ADDENDUM 1
RFP RM 09-18
ACTUARIAL ALUATION SERVICES
1. Can you provide the amount of the total fees paid to the current actuarial vendor in 2016 and 2017? Was the scope of that work the same as required in this RFP? 2016 - $11,000- 2017 - $3,500. In essence yes, however, this RFP contemplates the requirement to comply with GASB 75. 2. Please identify a current actuarial vendor. How long has the current actuarial vendor served the County in that capacity? Milliman, Inc. since 2008, contact Sebastian Jaramillo 3. Is the current actuarial vendor allowed to bid on this assignment? Yes 4. Has the County been totally satisfied with the current vendor? Not totally 5. How many people are currently covered by OPEB plan? 30 6. Please confirm that OPEB plan sponsored by county is a single-employer, agent multiple- employer or cost-sharing multiple-employer plan? Single-employer 7. Can you provide the copies of the most recent actuarial funding valuation report for OPEB plan and GASB disclosure report? Yes. 8. Will any preference be given to the bidder maintaining an office in the State of Florida? No 9. How many live meetings will be required under the terms of the engagement and must be included into the total fees? One optional live meeting annually at our request. It can be via voice conference or web meeting if needed. 10. Regarding cost proposal: does the County require bidders to provide not to exceed fee for experience study (Scope of Work, part 4) and additional services (Scope of Work, part 5), or we just need to provide the hourly rate for these particular services? – Items 1-4 are included in the required actuary services and should be included in the proposed fee. Additional services could be proposed in total (not hourly) or could be based on an hourly rate. Additional services will be requested as needed and are not guaranteed. 11. Paragraph # 32 of RFP documents includes the list of the forms to be submitted with proposal package. Please clarify A. Are we required to submit the draft of the contract agreement with proposal? Do we need to fill out any information? It’s our understanding that the contract will be signed with the winning bidder. It’s provided for informational purposes and it does need to be submitted as part of the proposal package as an acknowledgement of the terms and considerations that will be included in any related awarded contract. B. What in formation do we need to provide with the Standard Additional Clauses “Exhibit B” form? It appears that the form is not required any signature or certification. Please confirm that we need to include the form with the proposal package and what information needs to be provided with it. Exhibit B is provided to outline the contract provisions and contract form that will executed upon vendor selection. You do not need to include with the proposal package, however; by submitting your proposal you are acknowledging knowledge of the terms and conditions that will be included in any award agreement. erlt:al Be11efits
Overview of Benefits for: The Okaloosa County Board of County Commissioners Network: PDP Plus
The Preferred Dentist Program was designed to help you get the dental care you need and help lower your costs. You get benefits for awide range of covered services - both in and out of the network.The goal is to deliver affordable protection for a healthier smile and a healthier you.
In Network Out of Network Coverage Type %of Negotiated Fee %of R&C Fee1
Type A- Preventive 100% 100% Type B- Basic Restorative 80% 80% Type C- Major Restorative 50% 50% Type D-Orthodontia 50% 50% Deductible: Per Individual $50 $50 Applies to Type B&Cservices only Applies to Type B&Cse rvices only Deductible: Per Family $150 $150 Applies to Type B&Cservices only Applies to Type B&Cservices only Annual Maximum Benefits: $1200 $1200 Per Individual Orthodontia Lifetime Maximum: $1000 $1000 Per Individual Ortho applies to Child Only (Up to age 19) Dependent Age: Eligible for benefits until the day that he or she turns 26. 1. The Reasonable and Customary charge is based on the lowest of the: "Actual Charge" (the dentist's actual charge); or "Usual Charge" (the dentist's usual charge for the same or similar services); or "Customary Charge" (the 90th Percentile charge of most dentists in the same geographic area for the same or similar services as determined by MetLife).
Understanding Your Dental Plans The Preferred Dentist Program is designed to provide the dental coverage you need with the features you want. Like the freedom to visit the dentist of your choice- in or out of the network.
Plan benefits for in-network services are based on the percentage of the negotiated fee -the fee that participating dentists have agreed to accept as payment in full. Plan benefits for out-of-network services are based on the percentage of the Reasonable and Customary (R&C) charges. If you choose adentist who does not participate in the network, your out-of-pocket expenses may be more, since you will be responsible for paying any difference between the dentist's fee and your plan's payment for the approved service.
Once you're enrolled you may take advantage of online self-service capabilities with MyBenefits. • Check the status of your claims • Locate a participating dentist • Access Metlife's Oral Health Library • Elect to view your Explanation of Benefits on line To register, just go to www.metlife.com/mybenefits and follow the easy registration instructions.
PEANUTS© United FeatureSvndicate. Inc. Paae 1of.> I 011Hl'i140f PMn0R14HAII ~tat.sl Important Enrollment Information
You may only enroll for Dental Expense Benefits within 31 days of your Personal Benefits Eligibility Date, or if you have aQualifying Event or during the Plan's Annual Open Enrollment Period.
Qualifying Event: Request to be covered, or to change your coverage, upon aQualifying Event If there is aQualifying Event you may request to be covered, or to change your coverage, for Personal Dental Expense Benefits only within 31 days of aQualifying Event. Such a request will not be alate request. Except for marriage or the birth or adoption of achild, you must give us proof of prior dental coverage under your spouse's plan if you are requesting coverage under This Plan because of a loss of the prior dental coverage. If you make a request to be covered for Personal Dental Expense Benefits or arequest for change(s)in Personal Dental Expense Benefits within thirty-one days of aQualifying Event, your Personal Dental Expense Benefits or the change(s) in Personal Dental Expense Benefits will become effective on the first day of the month following the date of your request, subject to the Active Work Requirement, and provided that the change in coverage is consistent with your new family status.
Page2of5 Selected Covered Services and Frequency Limitations
Type A- Preventive How Many/ How Often - Prolhylaxis - Cleanings 1in 6months. •Ora Examinations 1in 6months. • Problem Focused Examinations 1in 12 months. •Towcal Fluoride Applications 2in 12 months for children up to 14th birthday. • Fu IMouth X-Rays 1in 5years. • Bitewing X-Rays (Adult/Child) 1in 12 months. • Space Maintainers Children up to 19th birthday. •Sealants 1pertooth in 3years (per permanent 1st &2nd non-restored molar) children up to 17th birthday. • Periapical X-rays •Emergency Palliative Treatment Type B- Basic Restorative How Many/ How Often •Repairs 1per tooth in 12 months. •Endodontics - Root Canal 1per tooth per lifetime. •General Anesthesia For oral surgery, extractions or other covered services. •Oral Surgery (Simple Extractions) •Oral Surgei (Surgical Extractions) •Other Oral urgery •Periodontal Sur~ery 1in 24 months per quadrant. • Periodontal Sea ing &Root Planing 1in 12 months per quadrant. •Periodontal Maintenance 4 in l year less the number of basic cleanings received. •Amalgam &Composite Fillings 1per tooth surface in 24 months. Composite Fillings covered on all teeth. •Consultations l in 12 months. Type C- Major Restorative How Many/ How Often •Implants Services: 1per tooth in 5years Repairs: 1per tooth in 12 months. •Bridges 1per tooth in 5years. • Dentures 1per tooth in 5years. •Crowns/lnlays/Onla~s 1per tooth in 5years. •Harmful Habits App iances •Bruxism Appliances •Prefabricated Stainless Steel &Resin 1per tooth in 10 Yea rs. Crowns Type 0-0rthodontia • Dependent children are covered until the day thri turn 19. Age limitations may vary by state. Please see your Plan description for complete details. In the event ofa conflict with this summary, the terms o the certificate will govern. • All procedures performed in connection with orthodontic treatment are payable as Orthodontia. •Benefits for the initial placement will not exceed 20% of the Lifetime Maximum Benefit Amount for Orthodontia. Periodic follow-ufi visits will be payable on a monthly basis durinJl the scheduled course of the orthodontic treatment. Allowable expenses for the initial placement, periodic to low-up visits and procedures performe in connection wi'th the orthodontic treatment, are all subject to the Orthodontia coinsurance level and Lifetime Maximum Benefit Amount as defined in the Plan Summary. •Orthodontic benefits end at cancellation of coverage.
The service categories and plan limitations shown in this document represent an overview of your plan benefits, but are not acomplete description of the plan. Before making any purchase or enrollment decision you should review the certificate of insurance which is available through MetLife or your employer. In the event of aconflict between this overview and your certificate of insurance, your certificate ofinsurance governs. Like most group dental insurance policies, MetLife group policies contain certain exclusions, limitations and waiting periods and terms for keeping them in force. The certificate of insurance sets forth all plan terms and provisions, including all exclusions and limitations.
*Alternate Benefits: Your dental plan provides that if there are two or more professionally acceptable dental treatment alternatives for adental condition, your plan bases reimbursement, and the associated procedure charge, on the least costly treatment alternative. If you receive a more costly treatment alternative, your dentist may charge you or your dependent for the difference between the cost of the service that was performed and the least costly treatment alternative.
Page 3of5 Exclusions We will not pay Dental Insurance benefits for charges incurred for: 1. Servic_es whic~ are not Dentally Necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which We deem experimental mnature; 2. Services for which You would not be required to pay in the absence of Dental Insurance; 3. Services or supplies received by You or Your Dependent before the Dental Insurance starts for that person; 4. Services which are primarily cosmetic (For residents ofTexas, see notice page section in your certificate). 5. Services which are neither performed nor prescribed by a Dentist except for those services of a licensed dental hygienist which are supervised and billed by a Dentist and which are for: • scali~g and polishing of teeth; or • fluoride treatments. For NY Sitused Groups, this exclusion does not apply. 6. Services or appliances which restore or alter occlusion or vertical dimension. 7. Restoration of tooth structure damaged by attrition, abrasion or erosion. 8. Restorations or appliances used for the purpose of periodontal splinting. 9. Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco. 10. Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss. 11. Decoration, personalization or inscription of any tooth, device, appliance, crown or other dental work. 12. Missed appointments. 13. Services • covered under any workers' compensation or occupational disease law; • covered under any employer liability law • for which the employerof the person receiving such services is not req uired to pay; or • received at afaciflty maintained by the Employer, labor union, mutual benefit association, or VA hospital. For North Carolina and Vir inia Sitused Grou s this exclusion does not apply. 14. Services paid under any workers' compensation, occupational disease or employer liability law as follows: • for persons who are covered in North Carolina for tile treatment of an Occupational Injury or Sickness which are paid under the North Carolina Workers' ComP.enSiltion Act only to the extent such services are the liability ofthe employee, employer or workers' compensation insurance carrier according to a'final adjudiartion under the North Carolina Wqrkers' Compensation Act or an orcfer of the Norm Carolina Industrial Commission approving asettlement agreemenf under the North Carolina Workers' Corn P.ensat1on Art· • or for P.ersons who are not covered in North Carolina, services paid or payable under any workers' compensation or occupational disease law. This exclusion only applies for orth Carolin Sltosed Grou s. 15. Services: • for which the employer of the person receiving such serv ices is not required to pay; or • received at a facmty maintained by the Employer, labor union, mutual benefit association, or VA hospital. This exclusion only applies for North Carolina Sitused Grou . 16. Services covered under any workers· compensation, occupational disease or employer liability law for which the employee/or Dependent received benefits under that law. This exclusion only applies for Virginia Sitused Groups. 17. Services: • for which the employer of the person receiving such services is not required to pay; or • received at afacinty maintained by the policyllolde_r, labor union, mutual benefit association, or VA hospital. This exclusion only applies for Vtr inia Sifused urou s. 18. Services covered under other coverage provided by the Employer. 19. Temporary or provisional restorations. 20. Temporary or provisional appliances. 21. Prescription drugs. 22. Services for which the submitted documentation indicates a poor prognosis. 23. The following when charged by the Dentist on aseparate basis: • claim form completion; · • infection control such as gloves, masks, and sterilization of supplies; or • local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide. 24. Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food. For NY Sitused Groups, this exclusion does not apply. 25. Caries susceptibility tests. 26. Initial installation of afixed and permanent Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. 27. Other fixed Denture prosthetic services not described elsewhere in this certificate. 28. Precision attachments, except when the precision attachment is related to implant prosthetics. 29. lnitial installation or replacement of a full or removable Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. 30. Addition of teeth to a partial removable Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. 31. Adjustment of a Denture made within 6months after installation by the same Dentist who installed it. 32. Implants to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. 33. l~pl~nts supported prosthetics to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally m1ssmg natural teeth. 34. Duplicate prosthetic devices or appliances. 35. Replacement of a lost or stolen appliance, Cast Restoration, or Denture. 36. Intra and extraoral photographic images. 37. Services or supplies furnished as aresult of a referral prohibited by Section 1-302 ofthe Maryland Health Occupations Article. Aprohibited referral is one in which a Health Care Practitioner refers You to a Heallh Care Entity in which the Health Care Practitioner or Health Care Practitioner's immediate fam ily or both own a Beneficial Interest or have aCompensation Agreement. For the purposes of this exclusion, the terms "Referral", "Health Care Practitioner" , "Health Care Entity'', "Beneficial Interest" and Compensation Agreement have the same meaning as provided in Section 1-301 ofthe Maryland Health Occupations Article. This exclusion only applies for Maryland Sitused Groups 38. Diagnosis and treatment of temporomandibular joint [fMJ) disorders. This exclusion does not apply to residents of Minnesota. 1 1 Some of ll1ese excluslo11S may not apply. Please see your plan design and certificate for de!ails. Uke most group dentaflnsurance policies,Me1Ufogroup insurance policles Page4of5 Common Questions... Important Answers Who is aparticipating dentist? Aparticipating dentist is ageneral dentist or specialist who has agreed to accept negotiated fees as payment in full for services provided to plan members. Negotiated fees typically range from 15-45% below the average fees charged in adentist's community for the same or substantially similar services.* * Based on internal analysis by MetLife. Savings from enrolling in adental benefits plan will depend on various factors, including how often membersvisit participating dentistsand the cost for services rendered. Negotiated fees are subject to change. Negotiated fees for non-covered services may not apply in all states. How do Ifind aparticipating dentist? There are thousands of general dentists and specialists to choose from nationwide- so you are sure to find one who meets your needs. You can receive a list of these participating dentists online at www.metlife.com/mybenefits or call 1-800-GET-METB (800-438-6388) to have alist faxed or mailed to you. What services are covered by my plan? All services defined under your group dental benefits plan are covered. Please review the enclosed plan benefits to learn more. Does the Preferred Dentist Program offer any discounts on non-covered services? Negotiated fees may extend to servim not covered und er your plan and services received after your plan maximum has been met, where permitted by applicable state law. If permitted, you may only be responsible for the negotiated fee. .,. Negotiated rees are subject to change. Negotiated fees for non-covered services may not apply in all states. May Ichoose anon-participating dentist? Yes. You are always free to select the dentist of your choice. However, if you choose a non-participating dentist, your out-of-pocket costs may be higher. He or she hasn't agreed to accept negotiated fees. So you may be responsible for any difference in cost between the dentist's fee and your plan's benefit payment. Can my dentist apply for participation in the network? Yes. If your current dentist does not participate in the network and you would like to encourage him or her to apply, ask your dentist to visit www.metdental. com, or call 1-866-PDP-NTWK for an application:x•The website and phone number are for use by dental professionals only. • Due t.ocontractual requirement's, MetLife is prevented from soliciting certa in providers. How are claims processed? Dentists may submit your claims for you, which means you have little or no paperwork. You can track your claims on line, and even receive e-ma il alerts when aclaim has been processed. If you need aclaim form, visit www.metlife.com/mybenefits or request one by calling 1-800- GET-METS (800-438-6388). Can Ifind out what my out-of-pocket expenses will be before receiving aservice? Ye5. You can ask for apretreatment estimate. Your general dentist or specialist usually sends MetLife a plan for your care and requests an estimate of benefits. The estimate helps you prepare for the cost of dental services. We recommend that you request apre-treatment estimate for services in excess of $300. Simply have your dentist submit a request on line at www.metdental.com or call 1-877-MET-DDS9. You and your dentist will receive abenefit estimate for most procedures while you are still in the office. Actual payments may vary depending upon plan maximums, deductibles, frequency limits and other conditions at time of payment. How can Ilearn about what dentists in my area charge for different procedures? If you haveMyBenefits you can access the Dental Procedure Fee Tool. You can use the tool to look up average in- and out-of-network fees for dental services in ~our area.*You 'll find fees for services such as exams, clea nings, fillings, crowns, and more. Just log in at www.metlife.com/mybenefits. The Dental Procedure ree Tool application is provided by go2dental.com. foe., an independent vendor. Network fee information is supplied to gQ2de ntal.comby MetLife and is not available for providers who participate with MetLife through avendor. Out-of-network fee information is provided by go2dental.com. This tool does not provide the payment information used by MetLife when processing your claims. Prior to receiving services, pretreatment estimates through your dentist will provide the most accurate fee and payment information. Can MetLife help me find adentist outside of the U.S. ifIam traveling? Yes. Through international dental travel assistance services1ou can obtain a referral to a local dentist by calling+1-312-356-5970 (collect) when outside the U. S. to receive immediate care until you can see your dentist. Coverage will be considered under your out-of-network benefits.** Please remember to hold on to all receipts to submit adental claim. "International dent'a ltravel assistance services are administered by AXA Assista nce USA, Inc. AXA Assistance is not affiliated with MetLife and any of its affiliates, and the services they provide are separate and apart from the benefits provided by MetLife. ** Refer to your dental benefits plan summary for your out-of-network dental coverage. How does MetLife coordinate benefits with other insurance plans? Coordination of benefits provision in dental benefits plans are aset of rules that are followed when apatient is covered by more than one dental benefits plan. These rules detennine the O!der in which the plans will pay ~enefits. If the ~etlife ~ental benefit plan is pri,:narv, MetLife will pay t~~ full am~unt ofb~nefits that would normally be available under the plan. If the MetLife dental benefit plan 1s secondary, most coordination of benefits prov1s1ons require MetLife to determine benefit5 after benefits have been determined under the primary plan. The amount of benefits payable by MetLife may be reduced due to the benefits paid under the primary plan. Do Ineed an ID card? No, you do not need to present an ID card to confirm that you are eligible. You should notify your dentist that you are enrolled in Metlife's Preferred Dentist Program. Your dentist can easily verify information about your coverage through atoll-free automated Computer Voice Responsesystem or online at www.metlife.com. · Do my dependents have to visit the same dentist that Iselect? No, you and your dependents each have the freedom to choose any dentist. Page 5 of 5 C. We have not seen any “Governmental Debarment and Suspension Form” with RFP package. Please advise if this form needs to be completed and included with proposal package, and provide a copy of the form or advise us how we can download it from public website. Everything you need is in the RFP package. D. Certification Regarding Lobbying Proposal Sheet: we understand that every bidder is required to sign “Prohibition to Lobbying” form, but we have not seen any separate Certification Regarding Lobbying Proposal Sheet Form. There is a Proposal Sheet included with RFP package, but it appears that this sheet will be used by County to evaluate proposals. Are we required to fill out any information in the Proposal Sheet and include it with proposal package?-Yes, please provide with the package as acknowledgement of the scoring criteria. Is there a separate “Certification Regarding Lobbying Proposal Sheet” form? – Yes, the form is titled LOBBYING – 31 U.S.C. 1352, as amended and does require certification. 12. What are the fixed fees billed in the last two years for the scope of services covered? $11,000 for full valuation, $3,500 for abbreviated roll forward valuation. 13. What special and/or out of scope services has been billed for in the last two years, in addition to the fixed fees? How many hours were billed for these services? No additional services were requested. 