
Out-of-Network
DED
DED
In-Network Specialist
$10
DED + 10%
DED + 10% DED
Out-of-Network
DED++50%
50%
DED++40%
40%
DED++40%
40%
DED + 50%
DED + 40%
DED + 40%
Office
Services
OfficeOut-of-Network
Services
E-Office Visit
Services
In-Network
Primary/Family
Care
$30
DED
DED
In-Network
Primary/Family
CarePhysician
Physician
$30
DED++10%
10%
DED++10%
10%
In-Network
Primary/Family Care Physician
$10 $55
DED + 10%
DED + 10% DED + 10%
In-Network
Specialist
DED
In-Network
Specialist
$55
DED++10%
10%
DED + 10%
In-Network Specialist
$10
DED + 10%
DED + 10%
Out-of-Network
DED
DED
DED
Out-of-Network
DED++50%
50%
DED++40%
40%
DED++40%
40%
Out-of-Network
DED + 50%
DED + 40%
DED + 40%
Provider
Services
at
Hospital
and
ER
Provider
Services
at
Hospital
and
ER
Office Services
In-Network
Primary/Family
Physician
DED
DED
In-Network
Primary/Family
CarePhysician
Physician
DED++20%
20%
DED++10%
10%
DED++10%
10%
In-Network
Primary/Family Care
Care
$30
DED + 10%
DED + 10% DED
In-Network
Specialist
DED
DED
In-Network
Specialist
DED++20%
20%
DED++10%
10%
DED++10%
10%
In-Network
Specialist
$55
DED + 10%
DED + 10% DED
Out-of-Network
DED + 50%
DED
+ 40% DED
40%
Out-of-Network
In-Ntwk
DED
In-Ntwk
Out-of-Network
In-Ntwk
DED++20%
20%
In-Ntwk
DED++10%
10% DED + In-Ntwk
In-NtwkDED
DED++10%
10%
Provider
Servicesat
atOther
Hospital
and ER
Provider
Services
Locations
Provider
Services
at
Other
Locations
In-Network
Primary/Family Care
Care
DED + 20%
DED + 10%
DED + 10% DED
In-Network
Primary/Family
Physician
$30
DED
In-Network
Primary/Family
CarePhysician
Physician
$30
DED++10%
10%
DED++10%
10%
In-Network
Specialist
DED + 20%
DED + 10%
DED + 10% DED + 10%
In-Network
Specialist
$55
DED
++10%
In-Network
Specialist
$55
DED
10%
DED + 10%
Out-of-Network
In-Ntwk DED + 20%
In-Ntwk DED + 10%
In-Ntwk DED + 10%
Out-of-Network
DED
DED
DED
Out-of-Network
DED++50%
50%
DED++40%
40%
DED++40%
40%
Provider Services at Other Locations
Radiology,
Pathology
and
Radiology,
Pathology
andAnesthesiology
Anesthesiology
In-Network
Primary/Family
Care Physician
$30
DED + 10%
DED + 10%
Provider
Services
at
Provider
Services
atAmbulatory
AmbulatorySurgical
Surgical
In-Network
Specialist
$55
DED + 10%
DED + 10%
Center
Out-of-Network
DED + 50%
DED + 40%
DED + 40%
Center
Radiology, Specialist
Pathology
In-Network
ASC:
DED
DED
In-Network
Specialistand Anesthesiology
ASC:$55
$55
DED++10%
10%
DED++10%
10%
Provider Services at Ambulatory Surgical
Hospital:
Hospital:DED
DED++20%
20%
Center
Out-of-Network
ASC:
In-Ntwk
In-Ntwk
Out-of-Network
ASC:$55
$55
In-NtwkDED
DED++10%
10%
In-NtwkDED
DED++10%
10%
In-Network Specialist
ASC: $55
DED + 10%
DED + 10%
Hospital:
In-Ntwk
DED +
Hospital:
In-Ntwk
Hospital:
DED
+ 20% DED +
20%
20%
Out-of-Network
ASC: $55
In-Ntwk DED + 10%
In-Ntwk DED + 10%
PREVENTIVE
Hospital: In-Ntwk DED +
PREVENTIVECARE
CARE
20%
Adult
AdultWellness
WellnessOffice
OfficeServices
Services
In-Network
$0
$0
$0
In-NetworkPrimary/Family
Primary/FamilyCare
CarePhysician
Physician
$0
$0
$0
PREVENTIVE
CARE
In-Network
Specialist
$0
$0
$0
In-Network
Specialist
$0
$0
$0
Adult Wellness Office Services
Out-of-Network
50%
40%
40%
Out-of-Network
50%(No
(NoDED)
DED)
40%(No
(NoDED)
DED)
40%(No
(NoDED)
DED)
In-Network Primary/Family
$0then
$0
Colonoscopies
(Routine)
Age
Age
50+
Age
Colonoscopies
(Routine) Care Physician
Age50+
50+
thenFrequency
Frequency
Age$0
50+then
thenFrequency
Frequency
Age50+
50+then
thenFrequency
Frequency
In-Network Specialist
$0
$0
$0
Schedule
Schedule
Schedule
ScheduleApplies
Applies
ScheduleApplies
Applies 40% (No DED)
ScheduleApplies
Applies
Out-of-Network
50% (No DED)
40% (No DED)
In-Network
$0
$0
$0
In-Network
$0
$0
$0
Colonoscopies (Routine-1 every 10 years)
Age 50+ then Frequency
Age 50+ then Frequency
Age 50+ then Frequency
Out-of-Network
$0
$0
Out-of-Network
$0
$0
$0
Schedule Applies
Schedule Applies
Schedule Applies $0
Mammograms
(Routine)
Mammograms
In-Network (Routine)
$0
$0
$0
In-Network
$0
$0
Out-of-Network
$0 $0
$0
$0
In-Network
$0
$0
$0
Mammograms (Routine)
Out-of-Network
$0
$0
$0
Out-of-Network
$0
$0
$0
In-Network
$0
$0
$0
Well
Office
WellChild
Child
OfficeVisits
Visits(No
(NoBPM)
BPM)
Out-of-Network
$0 $0
$0
$0
In-Network
Primary/Family
$0
$0
In-Network
Primary/FamilyCare
CarePhysician
Physician
$0
$0
$0
Well Child Office Visits (No BPM)
In-Network
Specialist
$0
$0
$0
In-Network
Specialist Care Physician
$0
$0
In-Network Primary/Family
$0 $0
$0
$0
Out-of-Network
50%
Out-of-Network
50%
(NoDED)
DED)
40%(No
(NoDED)
DED)
40%(No
(NoDED)
DED)
In-Network Specialist
$0 (No
$040%
$0 40%
Out-of-Network
50% (No DED)
7
40% (No DED)
40% (No DED)
www.myFBMC.com
Florida Blue
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
COST SHARING
Out-of-Network
Maximums shown are Per Benefit Period
Emergency
Room noted
Facility Services
(BPM) unless
(also see Professional Provider Services)
In-Network
Out-of-Network
Deductible (DED) (Per Person/Family Agg)
Urgent Care
Centers (UCC)
In-Network
In-Network
Out-of-Network
Out-of-Network
Coinsurance (Member Responsibility)
In-Network
FACILITY
SERVICES - HOSP/SURG/ICL/IDTF
Out-of-Network
Unless otherwise noted, physician services are
in addition to facility services. See Professional
Provider
OutServices.
