BENEFITS KNOW. your Benefits Guide Administered by Florida Blue. Do you have questions about your medical or prescription drug coverage?

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1 2013 BENEFITS GUIDE

2 2013 Benefits Guide Administered by Florida Blue We are pleased to announce that effective January 1, 2013 Florida Blue wiii be providing your medical and pharmacy Benefit options. This Benefit Guide provides important information and details regarding your medical and pharmacy plans for services received on or after January 1, Please read carefully to ensure you select the right plan for your healthcare needs. KNOW your BENEFITS Do you have questions about your medical or prescription drug coverage? Florida Blue is here to help, call us at Monday Thursday 8am to 6pm and Fridays 9am to 6pm. Pharmacy Go generic generic medications cost less than brand name medications and in most cases they are just as effective. Remember, if a brand name medication is prescribed, the plan will provide the generic equivalent. If you refuse to take the generic and elect to take the brand medication instead, you will pay the brand drug copayment plus the retail cost difference between the generic and brand name medication. Covered Medications Be sure to review Florida Blue s Medication Guide to find out if your current prescription is covered. The Medication Guide will also help you determine what tier your prescription falls into in order to help determine your cost. You can also locate generic alternatives in the guide to help you save money. The Medication Guide can be found on Mail Order Fill your maintenance medications with Florida Blue s Mail Order Pharmacy through Prime Therapeutics. Visit for information on how to request a mail order prescription. Authorization and Step Therapy Certain medications, as noted in the Medication Guide require a prior authorization or for you to try an alternative medication before your brand named prescription will be covered. This requirement is being waived for the first 90 days of your policy. If your medication requires prior authorization or step therapy, please be sure you work with your physician to request an authorization prior to April 1, 2013 to avoid any disruption to your prescription coverage. ID Cards All members will receive Florida Blue ID cards prior to January 1, Please note that only the policy holders name will appear on your ID card, covered dependent names will not be listed. However, when your provider reviews your eligibility online, or calls Florida Blue for coverage information, they will have access to your covered dependent information using the policy holders ID card. If you need additional ID cards, you can register on Florida Blue s member website ( or call customer service to request additional cards. Once you receive your ID card, you can register for your personalized Florida Blue member web page at floridablue.com or you can contact Customer Service to discuss any questions you may have. 2

3 2013 Benefits Guide Administered by Florida Blue Away From Home Care If you enroll in one of the HMO products, you will have access to certain health care services across the country. To meet the different health care needs of members and dependents who are away from home separate programs for short trips and long-term stays. For short trips, the BlueCard Program gives you access to doctors and hospitals in most locations, giving you the peace of mind that you ll always find the care you need. For longer trips (90 consecutive days or longer), the Away From Home Care Guest Membership program may be available for you and your covered dependents in most states. This program is designed to bring you peace of mind if you have a dependent attending school out-of-state, have family members living in different service areas, or have long-term work assignment in another state. Coverage is limited to another Blue Cross and Blue Shield Plan s HMO service areas. For eligibility information and specific locations where the Guest Membership program is available, please contact the customer service number indicated on your ID card. How to Save Blue365 You can save BIG on a wide variety of healthy products and services through our members-only discount program Blue365. Take advantage of exclusive discounts on fitness clubs, exercise equipment, contact lenses or glasses, and so much more! Register on when you receive your ID card and start saving! Care Consultants Planning an upcoming surgery or need help managing an ongoing condition? Contact a Care Consultant. Florida Blue s Care Consultants can help you navigate through the health care system and help you save money on your out-ofpocket expenses. Call Wherever you go, whenever you need it, you have access to your Florida Blue personal health care information. As a member, you can log in anytime and find everything you need to know about your health plan, plus free tools and resources. All you need is your member number, located on your member ID card. Review your plan benefits and find out where you stand with your deductible. Find a doctor or hospital in your plan s network. View claim activity, status and history. Print a temporary ID card or request a new ID card. And much more! Transition of Care Coverage of medical care by physicians or providers who are not participating may be granted for a new enrollee when requiring transfer to a participating provider might not be consistent with quality medical care. Examples of potential conditions for Transition of Coverage include: Pregnancy, surgical procedures that have already been scheduled; current cycle of chemotherapy or radiation treatment; or transplants that have already been scheduled. To determine if your situation meets the eligibility criteria, please contact customer service for instructions on how to request transition of care. Durable Medical Equipment (DME) Don t pay more than you should Shop, compare and save money. You have choices when it comes to the cost of your health care. The quality and price of medical services can vary depending on where you go. Compare quality and cost before you go, and then decide what s best for your care. Cost estimates are based on your plan and where you stand with your deductible. To get cost estimates, simply log in at floridablue.com and select Compare Medical Costs under Tools. You can also compare costs on your prescription drugs by pharmacy and find cheaper alternatives. The benefit elections you make will be binding. You will be governed by the terms, provisions and restrictions of the plans in which you enroll. Generally, unless you experience a qualified life event, your elections will remain in effect for the entire plan (calendar) year. This document highlights changes and important information. Please be sure to read all of your open enrollment materials carefully for complete benefit information for For additional questions regarding benefits, physician network, claims or eligibility, please contact Florida Blue s Customer Service team toll-free at