14. Are there any service concerns and/or limitations with the current actuary? No 15. How long has the current actuary been providing actuarial services? Since April 2008 16. Our standard consulting agreement terms and conditions include some limitation on liability for mere negligence or from consequential damages. a. Is the City County open to accepting mutually-agreeable contract terms, which include some limitation of liability on the work performed by the contracting actuarial firm? Yes b. Also, are there any statutory requirements regarding limitation of liability of which we should be aware? None known. c. Have you ever sued or threatened to sue your actuarial services vendor? If yes, please provide the dates and circumstances of such suits. No. 17. Please provide most recent copy of OPEB valuation report. Report is attached for your reference. 18. Most recent actuarial experience study - We have not had an experience study completed in the past. 19. Any projections performed for OPEB plans – Projections are included under Exhibit #5 in the attached valuation report. 20. Will the County require three separate reports (one each for: a) the Board of County Commissioners, Clerk of Court, and Property Appraiser; b) Tax Collector, and, c) the Sherriff? One report to include the Board of County Commissioners, Clerk of Court and Property Appraiser is sufficient. The Sheriff does not participate any of the County’s health insurance programs. The Tax Collector does not participate in the County’s health insurance program; however, his employees do participate in the County’s dental, life and disability programs. 21. If yes, can the County provide a break-down of Active, Inactive, and Retired participants for each group above? N/A 22. When are the final reports due each year for the for the OPEB valuation report? November 1st. 23. What is the expected due date for the required historical experience study? November 1st. 24. What are the expected due dates for the two assumption-based experience studies? November 1st. 25. Is it the County’s expectation that the experience studies and the ‘Additional Services’ as specified in RFP Section III - Scope of Work, Item 5 would be included in a fixed fee (not to exceed) bid for all services or billed at an hourly rate? Items 1-4 are included in the required actuary services and should be included in the proposed fee. Additional services could be proposed in total (not hourly) or could be based on an hourly rate. Additional services will be requested as needed and are not guaranteed. 26. Is the County requesting bid pricing for the (4) optional one-year renewal years? No. 27. RFP Section V. Selection Criteria, Bullet 3 states: “Previous experience of the project team, specifically in similar projects with governments in the Florida Retirement System, implementing GASB Statements 67, 68, 74, and 75, and evaluations of pre-funded OPEB plans. (Provide individual contact names, addresses, and phone numbers that may be used as references)”. Although our firm does perform defined pension plan valuations under GASB 67/68, our primary focus is on providing cost effective OPEB plan valuations under GASB 43/45 and GASB 74/75 and can provide local references for those actuarial services. Will the County accept bid proposals that only include GASB 45/75 references (locally and similar entities nationwide)? Yes 28. Why are these services going out to bid at this time? It has not been bid in the past. 29. Please indicate the make-up of the evaluation committee. We would just like to know the positions and titles. Finance, Administration & Compliance Manager with TDD, Airports Project Manager, Office Supervisor with Department of Corrections, Engineer II with Water and Sewer Department, and Operations Manager with Public Works Department 30. Please provide a copy of the incumbent actuary’s most recent engagement letter or contract with the County. Please see the link listed for the contract http://www.co.okaloosa.fl.us/sites/default/files/contracts/contra_pdf/C08-1626- RM.pdf 31. What fees were paid for special projects during the past three years? There were no special projects requested. 32. Does the plan have any concerns with the incumbent actuary? No. 33. Are there any current service or cost concerns that Okaloosa County wants to avoid with the new actuarial firm? N/A 34. The RFP includes a form titled “Indemnification and Hold Harmless” and a draft contract that has a section entitled “Indemnification and Hold Harmless”. Which one supersedes the other? Section XV111 supersedes, however; we still need the form within the bid package to be returned signed. Also, can these clauses and the contract be negotiated? Yes, the contract came be negotiated, it is only a draft contract and will not be final until after we have selected a vendor and had a negotiation meeting. However, most of the clauses are standard for our contract. 35. The OPEB benefits are currently unfunded. Do you have plans to start funding the OPEB benefits in a qualified Trust, which would require accounting under GASB No. 74? No 36. The RFP asks for previous projects that we have conducted for organizations of similar size and complexity in the FRS. Please clarify if “in the FRS” refers to an organization that actually participates in the Florida Retirement System or to an organization that is located in Florida (and not necessarily participating in the Florida Retirement System). FRS refers to an organization that actually participates I the Florida Retirement System. BlueOptions Benefit Booklet Patrick J. Geraghty Chairman of the Boa rd and Chief Ex ecutive Officer T his Benefit Booklet C ontains Deductible Prov isions Fo r Cust omer Ser vice Ass ista nce: 80 0- 35 2- 25 83 ~ BlueCross BlueShield BlueOptions (I Large Group ~ ' ® 22603 0107 BCA ~~e:,~~~~~:fthe Blue Cross and Blue Shield Association Table of Con ten ts Section 1: How to Use Your Ben efit Booklet ...... 1-1 Section 2: What I s Covered? ...... 2-1 Section 3: What I s Not Covered? ...... 3-1 Section 4: Medical Necessity ...... 4-1 Section 5: Underst anding Your Sh are of Health Care Expenses ...... 5-1 Section 6: Ph ysicians, Hospitals and Other Provider Options ...... 6-1 ® Section 7: BlueCard (Out-of-State) Pr ogram ...... 7-1 Section 8: Blueprint for Health P rograms ...... 8-1 Section 9: Pre-existing Conditions Exclusion Period ...... 9-1 Section 10: Eligibility for Coverage ...... 10-1 Section 11: En rollmen t and Effective Date of Coverage ...... 11-1 Section 12: Termina tion of Coverage ...... 12-1 Section 13: Continuin g Cover age Under COBRA ...... 13-1 Section 14: Conversion P rivilege...... 14-1 Section 15: Extension of Benefits...... 15-1 Section 16: The E ffect of Medicare Cover age / M edicare Secondary Pa yer P rovisions ...... 16-1 Section 17: Duplication of Coverage Under Other Health Plan s / P rograms ...... 17-1 Section 18: Su brogation ...... 18-1 Section 19: Right of Reimbursemen t...... 19-1 Section 20: Claims Processing ...... 20-1 Section 21: Relationships Between the Parties ...... 21-1 Section 22: General Provisions...... 22-1 Section 23: Defini tions ...... 23-1 Table of Cont ents i Section 1: How to Us e Your Benef it Booklet Th is is your Benefit Book let (fBookletf). You to your Co vered D epende nts , unless s hould read it carefully before you need Health express ly stated otherwise or unless , in the Care Services. It co ntains valuable information context in wh ich the term is used , it is clearly about : intended otherw ise. An y re ferences w h ich refer s olely to you as the Covered Employee Ł your BlueOptions benefits or s olely to your Co vered Dependen t(s) w ill Ł w hat is co vered be no ted as s uch. Ł w hat is excluded or not covered Ł references to fwef, fusf, and fourf throughout refer to Blue Cross and Blue Ł our coverage and p ayment rules Shield of F lorida, Inc. We may also refer to Ł our B lueprint for Health Programs ours e lves as fBCBSF.f Ł how a nd w hen to file a c laim Ł if a word or phras e starts w ith a ca pital letter, it is either the first wo rd in a sentence, Ł how much, and under what circumstances, a proper name, a title, or a defined term. If w e will pay the w ord or phras e h as a s pecial meaning, it Ł w hat you will ha ve to pa y a s your s har e w ill either be defined in the Definitions Ł and o ther important information includ ing s ection or defined within the particular w hen benefits may cha nge; how and when s ection where it is us ed. co verage s tops ; ho w to co ntinue coverage if Wh ere do you find in formati on on– you are no lon ger e ligible; how w e will coord inate benefits with other policies or Ł what particular t ypes of Health Care plans ; our s ubrogatio n rights ; and our right Services a re cov ered? of reimburs ement. Read the fWhat Is Covered?f and fWhat Is Refer to theSchedu le of Benefits included in this Not Covered?f sections. booklet to determine how much you have to pa y for particular Health Care Services. how much does BCBSF pay and how Ł much do you have to pay? Wh en r eading your B ooklet, please Read the fUnderstand ing Your Share of rem ember that: Health C are Expenses f s ection along w ith the Schedule of Benefits. Ł you s hou ld re ad this Booklet in its entirety in ® order to determine if a particular Health Care Ł how t o take advantage of the BlueCard Service is covered. ( Out-of-State) Program when you re ceive Services out-of-state? Ł the headings of s ections co ntained in this ® Ben efit Booklet are for reference purposes Read the fBlueCard ( Out-of-State) only a nd s hall not affect in any wa y the Programf section. meaning or interpretation of particular provisions. Ł references to f youf or fyourf throughout refer to you as the Covered E mployee and How to Use Your Benefit Bo ok let 1-1 how to add or remove a Dependent? what happens when your coverage Ł Ł ends? Read the fEnrollment and Effective Date of Coveragef section. Read the fTermination of Coveragef section. what happens if you are covered under what the terms used throughout this Ł Ł BlueOptions and another health plan? Booklet mean? Read the fDuplication of Coverage Under Read the Definitions s ection. Other Health Plans /Programsf s ection. Over view of How BlueOptions Works Whenever you need care, you have a choice. If you visit an: In-Network Provider Out-of-Network Provider You receive In-Network benefits, the You receive the Out-of-Network level of highest level of coverage availa ble. benefits Œ you will s hare more of the cost of your care. You do not have to file a claim; the claim You may b e requ ired to subm it a claim form. w ill be filed by the In-Netw ork Provider for you. The In-Network Provider* is res pons ible You s hou ld notify BCBSF of inpatient for Admiss ion Notification if yo u are admiss ions . admitted to the Hospital. *For Services rendered by an In-Network Provider loca ted outside of Florida, you should notify us o f inpatient admiss ions. How to Use Your Benefit Bo ok let 1-2 Section 2: What Is Cov ered? then in effect, except as s pec ified in this I ntroduction s ection; Th is s ection d es cribes the Heal th Care Services 4. in accordance with our benefit guidelines that are covered under this Bene fit Book let. All listed be low; benefits for Co vered Services are subject to 5. rendered w hile your coverage is in force; your share of the cos t and the b enefit and maximums listed on your Schedule of Benefits , the app licable Allow ed Amount, an y limitations 6. not specifically or generally limited (e.g., and/or exclusions , as w ell as other provisions Pre-existing C ondition exclusionary period) contained in this Booklet, and any or exclud ed u nder this Booklet. End orsement(s) in accordance w ith our Medical We w ill determine whether Services are Neces s ity co verage criteria and ben efit Covered Services under this Booklet after you guidelines then in effect. have o btained the Services and w e have Remember that exclusions and limitations a lso received a c laim for the Services. In s ome appl y to your co verage. Exclus ions and circums tances we may d etermine whether limitations that are specific to a t ype of Service Services might be Co vered Services under this are included alo ng with the bene fit description in Booklet before yo u ar e pro vided the Service. this section. Ad ditional exclusions an d For example, we may determine whether a limitations that may apply can b e found in the propos ed transp lant is a Covered Service under fWhat Is Not Covered?f section. More than one this Booklet before the transplant is provide d. limitation or exclusion may apply to a specific We are not obligated to determine, in advance, Service or a p ar ticular s ituation. w hether any Service not yet provided to you w ould be a C overed Service. Expenses for the Health Care Services listed in this section w ill be covered under this Booklet In determining whether Health Care Services only if the Services are: are Covered Services unde r this Booklet, no written or verbal repr es entation by an y 1. w ithin the Health Care Services categ ories emplo yee or ag ent of BCBSF, or by any other in this fWhat Is Covered?f section; pers on s hall wa ive or o therw ise modify the 2. ac tually ren dered ( not just propos ed or terms of this Booklet and, therefore, neither yo u, recommended) b y an appropriately licens ed nor the Group, nor an y he alth care Provider or hea lth care Provider w ho is recognized for other person s hould rely on an y such written or payment by us and for which we receive an verbal repres enta tion. itemized statement or des cription of the procedure or Service, which was ren dered, including a ny app licable procedure code, diagnosis code and other information we require in order to process a claim for the Service; 3. Medically Necess ary, as de fined in this Booklet and determined b y us in accordance w ith our Medical Neces sity coverage criteria What Is Cov e red? 2 -1 Allergy Testing and Treatments Our Benefit Guidelines Tes ting and desens itization therap y (e .g., In providing b ene fits for Covered Services, we injections) and the cos t of hypos ens itization may apply the b enefit guidelines listed below as s erum are covered. The Allowe d Amount for w ell as a n y other applicable pa yment rules allergy testing is bas ed upo n the type and s pecific to particular categor ies of Services: number of tests per formed b y the Ph ysician. 1. Our paymen t for certain Health Care The Allowe d Amount for allergy immunotherapy Services is included w ithin the A llowed treatment is bas ed upon the type and number of Amount for the primary procedure, a nd dos es . therefore no additio nal amount is pa yable by Ambulance Services us for any such Services. Ambulance Services provided b y a ground 2. Our paymen t is bas ed on the Allowe d vehicle may be covered provided it is necess ar y Amount for the actual Service rendered (i.e., to transp or t you from: payment is n o t based on the Allow ed Amount for a Service which is more complex 1. a Hosp ital which is unab le to provide proper than that actually rendered), and is not care to the nearest H ospital that can provide bas ed on the method utilized to perform the proper care; Service nor the da y of the week nor the time 2. a Hosp ital to your neares t home, or to a of da y the procedure is performed. Sk illed Nursing Facility; or 3. Our paymen t for a Service includes all 3. the place a medical emergency occurs to components of the Health Care Service the nearest Hos pital that can provide proper w hen the Service can b e d es cribed by a care. s ingle procedure code, or when the Service is an ess ential or integral part of the Expenses for Ambulance Services b y boat, as soc iated therape utic/dia gnos tic Service airplane, or helicopter sha ll be limited to the rendered. Allow ed Amount for a ground vehicle unles s: 1. the pick -up poin t is inaccess ible b y ground Covered Ser vices Categories vehicle; Ac cident Care 2. s peed in excess of ground vehicle speed is critical; or Health C are Services to treat an injury resulting from an Accident not related to your job or 3. the travel d istance involved in getting you to emplo yment are covered. the nearest Hos pital that can provide proper care is too far for medical safety, as Exclusion: determined by us . Health C are Services to treat an injury or illness Pleas e refer to your Schedule of Bene fits for the res ulting from an Accident related to your job or s eparate per-da y ma ximums for ground emplo yment are excluded except for Services transportat ion and air/water transportation. (not otherwise excluded) when you are not co vered by Workers™ Compens ation and that lack of coverage did not res ult from any intentional action or omiss ion b y you. What Is Cov e red? 2 -2 Ambulatory Surgical C enters Breast Reconstructive Surgery Health C are Services rendered at an Ambulatory Surgery to rees tablish s ymmetry between two Surgical C enter are covered and include: breas ts and implanted prosthes es incident to Mastec tomy is covered. In order to be co vered, 1. us e of operating and recovery rooms ; s uch surger y must be provided in a manner 2. res piratory, or inh alation therapy ( e.g., chos en b y your Physician, consistent w ith oxygen); prevailing medical standar ds, and in cons ultation w ith you. 3. drugs an d medicines administered (except for take home drugs) a t the Ambulatory Child Cleft Lip and Cleft Palate Treatment Surgical C enter; Treatment and Services for Child Cleft L ip and 4. intravenous s o lutions; Cleft Palate, including medical, dental, Sp eech 5. dres s ings, including ordinary cas ts; Therapy, a udiology, and nutrition Services for treatment of a child u nder the age of 18 who has 6. anes thetics and their administration; cleft lip or cleft pa late are covered. In ord er for 7. administration of, including the cos t of, s uch Services to be co vered, your Covered w hole blood or b lood products ; Depende nt™s Ph ysician mus t s pecifically pres cribe such Services a nd s uch Services must 8. transfusion supplies and e quipment; be conse quent to treatment of the cleft lip or 9. diagnostic Services, including radiology, cleft palate. ultrasou nd , laboratory, pathology and approved machine testing (e.g., EKG); and Concurrent Physician Care 10. chemotherapy treatment for proven Concurren t Physician care Services are malignant diseas e. co vered, provided: (a) the additio nal Physic ian ac tively participates in your treatment; (b) the Anesthesia Administration Services Cond ition involves more than o ne bod y s ys tem Administration of anesthes ia b y a Ph ysician or or is s o s e vere or complex that o ne Physician Certified Registered Nurs e Anesthetist (fCRNAf) cannot provide the care unass isted; and (c) the may be covered. In those ins tances wh ere the Physicians ha ve different specialties or have the CRNA is actively d irected by a Phys ician other s ame s pecialty with d ifferent sub-s pecialties . than the Phys ician who performed the surgical Consultations procedure, our pa yment for Covered Services, if any, will be made for both the CRNA and the Cons ultations pr o vided by a Physician are Physician Health Car e Services at the lower co vered if your attending Ph ysician requests the directed-ser vices Allowed Amount in accordance cons ultatio n a nd the consulting Ph ysician w ith our payment program for such Covered prepares a written report. Services then in effect. Contraceptive Injections Exclusion: Medication by injection is covered when Coverage does not include anesthes ia Services provided and administered by a Ph ysician, for by an operatin g Ph ysician, his or her partner or the purpose o f contraception, and is limited to as soc iate. the medication and administration. What Is Cov e red? 2 -3 Payme nt Guidelines for Medication and rendered in a H os p ital or Ambulatory Administration by Injection for Contraception Surgical Center. Physician office Services, r endered on the same Exclusion: day, in connection with the administration by 1. Dental Services provided more tha n 6 2 injection of the contraceptive medication, for w ell days after the d ate of an Accidental or preventive Services, are not reimburs ed Dental Injury regardles s of whe ther or s eparately un less the Group has purchas ed the not such s ervices could have been adu lt wellness benefit. rendered w ithin 62 days; a nd 2. Dental Implants . Dental Serv ices Dental Services are limited to the follow ing: Diabetes Outpatient Self-Management 1. Care and stabilization treatment rendered Diabetes o utpatient se lf-management training w ithin 62 days of an Accidental Dental Injury and educational Services and nutrition to Sound Natural Teeth. couns e ling ( including all Med ically N ecess ary equ ipment and supplies) to treat d iabetes , if 2. Extraction o f teeth required pr ior to radiation your treating Ph ysician or a Ph ys ician who therapy when you have a diagnos is of s pecializes in the treatment o f diabetes certifies cancer o f the head and/or neck. that such Services ar e Medically Necess ary, are 3. Anes thesia Services for dental care co vered. In order to be covered, d iabetes including g eneral anesthes ia and outpa tient self-management train ing and hos pitalization Services n eces s ary to ass ure educational Services must be provided under the safe delivery of necess ar y d ental care the direct sup ervision of a cer tified Diabetes provided to you or yo ur Co vered De pendent Educator or a board-certified Physician in a Hos p ital or Ambulatory Surgical Center s pecializing in e ndocrino logy. Add itionally, in if: order to be covered, nutrition counseling mus t be provided by a licens ed D ietitian. Covered a) the Covered Dependent is under 8 Services may also include the trimming of years of age a nd it is determined by a toena ils, corns, calluses , and therapeutic shoes dentist and the Covered D ependent™s ( including inserts and/or modifications) for the Physician that: treatment of severe diabet ic foot diseas e. i. denta l treatment is neces s ar y du e to a den tal Cond ition that is Notwi thstanding the above, if your Benefit s ignificantly comp lex; or Booklet was amended by a BCBSF Pharmacy Program Endorsement wh ich covers diabetes ii. the Covered Dependent h as a equ ipment and supplies, then d iabetes developmental disab ility in which equ ipment and s upp lies will be covered in patient manag ement in the dental accordance w ith the terms and cond itions of office has proven to be ineffective; s uch Pharmacy Program Endorsement. or b) you ha ve one or more medical Diagnostic Services Cond itions that w ould create significant Diagnost ic Services w hen ordered b y a or undue medical r isk for you in the Physician are limited to the follow ing: cours e of delivery of any neces sar y denta l treatment or surger y if not 1. radiology, ultras ound and nuclear medicine, Magn etic Res onance I maging (MRI); What Is Cov e red? 2 -4 2. laboratory an d p a thology Services; w heelchairs , crutches , canes , walkers, hospital beds , and oxygen equipment. 