of Pocket Maximum (Per Person/Family
Agg) Surgical Center
Ambulatory
In-Network
In-Network
Out-of-Network
Out-of-Network
Lifetime Maximum
Independent Clinical Lab
In-Network (Quest Diagnostics)
PROFESSIONAL PROVIDER SERVICES
Out-of-Network
Allergy Injections
Independent
Diagnostic Testing Facility In-Network Primary/Family Care Physician
Xrays and
AIS
(Includes
In-Network
SpecialistPhysician Services)
In-Network
- Advanced Imaging Services
Out-of-Network
(AIS)
E-Office Visit Services
In-Network
- Other
Diagnostic Care
Services
In-Network
Primary/Family
Physician
In-Network Specialist
Out-of-Network
InpatientOut-of-Network
Hospital (per admit)
Office Services
In-Network
In-Network Primary/Family Care Physician
In-Network Specialist
Out-of-Network
Out-of-Network
Inpatient
Rehab
Maximum
(PBP)and ER
Provider
Services
at Hospital
Outpatient
Hospital
(per visit) Care Physician
In-Network
Primary/Family
In-Network
In-Network Specialist
Out-of-Network
Provider Services at Other Locations
Out-of-Network
Primary/Family
TherapyIn-Network
at Outpatient
HospitalCare Physician
In-Network Specialist
In-Network
Out-of-Network
Radiology, Pathology and Anesthesiology
Out-of-Network
Provider Services at Ambulatory Surgical
Center
OTHER
SPECIAL SERVICES AND
In-Network Specialist
LOCATIONS
Advanced
Imaging Services in Physician's
Out-of-Network
Office
In-Network Primary/Family Care Physician
In-Network Specialist
Out-of-Network
PREVENTIVE CARE
Birthing
Center
Adult
Wellness Office Services
In-Network
In-Network Primary/Family Care Physician
In-Network Specialist
Out-of-Network
Durable Out-of-Network
Medical Equipment, Prosthetics,
Colonoscopies
(Routine-1 every 10 years)
Orthotics
BPM
In-Network (Carecentrix)
In-Network
Out-of-Network
Out-of-Network
HomeMammograms
Health Care BPM
(Routine)
In-Network
(Carecentrix)
In-Network
Out-of-Network
Out-of-Network
Well Child Office Visits (No BPM)
In-Network Primary/Family Care Physician
In-Network Specialist
Out-of-Network
www.myFBMC.com
BlueOptions
BlueOptions
BlueOptions
05771
HSA-Compatible 05180
(Single Coverage)
HSA-Compatible 05181
(Family Coverage)
No Maximum
No Maximum
No Maximum
DED + 20%
In-Ntwk DED + 20%
DED + 10%
In-Ntwk DED + 10%
DED + 10%
In-Ntwk DED + 10%
$30
BlueOptions
DED
+ 50%
05771
“Network Blue”
Only Available
To Employees
$250 hired
Prior to 1/1/14
$250
DED + 10%
BlueOptions
DED + 10%
BlueOptions
DED +05180
40%
HSA-Compatible
(Single Coverage)
“Network Blue”
DED
+ 40%
HSA-Compatible
05181
(Family Coverage)
“Network Blue”
DED + 10%
In-Ntwk DED + 10%
DED + 10%
In-Ntwk DED + 10%
$1,500 / $4,500
$4,500 /$60
$13,500
$1,500 / Not Applicable
DED
+ 10%
$3,000 / Not
Applicable
$3,000 / $3,000
DED + 10%
$6,000 / $6,000
20%
50% of Allowed Amount +
Subject to Balance Billing
Charges
Includes DED, Coins, &
Copays
$4,500$200
/ $9,000
$9,000 / $18,000
DED + 50%
No Maximum
10%
40% of Allowed Amount +
Subject to Balance Billing
Charges
Includes DED, Coins, &
Copays
$3,000 / Not
Applicable
DED
+ 10%
$6,000 / Not Applicable
DED
+ 40%
No Maximum
10%
40% of Allowed Amount +
Subject to Balance Billing
Charges
Includes DED, Coins, &
Copays
$6,000 /$6,000
DED + 10%
$12,000 / $12,000
DED + 40%
No Maximum
DED
DED + 40%
DED
DED + 40%
DED + 10%
DED + 10%
DED DED
+ 40%+ 10%
DED + 10%
DED + 10%
DED + 10%
DED + 40%
DED DED
+ 10%+ 10%
DED DED
+ 10%+ 40%
DED + 40%
DED + 10%
DED + 10%
DED + 10%
DED + 40%
DED + 40%
DED + 50%
$0
DED + 50%
$10
$10
DED$250
+ 50%
$50
$10
$10+ 50%
DED
DED + 50%