4 2013 Benefits Guide Administered by Florida Blue 2013 Benefit Summary COST SHARING BlueCare HMO 48 BlueOptions (PPO) BlueCare HDHP 65 Deductible (DED) (Per Person/Family Aggregate) Coinsurance (Member Responsibility) Out of Pocket Maximum (Per Person/Family Aggregate) Includes DED, Coins and all Copays (Excludes Rx) $300 / $600 30% Not Applicable $2,500 / $5,000 Not Applicable $750 / $1,500 $1,000 / $2,000 30% 50% $6,000 / $12,000 $9,000 / $18,000 $1,500 / $3,000 30% Not Applicable $5,000 / $10,000 Lifetime Maximum No Maximum No Maximum No Maximum PROFESSIONAL PROVIDER SERVICES Office Services (including Allergy injections, treatment & testing) Family Physician / Specialist Provider Services at Hospital and Emergency Room Family Physician or Specialist Provider Services at ASC Family Physician / Specialist Radiology, Pathology and Anesthesiology Provider Services at Ambulatory Surgical Center Family Physician / Specialist PREVENTIVE CARE Adult & Child Wellness Office Services Family Physician or Specialist Colonoscopies (for age 50+ then frequency schedule applies) Mammograms EMERGENCY/URGENT/CONVENIENT CARE $25 / $35 Hospital: ER: In-Network $25 / $35 $30 $30 / $40 Hospital: ER: In-Network $30 / $40 $35 50% (No DED) $25 / Hospital: ER: In-Network Ambulance & Out-of-Network $200 $200 Convenient Care Centers (CCC) Emergency Room Facility Services Urgent Care Centers (UCC) $25 $ % $ % $30 $30 $ % $ % $35 In-Network $25 4

5 2013 Benefits Guide Administered by Florida Blue 2013 Benefit Summary COST SHARING BlueCare HMO 48 BlueOptions (PPO) BlueCare HDHP 65 FACILITY SERVICES - HOSP/SURG/ICL/IDTF Ambulatory Surgical Center Independent Clinical Lab Independent Diagnostic Testing Facility - X-rays and AIS (Includes Physician Services) - Advanced Imaging Services (AIS) - Other Diagnostic Services Inpatient Hospital (per admit) $300 $30 $300 $35 Inpatient Rehab Maximum 21 Days 21 Days 21 Days Outpatient Hospital (per visit) MENTAL HEALTH AND SUBSTANCE ABUSE Inpatient Hospitalization Outpatient Hospitalization (per visit) Provider Services at Hospital and Emergency Room Family Physician or Specialist Provider Physician Office Visit Family Physician or Specialist Provider Emergency Room Facility Services (per visit) Provider Services at Locations other than Hospital/ER Family Physician or Specialist Provider OTHER SPECIAL SERVICES AND LOCATIONS Skilled Nursing Facility Physician Services Combined Outpatient Cardiac Rehabilitation & Occupational, Physical, Speech and Massage Therapies and Spinal Manipulations Durable Medical Equipment, Prosthetics, Orthotics Motorized Wheelchair All Other 30% (includes ER OON) Hospital: $25/$35 $ % $ % INN Facility DED+30% $25/$35 60 Visits/20 Manipulations Auth Required for Therapy $35 $500 $30 30% (includes ER OON) 30% $30/$40 $ % $ % 50% (No DED) INN Facility DED+30% $30/$40 60 Visits/20 Manipulations Auth Required for Therapy $40 $500 $45 (includes ER OON) Hospital: $25/ In-Network INN Facility DED+30% 60 Visits/20 Manipulations Auth Required for Therapy $500 5