3. Services involving bones or joints of the jaw (e.g., Services to treat temporomandibular Note: Repair or re placement of Durable joint [TMJ] d ysfunction) or facial region if, Medical Equ ipment d ue to growth of a child or under accep ted medical s tandards, such s ignificant change in functional s tatus is a diagnostic Services are neces s ary to treat Covered Service. Cond itions caus ed b y congenital or Exclusion: developmental deformity, diseas e, or injury; Durable Medical Equipment w hich is primarily 4. approved machine testing (e.g., for convenience an d/or comfort; mod ifications to electrocardiogram [EKG], motor vehicles and/or homes, including but not electroencephalograph [EEG], and other limited to, whee lchair lifts or ramps ; w ater electronic diagnostic medical procedures); therapy devices s uch as Ja cuzzis, h ot tubs , and s wimming pools or w h irlpools; exercise and 5. genet ic testing for the purpos es of mas sage equipment, electric scooters , hearing explaining curre nt signs and s ymptoms of a aids, air conditioners an d purifiers, humidifiers, pos s ible hereditar y disease . w ater softeners and/or purifiers, pillows , mattres ses or waterbeds , escalators , elevators, Dialysis Services s tair glides, emergency aler t equipment, handrai ls and grab bars , h eat ap pliances, Dialysis Services including equipment, training, dehumidifiers, a nd the replacement of Durable and medical supplies , when provided at a ny Medical Equ ipment s olely b ecaus e it is o ld or location by a Provider licensed to perform us ed are exclud ed. dialysis including a D ialysis Center are covered. Enteral Formulas Durable Medical Equipment Prescription and non-pres cription en teral Durable Medical Equipment whe n provided by a formulas for home use w hen pres cribed by a Durable Medical Equipment Provider and when Physician as neces s ar y to treat inherited pres cribed by a Phys ician, limited to the mos t diseas es of amino acid, or ganic acid, cos t effective equipment as determined by us is carbohydrate or fat metabolism as wel l as co vered. malabs orption originating from congenital Payme nt Guidelines for D urable Medical defects present at b irth or acquired during the Equipment neonatal perio d are co vered. Sup plies and service to repair medical Coverage to treat inh erited diseas es of amino equ ipment may be Covered Services only if you ac id and organic acids , for you up to your 25th ow n the equipment or you are purchas ing the birthd ay, shall include coverage for food equ ipment. Our payment for Durable Medical products modified to be low pro tein. Equ ipment will be based on the low es t of the following: 1) the purchas e price; 2) the Eye Care lease/purchas e price; 3) the rental rate; or 4) our Coverage includes the following Services: Allow ed Amount. Our A llowed Amount for such rental eq uipment will not exceed the total 1. Physician Services, soft lenses or s clera purchas e price. D urable Medical Equ ipment s hells, for the treatment of aphak ic patients ; includes, b ut is not limited to, the following: 2. initial glass es or contact lenses following ca taract surger y; and What Is Cov e red? 2 -5 3. Physician Services to trea t an injury to or 1. part-time ( i.e., less than 8 hours per d ay and diseas e of the e yes. less than a total of 40 hours in a calendar w eek) or intermittent (i.e., a visit of up to, but Exclusion: not exceeding, 2 hours per day) nursing Health C are Services to diagnose or treat vision care b y a Re g istered N urs e, Licensed problems w hich are no t a direct consequ ence of Practical Nurs e and/or home hea lth aide trauma or prior oph thalmic s urgery; eye Services; examinations; eye exercises or visual training; 2. home health a ide Services must be eye glas s es and contact lens es and the ir fitting cons istent w ith the plan of treatment, are e xclu ded. In add ition to the above, any ordered by a Physician, and rendered und er s urgical procedure performed primarily to correct the supervision o f a Re g istered Nurse; or improve myopia or other refractive disorders (e.g., radia l keratotomy, PRK and LASIK) are 3. medical social s ervices; also excluded. 4. nutritional guida nce; Home Health Care 5. res piratory, or inh alation therapy ( e.g., oxygen); and The Home Health C are Services listed belo w 6. Physical Therap y by a Phys ical Therapist, are covered when the follo w ing criteria are met: Occupational Therapy by a Occupational 1. you are una ble to lea ve yo ur home w ithout Therapist, and Spe ech Therapy by a cons iderable effort and the assistance of Spe ech Therapist. another p ers on because you are: bedridden Exclusions : or chairbound or becaus e you are restricted in ambulation, whether or not you use 1. homemaker or domestic maid ser vices; as sistive devices; or you are significantly 2. s itter or companion services ; limited in p hys ical activities due to a 3. Services rendered by an employee or Cond ition; and operator o f an a dult con gregate living 2. the Home Health Care Services rendere d facility; a n ad ult fos ter home; an adu lt day have b een pres cribed by a Ph ysician by way care center, or a nurs ing home facility; of a formal w ritten treatment plan which has 4. Spe ech Therapy provided for a d iagnos is of been review ed and renew ed b y the developmental delay; pres cribing Phys ician every 30 days . We res erve the right to req uest a copy of any 5. Cus todial Care; written treatment p lan in order to determine 6. food, hous ing, and home delivered meals; w hether s uch Services are covered under and this Booklet. 7. Services rendered in a Hospital, nursing 3. the Home Health Care Services are home, or intermediate care facility. provided directly by (or indirectly throu gh) a Home Health Agency; and Hospice Services 4. you are meeting or achieving the d esired Health C are Services provided in connection treatment goals s et forth in the treatment w ith a Hospice treatment program ma y b e plan as d ocumented in the clinical progress Covered Services, provided the Hosp ice notes. treatment program is approved b y your Home Health Care Services are limited to: Physician. We reserve the right to reques t that What Is Cov e red? 2 -6 your Ph ysician certify in w riting your life Therapy; a nd 4) other Services provided wh ile expectancy. you were an inp atient. In additio n, expens es for the followin g a nd Hospital Service s s imilar items are also excluded: Covered H ospital Services include: 1. gow ns a nd slippers; 1. room and board in a semi-private room 2. s hampoo, toothpas te, body lotions and w hen confined as an inpatient, unless the hygiene packe ts; patient must be iso lated from others for documented clinical reason s ; 3. take-home drugs; 2. intens ive care units, including cardiac, 4. telephone and television; progres s ive and neonatal care; 5. gues t meals or gourmet menus; and 3. us e of operating and recovery rooms ; 6. admiss ion kits. 4. us e of emergency rooms ; Inpatient Rehabilitation 5. res piratory, pulmonar y, or inhalation therap y Inpatient Rehab ilitation Services are covered (e.g., oxygen); w hen the follow ing criteria are met: 6. drugs an d medicines administered (except 1. Services must be provided under the for take home drugs) b y the Hospital; direction of a Physician and must be 7. intravenous s o lutions; provided by a Medicare certified facility in 8. administration of, including the cos t of, accordance w ith a comprehensive w hole blood or b lood products ; rehabilitation program; 9. dres s ings, including ordinary cas ts; 2. a plan of care must be de veloped and managed b y a coordinated multi-disciplinary 10. anes thetics and their administration; team; 11. transfusion supplies and e quipment; 3. co verage is limited to the specific acute, 12. diagnostic Services, including radiology, ca tastrophic target diagnos es of s evere ultrasou nd , laboratory, pathology and s troke , multiple trauma, brain/s pinal injury, approved machine testing (e.g., EKG); s e vere neurological motor disorders, and/or s e vere burns; 13. Physical, Speech, Occupational, and Cardiac Therapies; and 4. the individual must be able to actively participate in at least 2 rehabi litative 14. transplants as d escribed in the Transpla nt therapies a nd be a ble to tolerate a t least 3 Services subs ection. hours per da y of s k illed Rehab ilitation Exclusion: Services for at leas t 5 days a we ek and their Cond ition must be likely to resu lt in Expenses for the following Hos pital Services are s ignificant improvement; and excluded when s uch Services could ha ve been provided without admitting yo u to the Hos pital: 5. the Reha bilitation Services mus t be required 1) room and board provided during the at such intens ity, frequency and duration as admiss ion; 2) Phys ician visits provided wh ile you to make it impractical for the individual to w ere an inpat ient; 3) Occupational Therap y, receive s ervices in a less intensive setting. Spe ech Therapy, Physical Therapy, and Cardiac What Is Cov e red? 2 -7 Doc tor of Os teopathy ( D.O.), Hosp ital, Birth Inpatient Rehab ilitation Services are s ubject to Center, Midwife or Certified Nurs e Midwife may the inpatient facilit y Co payment, if applicable, be Co vered Services. Care for the mother and the benefit maximum set forth in the includes the p os tpartum ass essment. Schedule of Benefits. In order for the postpartum as ses sment to be Exclusion: co vered, such as ses sment mus t be provided at All Subs tance De pendenc y, drug and alcohol a Hosp ital, an attending Phys ician™s office, an related d iagnos es, Pain Management, and outpa tient maternity center, or in the home by a res piratory ventilator management Services are qua lified licensed health care profess ional excluded. traine d in care for a mother. Coverage under this Booklet for the postpartum ass ess ment Mammograms includes coverage for the physical ass ess ment Mammograms obta ined in a medical office, of the mother and any n eces s ary clinical tests in medical treatment facility or through a health keeping with prevailing medical s tandards . testing service that uses radiological equipment Exclusion: registered with the a ppropriate Florida regulatory agencies (or thos e of another s tate) for Maternity Services rendere d to a Covered diagnostic purposes or breas t cancer screening Person w ho becomes pregnan t as a Ges tationa l are Covered Services. Surrogate und er the terms of, and in accordance w ith, a Gestational Surrogacy Contract or Ben efits for mammograms may not be subject to Arrangement. Th is exclus ion applies to all the Calendar Year Deductible, Coinsurance, or expens es for prenatal, intra-par tal, and pos t- Copa yment (if applicable). Pleas e refer to your partal Maternity/Obstetrical Care, and Health Schedule of Benefits for more information. Care Services rendered to the Covered Person ac ting as a Ges tational Surrogate. Mastectomy Services For the definition o f Ges tational Surrogate and Breast cancer tr eatment including treatment for Gestational Surrogacy Co ntract s ee the phys ical comp lications re lating to a Mastectomy fDefinitionsf s ection of this Ben efit Booklet. ( including lymphedemas ), and outpatient p os t- s urgical follow-up in accordance w ith prevailing Mental Health Services medical standards as determined b y you and your attending Physician are covered. Diagnost ic evaluation, psychiatric treatment, Outpatient post-s urgical follow-up care for individua l therap y, and group therapy provide d Mastec tomy Services s ha ll be covered whe n to you by a Phys ician, Ps ychologist, or Mental provided by a Provider in accordance w ith the Health Profess ional for the treatment of a Mental prevailing medical standar ds and a t the most and N ervous Disor der may be co vered. These medically appropriate setting. The setting may Health C are Services include inpatient, be the Hosp ital, Physician™s office, outpatient outpa tient, and Partial H os p italization services. center, or your home. The treating Ph ysician, Partial Hospitalization is a Covered Service after consultatio n w ith you, may choose the w hen provided under the direction of a Physician appropriate setting. and in lieu of inpatient h os pitalization an d is combined with the inpatient Hospital benefit. Maternity Services Two da ys of Partial Hos pitalization will count as Health C are Services, including pre na tal care, one da y tow ard the inpatie nt Mental a nd delivery and postpartum care and as ses sment, Nervous Disord er benefit. provided to you, by a Doctor of Medicine (M.D.), What Is Cov e red? 2 -8 Exclusion: New born Ass es s men t: 1. Services rendered in connection with a An ass es s ment o f the newborn child is covered Cond ition not class ified in the most recently provided the Services w ere rendered at a pub lishe d version of the Diagnos tic an d Hos pital, the attend ing Phys ician™s office, a Birth Statistical Manual of Mental Disorders of the Center, or in the home by a Ph ys ician, Midw ife American Psychiatric As soc iation; or Certified Nurse Midw ife, and the performance of an y necess ar y clin ical tes ts and 2. Services for ps ycholog ical tes ting immunizations are w ithin pr evailing med ical as soc iated with the e valuation and dia gnos is s tandards. Thes e Services are not s ubject to of learning disabilities or for mental the Calendar Year Deductible. retardation ; Ambulance Services, when neces s ary to 3. Services extended be yond the p eriod transport the newb orn child to and from the neces s ar y for e valuation an d diagnos is of neares t appropr iate facility which is s taffed and learning disab ilities or for mental retardation; equ ipped to treat the ne w born ch ild™s Con dition, 4. Services for marriage couns eling, when not as determined by us and certified by the rendered in connection with a Co ndition attending Ph ysician as Med ically Necess ar y to clas sified in the most recent ly published protect the health and safety of the new born edition of the American Ps ychiatric ch ild, are covered. Ass ociation's Diag nostic and Statistical Orthotic Devices Manu al of Mental Disorders ; 5. Services for pre-marital cou nseling; Orthotic Devices including braces and truss es for the leg, arm, neck and back , and s pec ial 6. Services for court-ordered care or testing, or s urgical corsets ar e covered whe n prescribed by required as a condition of parole or a Physician and des igned and fitted by an probation; Orthotist. 7. Services for testing of aptitude, ability, Ben efits may be provided for necess ary intelligence or interest; replacement of an Ortho tic Device wh ich is 8. Services for testing a nd e valuation for the ow ned b y you whe n due to irreparab le damage, purpos e of maintaining employment; w ear, a ch ange in your Condition, or when neces s itated due to grow th of a child. 9. Services for cognitive remediation; Payment for s p lints for the treatment of 10. inpatient confinements that are primarily temporomandibular joint (fTMJf) d ysfunction is intended as a chan ge of en vironment; and limited to payment for one s plint in a six-month 11. inpatient (over nigh t) mental health Services period unless a more frequent replacement is received in a residential treatment facility. determined by us to be Medically Neces s ary. Exclusion: Newborn Care 1. Expenses for arch s up ports , s hoe inserts A newborn chi ld will be covered from the des igned to effect conformationa l changes moment of birth provided that the ne w born child in the foot or foot alig nment, orthopedic is el igible for coverage and properly enrolled. s hoes , over-the-counter, custom-made or Covered Services s hall cons ist of co verage for built-up s hoes , cast shoes , s neakers , ready- injur y or sicknes s, including the neces sary care made compress ion hose or support hose, or or treatment of med ically diagnosed congen ital s imilar type devices/app liances regardles s defects , birth abnormalities, and premature birth. What Is Cov e red? 2 -9 Car diac Therapy a) Services provided of intended us e, except for therapeutic under the supervision of a Physician , or s hoes (including inserts a nd/or an a ppropriate Provider trained for modifications) for the treatment of s evere Cardiac Therapy, for the pu rpos e of diabetic foot disease; aiding in the res toration of normal heart 2. Expenses for orthotic a ppliances or devices, function in connection w ith a myocardial w hich s traighten or re-s hape the infarction, coronar y occlus ion or conformation of the head or bones of the coronary bypas s s urger y ar e covered. sk ull or cranium through cranial banding or b) Occupational Therapy Services molding (e.g. dynamic orthotic craniop last y provided by a Ph ys ician or Occupationa l or molding helmets); and Therapist for the purpos e of aiding in the 3. Expenses for devices nece s sary to exercise, res toration of a previously impaired train, or participate in sports , e.g. custom- function lost d ue to a C ondition are made k nee braces. co vered. Osteoporosis Screening, Diagnosis, and c) Speech Therapy Services o f a Treatment Physician, Speech Therapist, or licensed audiologist to aid in the Screening, diagnosis, and treatment of res toration of speech loss or an os teoporos is for high-risk individuals is covered, impairment of speech resu lting from a including, but not limited to: Cond ition are covered. 1. es trogen-deficient individuals who are at d) Physical Therapy Services provided clinical risk for osteoporos is; by a Physician or Ph ysical Therapist for 2. individua ls w ho ha ve vertebral the purpose o f aiding in the res toration abnormalities; of normal ph ysical function lost due to a Cond ition are covered. 3. individua ls who are receiving long-term glucocorticoid (steroid) therap y; or e) Massage Therapy Mas s age provided by a Physician, Mass age Therap ist, or 4. individua ls who have primary Physical Therapist w hen the Mass age is hyperparathyroidism, and individuals wh o pres cribed as be ing Medically have a family histor y of os teopor os is. Neces s ary by a Ph ysician licensed Outpatient Cardiac, Occupational, Physical, Florida Statutes purs uant to Chapter Speech, Massage Therapies and Spinal 458 (Medical Practice), Chapter 459 Man ipulation Services ( Osteopathy), C hapter 460 (Chiropractic) or Chapter 461 (Podiatry) 1. Outpatient therapies listed below ma y be is covered. The Ph ysician™s pres cription Covered Services w hen ordered b y a mus t specify the number of treatments . Physician or other health care profess ional Payme nt Guidelines for Physica l and licensed to perform s uch Services. The outpa tient therapies listed in this category Massage Therapy are in ad dition to the Cardiac, Occupational, Mass age or a combination of Mass age and Physical and Speech Therap y benefits listed Physical Therap y Services are limited to four in the Home Health Care, Hospital, and (4) modalities per da y not to exceed the Sk illed Nursing Facility categories herein. Outpatient Cardiac, Occupa tiona l, Ph ys ical, Spe ech, and Mas sage Therapies a nd Spinal What Is Cov e red? 2-10 Manipulations ben efit maximum listed on the outpa tient facility, or electronically through a Schedule of Benefits. computer via the Interne t. Exclusion: Payme nt Guidelines for Physician Services Provided by Electronic M ea ns through a App lication or use of the follow ing or s imilar Computer: techniques or items for the purpos e of aiding in the provision o f a Mas s age: hot or co ld Expenses for online medical Services pro vided packs ; h ydrotherap y; colonic irrigation; electronically thro ugh a computer b y a Ph ysician thermal therap y; chemical or herbal via the Internet will be covered only if such preparations; paraffin baths; infrared light; Services: ultraviolet light; Hubb ard tank; contras t baths 1. w ere provided to a covered individual w ho are exclu ded. w as, at the time the Services w ere provided, 2. Spinal Manipulations: Se rvices b y an establ ished patient o f the Ph ysician Physicians for manipulations of the sp ine to rendering the Services; correct a s ligh t dislocation of a bone or joint 2. w ere in respo nse to an online inquiry that is demons trated by x-ray are covered. received through the Internet from the Payme nt Guidelines for Spinal co vered individua l with res pect to which the Man ipulations Services were provided; and We w ill cover u p to 26 s pinal manipulations 3. w ere provided by a Physician through a per Ca lendar Year, or the maximum benefit s ecure online healthcare communication listed in the Sch edule of Benefits , whichever s ervices vendor that, a t the time the occurs first. Services was re ndered, was under contract w ith BCBSF. The Schedule of Benefits s ets forth the maximum amount that we will p a y for a ny The term festab lished patient,f as us ed herein, combination of the outpatient therapies and s hall mean that the covered individual h as s p inal manipulation Services listed ab ove. received profess ional services from the For example, you may ha ve on ly utilized two Physician wh o provided the online medical (2) of your spinal manipulations for the Services, or another physician of the sa me Calendar Year, bu t if you have already met s pecialty who be longs to the sa me group the combined therap y maximum with other practice as that Physician, within the past three Services, this Benefit Booklet will not co ver years. any additional s pinal manipulations for that Exclusion: Calendar Year. Expenses for online medical Services pro vided Oxygen electronically thro ugh a computer b y a Ph ysician via the Internet other than through a healthcare Expenses for oxygen, the e quipment neces sary communication s er vices vendor that h as entered to administer it, and the administration of oxygen into contract with BCBSF. Expenses for online are covered. medical Services provided by a health care provider that is not a Physician a nd expens es for Physician Services Health C are Services rendered b y telephone are Medical or s urgical He alth Care Services also excluded. provided by a Ph ys ician, including Services rendered in the Ph ys ician™s office, in an What Is Cov e red? 2-11 Preventive Adult Wellness Services 3. pen ile pros thes is. If the preventive a dult wellnes s category is listed Covered Prosthetic De vices (except cardiac on your Schedule of Bene fits, Covered Services pacemakers, and prosthetic de vices incident to for preventive a dult we llnes s Services may b e Mastec tomy) are limited to the first s uch co vered under your Benefit Booklet. Pleas e permanent prosthes is (including the first refer to your Schedule of Bene fits for any temporary prosthesis if it is determined to be app licable preventive adult wellness Services neces s ar y) prescribed for e ach s pecific benefit maximums or limitations. Cond ition. Ben efits may be provided for necess ary Preventive Child Healt h Supervision Services replacement of a Prosthetic Device which is Periodic Phys ician-delivered or Ph ysician- ow ned b y you whe n due to irreparab le damage, s uper vised Services from the m oment of birth up w ear, or a change in your Condition, or when t h to the 17 b irthday are covered as follows : neces s itated due to grow th of a child. 1. periodic examinations, w h ich include a Exclusion: history, a physical examination, and a 1. Expenses for microprocess or controlled developmental ass es sment and anticipatory or myoelectric artificial limbs (e .g. C- guidance necess ar y to monitor the normal legs); and grow th and de velopment of a child; 2. Expenses for cos metic enhancements 2. oral a nd/or injectab le immunizations ; and to artificial limbs. 