Option 1 - DED + 20%
Option 2$30
- DED + 20%
$55
$500 PAD
DED + 50%
DED ++50%
21 Days
DED + 20%
Option
1 -+DED
DED
20% + 20%
In-Ntwk2DED
+ 20%
Option
- DED
+ 20%
DED + 50%
$30
$55
Option
1 - $55
DED + 50%
Option 2 - $80
DED + 50%
ASC: $55
Hospital: DED + 20%
ASC: $55
Hospital: In-Ntwk DED +
$250
20%
$250
DED + 50%
DED
$0+ 20%
$0+ 50%
DED
50%
DED)
No (No
Maximum
Age 50+ then Frequency
Schedule
DED +Applies
20%
$0
DED
+
50%
$0
20 Visits
DED
$0+ 20%
DED
$0+ 50%
$0
$0
50% (No DED)
8
DED + 40%
DED + 40%
Option 1 - DED + 10%
DED + 10%
Option
2 - DED + 10%
DED + 10%
DED
DED + 40%+ 40%
21 Days
Option 1 - DED + 10%
DED + 10%
Option 2 - DED + 10%
DED + 10%
DED + 40%
DED + 40%
21 Days
DED + 10%
DED + 10%
Option
- DED + 10%
Option
DED + 1
10%
DED
+ 10%1 - DED + 10%
In-Ntwk
DED
10% + 10% In-NtwkOption
DED + 2
10%
Option
2 -+DED
- DED + 10%
DED + 40%
DED + 10%
DED + 10%
Option
1 - DED + 10%
DED + 40%
Option 2 - DED + 10%
DED + 40%
DED + 40%
DED + 10%
DED + 10%
Option 1 - DED + 10%
DED + 40%
Option 2 - DED + 10%
DED + 40%
DED + 10%
DED + 10%
In-Ntwk DED + 10%
In-Ntwk DED + 10%
DED + 10%
DED + 10%
DED + 40%
DED + 10%
$0
$0
DED + 40%
40% (No
No DED)
Maximum
Age 50+ then Frequency
Schedule
Applies
DED
+ 10%
$0
DED
+ 40%
$0
20 Visits
DED + 10%
$0
DED + 40%
$0
$0
$0
40% (No DED)
DED + 10%
DED + 10%
DED + 40%
$0 DED + 10%
$0 DED + 40%
40% (No DED)
No Maximum
Age 50+ then Frequency
Schedule Applies
DED + 10%
$0
DED + 40%
$0
20 Visits
$0 DED + 10%
$0 DED + 40%
$0
$0
40% (No DED)
Florida Blue
COST SHARING
BlueOptions
BlueOptions
BlueOptions
05771
HSA-Compatible 05180
HSA-Compatible 05181
Maximums shown are Per Benefit Period
(Single Coverage)
(Family Coverage)
(BPM) unless noted
EMERGENCY/URGENT/CONVENIENT
CARE
COST SHARING
BlueOptions
BlueOptions
BlueOptions
No Maximum
No Maximum
No Maximum
Ambulance Maximum (per day)
05771
HSA-Compatible 05180
HSA-Compatible 05181
Maximums shown are Per Benefit Period
In-Network
DED
+
20%
DED
+
10%
DED + 10%
(Single
Coverage)
(Family
Coverage)
“Network
Blue”
(BPM) unless noted
Out-of-Network
In-Ntwk
DED + 20%
In-NtwkBlue”
DED + 10%
In-Ntwk
DED + 10%
Only
Available
“Network
“Network
Blue”
To Employees hired
Convenient Care Centers (CCC)
Prior to 1/1/14
In-Network
$30
DED + 10%
DED + 10%
Deductible
(DED) (Per Person/Family Agg)
Out-of-Network
DED + 50%
DED + 40%
DED + 40%
In-Network Room Facility Services
$1,500 / $4,500
$1,500 / Not Applicable
$3,000 / $3,000
Emergency
Out-of-Network
$4,500 / $13,500
$3,000 / Not Applicable
$6,000 / $6,000
(also see Professional Provider Services)
Coinsurance
In-Network(Member Responsibility)
$250
DED + 10%
DED + 10%
In-Network
20%$250
10% DED + 10%
10%
Out-of-Network
In-Ntwk
In-Ntwk
DED + 10%
Out-of-Network
50% of Allowed Amount +
40% of Allowed Amount +
40% of Allowed Amount +
Urgent
Care Centers (UCC)
Subject to Balance Billing
Subject to Balance Billing
Subject to Balance Billing
In-Network
$60
DED + 10%
DED + 10%
Charges
Charges
Charges
DED Coins,
+ 50%&
DED
+ 40%
DED
+ 40%
OutOut-of-Network
of Pocket Maximum (Per Person/Family
Includes DED,
Includes DED,
Coins,
&
Includes DED,
Coins,
&
FACILITY SERVICES - HOSP/SURG/ICL/IDTF
Agg)
Copays
Copays
Copays
In-Network
$4,500 / $9,000
$3,000 / Not Applicable
$6,000 /$6,000
Unless
otherwise noted, physician services are
$9,000 / $18,000
$6,000 / Not Applicable
$12,000 / $12,000
in Out-of-Network
addition to facility services. See Professional
Lifetime
No Maximum
No Maximum
No Maximum
Provider Maximum
Services.