6 2013 Benefits Guide Administered by Florida Blue 2013 Benefit Summary COST SHARING BlueCare HMO 48 BlueOptions (PPO) BlueCare HDHP 65 OTHER SPECIAL SERVICES AND LOCATIONS CONT Home Health Care Hospice (Office Visit) (Inpatient Facility) PRESCRIPTION DRUGS IN-NETWORK Retail (30 days) Generic/Preferred Brand/Non-Preferred Mail Order (90 days) Generic/Preferred Brand/Non-Preferred $20 $20 $10 / $40 / $75 $20 / $80 / $150 $20 $20 $10 / $40 / $75 $20 / $80 / $150 No Covered $10 / $40 / $75 $20 / $80 / $150 Diabetic Supplies (lancets, strips, etc.) obtained under the Rx benefit would be paid at 100% (no cost to member). Diabetic Supplies obtained through a participating DME vendor, would be processed under medical and paid at 100% (no cost to member). 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. IMPORTANT NUMBERS & HOURS OF OPERATION Contact: Phone Number Hours of Operation Florida Blue Customer Service (Medical and Pharmacy Inquiries) Prim (Mail Order Prescriptions) Caremark Specialty Pharmacy (Specialty Medication Pharmacy) CareCentrix (Durable Medical Equipment) Monday Thursday 8am 6pm Friday 9am 6pm / :30am to 8pm Monday Thursday 8am-8pm Friday 8am 6pm 6

7 Florida Blue mobile Need it. Find it. Go. For everyone members and non-members. 4Access health information and tools on the go. 4Works on any Smartphone Blackberry, iphone, Droid and even the ipad. 4Just type in floridablue.com from your mobile browser or download the FREE app for your iphone or Droid! Save Time. Save Money. Stay Healthy.

8 Florida Blue mobile Need it. Find it. Go. Save Time. 4Get your plan details such as deductibles, HSA balance and claims on the go 4Get a picture of your member ID card 4Locate doctors in your plan from wherever you are Save Money. 4Compare drug prices on the spot and map the nearest pharmacy 4Get connected to a person who can help you manage your out-of-pocket costs and find quality care 4Shop for affordable health plans and get a quote instantly Stay Healthy. 4Take charge of your health with the health toolkit 4Find a Florida Blue Center near you Scan with any QR Code app from your mobile phone to visit the floridablue.com mobile site. Get the app for your iphone or Android it s free! Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association

9 Did you know? Personalized resources are available to you at no additional cost. Did you know that if you or your child wake up during the night with a fever, you have access to a nurse for advice? Are you a mom-to-be who would like to join Healthy Addition a program designed to help you have a healthy pregnancy? Nurses and Health Coaches are available 24 hours a day, every day at To join Healthy Addition, call , Option 6. Did you know that a health assessment can give you a clearer picture of your overall health? In just 15 minutes, you ll find out what steps you can take to reduce your risks for a heart attack, stroke and other serious conditions. Log in to floridablue.com to take a Personal Health Assessment or meet with a nurse, in person, at a Florida Blue Center. Go to floridablue.com for locations. Did you know that if you re planning a medical procedure or dealing with a health condition, such as diabetes or COPD, you can get personalized help from a nurse? Our Care Consultants are experts when it comes to connecting you with a dedicated nurse, explaining quality care and treatment options, and helping you save money along the way. Our Care Consultants and nurses are waiting to help you. Call , or stop in a Florida Blue Center. Go to floridablue.com for locations. Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association