3. laboratory tes ts normally performed for a w ell child. Self-Administered Injectable Prescription Drugs In order to be covered, Services s ha ll be provided in accordance with prevailing medical Unless other w ise covered under a BCBSF s tandards cons istent with the Recommendations Pharmacy Program Endorsement to this Bene fit for Preventive Pediatric Health Care of the Booklet, only Self-Administered Injectable American Academy of Pediatrics. Prescription Drugs us ed in the treatment of diabetes, cancer, cond itions requiring immediate Expenses for these Services are not subject to s tabilization (e.g. anaphylaxis), or in the the Calendar Year Deductible, but are s u bject to administration of dialysis are covered. the Coinsur ance or the Copayment (if app licable). Skilled Nursing Facilities Prosthetic Devices The following H ealth Care Services may be Covered Services w hen you are a n inpatient in a The following Prosthetic De vices are co vered Sk illed Nursing Facility: w hen prescribed by a Ph ys ician and designed and fitted b y a Prosthetist: 1. room and board ; 1. artificial ha nds, arms, feet, legs an d eyes , 2. res piratory, pulmonar y, or inhalation therap y including p ermanent implan ted lens es (e.g., oxygen); following cataract s urgery, cardiac 3. drugs an d medicines administered wh ile an pacemakers, and prosthetic de vices incident inpatient (excep t take-home drugs ); to a Mas tectomy; 4. intravenous s o lutions; 2. app liances ne eded to effectively use artificial limbs or corrective braces; or What Is Cov e red? 2-12 5. administration of, including the cos t of, Exclusion: w hole blood or b lood products ; Expenses for prolonged car e and treatment of 6. dres s ings, including ordinary cas ts; Subs tance Dependenc y in a s pecialized inpatient or residential facility or inpatient 7. transfusion supplies and e quipment; confinements that are primarily intended as a 8. diagnostic Services, including radiology, change of environment are excluded. ultrasou nd , laboratory, pathology and Surgical Assistant Services approved machine testing (e.g., EKG); 9. chemotherapy treatment for proven Services rendered by a Physician, R egistered malignant diseas e; and Nurs e First Ass istant or Phys ician Ass istant w hen acting as a s urgical ass istant (provided no 10. Physical, Speech, and Occupat ional intern , resident, or other s taff physician is Therapies; available) when the as sistant is neces sar y are We reser ve the right to reques t a treatment plan co vered. for determining coverage and payment. Payme nt Guidelines for Surgical Assistant Exclusion: Services Expenses for an inpatient a dmiss ion to a Skilled The Allowe d Amount is limited to 20 percent of Nurs ing Facility for purpose s of Custodial C are, the surgical procedure™s Allo wed Amount. convales cent care, or any other Service primarily for the convenience of you and/or your Surgical Procedures family members or the Provider are excluded. Surgical procedures performed by a Physicia n Expenses for any inp atient days beyond the per may be covered including the following: pers on p er Ca lendar Year maximum number of 1. s terilization (tubal ligations and days listed on the Schedule of Bene fits are a lso vasectomies), regardless of Medical excluded. Neces s ity; Substance Dependency Care and Treatment 2. s urgery to correct deformity w hich was Care and treatment for Subs tance Dependenc y caus ed b y disease, trauma, birth defects, includes the following: grow th defects or prior therapeutic proces s es ; 1. Health C are Services ( inpatient and outpa tient or any comb ination thereof) 3. oral s urg ical procedures for e xcision of provided by a Ph ys ician, Psychologist or tumors, cysts , absces s es , and lesions of the Mental Health Profes sional in a program mouth; accredited b y the Joint Commiss ion of the 4. s urgical procedures involving b ones or joints Accreditation of Hea lthcare Organizations or of the jaw (e.g., temporomandibular jo int approved by the s tate of F lorida for [TMJ]) and facial region if, under accepted Detoxification or Substance Depende ncy. medical standards , such s u rger y is 2. Physician, Psychologist a nd Men tal Health neces s ar y to treat Con ditions caus ed b y Profess ional ou tpatie nt visits for the care congenital or developmental d e formity, and treatment of Subs tanc e Dependenc y as diseas e, or injury; and listed in the Sch edule of Benefits . 5. Services of a Phys ician for the p urpos e of rendering a second s urgical opinion and What Is Cov e red? 2-13 related d iagnos tic s ervices to he lp determine Trans plant inclu des pre-trans plant, trans plant the need for surgery. and pos t-discharge Services, and treatment of complications after transp lantation. We will pay Payme nt Guidelines for Surgical Procedures benefits only for Services, care and trea tment 1. Payment for multiple s urgical proce dures received or provided in connection w ith a: performed in addition to the primary surgical 1. Bon e Marrow Trans p lant, as defined herein, procedure, on the same or different areas of w hich is s pecifically listed in the rule 59B - the bod y, d uring the same operative ses s ion 127.001 of the Florida Adminis trative Code w ill be based on 50 percent of the Allowed or any succes s or or similar rule or covered Amount for any s econdar y s urgical by Medicare as des cribed in the mos t procedure(s ) performed and the recen tly published Medicare Covera ge Coinsurance or Copayment (if any) indicated Issues Manual iss ued b y the Centers for in your Schedule o f Benefits . This guideline Medicare a nd Medicaid Services. We will is applicable to all bilateral procedures a nd co ver the expens es incurred for the donat ion all s urgical procedures performed on the of bone marrow by a donor to the sa me s ame date of s ervice. extent such expenses w ould be covered for 2. Payment for Incidental surgical procedures you an d wi ll be s u b ject to the s ame is limited to the Allowed A mount for the limitations an d exclus ions a s w ould be primar y procedure, and there is no app licable to you. Coverage for the add itional payment for any incide ntal reas onable expens es of search ing for the procedure. An fincidental surgical donor w ill be limited to a search among proceduref includes s urgery wh ere o ne, or immediate family members and donors more than one, s urgical pr ocedure is identified through the Nationa l Bone Marrow performed through the s ame incision or Donor Program; operative a pproach as the primary s urgical 2. corneal transp lant; procedure w hich, in o ur opinion , is not clearly identified and/or does not add 3. heart trans plant ( including a ventricular s ignificant time or complexity to the surgica l as sist device, if indicated, when us ed as a s es s ion. For example, the removal of a bridge to heart transp lantation); normal appendix performed in co njunction 4. heart-lung combination trans plant; w ith a Medica lly Necess ary h ysterectomy is 5. liver transplan t; an incidental surgical procedure (i.e., there is no payment for the removal of the normal 6. kidney trans plant; append ix in the example). 7. pancreas ; 3. Payment for surgical procedures for fracture 8. pancreas trans plan t performed care, dislocation treatment, debridement, s imultaneously with a kidney transp lant; or w ound repair, unna boot , and other related Health C are Services, is included in the 9. lung-whole single or whole bilateral Allow ed Amount of the surgical procedure. transplant. We w ill cover d onor cos ts a nd organ acquisition Transplant Services for transplants, other than Bone Marrow Trans plant Services, limited to the procedures Trans plants, provided such cos ts are not listed be low, may be covered wh en performed at co vered in whole or in p art b y any other a facility acceptable to us, s ubject to the insurance carr ier, organization or person other conditions and limitations des cribed below. than the donor™s family or es tate. What Is Cov e red? 2-14 You ma y ca ll the cus tomer s ervice p hone 9. any artificial heart or mechanical d evice that number indicated in this Booklet or on your replaces either the atrium and/or the Identification Card in order to determine which ventricle. Bon e Marrow Trans p lants are co vered under this Booklet. Exclusion: Expenses for the following are excluded: 1. transplant procedures not included in the list abo ve, or otherw ise excluded under this Booklet (e.g., Experimental or Investigational trans plan t procedures); 2. transplant procedures involving the transplantation or implantation of any non- human organ or tiss ue; 3. transplant procedures related to the donat ion or acquisition of an organ or tiss ue for a recipient w ho is not covered b y us; 4. transplant procedures involving the implant of an artificial organ, including the implant of the artificial organ; 5. any organ, tiss ue, marrow , or stem cells w hich is/are so ld rather than dona ted; 6. any Bone Marrow Trans plant, as d efined herein, w hich is not s pecifically listed in rule 59B-127.001 of the Florida Administrative Code or any s uccess or or similar rule or co vered by Medicare purs uant to a national co verage decision made by the Centers for Medicare and Medicaid Services as evidenced in the mos t recently p ublishe d Medicare Coverage Iss ues Manua l; 7. any Service in connection with the identification of a donor from a local, state or national listing, except in the case of a Bone Marro w Transplant; 8. any non-medical costs , including but not limited to, temporary lodging or transportat ion costs for you and/or your family to and from the approved facility; or What Is Cov e red? 2-15 Section 3: What Is Not Cov ered? traditional Oriental medicine including I ntroduction acupuncture ; naturopathic medicine; Your Booklet express ly excludes the follow ing environmental medicine including the field of Health C are Services, s upp lies , drugs or clinical ecolog y; chelation therapy; charges . The following exclusions are in thermography; mind-body interactions s uch as add ition to an y exclusions s pecified in the fWhat meditatio n, imagery, yoga, dance, and art Is Covered?f section. therapy; biofeedback; prayer and mental hea ling ; manual he aling methods s uch as the Abortions wh ich are elective. Alexander technique, aromatherap y, Ayur vedic mas sage , craniosacral balancing, Feldenkrais Adult W ellness preventive care or routine method, Hellerwork , polarity therapy, Reichian s creening Services, except as s pecified under therapy, reflexology, rolfing, s hiatsu, traditional the Preventive Adult Wellness Services category Chines e mass age, Trager therap y, trigg er-point on the Sch edule of Benefits . myotherapy, and b iofield therapeutics; Re iki, Ar c h Supports, s hoe inser ts des igned to effect SHEN therap y, and therapeutic touch; conformational changes in the foot or foot bioelectromagnetic applications in medicine; a nd alignment, orthopedic sho es , over-the-counter, herbal therapies. cus tom-made or built-up shoes , cas t s hoes , Complications of Non-Covered Services , s neakers , ready-made compress ion hose or including the diagnos is or treatment of any s upport hose, or s imilar type devices/app liances Cond ition which is a complication of a non- regardless of intende d us e, except for co vered Health Care Service (e.g., Health Care therapeutic s hoes ( including inserts and/or Services to treat a complication of cosmetic modifications) for the treatment of s evere diabetic foot disease. s urgery are not covered). As sisted Reproductive Therapy (Infertility) Contraceptive medications , devices, including, but not limited to, ass ociated Services, app liances , or o ther Health Care Services whe n s upplies, a nd medications for In Vitro provided for contraception, except w hen Fertilization (IVF); Gamete Intrafallopian indicated as covered, under the adult wellness Transfer (GIFT) procedures ; Zygote benefit, on the Schedule of Benefits (when Intrafallopian Transfer (ZIFT) procedures; s e lected b y the Group), or otherwise covered in Artificial Insemination (AI); embryo transport; the fWhat Is Co vered?f section . s urrogate paren ting; donor semen and r elated Cosmetic Services , including any Service to cos ts including collection and preparation; and improve the appearance or self-perceptio n of an infertility treatment medication. individua l (except as co vered under the Breast Aut opsy or postmortem examination services, Recons tructive Surgery category), including and unles s s pecifically reques ted b y us. w ithou t limitation: cos metic s urger y and procedures or s upp lies to correct ha ir loss or Complementary or Alternative M edicine sk in wrinkling (e.g., Minoxidil, Rogaine, Retin-A), including, but not limited to, s elf-care or self-help and hair implants/transp lants . training; homeopathic medicine and counseling; Ayurvedic medicine s uch as lifest yle modifications and pur ification therapies; What Is Not Cov ered? 3-1 Costs re lated to telephone cons ultations, failure of your p ar ticular cancer in Medical to keep a sched uled app ointment, or completion Litera ture. Drugs pres cribed for the of an y form and/or medical information. treatment of cancer that have not been approved for any indication are excluded. Custodial Care and an y se rvice of a custodial 2. All dru gs disp ens ed to, or p urchas ed b y, yo u nature, including and without limitation: He alth from a pharmacy. This exclusion d oes not Care Services primarily to ass ist in the activities appl y to drugs dispens e d to you wh en : (a) of daily living; res t homes ; home companions or you are an inp atient in a Hospital, s itters; home parents ; domest ic maid services; Ambulatory Surgical Center, Skilled N urs ing res pite care; and pro vision of services wh ich are Facility, Psychiatric Facility or a Hos pice for the sole purpos es of allowin g a family facility; (b) you are in the outpatient member or caregiver of a C overed Person to department of a Hos pital; ( c) dispens e d b y a return to work . pharmacy under contract with us to provide Dental Care or treatment of the teeth or their injectable medications , indicated as co vered s upporting structures or gums, or dental under the fWhat Is Covered?f sectio n of this procedures , including but not limited to: Ben efit Booklet, to you at home for self- extraction of teeth, restoration of teeth with or administration , or to your Physician for w ithou t fillings, crow ns or other materials, administration to you in the Physician™s bridges, clean ing of teeth, dental implants , office; or (d) you are receiving Home Health dentures , periodontal or endodontic procedures, Care according to a plan of treatment and orthodontic treatment (e.g., braces), intraoral the Home Health Care Agenc y b ills us for pros thetic devices, palatal expansion devices, s uch drugs. bruxism appliances, and d ental x-rays . This 3. Any non-Prescription medicine, remedies , exclusion also applies to Phas e II trea tments (as vaccines , biological products (e xcept defined by the American D ental As s ociation) for insulin), pharmaceuticals or chemical TMJ dysfunction. This exclusion does not appl y compounds, vitamins, mineral s upp lements , to an Accidental D enta l Injury an d the Child C left fluoride products, over-the-counter drugs, Lip and Cleft Palate Treatment Services products , or health foods. ca tegory as d es cribed in the fWhat Is Covered?f s ection. 4. Any drug which is indicated or us ed for s e xual d ysfunction (e.g., Viagra, Muse, Diabetic Equipment and Supplies us ed for the Edex, C averject, papaverine, Yocon, and treatment of diabetes w hich are otherwise phentolamine). co vered under a BCBSF Pharmacy Program End orsement to this Bene fit Book let. 5. Any Self-Administered Injectable Prescription Drug wh ich is otherw ise Drugs co vered under a BCBSF Pharmacy Program 1. Prescribed for uses other than the Food and End orsement to this Bene fit Book let except Drug Administration (FDA) approved labe l for a Self-Administered Injectable indications. This exclus ion does not apply to Prescription Drug ind icated as covered in any drug pres cribed for the treatment o f the fWhat Is Co vered?f section of this cancer that has been ap proved by the FDA Ben efit Booklet. for at least one indication, provided the drug Experimental or Investigational Services, is recogn ized for treatment of your p ar ticular except as otherw ise covered under the Bone cancer in a Standard R e ference Marro w Transplant provision of the Trans plant Compendium or recommended for treatment What Is Not Cov ered? 3-2 Services category, and except for any dru g 6. expens es for claims den ied becaus e w e did pres cribed for the treatment of cancer that has not receive information reques ted from you been approved by the Federal Foo d a nd Drug regarding whether or not you have other Administration (FDA) for at least one indication, co verage and the details of such coverage; provided the drug is recogn ized for treatment of 7. any Health Care Services to diagnos e or the particular cancer in a Standard Reference treat a Cond ition which, d irectly or indirectly, Compendium or recommended for treatment of res ulted from or is in connection with: your particular cancer in Medical Literature. a) w ar or an act of war, whether declared Drugs pres cribe d for the treatment of cancer that or not; have n ot been appr oved for any indication are excluded. b) your participatio n in, or commiss ion of, any act p unishab le by law as a Food and Food Products prescribed or not, misdemeanor or felony, or which except as co vered in the En teral Formulas cons titutes r iot, or rebellion; s ubs ection of the fWhat Is Covered?f section. c) your engaging in an illegal occupation; Foot Care w hich is routine, including any He alth d) Services received at military or Care Service, in the abs ence o f diseas e. This government facilities ; or exclusion includ es, but is not limited to: non- e) Services received to treat a Condition s urgical treatment of bunions ; flat feet; fallen arising out of yo ur s ervice in the armed arches ; chronic foot stra in; trimming of toenails; forces , reserves and/or National Guard; corns ; or calluses . 8. Health C are Services rendered b ecaus e General Exclusions include, but are not limited they were ordered b y a cou r t, unless s uch to: Services are Covered Services under this 1. any Health Care Service r ece ived prior to Ben efit Booklet; and your Effective D ate or after the date your 9. any Health Care Services r endered b y or co verage terminates; through a medical or dental department 2. any Health Care Services n ot within the maintained b y or on beh alf of an employer, s ervice categories des cribed in the fWhat is mutual as s ociation, labor u nion, trust, or Covered?f s ection, any rider, or s imilar person or group. End orsement attached hereto, unless s uch Genetic Screening including the e valuation of s ervices are s p ec ifically r equired to be genes to determine if you are a carrier of an co vered by applicable law; abnormal gene that puts you at r isk for a 3. any Health Care Services p ro vided by a Cond ition. Physician or other health care Provider Hearing Aids (external or implantable) and related to yo u by blood or marriage; Services related to the fitting or provision of 4. any Hea lth Care Service w hich is not hearing aids, includ ing tinnitus maskers, Medically Necess ary as deter mined by us batteries , a nd cost of repair. and defined in this Booklet. The ordering of Maternity Services rendered to a C overed a Service by a hea lth care Provider does not Person w ho becomes pregnant as a Ges tational in itself make such Service Medically Surrogate und er the terms of, and in accordance Neces s ary or a Co vered Service; w ith, a Gestat ional Surroga cy Contract or 5. any Health Care Services r endered at no Arrangement. Th is exclus ion applies to all charge; expens es for prenatal, intra-par tal, and pos t- What Is Not Cov ered? 3-3 in the Hospital, Skilled Nursing Facility, Home partal Maternity/Obstetrical Care, a nd H ealth Health C are, and Outpatie nt Cardiac, Care Services rendered to the Covered Person Occupational, Phys ical, Speech, Mass age ac ting as a Ges tational Surrogate. Therapies an d Spinal Manipulations categories For the definition of Ges tational Surrogate and of the fWhat Is Covered?f s ection. Gestational Surrogacy Co ntract s ee the Rehabilitative Therapies provided for the fDefinitionsf s ection of this Ben efit Booklet. purpos e of maintaining rather than improving Oral Surgery except as provided under the your Con dition are also excluded. fWhat Is Covered?f s ect ion. Reversa l of Voluntary, Surgically-Induced Orthomolecular Therapy includ ing nutrients, Sterility including the revers a l of tub al ligations vitamins, and food supp lements. and vasecto mies. Personal Comfort, H ygiene or Convenience Sexual Re assignment, or Modification Items and Services de emed to be not Medically Services including, but not limited to, any H ea lth Neces s ary and not d irectly related to your Care Services related to s uch treatment, such treatment including, but not limited to: as ps ychiatric Services. 1. beaut y and barber services; Smoking Cessat ion Programs including any 2. clothing includ ing support h os e; s ervice to eliminate or reduce the dependenc y 3. radio and television; on, or addiction to, tobacco, including but not 4. gues t meals and accommodations; limited to nicotine withdraw al pro grams and nicotine products (e.g., gum, transdermal 5. telephone charges ; patches, etc.). 6. take-home s upplies; 7. travel expenses (other than Medically Sports-Related devices and s er vices us ed to Neces s ary Ambulance Services); affect performance primarily in sports -related ac tivities ; a ll expenses related to ph ysical 8. motel/hotel accommodations; conditionin g pro grams such as athletic training, 9. air conditioners, furnaces, air filters, air or bod ybuilding, exercise, fitnes s , flexibility, and w ater purification syst ems , w ater so ftening diversion or g eneral motivation. s ystems, humidifiers, dehum idifiers , vacuum cleaners or an y other s imilar equipment and Training and E ducational Programs, or devices us ed for environmental contro l or to materials, including, but not limited to programs enhance an environmental setting; or materials for pain management and vocational r ehabilitation, except as provided 10. hot tubs, Jacuzzis, heated s pas, poo ls, or under the Diabetes Ou tpatient Self Mana gement members hips to h ealth clubs; ca tegory of the fWhat Is Covered?f section. 11. heating pads, hot water bottles, or ice p acks ; 12. phys ical fitness equipment; Travel or vacation expense s even if pres cribed or ordere d b y a Provider. 