Ambulatory Surgical Center
PROFESSIONAL
PROVIDER SERVICES
In-Network
$200
DED + 10%
DED + 10%
Allergy
Injections
Out-of-Network
DED + 50%
DED + 40%
DED + 40%
In-Network Primary/Family
$10
DED + 10%
DED + 10%
Independent
Clinical Lab Care Physician
In-Network
$10 $0
DED + 10%
DED + 10%DED
In-NetworkSpecialist
(Quest Diagnostics)
DED
Out-of-Network
DEDDED
+ 50%
DED +
40%+ 40%
DED + DED
40% + 40%
Out-of-Network
+ 50%
DED
E-Office
Visit Services
Independent
Diagnostic Testing Facility In-Network
Primary/Family
Care Physician
$10
DED + 10%
DED + 10%
Xrays
and AIS
(Includes Physician
Services)
In-Network
$10$250
DED +
10%+ 10%
DED + DED
10% + 10%
In-NetworkSpecialist
- Advanced Imaging Services
DED
Out-of-Network
DED + 50%
DED + 40%
DED + 40%
(AIS)
Office Services
In-Network - Other Diagnostic Services
$50
DED + 10%
DED + 10%
In-Network Primary/Family Care Physician
$30
DED + 10%
DED + 10%
Out-of-Network
DED + 50%
DED + 40%
DED + 40%
In-Network Specialist
$55
DED + 10%
DED + 10%
Inpatient Hospital (per admit)
Out-of-Network
DED + 50%
DED + 40%
DED + 40%
In-Network
Option 1 - DED + 20%
Option 1 - DED + 10%
Option 1 - DED + 10%
Provider
Services at Hospital and ER
Option
2 20%
- DED + 20%
Option
2 - DED + 10%
Option
2 - DED + 10%
In-Network Primary/Family Care Physician
DED +
DED + 10%
DED
+ 10%
Out-of-Network
$500
PAD
+ DED + 50%
DED
In-Network
Specialist
DED
+ 20%
DED +
10%+ 40%
DED + DED
10% + 40%
Inpatient
Rehab Maximum (PBP)
21 Days
21+Days
Days
Out-of-Network
In-Ntwk DED
+ 20%
In-Ntwk DED
10%
In-Ntwk DED 21
+ 10%
Outpatient
Hospital
(per visit)
Provider
Services
at Other
Locations
In-NetworkPrimary/Family Care Physician
Option$30
1 - DED + 20%
Option
1 - DED + 10%
Option
1 - DED + 10%
In-Network
DED + 10%
DED
+ 10%
Option$55
2 - DED + 20%
Option
2 - DED + 10%
Option
2 - DED + 10%
In-Network Specialist
DED + 10%
DED
+ 10%
Out-of-Network
+ 50%
DED
Out-of-Network
DEDDED
+ 50%
DED +
40%+ 40%
DED + DED
40% + 40%
Therapy atPathology
Outpatient
Hospital
Radiology,
and
Anesthesiology
Provider
Services at Ambulatory Surgical
In-Network
Option 1 - $55
Option 1 - DED + 10%
Option 1 - DED + 10%
Center
Option 2 - $80
Option 2 - DED + 10%
Option 2 - DED + 10%
In-Network
Specialist
ASC:
$55
DED +
10%+ 40%
DED + DED
10% + 40%
Out-of-Network
DED
+ 50%
DED
Hospital: DED + 20%
OTHER SPECIAL SERVICES AND
Out-of-Network
ASC: $55
In-Ntwk DED + 10%
In-Ntwk DED + 10%
LOCATIONS
Hospital: In-Ntwk DED +
Advanced Imaging Services in Physician's
20%
Office
In-Network Primary/Family Care Physician
$250
DED + 10%
DED + 10%
PREVENTIVE CARE
In-Network Specialist
$250
DED + 10%
DED + 10%
Adult Wellness Office Services
Out-of-Network
DED + 50%
DED + 40%
DED + 40%
In-Network Primary/Family Care Physician
$0
$0
$0
Birthing Center
In-Network Specialist
$0
$0
$0
In-Network
DEDDED)
+ 20%
DED
+ 10%
Out-of-Network
50% (No
40% (No
DED)
40% (NoDED
DED)+ 10%
Out-of-Network
DEDFrequency
+ 50%
DED
+ 40%
+ 40%
Colonoscopies
(Routine-1 every 10 years)
Age 50+ then
Age 50+ then
Frequency
Age 50+ then DED
Frequency
Durable Medical Equipment, Prosthetics,
No Maximum
NoApplies
Maximum
Maximum
Schedule
Applies
Schedule
ScheduleNo
Applies
Orthotics
BPM
In-Network
$0
$0
$0
In-Network (Carecentrix)
DED
DED + 10%
Out-of-Network
$0 + 20%
$0
$0 DED + 10%
Out-of-Network
DED + 50%
DED + 40%
DED + 40%
Mammograms
(Routine)
Home
Health Care BPM
20 Visits
In-Network
$0
$020 Visits
$0 20 Visits
In-Network (Carecentrix)
DED
DED + 10%
Out-of-Network
$0 + 20%
$0
$0 DED + 10%
Well
Child Office Visits (No BPM)
Out-of-Network
DED + 50%
DED + 40%
DED + 40%
In-Network Primary/Family Care Physician
In-Network Specialist
Out-of-Network
$0
$0
50% (No DED)
$0
$0
40% (No DED)
9
$0
$0
40% (No DED)
www.myFBMC.com
Florida Blue
Group Health Plan Premiums
2015 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
$298.40
Retiree & Spouse
$596.80
BlueMedicare Group PPO Plan 2
Premiums for Medicare Eligible Retirees and Medicare-Eligible Dependents (age 65 and older)
Retiree
Retiree Only
$201.63
Retiree & Spouse
$403.26
www.myFBMC.com
10
St. Lucie County School Board
2015 BlueMedicare Group PPO* (Employer PPO) Health Benefits
Benefits
Premium (per member, per month)
BlueMedicare Group PPO* Plan 1
$298.40
Deductible
$0 In-Network / $1,000 Out-of-Network
Out-of Pocket Max (based on plan year)
$1,000 In-Network / $3,000 Out-of-Network.