10 Quality care at lower costs Know before you go! Knee Replacement $23,046 or $19,501 Wow! That s a difference of $3,545! Cholesterol lowering drugs for a year $1,546 or $160 Go generic! MRI of the Spine $1,200 or $600 Who knew? It s easier to find quality care and save money when you re informed before you go to the doctor, the hospital, an imaging center, an emergency room or a pharmacy. Our team of Care Consultants understands the big health care picture. Let us answer your questions about plan benefits, treatment choices, cost saving options, community resources and more. We re here to make your health care decisions easier and ultimately, save you time and money. If you knew you could save hundreds of dollars on your treatment, would you? Of course! When is a good time to call? Anytime you need help making important health care decisions! Before you get medical treatment from a doctor or facility. Before you buy specialized or expensive medicine. The moment you have trouble getting care or coordinating care with multiple providers. Who will you talk to? Health experts who work together to save you time, money and hassle! Nurses. Plan Benefit Specialists. Community Resource Professionals. What will you know before you go? Your options for saving money and more! The cost for the same procedure, same quality, at different locations. Doctors and facilities in your plan s network. Medicines and pharmacies that may cost less. Benefit authorizations required for certain procedures and prescriptions. Call a Care Consultant toll-free at , Monday through Friday, 8 AM to 9 PM SU Stop in a Florida Blue Center, Monday - Saturday, 10 AM to 8 PM. For locations and a calendar of FREE events, go to FloridaBlue.com or call

11 floridablue.com is at your service Wherever you go, whenever you need it, you have access to your Florida Blue personal health care information. As a member, you can log in anytime and find everything you need to know about your health plan, plus free tools and resources. If you haven t already registered it s easy! Just visit floridablue.com. All you need is your member number (located on your member ID card). You ll have access to all the information you need to take control of your health right at your fingertips! floridablue.com gives you personal health information when you need it. u Review your plan benefits and find out where you stand with your deductible. u Find a doctor or hospital in your plan s network. u Shop, compare and estimate your costs for office visits, imaging services and surgeries so you know before you go. u Compare drug prices with the Pharmacy Shopping Tool. u View claim activity, status and history. u Create a Personal Health Record so your doctor visits and lab results are all in one secure place. u Access your monthly Health Statement which gives you an overview of savings, claims and expenses. u Print a temporary ID card or request a new member ID card. u Take your Personal Health Assessment to get a clear picture of your health status and create action plans that work with your personal needs and lifestyle. u Consider Lifestyle Improvement Programs such as smoking cessation, stress management, or weight and nutritional programs, to help monitor and improve your overall well-being. u Rate and review doctors using the Zagat Health Survey. u Get access to health-related Member Discounts such as gym memberships, weight loss programs, vision and hearing care. And remember, we re here to answer any questions you may have. Just call the toll-free number on the back of your member ID card! Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc., an Independent Licensee of the Blue Cross and Blue Shield Association

12 Create your Online Account Today You ll have access to personalized benefits and health information any time, day or night! 1 Go to Click on Login, and then Register. You ll need your Member Number (located on your Member ID card) and a valid address. 2 Enter your information on each screen and click Continue. 3 Click Login once your registration is confirmed. Enter your User ID and Password to access MyBlueService