13. hand rails and grab bars ; and 14. Mass ages except as covered in the fWhat Is Volunteer Serv ices or Services wh ich would Covered?f s ection of this Book let. normally b e provided free o f charge and an y charges ass ociated with Deductible, Private Duty Nursing Car e rendered at any Coinsurance, or Cop ayment (if applicable) location. requirements wh ich are w aived b y a health care Rehabilitative Therapies provided on an Provider. inpatient or outpatien t basis, except as provided What Is Not Cov ered? 3-4 Wei ght Control Services including any Service to los e, gain , or maintain weight regardless of the reason for the Service or whether the Service is part of a treatment plan for a Cond ition. Th is exclus ion includes , but is not limited to weight control/loss programs ; appetite s uppres s ants and other medications ; dietary regimens; food or food s upplements ; exercise programs; exercise or other equipment; gas tric or s tomach bypass or stapling, intes tinal bypass , gas tric balloons , jaw wiring, jejunal bypass , gas tric shun ts, and procedures designed to res trict your ability to ass imilate food. Wigs and/or cranial prosthes is. Work Related He a lth Ca re Services to treat a w ork related Condition to the extent you are co vered; or required to be covered by Workers ™ Compensation law. An y Service to diagnos e or treat any Condition resulting from or in connec tion with your job or employment will be excluded, except for Medically Necess ar y s ervices (not otherwise excluded) for an individua l who is not covered by Workers™ Compensation and tha t lack of coverage did not res ult from any intentional action or omiss ion b y that individ ual. What Is Not Cov ered? 3-5 Section 4: Medical Necess ity In order for Health Care Services to be co vered 1. s taying in the H os p ital because under this Booklet, such Services mus t meet all arrangements for discharge have n o t been of the requ irements to b e a Covered Service, completed; including b eing Medically Neces s ary, as defined 2. us e of laboratory, x-ray, or other diagnos tic by us . testing that has no clear indication, or is not It is important to remember that any review of expected to a lter your treatment; Medical Necess ity we unde r take is solely for the 3. s taying in the H os p ital because s upervision purpos es of determining coverage, b enefits , or in the home, or care in the home, is not payment under the terms of this Booklet and not available or incon venient; o r bein g for the purpos e of recommending or pro viding hos pitalized for any Service wh ich could medical care. In conducting our re view of have b een provided adequately in an Medical Necess ity, we may review s p ec ific altern ate s etting (e.g., Hospital outpatient medical facts or information pertaining to you . department); or Any s uch re view, howe ver, is s trictly for the 4. inpatient admiss ions to a Hospital, Skilled purpos e of determining whether a Hea lth Care Nurs ing Facility, or any other facility for the Service provided or propos ed meets the purpos e of Cus todial Care, convalescent definition of Medical Neces s ity in this Booklet. care, or an y other Service primarily for the In applying the definition of Medical Necess ity in conven ience of the pat ient or h is or her this Booklet to a sp ecific Health Care Service, family members or a Provider . w e may apply our coverage and pa yment guidelines then in effect. Note: W hether or not a Health Care Service is specifically listed a s an exclusion, the fact All dec isions that require or pertain to t hat a Provider may prescribe, recomme nd, independent profess ional medical/clinical approv e, or furnish a H ealth Care Service judgement or training, or the need for medical does n ot mean that the Service is M edically s ervices, are s ole ly your respons ib ilit y an d that Necessa ry (as defined by us) or a Covered of your treating Physicians and hea lth care Service. Please refer to the fDefinitionsf Providers . You and your Physicians are sec iton for the definitions of fMedically res pons ible for deciding wh at medical care Necessa ryf or fMedical Necessityf. s hould be rendered or received and when that care s hou ld b e provided. We are s o lely res pons ible for determining w hether expens es incurred for medical care are covered under this Booklet. In making coverage decisions , we w ill not be deemed to p articipate in or override your decisions concerning your health or the medical decisions of your health care Providers. Examples of hospitalization and other Health Care Services that are not Medically Necess ary include, but are not limited to: M edical Necessity 4-1 Section 5: Un derstanding Y our Sh are of Health Care Expen s es Th is s ection explains w hat your share o f the to a C opa yment requ irement. This is the dollar hea lth care expens es will be for Covered amount you have to pa y when you receive these Services you receive. In addition to the Services. Please refer to your Schedule of information explained in this s ection, it is Ben efits for the spec ific Covered Services, important that you refer to your Schedule of w hich are s ubject to a Copayment. Listed below Ben efits to determine yo ur s hare of the cos t with is a brief description of s ome o f the Copayment regard to Covered Services. requirements that may apply to your plan. If our Allow ed Amount or the Provider™s actua l charge Calendar Year Deductible for a Covered Service rendered is less than the Copa yment amount, you mus t pa y the les ser of 1. Individual Calendar Year D eductible: our A llowed Amount or the Provider™s actual charge for the Covered Service. Th is amount, when app licable, must be s a tisfied by you an d each of your Co vered 1. Office Services Cop ayment: Depende nts each Calendar Year, before If your plan is a C opa yment pla n, the any payment will be made. Only thos e Copa yment for Covered Se r vices rendered charges indicated on claims we receive for in the office (when app licable) must be Covered Services w ill be credited toward the s a tisfied by you, for each office Service Individual Calend ar Year Deductible and before any p a yment w ill be made. The only u p to the ap plicable Allowed Amount. office Services Copa yment applies Covered Services, w hich are s ubject to a regardless of the reaso n for the office visit Copa yment are --not s ubject to the Calendar and applies to a ll Covered Services Year Deductib le. rendered in the o ffice, w ith the exception of 2. Family Calendar Year Deductib le: Durable Medical Equipment, Prosthetics, and Orthotics. Once your family has met the family Calendar Year Deductible, neither you nor Generally, if more than one Covered Service your Covered Dependents w ill have any that is s ubject to a Copayment is render ed add itional Calendar Year Deductible during the s ame office visit, you will be res pons ibility for the remainder of that res pons ible for a single Copa yment which Calendar Year. The maximum amount that w ill not excee d the highes t Copa yment any one Covered Pers on in your family can s pecified in the Schedule of Benefits for the contribute tow ard the family Calendar Year particular Health Care Services rend ered. Deductible is the amount applied tow ard the 2. Copa yment for inpatient facility Services: Individual Calendar Year D eductible. The Copayment for Inpa tient Facilit y Note: Please s e e your Schedule of Benefits Services, if applicable to your pla n, mus t be for more information. s a tisfied by you, for each inpatient admiss ion to a Hospital, Psyc hiatric Facility, Copayment Requirem ents or Substance Abus e Facility, before any payment will be made by us for any claim for Covered Services rendered b y certain Providers inpatient C overed Services. The or at certain locations or s ettings will be s ubject Under standing Your Sh are of He a lth Care E xpe nses 5-1 Copa yment for inpatient facility Services, if The Copayment for emergenc y room facility app licable to your plan, applies regard less of Services, if applicable to your pla n, applies the reason for the admission, an d app lies to regardless of the reaso n for the visit, is in all inpatien t admiss ions to a Hospital, add ition to any applicable Coinsurance Ps ychiatric Facility or Substance Abus e amount, and applies to emergency room Facility in or outside the state of Florida. facility Services in or outs ide the state of Add itionally, you w ill be respons ible for out- Florid a. The Copa yment for emergency of-pocket expenses for Covered Services room facility Services, if applicab le to your provided by Phys icians an d other health plan, must be s atisfied by you for each visit. care profess ionals for inpatient a dmiss ions. If you are admitted to the Hosp ital as an inpatient at the time of the emergency room Note: Copa yments for inpatient facility visit, the Copa yment for emergency room Services vary depending o n the facility facility Services, if app licable to your plan, chos en . ( Pleas e s ee the Schedule of w ill be wa ived, but you will still be Ben efits for more information). res pons ible for your share of the expenses 3. Copa yment for Outpatient Facility Services: for inpatient facility Services as listed in your Schedule of Benefits. The Copayment for outpatient facility Services, if applicable to your pla n, mus t be Coinsur ance Requiremen ts s a tisfied by you, for each outpatient visit to a All applicable Calendar Year Deductible or Hos pital, Ambulator y Surg ical Center, Copa yment amounts must be satisfied before Independent Diagnos tic testing Facility, w e will pay a ny portion of the Allowe d Amount Ps ychiatric Facility or Substance Abus e for Covered Services. For Services that are Facility, before any paymen t will be made by s ubject to Coinsurance, the Coins urance us for any claim for outpatient C overed percentage of the a pplicable Allow ed Amount Services. The Co pa yment for Outpatient you are res pons ible for is listed in the Schedule Facility Services, if app licable to your plan, of Benefits. app lies regard less of the reason for the visit, and applies to a ll outpatient visits to a Note: If a particular Covered Service is not Hos pital, Ambulator y Surg ical Center, available from any In-Network Provider, the Independent Diagnos tic testing Facility, Coinsurance percentage that we w ill base Ps ychiatric Facility or Substance Abus e payment on for that Covered Service will not be Facility in or outside the state of Florida. less than ten (10%) percentage points lower Add itionally, you w ill be respons ible for out- than the Coinsurance perc entage w e wo u ld of-pocket expenses for Covered Services have b as ed p ayment on had the Co vered provided by Phys icians an d other healthcare Services been available from an In-Network profess ionals. Provider. Note: Copa yments for outpa tient facility Services vary depending o n the facility chos en a nd the Services re ce ived. ( Please s ee the Schedu le of Ben efits for more information). 4. Copa yment for Emergency Room Facility Services: Under standing Your Sh are of He a lth Care E xpe nses 5-2 Copa yments, under the pres cription drug Out-of-Pocket Calendar Year co verage, w ill n ot apply to the Calendar Year Maxim um Deductible or the out-of-pocket Ca lendar Year Out-of-Pocket Maximum Amount maximums under this Booklet. 1. Individual out-of-pocket Calendar Ye ar Pr ior Coverage Credit maximum: We w ill give you credit for the satisfaction or Once you have reached th e ind ividual o ut- partia l satisfaction of an y Calendar Year of-pocket Calendar Year maximum amount Deductible and Calendar Year Coinsurance listed in the Sch edule of Benefits , you will maximums met by you under a prior group have no add itional out-of-pocket insurance, b lanket insur ance, franchise res pons ibility for the remainder of the insurance or group H ealth Mainten ance Calendar Year and we will pay for Covered Organization (HMO) policy maintained b y the Services rendered during the remainder of Group if the Group Master Policy r eplaces s uch that C a lendar Year at 100 percent of the a policy. Th is provision only applies if the prior Allow ed Amount. group insurance, b lanket insurance, franchise 2. Family out-of-pocket Cale ndar Year insurance or HMO coverage purchase d b y the maximum: Group was in effect immediately preceding the Once your family has reach ed the family Effective Date of this Group policy. This out-of-pocket Calendar Yea r maximum provision is only a pplicable for you durin g the amount listed in the Schedu le of Benefits, initial C a lendar Year of coverage under the neither you nor your covered family Group Master Policy a nd the follow ing rules members w ill have any additional out-of- appl y: pocket respons ibility for the remainder of 1. Prior Coverage Cred it for Deductible: that C a lendar Year and we w ill p ay for For the initial Calendar Year of coverage Covered Services rendered during the , under the Group Master Policy only charges remainder of that Calendar Year at 100 credited by the Group™s pr ior insurer , percent of the A llowe d Amount. The tow ards your Deductib le requirement, for maximum amount an y one Covered Person Services rendered during the 90-day period in your family can contribute tow ard the immediately prece ding the Effective Date of family out-of-pocket Calendar Year the Group Mas ter Policy, will be credited to maximum is the amount ap plied tow ard the the Calendar Year Deductible requirement individua l out-of-pocket Calendar Year under this Book let. maximum. Pleas e see your Schedule of Ben efits for more information. 2. Prior Coverage Cred it for Coinsurance: Note: The Calendar Ye ar Deductible, a n y Charges cred ited b y the Group™s prior app licable Copa yments and Co insurance insurer, towards your Coinsurance C a lendar amounts w ill accumulate towards the Calendar Year Maximum, for Services rendered Year out-of-pocket maximums. Any benefit during the 9 0-da y p eriod immediately penalt y red uctio ns, non-covered charges or a n y preceding the Effective Date of the Group charges in excess of the Allowed Amount will Master Policy, will be credited to your out-of- not accumulate towards the out-of-pocket pocket Calendar Year maximum under this Calendar Year maximums. If the Group has Booklet. purchas ed pres cription drug coverage, an y app licable Deductible, Coins urance or Under standing Your Sh are of He a lth Care E xpe nses 5-3 3. Prior coverage credit to war ds the C alendar you ha ve other coverage and the d etails of Year Deductib le or out-of-pocke t Calendar s uch coverage; and Year maximums will o nly be given for Health 7. charges for Health C are Se r vices w hich are Care Services, wh ich wou ld have been excluded. Covered Services under this Booklet. Add itionally, you are res pons ible for any 4. Prior coverage credit u nder this Booklet o nly Premium contribution amount requ ired by your app lies at the initial e nrollment o f the en tire Group. Group. You and/or the Group are How we w ill Credit Calen dar Y ear res pons ible for providing us with an y information necess ary for us to apply this Benefit Maximu ms an d the Total prior co verage cred it. Maxim um Benefit per Person Except as des cribed be low, only amounts Benefit Maximu m Carr yover ac tually pa id by us for Covered Services wi ll be credited tow ards an y a pplicable Calen dar Year If immediately before the Effective D ate of the benefit maximums and the total ma ximum Group, you were covered under a prior group benefit per person (lifetime maximum). The policy iss ued by BCBSF to the Group, amounts amounts w e pa y which are credited tow ards app lied to your Calendar Year benefit your Calendar Year b enefit maximums and your maximums and lifetime maximums under the total maximum benefit per person w ill be bas ed prior BCBSF policy, will be applied tow ard your on o ur Allo w ed Amount for the C overed Calendar Year benefit maximums and lifetime Services provided. maximums under this Booklet. Unless otherw ise s pecified o n your Schedule of Benefits. Additional Expenses You Must Pa y In additio n to yo ur s hare of the expenses des cribed above, you are also res pons ible for: 1. any applicable C opa yments; 2. expens es incurred for non-covered Services; 3. charges in excess of an y maximum benefit limitation listed in the Schedule of Benefits (e.g., the lifetime maximums and Cale ndar Year maximums); 4. charges in excess of the Allowed Amount for Covered Services rendered b y Providers w ho h ave n ot agreed to accept our Allowed Amount as pa yment in full; 5. any benefit reductions; 6. payment of expens es for claims denied becaus e w e d id not receive information reques ted from you regarding whether or not Under standing Your Sh are of He a lth Care E xpe nses 5-4 Section 6: Ph y sician s , H ospitals an d Oth er Provider Option s I ntroduction particular Co vered Service is bas ed on our Allow ed Amount for that Co vered Service. It is important for you to u nders tand how the Your Schedule of Benefits des igna tes the panel Provider you se lect a nd the s etting in wh ich you of Netw orkBlue Providers w ho are participating receive He alth Care Services affects how much for your s pecific plan of coverage. This is you are res pons ible for pa ying und er this important becaus e these Providers are Booklet. This s ection, along with the Schedu le cons idered your In-Network Providers for of Benefits and our Provider Director y, describes purpos es of this Benefit Booklet. the hea lth care Provider o ptions available to you and our p a yment rules for Services you receive. With BlueOptions, yo u may choose to receive Services from any Provider. How ever, you w ill As us ed throughout this s ection fout-of-pocket be a b le to low er the amount you have to pa y for expens esf or fout-of-pocketf refers to the Covered Services b y rece iving care from an In- amounts you are required to pa y including an y Network Provider. Although yo u h ave the option app licable Copa yments, the Ca lendar Year to select any Provider you choose, w e Deductible and/or Coins urance amounts for encourage you to s elect a nd develop a Covered Services. relationship w ith an In-Network Family Physician. There are s e veral a dvantages to You are entitled to preferred provider type s e lecting a Fa mily Physician. Family Phys icians benefits when you receive Covered Services are trained to provide a broad range of med ical from In-Network Providers. You are entitled to care and can be a valuable res ource to traditional program type benefits at the point of coord inate your o verall healthcare needs. s ervice when you receive Covered Services Developing and continuing a relations hip with a from Traditional Program Providers or ® Family Physician allo ws the phys ician to BlueCard ( Out-of-State) Traditional Program become know ledgeable about you and yo ur Providers , in conformity with Section 7: ® family™s hea lth histor y. A Family Ph ys ician can BlueCard ( Out-of-State) Program. help yo u determine w hen you need to visit a s pecialist a nd a lso help you find one b ased o n Pr ovider Participation Status their knowledge of you and your s p ecific hea lthcare needs. Types of Family Physicians In order to help control health care costs, we are Family Practitioners, General Practition ers, have entered into contracts w ith certain Internal Medicin e d octors and Pediatricians. Providers to p ar ticipate in NetworkBlue, on e o f Additionally, care rendered by Family Ph ys icians our preferred provider networks . We have also us ually r es ults in low er out-of-pock et expens es entered into contracts w ith certain Providers to for you. Whether you select a Family Physician participate in our Traditional Program. We or another type o f Ph ysician to render Health negot iate with these Providers to establish Care Services, pleas e r emember that using In- maximum allow ances and paymen t rules for Network Providers w ill res ult in lower out-o f- Covered Services as o ne way to control health pocket expenses for you. You s h ould alw ays care costs . The allowa nces we es tablish are determine whether a Provider is In-Network or ca lled our Allowed Amounts . The amount you Out-of-Netw ork prior to receiving Services to are res pons ible for pa ying out-of-pocket for a Ph y sicians, Hospitals and Othe r Prov ider Options 6 -1 determine the amount you are respons ible for Out-of-Network Pr oviders paying out-of-pocket. When you use Out-of-Network Providers your out-of-pocket expenses for Covered Services Location of Service w ill be higher. We will base our payment o n the In addition to the participation status of the Allow ed Amount at the Coinsurance p ercentage Provider, the location or setting where you listed in the Sch edule of Benefits . [Further, if the receive Services can affect the amount you pay. Out-of-Netw ork Provider is a Traditional For example, the amount you are r espons ible for ® Program Provider or a BlueCard (Out-of-State) paying out-of-pocket w ill vary whether you Traditional Program Provider, our pa yment to receive Services in a H os pital, a Pro vider™s s uch Provider may be under the terms of that office, or an Ambulatory Surgical Center. Provider™s contract.] If your Schedule of Pleas e refer to your Schedule of Bene fits for Ben efits and BlueOptions Provider directory do s pecific information regarding your out-of-pocket not include a Provider as In-Network under your expens es for such situations . After yo u a nd benefit plan, the Provider is cons idered Out-of- your Ph ysician have determined the p lan of Network . treatment most appropriate for your care, you s hould refer to the fWhat Is Covered?f section and your Schedule of Benefits to find out if the s pecific Health Care Services are covered and how much you will have to pay. You shou ld also cons ult with your Ph ys ician to determine the mos t appropriate setting bas ed on your health care and financial needs. To verify if a Provider is I n -Network for you r plan you can: 1) review your current Blue Options Pro vider Directory; 2) acces s the BlueOptions Pro vider d irectory at our web-s ite at w w w.bcbsfl.com; and/or 3) ca ll the cus tomer s er vice phone number in this Booklet or on your Ide ntification Car d. I n-Network P roviders When you use In-Network Provid ers, yo ur out- of-pocket expenses for Covered Services w ill be lower . We will bas e our payment on the Allowe d Amount at the C o insurance percentage listed in the Schedule of Benefits. Consult your Schedule of Benefits to determine what pane l of Providers in the BlueOptio ns Provider directory is designated as In-Netw ork for your plan. Ph y sicians, Hospitals and Othe r Prov ider Options 6 -2 In-Network Out-of-Ne twork What expense s Ł Any applicable Copayments, Deductible(s) and/or Coins urance are you requirements; responsible for Ł Expenses for Services wh ich are n ot covered; paying? Ł Expenses for Services in exces s of an y bene fit maximum limitations; Ł Expenses for claims denied becaus e w e did not receive information reques ted from you regarding whether or not you have other coverage and the details of s uch coverage; and Ł Expenses for Services wh ich are excluded. Who is Ł The Provider w ill file the claim Ł You are respons ible for filing the claim res ponsible for for you and pa yment will b e and pa yment w ill b e made directly to filing your made directly to the Provider. the Covered Emplo yee. If yo u receive claims? Services from a Provider w ho participates in our Traditional Program ® or is a BlueCard (Out-of-State) Tradition al Program Provider, the Provider will file the claim for you. In those instances pa yment w ill be made directly to the Provider. Can you be billed Ł NO. You are protected from Ł YES. You are respons ible for paying the difference being billed for the difference in the difference betw een what w e pay between what we our Allowed Amount and the and the Provider™s charge. Howe ver, pay the Provider Provider™s charge wh en you us e if you rece ive Services from a and the Provider™s In-Network Providers. The Provider who participa tes in our charge? Provider will accept our Allowed Tradition al Program, the Provider will Amount as pa yment in full for accept our Allowed Amount as Covered Services except as payment in full for Covered Services otherw ise permitted under the s ince such Traditional Program terms of the Provider™s contract Providers have agreed no t to bill you and this Booklet. for the difference. Further, under the ® BlueCard (Out-of-State) Program, w hen you receive Covered Services ® from a BlueCard (Out-of-State) Tradition al Program Provider, you may be r espons ible for paying the difference betw een what the Host Blue pays and the Provider™s billed charge. Note: You are s o lely r espons ible for se lecting a Provid er w hen obtaining Health Care Servic es and for verifying whe ther that Provider is In-Netw ork or Out-of-Network at the time Health Care Services are rendered. You are a lso res pons ible for determining the corresponding p ayment options, if an y, at the time the Health Care Services are rendered. Ph y sicians, Hospitals and Othe r Prov ider Options 6 -3 Physician that you determine the Hos pitals Ph ysicians w here your Ph ys ician has admitting pr ivileges. When you receive Covered Services from a You can find out wha t Hosp itals yo ur Ph ysician Physician you will be resp ons ible for a admits to b y co ntacting the Ph ysician™s office. Copa yment and /or the Calendar Year Th is w ill provide you with in formation that will Deductible and the applicab le Coins urance. help yo u determine a portion of what your out-of- Several factors w ill d etermine your out-of-pocket pocket cos ts may be in the event you are expens es including your Schedule of Benefits, hos pitalized. w hether the Physician is In-Network or Out-of- Refer to your Sch edule of Benefits to determine Network , the location of service, the type of the app licable out-of-pocket expenses you are s ervice rendered, and the Physicia n™s s pecialty. res pons ible for paying for Hospital Services. Remember that the location or s ett ing where a O ther P roviders Service is rendered can affect the amount you are res pons ible for pa ying out-of-pocket. After With BlueOptions you have access to other you an d your Ph ysician have determined the Providers in addition to the ones pre vious ly plan of treatment most appropr iate for your care, des cribed in this s ect ion. Other Providers you s hou ld re fer to the Schedule of Benefits and include facilities that provide alternative cons ult with your Ph ys ician to determine the outpa tient settin gs or other persons and e ntities mos t appropriate setting bas ed on your health that s p ec ialize in a specific Service(s). While care and financial needs. these Providers may be recognized for payment, Refer to your Sch edule of Benefits to determine they ma y not be included as In-Network the app licable Copayments, Coinsurance Providers for your plan . Ad ditionally, all of the percentage and/or Calendar Year Deductible Services tha t are within the s cope of certain