In-Network out-of-pocket max accumulates
toward Out-of-Network out-of-pocket max.
Physician Office
Primary Care (per visit)
In-Network $10 copay
Out-of-Network CYD & 20%
Specialist Care (per visit)
In-Network $30 copay
Out-of-Network CYD & 20%
e-visit
In-Network $5 copay
Out-of-Network CYD & 20%
Convenient Care Center
In-Network $30 copay
Out-of-Network CYD & 20%
Podiatry Services (per visit)
(Routine foot care up to 6 visits per year)
In-Network $30 copay
Out-of-Network CYD & 20%
Chiropractic Services (per visit)
For each Medicare covered visit (manual
manipulation of the spine to correct
subluxation)
In-Network $20 copay
Out-of-Network CYD & 20%
Outpatient Mental Health Care (per visit)
For individual or group therapy
(includes partial hospitalization)
In-Network $35 copay
Out-of-Network CYD & 20%
Outpatient Substance Abuse Care (per visit)
In-Network $35 copay
Out-of-Network CYD & 20%
Part B drugs (including Chemotherapy)
In-Network 20% coinsurance
Out-of-Network CYD & 20% coinsurance
Allergy Injections
In-Network $5 copay
Out-of-Network CYD & 20%
Other Services
Outpatient Surgery
In-Network
• $150 copay for each outpatient
hospital facility visit
• $100 copay for each visit to an
ambulatory surgical center
Out-of-Network CYD & 20%
Y0011_31917 0414R4 EGWP C: 06/2014
1
11
www.myFBMC.com
Benefits
BlueMedicare Group PPO* Plan 1
In-Network / Out-of-Network
• $0 copay for Physician Services
Diagnostic Tests, X-Rays
Office
In-Network
• PCP $10 copay
• Specialist $30 copay
Out-of-Network CYD & 20%
IDTF
In-Network $50 copay
Out-of-Network CYD & 20%
Lab Services
Independent Clinical Lab
Outpatient Hospital
In-Network $0 copay
In-Network $15 copay
Out-of-Network CYD & 20%
Advanced Imaging (MRI, MRA, Cat Scan, Pet
Scan & Nuclear Med):
Office
In-Network $125 copay
Out-of-Network CYD & 20%
IDTF
In-Network $125 copay
Out-of-Network CYD & 20%
Outpatient Hospital
In-Network $150 copay
Out-of-Network CYD & 20%
Outpatient Hospital Services (per visit):
•
•
•
•
•
Occupational Therapy, Physical
Therapy, Speech & Language Therapy,
Cardiac and Pulmonary Rehab
Radiation
Dialysis
Lab only
All other Diagnostic Tests, X-Rays
Advanced Imaging, etc.
In-Network
Out-of-Network
$30
CYD & 20%
$50
20%
$15
$150
CYD & 20%
20%
CYD & 20%
CYD & 20%
Urgently Needed Care
(This is not emergency care, and in most cases
is out of the service area.)
In-Network / Out-of-Network $30 copay
Emergency Services
In-Network / Out-of-Network $50 copay
Worldwide coverage
Dental, Hearing and Vision – Medicare-covered
In-Network $30 copay
Out-of-Network CYD & 20%
Y0011_31917 0414R4 EGWP C: 06/2014
www.myFBMC.com
2
12
Benefits
BlueMedicare Group PPO* Plan 1
Home Health
In-Network $0 copay
Out-of-Network 50% Coinsurance
Ambulance
In-Network / Out-of-Network $150 copay for
Medicare-covered ambulance services
Outpatient Medical Services and Supplies
Durable Medical Equipment/Diabetic Supplies
• Diabetic Supplies (glucose meters, test
strips and Lancets) – needles, syringes
and insulin for self-injection is covered
under your Part D benefit
•
Equipment: Plan-approved electric
customized wheelchairs, electric
scooters
•
All other Medicare-covered durable
medical equipment
In-Network $0 copay
Out-of-Network CYD & 20%
In-Network 20% coinsurance
Out-of-Network CYD & 20%
In-Network $0 copay
Out-of-Network CYD & 20%
Prosthetic Devices
In-Network $0 copay for Medicare-covered
items
Out-of-Network CYD & 20%
Outpatient Rehabilitation - Office or Free
Standing Facility Services:
• Occupational Therapy
• Physical Therapy
• Speech and Language Therapy
• Cardiac and Pulmonary Rehab
(Including Intensive)
• Dialysis
In-Network $30 copay for each visit
Out-of-Network CYD & 20%
In-Network/Out-of-Network 20% coinsurance
Outpatient Rehabilitation – Outpatient Hospital
Services:
• Occupational Therapy
• Physical Therapy
• Speech and Language Therapy
• Cardiac and Pulmonary Rehab
In-Network $30 copay for each visit
Out-of-Network CYD & 20%
Inpatient Care
Inpatient Hospital Care
(includes Substance Abuse)
In-Network
• $150 copay 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 CYD & 20%
Inpatient Mental Health Care
(may also include Substance Abuse)
In-Network
• $200 copay each day for day(s) 1-7
for a Medicare-covered stay in a
Y0011_31917 0414R4 EGWP C: 06/2014
3
13
www.myFBMC.com
Benefits
BlueMedicare Group PPO* Plan 1
network psychiatric hospital
For day(s) 8-90, $0 copay for
Medicare-covered stay in a network
psychiatric hospital
190-day lifetime limit in a psychiatric hospital
Out-of-Network CYD & 20%
•
Skilled Nursing Facility
(in a Medicare-certified skilled nursing facility)
In-Network
• $0 copay each day for days 1-20 per
benefit period
• $75 copay 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 CYD & 20%
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 copay for Medicare-covered
Screening Mammogram
Out-of-Network 20%
Pap Smears and Pelvic Exams
(for women with Medicare)
In-Network:
• $0 copay per Pap smear
• $0 copay per pelvic exam
Out-of-Network 20%
Bone Mass Measurement
(for people with Medicare who are at risk)
In-Network:
• $0 copay for each Medicare-covered
Bone Mass Measurement
Out-of-Network 20%
Colorectal Screening Exams
(for people with Medicare age 50 and older)
In-Network:
• $0 copay for Medicare-covered
Colorectal screening exam
Out-of-Network 20%
Prostate Cancer Screening Exams
(for men with Medicare age 50 and older)
In-Network:
• $0 copay for Medicare-covered
Prostate Cancer Screening exam
Out-of-Network 20%
Vaccines – Medicare covered
In-Network / Out-of-Network
• $0 copay for Influenza vaccine
• $0 copay for Pneumococcal vaccine
• $0 copay for Hepatitis B vaccine
Health & Wellness Benefit
Y0011_31917 0414R4 EGWP C: 06/2014
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14
∗
Benefits
BlueMedicare Group PPO* Plan 1
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.