13 Prim delivers Prim , the mail-service pharmacy trusted by your health plan, delivers your maintenance or long-term medications right where you want them. No driving to the pharmacy. No waiting for your prescriptions to be filled. Savings 90-day supplies offer deeper discounts through bulk purchasing and no dispensing fees that means lower out-of-pocket pharmacy costs for you Convenience Prescriptions delivered to the address of your choice Medications ordered your way online, over the phone or through the mail Up to a 90-day supply of medication for each order Plain-labeled packaging protects your privacy Service Notification through or over the phone your choice when your order is received and when your prescriptions are sent Member service agents available 24/7 Licensed, U.S.-based pharmacists available seven days a week Refill reminder notifications Regular delivery at no additional cost Learn how to get started Today

14 Getting started is easy Order your prescriptions online or through the mail. Choose the option you like best! Online Visit MyPrim .com Transition your prescriptions from a retail pharmacy to mail» Fill out the online form and Prim will take care of the rest» Expect your medications in five to eight business days after Prim receives approval from your prescriber Through the mail Talk to your doctor» Ask for a prescription for a 90-day supply of each of your maintenance medications» Ask for a prescription for a 14-day supply to fill at a retail pharmacy for immediate use if needed Complete the Prim order form» Find Prim forms at MyPrim .com OR call Prim at » Mail your prescription, completed order form and payment to Prim » Expect your medications in five to eight business days after Prim receives your order Refills are easy Refill dates are shown on each prescription label, and Prim will remind you when a refill is due. You have several options to order prescription refills. Choose the option that best suits you. Online Visit MyPrim .com to refill a prescription or renew an expired prescription Over the phone Call the automated Prim refill system at Through the mail Complete and mail in the prescription refill form sent with your order Questions? To learn more, visit our easy-to-use website at MyPrim .com A FL Prime Therapeutics LLC 04/12 Prim is a registered trademark of Prime Therapeutics LLC.

15 Prescription Drug and Pharmacy Pharmacy Information Information Side 1 You can count on us for help getting the right medicine at the lowest price. Medical conditions have several drug options. That s why we have a team of pharmacists, doctors and other experts continually working to determine which medicines are clinically effective, safe AND cost less. Ultimately, you and your doctor will decide what medicine is best for you. Wherever you go, whenever you need it, you have access to drug and pharmacy information online. If you have a complex condition or just prefer to talk with someone, you can also call us toll-free at the Customer Service number on your member ID card, or meet with us in person at your Florida Blue Center. To understand how your prescription benefits work, it helps to familiarize yourself with your Prescription Drug program. When you get a prescription, the amount you ll pay at the pharmacy will depend on these four things: 1. Is the drug covered by your prescription plan? The Medication Guide includes a list of covered drugs called a formulary. Our formulary may be updated up to four times a year after careful review by a team of medical experts. We evaluate how well the drugs work and how they compare to other drugs for the same condition. Clinical effectiveness, safety risks, side effects and costs are all considered during this review, and help us determine which drugs can help you stay well and keep your costs down. 2. What Tier is the drug? There are several prescription plans available, including plans that cover only Tier 1 drugs, plans that cover Tier 1 and Tier 2 drugs and plans that cover Tier 1, 2 and 3 drugs. With most plans, if you choose a Brand Name drug when a Generic is available, you ll pay your benefit amount plus the difference in cost between the two drugs. If a Brand Name drug is medically necessary, your doctor must write it on your prescription to avoid paying the difference. Please refer to your benefit materials for more details. The table below describes each Benefit Tier and how it affects your cost. Drug Tier Prescription Drug Description Your Cost Tier 1 Covered Generic Medication $ Tier 2 Covered Preferred Brand Medication $$ Tier 3 Covered Non-Preferred Brand Medication $$$ Help with your medicine online, anytime. Log in at floridablue.com. See your Medication Guide for drugs that may be covered and special requirements. Find participating pharmacies. Review your benefits including prescription copays or coinsurance. See what you ll pay for specific medications. See the cost of other medications that may be just as effective. View your prescription history. Look up drug information, including interactions with other drugs. Refill mail order drugs. Set up refill reminders. Get prescription forms. Tips for Saving Money Take your member ID card to the pharmacy. Use participating pharmacies. Use Generic Drugs when available. Ask about over-the-counter medicine alternatives. Order maintenance medication by mail. Know more before you go to the pharmacy. Log in at floridablue.com Know which drugs are covered. Compare drug costs at different pharmacies. Compare the cost of alternate drugs that may cost less. Research drug side effects and interactions. Check for prior authorization or step therapy requirements. Need help? We re here for you. Please call the toll-free customer service number on the back of your member ID card or visit us at a Florida Blue Center. For Center locations and hours, log in to floridablue.com. Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association