amount you are resp ons ible for paying for Providers ™ licenses may not be Covered Physician Services. Services under this Book let. Please refer to the fWhat Is Covered?f an d fWhat Is Not Co vered?f Hospitals s ections of this Booklet an d your Schedule o f Ben efits to determine yo ur out-of-pocket Each time you receive inpatient or outpatient expens es for Covered Services rend ered b y Covered Services at a Hospital, in addition to these Providers. any out-of-pocket expense s related to Physician Services, you will be resp ons ible for out-of- You ma y b e a ble to receive certa in outpatient pocket expenses related to Hospital Services. Services at a location other than a Hos pital. The amount you are resp ons ible for paying for We are able to negotiate low er pa yment Services rendered at s ome alternative facilities amounts w ith some Hos pitals than w ith others. is generally less than if you had rece ived those Because of this, In-Network Hos pitals ha ve been s ame Services at a Hos pital. divided into two grou ps , w hich are referred to as foptio nsf on the Schedule of Benefits. The Remember that the location of Service can amount you are resp ons ible for paying out-of- impact the amount you are res pons ible for pocket is different for each of these options . paying out-of-pocket. After you and your Remember that there are also different out-of- Physician have de termined the plan o f treatment pocket expenses for Out-of-Network Hos pitals. mos t appropriate for your c are, you sh ould refer to the Schedule of Bene fits and co nsult with Since not all Physicians admit patients to e very your Ph ysician to determine the mos t Hos pital, it is important when choos ing a appropriate setting base d on your health care Ph y sicians, Hospitals and Othe r Prov ider Options 6 -4 and financial needs . When Services are rendered at an outpatient facility other than a Hos pital there may b e a n out-of-pocket expense for the facility Provider as w ell as an out- of- pocket expense for other types of Providers. Assignmen t of Benefits to Providers Except as s et forth in the last paragra ph of this s ection, we w ill not h onor an y of the following as signments , or attempted ass ignments, by you to any Provider: Ł an as s ignment of the benefits du e to you for Covered Services under this Benefit Booklet; Ł an ass ignment of your right to receive payments for Covered Services und er this Ben efit Booklet; or Ł an ass ignment of a c laim for damage res ulting from a breach, or an a lleged breach, of the Group Mas ter Policy. We specifically res erve the right to h onor an as signment of benefits or pa yment by you to a Provider who : 1) is In-Network under your plan of coverage; 2) is a Ne tworkBlue Provider even if that Provider is not in the panel for your p lan of co verage; 3) is a Traditional Program Provider; ® 4) is a BlueCard ( Out-of-State) PPO Program ® Provider; or 5) is a BlueCard (Out-of-State) Traditional Program Provider. Ph y sicians, Hospitals and Othe r Prov ider Options 6 -5 ® Section 7: BlueCard (Ou t-of- State) Program ® us ual BlueCard method noted above in Pr oviders Ou tside the State of paragraph one of this section or require a Florida s urcharge, w e w ill then calculate your liability for When you obtain Health Care Services from any Covered Services in accordance with the ® BlueCard participating Providers outs ide the applicable state s tatute in e ffect at the time you geograph ic area we s erve, the amount you pay received yo ur care. lower for Covered Services is calculated on the of: Ł The billed charges for your Covered Services, or Ł The negotiated price tha t the on-site Blu e Cros s and/or Blue Shield Plan (fHos t Bluef) pas s es on to us . Often, this fnegotiated pricef will consist of a s imple discount, which reflects the actual price paid b y the Hos t Blue. But s ometimes it is an es timated price that factors into the actual price expected settlements , withholds, any o ther contingent payment arrangements and non- claims transactions with your health care Provider or with a s pecified group of Providers. The negotiated price may a lso be billed charges reduced to reflect an aver age expected sa vings w ith your health care Provider or with a s pecified group of Providers. The price that reflects average savings may res ult in greater variation ( more or less ) from the actual price paid than will the es timated price. The negotiated price w ill a lso b e pros pectively adjusted in the future to correct for over- or underes timation of past prices. How ever, the amount you pay is cons idered a final pr ice. Statutes in a s mall n umber of s tates may require the Hos t Blue to use a b as is for ca lculating a covered individual™s liability for Covered Services that does not reflect the entire s a vings realized, or expected to be realized, on a particular claim or to add a s urcharge. Sho uld any state s tatutes mandate liability calculation methods tha t differ from the ® BlueCard (Out-of-St ate) Prog ram 7 -1 Section 8: Blueprin t for Health Program s I ntroduction comply with our a dmiss ion notification requirements, you sh ould ask the Hos pital, We have es tablished (and from time to time Ps ychiatric Facility, Substance Abus e Facility or es tablish) various cus tomer-focused health Sk illed Nursing Facility (as app licable) if w e education and information programs as w ell as have b een not ified of your admiss ion. For an benefit utilization management and utilization admiss ion outside of Florida, you or the Hosp ital, review pro grams. Thes e programs, collectively Ps ychiatric Facility, Substance Abuse Facility or ca lled the Blueprint For Health Programs, are Sk illed Nursing Facility (as app licable) s h ould des igned to 1) provid e you with information that notify us o f the admission. Mak ing s ure that w e w ill help you make more informed decisions are notified of your admiss ion will enable us to about your health, 2) he lp us facilitate the provide you information about the Blueprint for management and review of coverage a nd Health Programs available to you. You or the benefits provide d u nder our policies; and Hos pital, Psychiatric Facility, Subs tance Abuse 3) pres ent opportunities, as explained b elow, to Facility or Skilled Nursing Facility (as appl icable) mutually agree upon alternative benefits or may notify us o f your a dmiss ion by calling the payment alternatives for cost-effective medically toll free customer s er vice number on your ID appropriate Health Care Services. card. Admission Notification Out-of-Network Our admiss ion notification requ irements vary For admiss ions to an Out-of-Network Hos p ital, depend ing on whether you are admitted to a Ps ychiatric Facility, Substance Abus e Facility or Hos pital, Psychiatric Facility, Subs tance Abuse Sk illed Nursing Facility, you or the Hospital, Facility or Skilled Nursing Facility wh ich is In- Ps ychiatric Facility, Substance Abus e Facility or Network or Out-of-Network . To find out about Sk illed Nursing Facility sho uld notify us o f the the participation s tatus of any of these providers, admiss ion. Notifying us of your admiss ion will you can: enable us to provide you information about the 1. review the Provider Director y the n in effect; Blueprint for Health Programs available to you. You or the Hos p ital ma y notify us of your 2. acces s our web-s ite at w w w .bcbs fl.com ; admiss ion by calling the toll free customer and/or s ervice number on your Identification Card. 3. ca ll the cus tomer s er vice phone number in this Booklet or on your Ide ntification Car d. I npatient Facility Program In-Network Under the inpatient facilit y program, w e may review H os p ital s tays, Skilled Nursing Facility Under the admiss ion notification requirement, ( SNF) Services, and other Health Care Services w e must be notified of all inpatient admissions rendered during the cours e of an inpatie nt stay ( i.e., elective, planned, urgen t or emergency) to or treatment program. We may conduc t this In-Network Hos p itals, Ps ychiatric Facilities, review w hile you are inpatient or after your Subs tance Abuse Facilities or Sk illed Nurs ing discharge. The revie w is conducted s olely to Facilities. While it is the s o le respons ibility of determine whether we s hould provid e coverage the In-Network Provider located in F lorida to Bluepr int For Health Prog rams 8-1 and/or payment for a particular a dmiss ion or Providers ha ve agreed no t to b ill, or collect, any Health C are Services rendered during that payment whats oever from you or us, or any admiss ion. Us ing our estab lished cr iteria the n in other person or entity, with respect to H ealth effect, a concurrent review of the inpatie nt stay Care Services if: 1) we perform a focused review may occur at regular intervals. We will provide under the focused utilization management notification to your Physician whe n inpatient program; and 2) w e de termine that the Health co verage criteria is no longer met. In Care Services are not Medically Necess ar y in administering the inpatien t facility program, we accordance w ith our Medical Necess ity criteria may review s pecific medical facts or information or incons istent with o ur be nefit guidelines then in and as s es s , among other things, the effect. appropriateness of the Services being rendered, Mem ber Focused P rograms hea lth care setting and/or the level of care of an inpatient admiss ion or other health care The Blueprint for Health Programs may include treatment program. An y s u ch reviews b y us , voluntary programs for certain members . Thes e and an y reviews or as s es s ments o f s pecific programs may ad dress hea lth promotion, medical facts or information wh ich we conduct, prevention and early detection of disease, are s olely for purposes of mak ing coverage or chron ic illness management programs , case payment decisions und er this Benefit Booklet management programs and other member and not for the purpose of reco mmending or focused programs . providing medical care. In anticipation of your needs follow ing an Personal Case M anagement Program inpatient s tay, we may pro vide you a nd your Physician w ith information about other Blueprint The pers onal case management program for Health Programs, w h ich may be beneficia l to focuses on members who s uffer from a you, and help you and your Physician ide ntify ca tastrophic illnes s or injury. In the event you hea lth care resources , wh ich may b e available in have a catastrophic or chronic Condition, we your community. Up on reques t, we will answ er may, in our sole discretion, ass ign a Pers onal ques tions your Ph ysician has regarding your Cas e Manager to you to he lp coord inate co verage or bene fits following d ischarge from co verage, ben efits, or pa yment for Health Care the Hospital. Services you receive. Your participation in this program is completely voluntary. Provider Focused Utilization M anagement Under the persona l cas e management program, Program w e may elect to offer alternat ive benefits or Certain Ne twork Blue Providers have a greed to payment for cost-effective Health Care Services. participate in our focused utilization Thes e alternative benefits or pa yments may be management program. This pre-s ervice review made available b y us o n a case-by-cas e bas is program is intended to promote the efficient w hen yo u meet our cas e management criteria delivery of medically appropriate Health Care then in effect. Such altern ative b enefits or Services by Ne twork Blue Providers. Under this payments, if any, will b e made available in program we may perform focused pros pect ive accordance w ith a trea tment plan with wh ich reviews of all or spec ific Health Care Services you, or your representative, and your Phys ician propos ed for you. In order to perform the agree to in writing. review, we may require the Provider to submit to The fact that we may offer to pay for, or that we us s pecific medical information relating to Health have p aid for certain H ealth Care Services Care Services prop os ed for you. Network Blue Bluepr int For Health Prog rams 8-2 under the persona l cas e manage ment program expens es, wh ich have been or w ill be incurre d in n o wa y obligates us to continue to provide or for medical care are, or will be, covered un der pay for the s ame or s imilar Services. Nothing this Booklet. In fulfilling this res pons ib ilit y, we contained in this s ect ion shall be deemed a w ill not b e de emed to participate in or o verride w aiver of our r ight to enforce this Benefit Booklet the medical decisions of your health care in s trict accordance with its terms . The terms of Provider. this Booklet will cont inue to apply, except as You, a treating Phys ician, Hospital, or other s pecifically mod ified in writing b y us in Provider may re ques t that we review a Blueprint accordance w ith the personal case management for Health Program coverage or payment program rules then in effect decision, pr ovided such a reques t is recei ved b y us , in writing, w ithin 90 da ys of the date of the Health Information, Promotion, Prevention decision. The review req ues t must include all and Illness M anagement Progr ams information deemed relevant or neces sar y by Thes e Blueprint for Health Programs may us . We will review the decis ion in light of such include health information that supports m ember information and notify you or your education and choices for healthcare iss ues . repres en tative, the Hosp ital and/or the Physician Thes e programs focus on keep ing you well, help of the review dec ision. to identify early pre ventive measures of Pleas e n ote that we res erve the right to treatment and help m embers w ith chron ic discontinue or modify the Hos pital a dmiss ion problems to enjoy lives that are as pro ductive notification requ irement and any Blueprint for and healthy as pos sible. These programs may Health Program at any time w ithout cons ent include prenatal educa tional programs and from you or the Group. illnes s management programs for Conditions s uch as diabetes, cancer and heart diseas e. Thes e programs are voluntary and are designed to enhance your ability to make informed choices an d d ecisions for your unique h ealth care needs . You may call the toll free customer s ervice number on your Identification Card for more information. Your participation in this program is completely voluntary. IMPORTANT INFORM ATION RELATING TO BCBSF™S BLUEPRINT FOR HEALTH PROGRAMS All dec isions that require or pertain to independent profess ional medical/clinical judgment or training, or the need for medical s ervices, are s ole ly your respons ib ilit y an d the res pons ibility of your Phys icians and other hea lth care Providers. You and yo ur Ph ysicians are res pons ible for deciding what medical care s hould be rendered or received, and wh en and how that care shou ld be pro vided. We are s o lely res p onsible for determining whether Bluepr int For Health Prog rams 8-3 Section 9: Pre-ex istin g Condition s Exclu sion Period 7. Genetic Information in the abs ence of a I ntroduction diagnos is of the Condition; Generally, there is no coverage under this 8. routine follow-up care of breas t cancer after the Booklet for Health Care Ser vices to treat a person w as determ ined to be free of breas t Pre-existing C ondition, or C onditions ar ising cancer; from a Pre-existing Con dition, until you ha ve 9. Conditions ar ising from domestic violence; or been continuously covered under this Booklet for a 12-month period. This 12- 10. inherited diseas es of amino acid, organic acid, month Pre-existin g Co ndition exclus ionary carbohydrate or fat metabolism as well as period begins on the first d a y of the Waiting malabsorption origin ating from congenital Period if you are an initial enrollee; or your defects pres ent at b irth or acquired during the Effective Date of coverage under the Bo oklet neonatal period. if you are a special or annu al e nrolle e. This Genetic Information, as used above, means exclusionary period also ap plies to any information abou t genes , gene products, and pres cription drug that is pres cribed in inherited character istics that may derive from the connec tion with a Pre-existing Cond ition. individual or a family member. This includes Th is Pre-existing Co ndition exclusionary information regarding carrier status and information period does not apply to: derived from laboratory tes ts that identify mutations in spec ific genes or chromosomes , phys ical medical 1. the Covered Employee and each examinations , family h istories, and direct analysis of Covered D ependent w ho was covered genes or chromosomes. under the Group™s prior medical plan on the date immediately pr eceding the Pre-existing Condition Definition Effective Date of coverage under this Booklet; A Pre-existing Cond ition means an y Condition 2. you if you wer e enrolled during the Initial related to a p h ysical or mental Conditio n, regardles s Enrollment Period prior to the Effective of the cause of the Condition, for which medical Date of the Group; or advice, diagnos is, care, or treatment was recommended or received during the s ix-month 3. you whe n the Group has elected to period immediately preceding: w aive, in writing, at the time of Group App lication the Pre-existing Conditions 1. the first day of your Waiting Period for initial exclusionary period for all s ubs equent enrolle es; or Eligible Emplo yees and/or Eligible 2. your Effective D ate of coverage u nder the Depende nts ; Group Master Policy for s pecial and an nual 4. pregnanc y; enrolle es. 5. a new born child or an adopted new born ch ild properly enrolled und er this Booklet; 6. an a dopted ch ild that has Creditable Coverage; Pre-ex isting Conditio ns Ex clu sion Perio d 9 -1 5. benefits to members and certain former Re ducing th e Pre-existing members of the uniformed services and their Conditions Exclusionar y Period dependen ts; No matter w hether you enroll when first 6. a medical care program of the Indian H ealth eligible or at a later date (such as an An nual Service or of a tribal organization; Open Enrollment Period or as a res ult of 7. a State health be nefits r isk poo l; s pecial enrollment), you may be able to reduce or even eliminate the Pre-existing 8. a he alth p lan offered under chapter 8 9 of Title 5, Cond itions exclusionar y period if you have United States Cod e; prior Creditable Coverage. 9. a public health plan; If you are enrolling w hen you are first eligible 10. a he alth be nefit plan of the Peace Corps; for coverage and you h a ve no more than a 63-da y bre ak in Creditable Coverage as of 11. State Ch ildren™s Health Ins urance Program your Enrollment Date u nder this Booklet, (S-CHIP); your Pre-existing Conditions exclusionar y 12. public health plans es tablis hed by the federal period will be reduced by th e amount of prior government; or Creditable Coverage you have. 13. public health plans es tablis hed by foreign If, on the other hand, you are enrolling under governments. this Booklet at any other time as allow ed under its terms, such as dur ing an Annual Provin g Creditable Cover age Open Enrollment Period or a Special Enrollment Period, your Pre-existing You may provide a Prior/Concurrent Coverage Cond itions exclusionar y period w ill be Affidavit or Certification of Creditable C overage to reduced by the amount of any Cre ditable prove the amount of time you were covered under Coverage you h ave; provided there is no Creditable Coverage. Prior hea lth insurers and/or more than a 6 3-da y bre ak in coverage prior group health plans are required to provide a to your Enrollment Date in this Booklet. certification of Creditable Coverage to you up on termination of your coverage and at any time upon If you have no Creditable Coverage or none request up t o 24 months after termination of your that can reduc e the Pre-existing Cond itions prior h ealth coverage. If yo u do not provide a exclusionary period, the full 12-month Pre- certification, then you must provide us some other existing Co nditions exclus ionary period will evidence of Cred itable Coverage such as a cop y of appl y. an ID card or health ins urance bill from a prior Creditable Coverage carrier and attest to the amount of time you were covered un der the Creditab le C overage. Creditable Coverage is hea lth care coverage that ma y inc lude any of the following: 1. a group health insurance plan; 2. individua l health insurance; 3. Medicare Part A and Part B; 4. Medicaid; Pre-ex isting Conditio ns Ex clu sion Perio d 9 -2 Section 10: Eligibility f or Cov erage Each employee or other individual w ho is e ligible 1. retired employees ; to participate in the Group Plan , and who meets 2. add itional job c lass ifications ; and continues to meet our eligibility 3. emplo yees of affiliated or subs idiary requirements describ ed in this Booklet, shall be companies of the Group, provided such entitled to apply for coverage with us und er this companies and the Group are un der Booklet. Thes e eligibility requirements are common control; and binding u pon yo u a nd/or your eligible family members as we ll as the Group. No changes in 4. other individuals as determined by us and our el igib ilit y req u irements w ill be permitted the Group (e.g., members of as soc iations or unles s w e have be en notified of and have labor unions). agreed in wr iting to any such change in Any expansion of the Co vered Employee advance. We may re qu ire acceptable eligibility clas s mus t be approved in writing b y us documentation that a n individual meets and and the Group pr ior to such expansion, and may continues to meet the eligibility r equirements be s ubject to d ifferent Rates . s uch as a court order n a ming the Co vered Employee as the legal guardian or appropriate Eligibility Requirem ents for adopt ion documentation described in the De pendent(s) f Enrollment and Effective D ate of Co veragef s ection. An individual who meets the eligibility cr iteria s pecified b elow is an Eligible Dependent and is Eligibility Requirem ents for Covered eligible to apply for coverage under this Booklet: Em ployees 1. The Covered Employee's s pous e under a In order to be eligible to enroll as a C o vered legally valid existing marriage; Employee, an individual must be an Eligible 2. The Covered Employee™s natural, new born, Employee. An Eligible Employee mus t meet adopted, Foster, or step ch ild(ren) (or a child each o f the follo w ing requirements: for w hom the Covered Employee has b een 1. The employee mus t be a bona fide court-appointed as legal gu ardian or legal emplo yee; cus todian) until the end of the Cale ndar Year in which the ch ild reaches age 25 (or in 2. The employee's job must fall within a job the cas e of a Fos ter Child, is no longer clas sification identified on the Group eligible under the Foster Child Program), App lication; and w ho is: 3. The employee mus t have completed any a) depende nt upon the Co vered Emplo yee app licable Waiting Period identified on the for financial support; and Group Application; and i. living in the hous ehold of the 4. The employee mus t meet a ny additional Covered Employee or a full-time or eligibility re quirement(s) identified on the part-time student; or Group Application. ii. the child do es not live in the The Covered Employee eligibility class ification hous ehold of the Covered Employee may be expanded to include: and is not enrolled as a full or part- Eligibility For Cov erage 10-1 time s tudent because the child h as not met the age requ irement to beg in elementar y s ch ool education; or b) in the case of a handicapped depen dent ch ild, s uch child is eligible to continue co verage, beyond the limiting age of 25 , as a Covered Dependent if the ch ild is: i. otherw ise eligible for coverage under the Group Master Policy; ii. incapable of self-sus taining emplo yment by re as on of mental retardation or ph ysical hand icap; and iii. ch iefly dep endent upon the Covered Employee for suppor t and maintenance provided that the s ymptoms or causes of the child™s handicap existed prior to the child™s t h 25 birthday. Th is eligibility shall terminate on the last day of the month in wh ich the child does not meet the r equirements for extended eligibility as a hand icapped child. or 3. The newborn child of a Covered Dependent ch ild. Coverage for s uch ne wborn child will automatically terminate 18 months a fter the birth of the newb orn child. Note: It is your sole re sponsibility as the Cov ered Employee to establish that a child meets the applicable r equirements for eligibility. Eligibility will terminate on the last da y of the month in wh ich the child no longer meets the eligibility criteria required to be an Eligible Dependent. Eligibility For Cov erage 10-2 Section 11: Enrollmen t an d Ef f ectiv e D ate of Cov erage Eligible Emplo yees and Eligible Dependents 2. provide any a dditional in formation nee ded to may enroll for coverage according to the determine e ligib ilit y, at our request; provisions below. 