15
www.myFBMC.com
St. Lucie County School Board
2015 BlueMedicare Group Rx* (Employer PDP)
Benefits
Premium
Deductible
Retail
Tier 1 - Preferred Generics
Tier 2 - Non-Preferred Generics
Tier 3 - Preferred Brand
Tier 4 - Non-Preferred Brand
Tier 5 - Specialty Drugs
Mail Order
BlueMedicare Group Rx* Option 1
Included with PPO1 Plan
$0
31-day Supply
$10
$10
$40
$70
25%
90-day Supply with PRIME Mail Order
Tier 1 - Preferred Generics
Tier 2 - Non-Preferred Generics
Tier 3 - Preferred Brand
Tier 4 - Non-Preferred Brand
Tier 5 - Specialty Drugs
Gap
Tier 1 - Preferred Generics
Tier 2 - Non-Preferred Generics
Tier 3 - Preferred Brand
Tier 4 - Non-Preferred Brand
Tier 5 - Specialty Drugs
Catastrophic
$0
$0
$80
$140
25%
31-day Supply
$10
$10
$40
$70
25%
Greater of $2.65 or 5% / Greater of $6.60 or 5%
∗
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.
∗
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_31964 0414R1 EGWP C: 06/2014
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16
St. Lucie County School Board
2015 BlueMedicare Group PPO* (Employer PPO) Health Benefits
Benefits
Premium (per member, per month)
BlueMedicare Group PPO* Plan 2
$201.63
Deductible
$0 In-Network / $2,000 Out-of-Network
Out-of Pocket Max (based on plan year)
$2,000 In-Network / $4,000 Out-of-Network.
In-Network out-of-pocket max accumulates
toward Out-of-Network out-of-pocket max.
Physician Office
Primary Care (per visit)
In-Network $35 copay
Out-of-Network CYD & 40%
Specialist Care (per visit)
In-Network $50 copay
Out-of-Network CYD & 40%
e-visit
In-Network $5 copay
Out-of-Network CYD & 40%
Convenient Care Center
In-Network $50 copay
Out-of-Network CYD & 40%
Podiatry Services (per visit)
(Routine foot care up to 6 visits per year)
In-Network $50 copay
Out-of-Network CYD & 40%
Chiropractic Services (per visit)
For each Medicare covered visit (manual
manipulation of the spine to correct
subluxation)
In-Network $20 copay
Out-of-Network CYD & 40%
Outpatient Mental Health Care (per visit)
For individual or group therapy
(includes partial hospitalization)
In-Network $40 copay
Out-of-Network CYD & 40%
Outpatient Substance Abuse Care (per visit)
In-Network $40 copay
Out-of-Network CYD & 40%
Part B drugs (including Chemotherapy)
In-Network 20% coinsurance
Out-of-Network CYD & 40%
Allergy Injections
In-Network $10 copay
Out-of-Network CYD & 40%
Other Services
Outpatient Surgery
In-Network
• $250 copay for each outpatient hospital
facility visit
• $175 copay for each visit to an
ambulatory surgical center
Out-of-Network CYD & 40%
Y0011_31918 0414R3 EGWP C: 06/2014
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Benefits
BlueMedicare Group PPO* Plan 2
In-Network / Out-of-Network
• $0 copay for Physician Services
Diagnostic Tests, X-Rays
Office
IDTF
Lab Services
Independent Clinical Lab
Outpatient Hospital
Advanced Imaging (MRI, MRA, Cat Scan, Pet
Scan & Nuclear Med):
Office
IDTF
In-Network
• PCP $35 copay
• Specialist $50 copay
Out-of-Network CYD & 40%
In-Network $100 copay
Out-of-Network CYD & 40%
In-Network $0 copay
In-Network $30 copay
Out-of-Network CYD & 40%
In-Network $175 copay
Out-of-Network CYD & 40%
In-Network $175 copay
Out-of-Network CYD & 40%
In-Network $250 copay
Out-of-Network CYD & 40%
Outpatient Hospital
Outpatient Hospital Services (per visit):
•
•
•
•
•
Occupational Therapy, Physical
Therapy, Speech & Language Therapy,
Cardiac and Pulmonary Rehab
Radiation
Dialysis
Lab only
All other Diagnostic Tests, X-Rays
Advanced Imaging, etc.
In-Network
Out-of-Network
$40
CYD & 40%
$50
20%
$30
$250
CYD & 40%
20%
CYD & 40%
CYD & 40%
Urgently Needed Care
(This is not emergency care, and in most cases
is out of the service area.)