16 Prescription Drug and Pharmacy Pharmacy Information Information Side 2 3. Are there additional requirements, limits or authorization needed first? With certain medications there are potential safety risks, such as over use, which can be harmful to your health and costly to your wallet. These medications may be included in one or more of our Responsible Rx programs such as Prior Authorization, Responsible Steps or Responsible Quantity. Your Medication Guide indicates which drugs are included in these programs. Below is a description of how each program works: Prior Authorization. Prior Authorization means that your doctor will need to submit medical documentation and an authorization form before a drug will be covered by your plan. You or your doctor can obtain the authorization form at floridablue.com. Responsible Quantity. Some drugs have a maximum quantity that is covered for a given time period. For example, if your doctor prescribes a medication that has a 30-day limit of 9 tablets, your plan covers 9 tablets that month. These safety limits are based on the drug manufacturer s and Food and Drug Administration s dosing guidelines. Responsible Steps (Step Therapy). Certain drugs are not covered unless you try another FDA approved drug first. There may be a lower cost drug that is clinically and cost effective to treat your condition. If an alternate drug is not recommended for you or you had other insurance when you tried the alternate drug, simply ask your doctor to submit an authorization form to request that the drug be covered. This form is at floridablue.com. 4. Are you using a participating retail, mail order or specialty pharmacy? Where you go for your prescriptions will depend on the kind of medication you need. You ll pay less and avoid filing a claim when your prescriptions are filled at a participating pharmacies retail, mail order or specialty. Retail Pharmacy, for up to a 30-day supply Fill prescriptions for non-specialty Generic and Brand Name drugs at your local participating retail pharmacy, including many national chains such as CVS/pharmacy, Publix, Target, Walgreens, Walmart and Winn-Dixie. Retail Extended Pharmacy, for up to a 90-day supply For maintenance medicines that you take regularly, certain retail pharmacies are designated as an extended pharmacy and can provide up to a 90-day supply of medication. Other retail pharmacies may only dispense 30 days of medication. Mail-order, for up to a 90-day supply Ordering your drugs by mail can save you time and money. With most plans you pay less for ordering a 90- day supply at one time, by mail, rather than going to a retail pharmacy, one month at a time. With a new prescription, simply complete a mail order form (available online) and mail it along with an original 90-day supply prescription from your doctor. Then order refills online at floridablue.com. Specialty Pharmacy Certain Self-Administered specialty drugs such as injectible, infused, oral or inhaled drugs must be purchased from our participating specialty pharmacy, CareMark. If your medication is a Self- Administered Specialty drug, simply call CareMark toll-free at To find a participating pharmacy near you, please log in at floridablue.com. Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association

17 Your Employee Assistance Program Help When You Need It Call or Any of us can experience personal problems that might affect us on or off the job. Stress, conflicts, family worries, financial/legal issues and balancing work and home life are some examples. We would like to remind you to take advantage of our Employee Assistance Program (EAP) services. Corporate Care Works, Inc. (CCW), our provider, helps employees solve challenges in a confidential manner and here s how it works: It s FREE- Unlimited access to licensed counselors for EAP assessment, short-term problem resolution, and/or linkage to community resources is all included. It s CONFIDENTIAL The services are delivered within Federal Confidentiality Guidelines. The participating employer receives a statistics only report. It s VOLUNTARY It s your choice to utilize our EAP services. It s PROFESSIONAL Licensed counselors are available nationally 24 hours a day. We hope that you will choose to avail yourself of these valuable services should you or a family member have a need.

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