3. agree to pay your portion of the required Any Eligible Employee or Elig ible Dependent Premium; and w ho is not properly enrolled with us will not be 4. complete and s ubm it, through your Group, co vered under this Book let. We will have no an Enrollment Form to add Eligible obligation wh atsoe ver to a ny individua l who is Depende nts or delete Covered Dependents. not properly enrolled. When making application for coverage, you mus t elect one of the types of coverage Gener al Rule s for Enr ollment available u nder your Group™s progra m. Such 1. Any Employee and/or Eligible Dependent types may include: w ho is eligible for coverage under this Employee Only Coverage - This type of Booklet ma y ap ply for coverage by co verage provides co verage for the Eligible completing and s ubmitting an Enrollment Employee only. Form to the Group. Employee/Spouse Cov erage - This t ype of 2. All factual r epres entations on the Enrollment co verage provides co verage for the Eligible Forms mus t be accurate and comp lete. An y Employee and the employee's s pous e under a false, incomplete, or misleading information legally valid existing marriage. provided durin g the enrollment proces s, or Employee/Child(ren) Coverage - This typ e of at any other time, may res u lt, in addition to co verage provides co verage for the Eligible any other lega l righ t(s) w e may have, in Employee and the employee's eligible child(ren) disqualification for, termination of, or only. res c ission o f coverage. Employee/Family Coverage - This type of 3. We w ill not provide coverage and benefits to co verage provides co verage for the Eligible any ind ividual w ho would not ha ve be en Employee and the employee's Eligible entitled to enrollment with us, had accurate Depende nts . and complete information been provided on There ma y be an additional Premium charge for a timely basis o n the Enrollment Forms. In each Co vered D epende nt based on the s uch cas es, w e may require you or an co verage s e lected by the Group. individua l lega lly resp ons ible for you, to reimburse us for any payments we made on En rollment Periods your behalf. The enrollment periods for applying for coverage En rollment Forms/Electing Coverage are as follo ws : To apply for coverage, you as the Eligible Initial Enrollment Period is the period of time Employee must: during which an Eligible Employee or Elig ible Depende nt is first e ligible to enroll. It starts on 1. complete and s ubm it, through your Group, the Eligible Emplo yee™s or Eligible De penden t™s the Enrollment Form; initial date of eligibility and ends no less than 30 days later. Enrollment and Effe ctiv e Date o f Cov erage 11-1 Annual Open Enrollment Period is the period and the follow ing guidelines w ill be ap plied of time during w hich each Eligible Employee is w hen enrolling a new born ch ild: given an opportunity to s e lect coverage from a. If we receive wr itten notice within 30 among the alternatives included in the Group ™s days after the d ate of birth, the Effective hea lth benefit progr am. The period is Date of coverage w ill be the date of birth es tablished b y us , occurs annually, and will tak e and no Premium w ill be charged for the place prior to the Anniversary Date. new born child for the first 30 days of Special Enrollment Period is the 30-day period co verage. of time immediately follow ing a s pecial b. If we receive wr itten notice 31 to 60 circums tance during w hich an Eligible Employee days after the d ate of birth, the Effective or Eligible Depe ndent may apply for coverage. Date of coverage w ill be the date of birth Special c ircumstances are des cribed in the and the appropr iate Premium will be Special Enrollment Period subs ection. charged from the date of birth. Em ployee En rollment c. If we receive wr itten notice more than 60 days after the d ate of birth and Annual 1. An Eligible Employee mus t enroll during the has not Open Enrollment occurred Initial Enrollment Period in order to become s ince the date of birth, the Effective co vered as of the Effective Date of the Date of coverage w ill be the date of birth Group. Eligible Dependents may also be and the appropr iate Premium will be enrolled during the Initial Enrollment Period. charged from the date of birth. The Effective Date of co verage for an d. If we receive wr itten notice more than 60 Eligible De pendent(s ) will be the s ame as days after the d ate of birth and Annual the Covered Employee™s Effective D ate. Open Enrollment has occurred , the 2. An individual who becomes an Eligible new born child may n ot be added until the Employee a fter the Group's Effective Da te next Annual Open Enrollment Period or ( for example, new ly-hired employees) must Special Enrollment Period. enroll before or within the Initial Enrollment Note: The gu idelines a bove only apply to Period. The Effective Date of coverage for new borns born after the Effective Da te of the s uch individual will begin o n the date Covered Employee . If a child is born before the s pecified o n the Group App lication. Effective Date of the C o vered Employee an d w as not added during the Initial Enrollment De pendent Enr ollment Period, we must receive an Enrollment Form. If An individual may be adde d up on b ecoming an the Enrollment Form is received within 30 da ys Eligible Dependent of a Co vered Emplo yee. after the b irth of the child, no Premium will b e Below are s pecial ru les for certain Eligib le charged for the first 30 da ys of coverage. If the Depende nts . Enrollment Form is received 31-60 days after the b irth of the child, any applicable Premium Newborn Child Œ To enroll a new born ch ild mus t be paid back to the Effective Date of w ho is an E ligible Dependent, the Co vered co verage of the Co vered Emp loyee. In the Employee must submit an Enro llment Form event we are not notified within 60 da ys of the to us through the Group. The Effective Date birth of the newb orn child, the Covered of coverage for a newborn ch ild will be the Employee must m ake application during an date of birth. We must be notified, in wr iting, Ann ual Open Enrollment Period or Special Enrollment Period. Enrollment and Effe ctiv e Date o f Cov erage 11-2 Note: Coverage for a newborn child of a Enrollment Period or Special Enrollment Cov ered Dependent child will automatically Period. terminate 18 months after the birth of the Note: The guidelines a bove only appl y to newborn child. adopted new borns born after the Effective Date Adopted Newborn Child Œ To enroll an of the Co vered Employee. If a child is born adopted new born child, the Covered before the Effective Date of the Covered Employee must submit an Enro llment Form Employee and was not added during the Initial through the Group to us. The Effective Date Enrollment Period, w e must receive an of coverage for an adopted newb orn child, Enrollment Form. If the Enrollment Form is eligible for coverage, will be the moment of received within 30 days after the birth of the birth, provided that a written agre ement to ch ild, no Premium w ill be charged for the first 30 adopt such ch ild has been entere d into by days of coverage. If the Enro llment Form is the Covered Employee prior to the birth of received 31-60 days a fter the b irth of the s uch child, whether or n ot such an adopted new born child, any applicable Premium agreement is enforceable. We may req uire mus t be paid back to the Effective Date of the Covered Employee to p rovide an y co verage of the Co vered Emp loyee. In the information and/or documents which we event we are not notified within 60 da ys of the dee m necess ary in order to administer this birth of the adopted new born child, the Covered provision. The following guidelines will be Employee must m ake application during an app lied wh en enrolling an adopted newb orn Ann ual Open Enrollment Period or Special ch ild: Enrollment Period. a. If we receive wr itten notice within 30 If the adopted newbor n child is n ot ultimately days after the b irth, the Effective Da te of placed in the residence of the Co vered co verage w ill be the date of birth and no Employee, there sha ll be no coverage for the Premium w ill be charged for the first 30 adopted new born child. It is your resp onsibility days of coverage for the adopted as the Covered Employee to notify us w ithin ten new born child. ca lendar days of the da te that placement w as to occur if the adopted ne wborn child is no t placed b. If we receive wr itten notice 31 to 60 in your residence. days after the b irth, the Effective Da te of Adopted/Foster Children Œ To enroll a n co verage w ill be the date of birth and the appropriate Premium will be charged adopted child or Foster Child, the Covered from the date of birth. Employee must submit an Enro llment Form during the 3 0-da y p eriod immediately follo wing c. If we receive wr itten notice more than 60 the date of placement and pay the ad ditional days after the d ate of birth and Annual Premium, if an y. The Effective Da te for an Open Enrollment has not occurred, the adopted child or Foster Child (other than an Effective Date of coverage will be the adopted new born child) will be the date s uch date of birth and the appro priate adopted or Foster Child is placed in the Premium w ill be charged from the date res idence of the C overed Employee in of b irth. compliance with Florida law . If timely notice is d. If we receive wr itten notice more than 60 given, no additional Premium w ill be ch arged for days after the d ate of birth and Annual co verage of the ad opted ch ild for the d uration of Open Enrollment has occurred , the the notice period. An y Pre-existing Co ndition adopted new born child may not be exclusionary period will not app ly to an adopted added until the next Annual Open ch ild but will apply to a Foster Child. We may Enrollment and Effe ctiv e Date o f Cov erage 11-3 require the Co vered Employee to provide any is enrolled as a res ult of marriage is the date o f information and/or documents we deem the marriage. neces s ar y, in order to properly administer this Court Order Œ The Co vered Employee may s ection. appl y for coverage for an Eligible Dependent In the e vent w e are n ot notified within 30 da ys o f outside of the Initial Enrollment Period and the date of placement, the child will be added as Ann ual Open Enrollment Period if a court has of the da te of placement s o long as the Covered ordered co verage to be provided for a minor Employee provides n otice to the Group, and we ch ild under their p lan. To a pply for coverage, receive the Enrollment Form w ithin 6 0 da ys of the Covered Employee mus t complete an the placement, and a ny app licable Premium is Enrollment Form through the Group and forward paid back to the date of placement. In the event it to us. The Co vered Employee must m ake w e are not notified within 60 da ys o f the date of app lication for enrollment within 30 d a ys of the placement, the Covered Employee must make court order. The Effective Date of coverage for app lication dur ing an Annual Open Enro llment an Eligible De pendent w ho is enrolled as a Period or Special Enrollment Period in order for res ult of a court order is the date requ ired by the the adopted child or Foster Child to be covered. court or the next billing date. For all children covered as adop ted children, if the final decree of ad option is not iss ued, An nu al Open En rollment Period co verage s ha ll not be continued for the propos ed adopted child. I t is the respons ib ilit y Eligible Emplo yees and/or Eligible Dependents of the Co vered Employee to notify us if the w ho d id not apply for coverage during the Initial adopt ion does not take place. Up on rece ipt of Enrollment Period or a Special Enrollment this notification, we will terminate the coverage Period may apply for coverage during a n Annual of the chi ld as of the Effective D a te of the Open Enrollment Period. The Eligible Employee adopted ch ild upon receipt of the written notice. may enroll b y completing the Enrollment Form during the Annu al Open Enro llment Period. If the Covered Employee's s tatus as a foster parent is terminated, coverage will e nd for an y The Effective Date of co verage for an Eligible Fos ter Child. It is the res pons ibility of the Employee and a n y Eligible Dependent(s ) will b e Covered Employee to notify us in writing that the the first billing date following the Annual Op en Fos ter Child is no longer in the Covered Enrollment Period. Employee™s care. Upo n receipt of this Eligible Emplo yees w ho do not e nroll or ch ange notification , we w ill terminate the coverage of the their coverage se lection during the Annua l Open ch ild on the date provided by the Group or on Enrollment Period, must w a it until the next the first billing date following receipt of the Ann ual Open Enrollment Period, unless the written notice. Eligible Emplo yee or the Eligible Dependent is Marital Status ŒThe Co vered Employee may enrolled due to a spec ial circumstance as appl y for coverage of an Eligible Depe ndent due outlined in the Special Enrollment Period to a legally valid marriage. To apply for s ubs ection of this s ection. co verage, the C overed Employee mus t complete the Enrollment Form through the Special Enr ollmen t Peri od Group and forward it to us . The Covered Employee must m ake application for enrollment An Eligible Employee and/or the Employee™s w ithin 30 days of the marriage. The Effective Eligible De pendents may apply for coverage Date of coverage for an Eligib le D epend ent who outside of the Initial Enrollment Period an d Enrollment and Effe ctiv e Date o f Cov erage 11-4 Ann ual Enrollment Period as a result of a special The Effective Date of co verage for you and your enrollment event. To apply for coverage, the Eligible De pendents added as a result of a Eligible Emplo yee an d/or the Employe e™s s pecial enrollment event is the date of the Eligible De pendents must complete the s pecial enrollment event. Eligible Employees app licable Enrollment Form and forward it to the w ho d o not enroll or chang e their coverage Group within 30 days of the date o f the special s e lection d uring the Special Enro llment Perio d enrollment event. For purpos es of this mus t wait until the next Annual Open Enrollment s ubs ection , the following are the s pec ial Period (See the D epend ent Enrollment enrollment events: s ubs ection of this s ect ion for the rules re lating to the enrollment of Eligible D ependen ts of a 1. you lose your coverage under another group Covered Employee). hea lth benefit plan (as an employee or depende nt), or coverage under other hea lth O ther P rovisi ons Regar ding insurance, or COBRA con tinuation En rollment an d Effective Da te Of co verage that you were covered under at Coverage the time of initial enrollment provided that: a) w hen offered coverage under this p lan 1. Rehired Employees: at the time of initial e ligibility, you s tated, Individuals w ho are rehired as emplo yees of in writing , that coverage under a group the Group are cons id ered newly hired hea lth plan or health insurance emplo yees for purposes of this s ection. The co verage w as the reas on for declining provisions of the Group Master Policy ( w hich enrollment; and includes this Booklet), wh ich are applicable b) you lost yo ur other coverage under a to newly hired employees a nd their Eligible group health benefit plan or health Depende nts (e.g., enrollment, Effective insurance coverage as a res ult of Dates of coverage, Pre-exis ting Condition termination of employment, reduction in exclusionary period, and Waiting Period) are the number of hours you work , reaching app licable to rehired employe es and the ir or exceeding the maximum lifetime of all Eligible De pendents. benefits under other health coverage, 2. Premium Payments: the employer ceased offering gro up In thos e instances w here an individual is to hea lth co verage, dea th of your spous e, be a dded to coverage (e.g., a new Eligible divorce, legal s e paration or employer Employee or a new Eligible Dependent, contributions toward s uch c overage was including a ne w born or adopted child), that terminated. individua l's co verage s h a ll be effective, as Note: Los s of coverage for failure to pa y des cribed in this s ect ion, pr ovided we your portion of the required Premium on a receive the applicable add itional Premium timely basis or for cause (s uch as mak ing a payment within 30 da ys o f the d a te we fraudulent claim or an intentional notified the Group of s uch amount. In no misrepres en tation of a material fact in event s hall an ind ividual b e covered under connec tion with the prior health coverage) is this Group Mas ter Policy if we do not receive not a qualifying event for s pecial enrollment. the app licable Premium payme nt within 2. you get married or obtain a dependent s uch time period. through b irth, adoption or placement in anticipation of ado ption. Enrollment and Effe ctiv e Date o f Cov erage 11-5 Section 12: Termin ation of Cov erag e In the e vent you as the Covered Employe e wish Termin ation of a Covered Employee™s to delete a Covered Dependent from coverage, Coverage an Enrollment Form s hould be forwarde d to us A Covered Employee™s co verage will through the Group. automatically terminate at 12:01 a.m.: In the e vent you as the Covered Employee w ish 1. on the date the Group Master Policy to terminate a spous e's co verage, (e.g., in the terminates; cas e of divorce), you must s ubmit an Enrollment Form to the Group, prior to the requested 2. on the last da y of the first month that the termination date or within 10 days of the date Covered Employee fails to contin ue to meet the divorce is fina l, wh ichever is applicable. any of the app licable e ligibility requirements; 3. on the date the Covered Employee ™s Termin ation of an I ndividual™s co verage is terminated for cause (s ee the Coverage for Cause Te rmination of an Individual Coverage for Caus e subs ection); or If, in our opinion, any of the following e vents occur, we may terminate an individual's 4. on the date sp ecified by the Group that the co verage for cause: Covered Employee™s co verage terminates. 1. fraud, material misrepres entation or Termin ation of a Covered omiss ion in appl ying for coverage or De pendent™s Coverage benefits; 2. the knowin g m isrepresentation, omiss ion or A Covered Dependent's coverage will the giving of false information on Enrollment automatically terminate at 12:01 a.m.: Forms or other forms completed for us, by or 1. on the date the Group Master Policy on your behalf; or terminates; 3. misus e of the Identification Card. 2. on the d ate Covered Employee ™s coverage Note: Only fraudulent misstatements on the terminates for any reas on; Enrollment Form may be used by us to void 3. on the last da y of the first month that the covera ge or deny any claim for loss incurred Covered D ependent fails to continue to meet or disability, if discovered after two years any of the app licable e ligibility requirements from your Effective Date. (e.g., a child reaches the limiting age, or a s pous e is divorced from the Covered Notice of Termin ation Employee); It is the Group™s res pons ib ility to immediately 4. on the date we specify that the C overed notify you of terminatio n of the Group Master Depende nt™s co verage is terminated by us Policy for a n y reason. for cause; or 5. on the date sp ecified by the Group that the Covered D ependent™s coverage terminates. Termination of Cov erage 12-1 Responsibilities of BCBSF Upon Termin ation of Your Coverage Upon terminatio n of coverage for you or your Covered D ependents for a ny reason, w e w ill have n o further liability or r es pons ibility w ith res pect to such individual, except as other w ise s pecifically d es cribed in this Booklet. Certi fication of Creditable Coverage In the e vent coverage terminates for any reas o n , w e will iss ue a written certification of Creditable Coverage to you. The certification of Creditable Coverage will indicate the period of time you were enrolled w ith us. Creditable Coverage may reduce the length of an y Pre-exist ing Condition exclusionary period b y the length of time you had prior Creditable Coverage. Upon reques t, we w ill send you another certification of Creditable Coverage within a 24- month period after termination of coverage. The s ucceeding carrier will be respo ns ible for determining if our coverage meets the qualifying Creditable Coverage gu idelines (e.g., no more than a 63-da y bre ak in coverage). Termination of Cov erage 12-2 Section 13: Contin u ing Coverage Un der COBRA *Note: A Federal co ntinuation of coverage law , known You and your Covered Dependents as the Cons olidated Omnibus Budget are el igib le for an 11 month e xtension of the Reconciliation Act of 1985 (COBRA), as 18 month COBRA co ntinuation option above amended, may apply to the Group. If COBRA ( to a total of 29 months) if you or your app lies to the Group, you or your Covered Covered D ependent is totally disabled (as Depende nts may be entitled to continue defined by the Social Security Administrat ion co verage for a limited period of time, if you meet ( SSA)) at the time of your termination, the app licable requirements, mak e a timely reduc tion in h ours or w ithin the first 60 da ys election, and pa y the proper amount required to of CO BRA continuation coverage. The maintain coverage. Covered Person must supp ly notice of the disab ility determination to the Group within You mus t contact the Group to determine if you 18 months of becoming eligible for or your Covered Dependent are entitled to continuat ion coverage and no later than 60 COBRA continu ation of coverage. The Group is days after the SSA™s deter mination date. s o lely res p onsible for meeting a ll of the obligations un der COBRA, includ ing the 2. Your Covered Dependent(s ) may elect to obligation to notify all Covered Persons of their continue their coverage for a period not to r ights under CO BRA. If the Group or you fail to exceed 3 6 months in the case of: meet your ob ligations und er COBRA and this a) the Covered Employee™s entitlement to Group Master Policy, we w ill not be lia ble for any Medicare; claims incurred b y you or your Covered b) divorce or legal s eparation of the Depende nt(s) after termination of coverage. Covered Employee; A summary of your COBRA rights and the c) death of the Covered Emplo yee; genera l conditio ns for qualification for CO BRA continuat ion coverage is pr ovided below . Th is d) the employer files bankruptc y (subject to s ummary is not meant as a repres entation that bankruptcy court approval); or any of the COBRA obligations of the Group are e) a Dependent ch ild may elect the 3 6 met b y the purchase of the Group Master Policy; month extension if the Dependent child the duty to meet such obligations remains w ith ceas es to be an Eligible Dependent the Group. under the terms of the Group™s The following is a s ummary o f wha t you may co verage. elect, if COBRA ap plies to the Group and you Children born to or placed for adoption with the are el igib le for s uch co verage: Covered Employee d uring the contin uation 1. You ma y e lect to continue their coverage for co verage p eriods noted above are a lso eligible a period not to excee d 1 8 months * in the for the remainder of the continuation per iod. cas e of: If you are eligible to contin ue group health a) termination of employment of the insurance coverage pursuant to COBRA, the Covered Employee other than for gross following cond itions must be met: misconduc t; or 1. The Group must notify you of your b) reduced hours of employment of the continuat ion of coverage rights under Covered Employee. Continuing Cov erage Under COBRA 13-1 COBRA within 14 da ys of the e vent, wh ich An election by an Covered Emplo yee or creates the continuation option. If coverage Covered Dependent spous e s hall be deemed to w ould be lost du e to Me dicare entitlement, be an e lection for any other qualified beneficiar y divorce, legal s e paration or the failure of a related to that Covered Emplo yee or Co vered Covered Dependent child to meet eligibility Depende nt spous e, un less otherw ise specified requirements, you or your Covered in the election form. Depende nt mus t notify the Group, in wr iting, Note: This section shall not be interpreted to w ithin 60 days of any of the se events. The grant any continuation rights in excess of Group™s 14-da y n otice requirement runs t hose required by COBR A and/or Section from the date of rece ipt of s uch notice. 