In-Network / Out-of-Network $50 copay
Emergency Services
In-Network / Out-of-Network $65 copay
Worldwide coverage
Dental, Hearing and Vision – Medicare-covered
In-Network $50 copay
Out-of-Network CYD & 40%
Y0011_31918 0414R3 EGWP C: 06/2014
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18
Benefits
BlueMedicare Group PPO* Plan 2
Home Health
In-Network $0 copay
Out-of-Network 50% Coinsurance
Ambulance
In-Network / Out-of-Network $150 copay for
Medicare-covered ambulance services
Outpatient Medical Services and Supplies
Durable Medical Equipment/Diabetic Supplies
• Diabetic Supplies (glucose meters, test
strips and Lancets) – needles, syringes
and insulin for self-injection is covered
under your Part D benefit
•
Equipment: Plan-approved electric
customized wheelchairs, electric
scooters
•
All other Medicare-covered durable
medical equipment
Prosthetic Devices
Outpatient Rehabilitation - Office or Free
Standing Facility Services:
• Occupational Therapy
• Physical Therapy
• Speech and Language Therapy
• Cardiac and Pulmonary Rehab
(Including Intensive)
• Dialysis
Outpatient Rehabilitation – Outpatient Hospital
Services:
• Occupational Therapy
• Physical Therapy
• Speech and Language Therapy
• Cardiac and Pulmonary Rehab
In-Network $0 copay
Out-of-Network CYD & 40%
In-Network 20% coinsurance
Out-of-Network CYD & 40%
In-Network $0 copay
Out-of-Network CYD & 40%
In-Network $0 copay for Medicare-covered
items
Out-of-Network CYD & 40%
In-Network $40 copay for each visit
Out-of-Network CYD & 40%
In-Network/Out-of-Network 20% coinsurance
In-Network $40 copay for each visit
Out-of-Network CYD & 40%
Inpatient Care
Inpatient Hospital Care
(includes Substance Abuse)
In-Network
• $250 copay 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 CYD & 40%
Inpatient Mental Health Care
(may also include Substance Abuse)
In-Network
• $250 copay each day for day(s) 1-7 for
a Medicare-covered stay in a network
Y0011_31918 0414R3 EGWP C: 06/2014
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Benefits
BlueMedicare Group PPO* Plan 2
psychiatric hospital
• For day(s) 8-90, $0 copay for Medicarecovered stay in a network psychiatric
hospital
190-day lifetime limit in a psychiatric hospital
Out-of-Network CYD & 40%
Skilled Nursing Facility
(in a Medicare-certified skilled nursing facility)
In-Network
• $0 copay each day for days 1-20 per
benefit period
• $100 copay 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 CYD & 40%
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 copay for Medicare-covered
Screening Mammogram
Out-of-Network 40%
Pap Smears and Pelvic Exams
(for women with Medicare)
In-Network:
• $0 copay per Pap smear
• $0 copay per pelvic exam
Out-of-Network 40%
Bone Mass Measurement
(for people with Medicare who are at risk)
In-Network:
• $0 copay for each Medicare-covered
Bone Mass Measurement
Out-of-Network 40%
Colorectal Screening Exams
(for people with Medicare age 50 and older)
In-Network:
• $0 copay for Medicare-covered
Colorectal screening exam
Out-of-Network 40%
Prostate Cancer Screening Exams
(for men with Medicare age 50 and older)
In-Network:
• $0 copay for Medicare-covered Prostate
Cancer Screening exam
Out-of-Network 40%
Vaccines – Medicare covered
In-Network / Out-of-Network
• $0 copay for Influenza vaccine
• $0 copay for Pneumococcal vaccine
• $0 copay for Hepatitis B vaccine
Health & Wellness Benefit
Y0011_31918 0414R3 EGWP C: 06/2014
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4
20
∗
Benefits
BlueMedicare Group PPO* Plan 2
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.
Y0011_31918 0414R3 EGWP C: 06/2014
21
www.myFBMC.com
5
St. Lucie County School Board
2015 BlueMedicare Group Rx* (Employer PDP)
Benefits
Premium
Deductible
Retail
Tier 1 - Preferred Generics
Tier 2 - Non-Preferred Generics
Tier 3 - Preferred Brand
Tier 4 - Non-Preferred Brand
Tier 5 - Specialty Drugs
Mail Order
BlueMedicare Group Rx* Option 3
Included with PPO2 Plan
$75 for Brand Drugs Only
31-day Supply
$10
$10
$45
$95
33%
90-day Supply with PRIME Mail Order
Tier 1 - Preferred Generics
Tier 2 - Non-Preferred Generics
Tier 3 - Preferred Brand
Tier 4 - Non-Preferred Brand
Tier 5 - Specialty Drugs
Gap
Tier 1 - Preferred Generics
Tier 2 - Non-Preferred Generics
Tier 3 - Preferred Brand
Tier 4 - Non-Preferred Brand
Tier 5 - Specialty Drugs
Catastrophic
$10
$10
$135
$285
33%
31-day Supply
$10
$10
45%
45%
33% (Generic) / 45% (Brand)
Greater of $2.65 or 5% / Greater of $6.60 or 5%
∗
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.
∗
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_31966 0414R1 EGWP C: 06/2014
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22
Dental Plan
Delta Dental PPO for both COBRA and Retiree Participants
St. Lucie County Schools is pleased to partner with Delta Dental to offer
a PPO† plan that makes it easy for you to find a dentist and control your
costs when you visit a network dentist. Here are some of the great things
you’ll need to know about enrolling with Delta Dental:
• Save with a PPO dentist. Our PPO network dentists accept reduced
fees for covered services, so you’ll usually pay the least when you
visit a PPO network dentist. Non-Delta Dental dentists may balance
bill you the difference between the contracted fee and their usual fee.
• Large dentist network. Since Delta Dental offers access to some of
the largest dentist networks in the U.S.,‡ chances are there’s a wide
choice of PPO dentists near your home or office. Use your desktop
or mobile device to search for a dentist at deltadentalins.com.
• Visit the dentist of your choice. Want to visit a non-Delta Dental
dentist? No problem. You can visit any licensed dentist, but your costs
are usually lowest with a PPO dentist.
• Log in to Online Services. Check benefits, eligibility and claims
status, view or print an ID card and use our “Fee Finder” tool to
check average costs in your area. You can also change your Profile
preference to go paperless. Use your mobile device to access many of
these tools on the go; show the dental office your ID card information
instead of carrying a printed card.
Visit the SmileWay® Wellness section of our site for dental health articles,
videos, quizzes and a risk assessment tool. You can also subscribe to
our free dental health e-newsletter.
† In Texas, Delta Dental Insurance Company offers a Dental Provider Organization (DPO) plan.
‡ Netminder Dental Network Trend Report, March 2013.
Your Saving with a PPO Dentist
SAVE MORE
Non PPO
Dentist
PPO
Dentist
23
www.myFBMC.com
Dental Plan
Plan Benefit Highlights for: St. Lucie County School Board
16510
Effective
1/1/2014Participants
Group
No: for
Delta Dental
PPO
both COBRA
andDate:
Retiree
Eligibility
Primary enrollee, spouse and eligible dependent children to age 26, or to
age 30 if the specific conditions of eligibility are met.
Deductibles*
$50 per person / $150 per family each calendar year
Deductibles waived for D & P?
Maximums*
D & P counts toward maximum?
RATES EFFECTIVE
1/1/2014
to 12/31/2015
1/1/15 -12/31/15
Yes
Low Plan: $1,000 per person each calendar year
High Plan: $1,500 per person each calendar year
No
RETIREE
(Monthly)
COBRA
( Monthly)
EE Only EE + One Low
$23.49
$49.35
High
$28.63
$60.24
Low $23.96 $50.34 High
$29.20
$61.45
EE + Two or more $85.01
$106.20
$86.71 $108.32
Benefits and
Covered Services**
Low Plan
Delta Dental
PPO dentists†
Non-Delta Dental
PPO dentists†
High Plan
Delta Dental
PPO dentists†
Non-Delta Dental
PPO dentists†
Diagnostic & Preventive
Services (D & P)
100 %
100 %
100 %
90 %
Basic Services
80 %
80 %
90 %
80 %
Endodontics (root canals)
80 %
80 %
90 %
80 %
Non- Surgical Periodontics
80 %
80 %
90 %
80 %
Surgical Periodontics
50 %
50 %
60 %
50 %
Oral Surgery
80 %
80 %
90 %
80 %
50 %
50 %
60 %
50 %
Orthodontic Benefits
50 %
50 %
50 %
50 %
Orthodontic Maximums
$ 500
$ 500
$ 1,000
$ 1,000
Exams, cleanings, x-rays, sealants
Fillings, simple tooth extractions
Covered Under Basic Services
Covered Under Basic Services
Covered Under Major Services
Covered Under Basic Services
Major Services
Crowns, inlays, onlays and cast
restorations, bridges and dentures,
implants
dependent children
Lifetime
* If you switch plans during the calendar year your Deductible and Annual Maximum may be adjusted accordingly.
** Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on
Delta Dental contract allowances and not necessarily each dentist’s actual fees.
†
Fees are based on PPO contracted fees for PPO dentists, PPO contracted fees for Premier dentists and PPO contracted fees for nonDelta Dental dentists.
Delta Dental Insurance Company
1130 Sanctuary Parkway, Suite 600
Alpharetta, GA 30009
Customer Service
800-521-2651
Claims Address
P.O. Box 1809
Alpharetta, GA 30023-1809
deltadentalins.com
This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or Summary Plan Description. If you
have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your company’s benefits representative.
www.myFBMC.com
24
HLT_PPO_2COL_HILO_DDIC (Rev. 3 1/13)
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
Co-payment/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 — VCP offers the LASIK procedure for plan members
who are nearsighted or have astigmatism and wear glasses or contacts.
VCP contracted with LASIK facilities and eye doctors to offer LASIK
to covered employees and family members at substantially reduced
fees. Plan members will pay no more than $1,800 for treating one
eye, or $3,600 for both eyes.
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
25
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 to convert your group policy to an individual policy.
• 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-5A/B
Your Pre-tax 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 26
$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 1/1/2015
There are a number of levels of group term
life insurance: $10,000
$30,000
$50,000
Retirees under 65
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
$45,000
$50,000
$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.
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
$45,000
$50,000
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.
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
45-49 50-54 55-5960-64
$3.10
$3.10
$3.10
$3.10
$5.50
$6.95
$8.85 $11.45
$7.90 $10.80 $14.60 $19.80
$10.30 $14.65 $20.35 $28.15
$12.70 $18.50 $26.10 $36.50
$15.10 $22.35 $31.85 $44.85
$17.50 $26.20 $37.60 $53.20
$19.90 $30.05 $43.35 $61.55
$22.30 $33.90 $49.10 $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 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-30A/B
27
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
28
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.
29
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 2015 calendar year begins October 15,
2014 and runs through December 7, 2014. If you elect the St. Lucie County
School Board Prescription Drug Plan for 2015, 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 2015 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
30
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:
09/15/14
St. Lucie County School Board
Risk Management
4204 Okeechobee Road, Fort Pierce, FL 34947
(772) 429-5520
31
www.myFBMC.com
Notes
www.myFBMC.com
32
Notes
33
www.myFBMC.com
Benefits Directory
Florida Blue
Customer Service - Commercial Plans Retirees/COBRA
Mon - Fri, 8:00 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
1-800-926-6565 (ext. 89724, for prospective members)
Delta Dental Insurance Company
Customer Service
Mon - Thurs, 7:15 a.m. - 7:30 p.m. ET
1-800-521-2651
www.deltadentalins.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 (Retiree Services)
Direct Bill Department
P.O. Box 10789
Tallahassee, FL 32302-2789
Service Center 1-855-LUCIE4U (1-855-582-4348)
www.myrsc.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 2014
FBMC/SLCSB_CR/0814