4980B of the Internal Revenue Code. 2. You mus t elect to continue the coverage Additionally, the Group Master Policy shall w ithin 60 days of the later of: be deemed to have been modified, and sha ll be interpreted, so as to comply with COBRA a. the date that the coverage terminates ; or and changes to COBRA that are mandatory b. the date the notification of continuation of with respect to the Group. coverage rights is s ent by the Group. 3. COBRA coverage will terminate if yo u become covered under any other group hea lth insurance plan. Ho w ever, COBRA co verage may continue if the new group hea lth insurance plan contains exclusions or limitations du e to a Pre-existing Cond ition that would affect your coverage. 4. COBRA coverage will terminate if yo u become entitled to Medicare. 5. If you are totally disa bled and eligible and elect to extend your continuation of co verage, you may not continue such extension of coverage more than 30 days after a determination b y the Social Security Administration that you are no longer disab led. You mus t inform the Group o f the Socia l Security Administration™s determination w ithin 30 days of s uch determination. 6. You mus t mee t all Premium payment requirements, and all other eligibility requirements describ ed in COBRA, and, to the extent not incons istent with COBRA, in the Group Mas ter Policy. 7. The Group must continue to provide group hea lth co verage to its emp loyees . Continuing Cov erage Under COBRA 13-2 Section 14: Conv ersion Privileg e converted policy application will be denied and Eligibility Criteria for Con version you will not be entitled to a converted p olicy. You are entitled to appl y for a BCBSF individual Add itionally, you are not entitled to a converted policy (h ereinafter referred to as a fconverted policy if: policyf or fconversion policyf) if: 1. you are eligible for or covered under the 1. you were cont inuous ly covered for at least Medicare program; three months under the Group Master 2. you failed to pay, on a timely basis, the Policy, and/or under anothe r group policy contribution required by the Group for w ith your Group, tha t provided s imilar co verage u nder this Group Master Policy; benefits immediately prior to the Group Master Policy; and 3. the Group Mas ter Policy was rep laced within 31 d a ys after termination by a ny group 2. your coverage was terminated for any policy, contract, p lan, or program, including reas on, including discontinuance o f the a self-insured p lan or program, that provides Group Master Policy in its entirety and benefits similar to the benefits pro vided termination of continued co verage u nder under this Book let; or COBRA. 4. a) you fall under one of the follow ing Notify us in writing or by telephone if you are ca tegories an d meet the requirements of interes ted in a conversion policy. Within 14 4.b. below: days of such notice, we w ill send you a conversion po lic y application, premium notice i. you are covered under any H os pital, and out line of coverage. The out line of s urgical, medical or major medical co verage w ill contain a brief description of the policy or contract or under a benefits and coverage, exclusions and prepa yment plan or under any other limitations , and the a pplicab le Deductible(s ) and plan or pro gram that provides Coinsurance provisio ns. benefits which are similar to the benefits provide d u nder this Booklet; We must receive a completed application for or a converted policy, and the applicable premium payment, within the 63 -day period ii. you are eligible, whether or not beginning on the date the coverage under co vered, under any arrang ement of t he Group M aster P olicy t erminated. If co verage for individuals in a group, covera ge has been terminated, due to the w hether on an insure d, unins ured, non-payment of premium by the Group, we or partially insur ed b as is, for must receive the completed converted policy benefits similar to thos e provided application and the ap plica ble premium under this Book let; or pa yment within the 63-day period beginning iii. benefits similar to the benefits on the date n otice was giv en that the Group provided under this Booklet are Master Policy t erminated. provided for or are a vailab le to you In the e vent w e do not receive the con verted purs uant to or in accordance w ith policy applicatio n a nd the initial premium the requirements of an y state or payment within such 63-day period, your Conv e rsion Privilege 14-1 federal law (e.g., COBRA, Medicaid); and b) the benefits pro vided under the s ources referred to in para graph 4.a. i or the benefits provide d or available under the s ource referred to in paragraph 4 .a.ii. and 4 .a.iii. above, toge ther w ith the benefits provide d b y our converted policy wou ld resu lt in o ver insurance in accordance w ith our over insurance s tandards, as determined b y us. We have no obligation to notify you of this conversion privilege when your coverage terminates or at any other time. It is your sole responsibility to exercise this conversion privilege by submitting a BCBSF converted policy application and the initial premium payme nt to us on a timely basis. The converted policy may be issued without evidence of insurability and shall be effective t he day following the day your coverage under the Group M aster Policy te rminated. Note: Our converted policies are not a continuation of coverage under COBRA or an y other states™ similar laws. Covera ge and benefits provided u nder a converted policy will not be identical to the coverage and benefits provided u nder t his Booklet. When applying for our converted policy, you have t wo o ptions: 1) a converted policy providing major medical coverage meeting the re quirements of 627.6675(10) Florida Statutes or 2) a converted p olicy providing covera ge and benefits identical to the covera ge and benefits required to be provided under a small employer standard health benefit plan pursuant to Section 627.6699(12) Florida Statutes. In any event, we will not be required to issue a converted policy unless required to do so by Florida law. We may have other options available to you. Call the telephone number on your Identification card for more information. Conv e rsion Privilege 14-2 Section 15: Extens i on of Benefi ts our op inion, you are unable to perform those Extension o f Benefits normal day-to-day activities w hich you wo uld In the e vent the Group Mas ter Policy is otherw ise perform and you require regular terminated, we wi ll not pro vide coverage for any care and attendance b y a Phys ician. Service rendered o n or after the termination 2. In the e vent you are receiving covered date. The extension of ben efits provisions denta l treatment as of the termination date des cribed below on ly apply when the entire of the Group Master Policy, w e w ill provide a Group Master Policy is terminated. The limited extension of such covered dental extension of benefits des cribed in this section do treatment provided: not app ly whe n your coverage terminates if the a) a course o f de ntal trea tment or dental Group Master Policy remains in effect. The procedures w ere recommended in extension of benefits pro visions are subject to all writing a nd commenced in accordance of the other provisions , including the limitations w ith the terms s pecified herein while you and e xclus ions. w ere covered under the Group Mas ter Note: It is your sole re sponsibility to provide Policy; acceptable documentation to us showing b) the dental procedur es were procedures t hat you are entitled to an extension of for other than routine examinations, benefits. proph ylaxis, x-rays, sea lants, or 1. In the e vent you are totally disab led on the orthodontic services; and termination date of the Group Master Policy c) the dental procedur es were performed as a res ult of a specific Accident or illness w ithin 90 days after the Group Master incurred while you were covered under this Policy terminated. Booklet, as determined by us, we w ill provide a limited extension of benefits for Th is extension of ben e fits is for Co vered the disab led individual only. This extension Services necess ar y to complete the of benefits is for Co vered Services denta l treatment on ly. This extension of neces s ar y to treat the disabling C ondition benefits will a utomatically terminate at only. Th is extens ion of be nefits w ill only the end of the 90-day period begin ning continue as long as the disabi lity is on the termination date of the Group continuous and uninterrupted. In a ny event, Master Policy or on the date you this extens ion of ben efits w ill automatically become covered under a succeeding terminate at the end of the 12-month period insurance, he alth maintenance beg inning on the termination date of the organization or self-ins ured plan Group Master Policy. providing coverage or Services for s imilar dental pr ocedures. You are no t For purposes of this section, you will b e required to be totally disabled in order to cons idered ftotally disabledf only if, in our be e ligible for this extension of ben e fits. opinion , you are unable to work a t any gainful job for which you are su ited b y Pleas e refer to the D ental Care category of education, training, or experience, and yo u the fWhat Is Co vered?f section for a require regular care and attendance b y a des cription of the d ental ca re Services Physician. You are totally disabled on ly if, in co vered under this Book let. Ex t en sion of B enefits 15-1 3. In the e vent you are pregnant as of the termination date of the Group Master Policy, w e will provide a limited extension of the maternity expens e b ene fits provided b y this Booklet, provided the pregn ancy commenced w hile the pregnant individual w as covered under the Group Mas ter Policy, as determined by us. This extension of benefits is for Covered Services neces s ar y to treat the preg nancy o nly. This extension of benefits will automatically terminate on the date of the b irth of the child. You are not required to be totally disabled in order to be eligible for this extension of benefits. Ex t en sion of B enefits 15-2 Section 16: The Eff ect of Medicare Cov erage/ Medicare Secon dary Payer Provision s When you become covered under Medicare and entitlement, then the group health insura nce continue to be eligible and covered un der the co verage w ill remain primary for the ESRD Group Master Policy, our coverage will be coord ination period. If you become eligible for primar y and the Medicare b enefits will be Medicare d ue to ESRD, w e w ill provide grou p s econdar y, but only to the extent required by hea lth co verage, as des cribed in this s ect ion, o n law. In all other instances, our coverage will be a primary basis for 30 months . s econdar y to an y Med icare bene fits. To the Disabled Active I ndiv iduals extent we are the primary payer, c laims for Covered Services s hould be filed with us first . We w ill provide primary coverage to you if: Under Medicare, your Group MAY NOT offer, 1. the Group is a part of a he alth plan that has s ubs idize, procure or provide a Medicare co vered employees of at leas t one employer s upplement policy to you. Also , your Group of 100 or more full-time or part-time MAY NOT induce you to de cline or terminate emplo yees on 5 0 p ercent or more of its your group he alth insurance coverage and elect regular busines s da ys d uring the previous Medicare as primary p aye r. Calendar Year; and If you become 65 or become eligible for 2. you are entitled to Medicare coverage Medicare d ue to End Stage Rena l D iseas e becaus e of disab ility (un less you have (fESRDf), you must notify your Group. ESRD). I ndividuals With E nd S tage Renal Primary co verage under the Group Master Disease Policy is s ubject to the following terms: 1. For a Covered Pers on, w e w ill provide If you are entitled to Medicare coverage co verage on a primar y basis during an y becaus e of ESRD, w e w ill provide group hea lth month in wh ich that individual meets the co verage o n a primary basis for 30 months des cription s et out in the above paragraphs. beg inning with the earlier of: 2. Individual entitlement to primary coverage 1. the month in which you became en titled to under this s ubs ection will terminate Medicare Part A ESRD benefits; or automatically w hen: 2. the first month in w hich you w ou ld h ave a) the Covered Person turns 65 years of been entitled to Medicare Part A ESRD age ; or benefits if a timely application h ad b een made. b) the Covered Person no longer qualifies for Medicare coverage becaus e of If Medicare was primary prior to the time you disab ility; or became eligible due to ESRD, then Medicare w ill remain primary (i.e., persons entitled d ue to c) the Covered Person elects Medicare as disab ility whos e employer has less than 100 the primary payer . Co verage w ill emplo yees, retirees and/or their spous es over terminate as of the day of s uch e lection. the age of 65). A lso, if group health ins urance co verage w as primary prior to ESRD The Eff ect of M edicare Cov erage/ Medicare Secondary P ay er Prov ision s 16-1 3. Entitlement of the Co vered Person to primar y coverage under this s ubsection will terminate automatically if the Co vered Employee no longer qualifies as s uch under app licable Medicare regulations and instructions. The Group must notify us, w ithou t delay, of an y such change in status. Miscellaneous 1. Th is s ection s hall be s ubject to, modified (if neces s ar y) to conform to or comply with, and interpreted with reference to the requirements of federal statutor y and regulatory Medicare Secondary Payer provisions as those provisions re late to Medicare b eneficiaries w ho are covered under the Group Master Policy. 2. We w ill not b e liable to the Group or to an y individua l covered under the Group Master Policy on account of any nonpa yment of primar y benefits res u lting from an y failure of performance of the Group's obligations as des cribed in this s ect ion. 3. If we should e lect to mak e primary p ayments for Covered Services rende red to an emplo yee or De pendent described in this s ection in a period prior to r eceipt of the information required by the terms of this s ection, we may require the Group to reimburse us for s uch pa yments. Alternatively, we may require the Group to pay the Rate d ifferential that resulted from the Group's failure to provide us with the required information in a timely manner. The Eff ect of M edicare Cov erage/ Medicare Secondary P ay er Prov ision s 16-2 Section 17: Duplication of Cov erage Under Oth er H ealth Plans / Program s 3. any other plan, program or insurance policy, Coordination of Benefits including a n a utomobile PIP insurance Coordination of Benefits (fCOBf) is a limitation policy and/or medical p a yment coverage of coverage an d/or benefits to be provided b y w hich the la w permits us to coordinate us . This provision is required b y and subject to benefits with; applicable federal and/or Florida law concerning 4. Medicare, as des cribed in fThe Effect of coordination of health insurance be nefits and will Medicare Coverage/Medicare Secondar y be modified to the extent necessary to enable us Payer Provisionsf s ection; and to comply w ith such laws. 5. to the extent p ermitted by law, any other COB de termines the manner in wh ich expenses government s pons ored he alth insurance w ill be paid whe n you are covered under more program. than one he alth p lan, program, or policy The amount of our pa yment, if an y, when w e providing benefits for Health Care Services. coord inate benefits under this s ection, is bas ed COB is des igned to avoid the cos tly dup lication on wh e ther or not we are the primary payer. of pa yment for Covered Services. It is your When w e are pr imary, we w ill pay for Covered res pons ibility to pro vide us and your Physician Services without regard to coverage under other w ith information concerning an y duplication of plans . When we are not primary, our payment co verage under an y other health plan, program, for Covered Services ma y be red uced s o that or pol icy you or your Co vered De pendents may total benefits un der a ll your plans w ill not exceed have. This means you must notify us in writing if 100 percent of the total rea s onable expens es you ha ve other applicable coverage or if there is ac tually incurred for Covered Services. For no other coverage. You may be requested to purpos es of this s ection, in the event you provide this information at initial enrollment, b y receive Co vered Services from a Network Blu e written corres pondence annua lly thereafter, or in Provider or an Out-of-Network Provider w ho connec tion with a s pecific Health C are Service participates in our Traditional Program, ftotal you rece ive. If we do not receive the information reas onable expens es f s hall mean the amount w e reques t from you, w e may den y your c laims w e are obligated to pa y to the Pr ovider pursuant and you wi ll be r es pons ible for pa yment of any to the ap plicable agreement w e have with s uch expens es related to den ied claims. Provider. In the event that the primary Health p lans, programs or policies wh ich may be pa yer™s payme nt exceeds our Allowed s ubject to COB include, b ut are not limited to, Amount, no payment will be made for such the follow ing which will be referred to as Services. "plan(s)" for purpos es o f this section: The following ru les s hall be used to estab lish the 1. any group or non-group he alth ins urance, order in which b enefits und er the resp ective group-type s e lf-insurance, or HMO plan ; plans will be determined: 2. any group p lan iss ued b y any Blue Cross 1. When w e co ver you as a C overed and/or Blue Shield organization(s ); Depende nt and the other plan covers you as Duplication of Cov erag e Unde r Other H ealth Plans/Prog rams 17-1 other than a d epende n t, we w ill be We w ill not coor dinate benefits aga ins t an s econdar y. indemnity-t ype policy, an exces s insurance policy, a policy with coverage limited to 2. When we cover a d epende nt child whos e s pecified illness es or accidents, or a parents are not separ a ted or divorced: Medicare sup plement policy. 6. If you are covered under a COBRA a) the plan of the pare nt whos e birthday, continuat ion plan as a res ult of the purchas e excluding year of b irth, falls earlier in the of coverage as provided under the year will be primar y; or Cons olidated Omnibus Bu dget b) if both parents have the same birthday, Reconciliation Act of 1985, as amended , excluding year of b irth, and the other and a lso under another group plan, the plan has co vered o ne of the pare nts following order of b enefits applies: longer than us , we w ill be secondar y. a) first, the plan covering the person as an 3. When we co ver a dependent child w hose emplo yee, or as the employee™s parents are s eparated or d ivorced: Depende nt; and a) if the p arent with custody is not b) s econd , the coverage purchas ed under remarried, the p lan of the parent w ith the plan coverin g the pers on as a former cus tody is primary; emplo yee, or as the former employee™s Depende nt provided accor ding to the b) if the p arent with custody has remarried, provisions of COBRA. the plan of the pare nt with custod y is primar y; the s tep-parent's p lan is 7. If the other plan does no t ha ve rules that s econdar y; and the p lan of the p arent es tablish the s a me order of benefits as w ithou t custody pa ys last; under this Book let, the benefits under the other plan w ill be determined primary to the c) regardless of w hich parent has cus tody, benefits under this Booklet. w henever a court decree s pecifies the parent w ho is financially re s pons ible for Facility of Pa yment the child's hea lth care expenses , the plan of that paren t is primary. Whenever payments wh ich are paya ble by us 4. When w e co ver a dependent child and the under this Booklet are made b y any other depende nt child is also co vered under pers on, plan , or organization, we w ill have the another p lan: r ight, exercisable alone and in our s ole discretion, to pa y over to any s uch pers on, plan, a) the plan of the pare nt who is neither laid or organization making s uch other payments , off nor retired w ill be primary; or any amounts w e determine to be required in b) if the other p lan is not subje ct to this order to sa tisfy our coverage obligations rule, and if, as a resu lt, s uc h plan does hereunder. Amounts s o paid shall be deemed to not agree on the order of benefits, this be p a id under this Booklet and, to the extent of paragraph s hall no t apply. s uch payments, we w ill be fully discharged from liability. 5. When rules 1, 2, 3, and 4 above do not es tablish a n ord er of benefits, the plan wh ich has covered you the longes t s hal l be primar y. Duplication of Cov erag e Unde r Other H ealth Plans/Prog rams 17-2 Non-Duplication of Governm ent Pr ograms and Workers™ Compensation The benefits u nder this Boo klet s hall not dup licate any benefits to wh ich you or your Covered D ependents are entitled to or eligible for under government programs (e.g., Medicare, Medicaid, Veterans Administration) or Workers™ Compensation to the e xtent allowe d b y law, or under an y e xtension o f benefits of coverage under a prior p lan or progr am w hich may be provided or required by law. Duplication of Cov erag e Unde r Other H ealth Plans/Prog rams 17-3 Section 18: Sub rogation If you are injured or become ill as a result of another p ers on™s or entity™s intentional act, neg ligence or fault, you must notify us concerning the circumstances und er wh ich you w ere injured or became ill. You or your law yer mus t notify us , by certified or registered mail, if you inten d to claim damages from s omeone for injuries or illnes s . I f you r ecover money to compens ate for the cost/expense of Health Care Services to treat your illnes s or injury, we are legally entitled to recover payments made on your behalf to the doctors, hospitals, or other providers wh o treated you . Our legal righ t to recover money we h ave p aid in such cases is ca lled "s ubrogationf. We ma y reco ver the amount of any payments w e made on your behalf minus our pro rata share for any cos ts and a ttorney fees incurred b y you in pursuing and recovering damages. We may s ubro gate aga inst a ll mone y reco vered regard less of the s ource o f the money including, b ut not limited to, unins ured motorists co verage. Although we may, bu t are not required to, take into cons ideration any s pecial factors relating to yo ur s pecific case in reso lving our subrogation claim, w e will have the first right o f recovery out of any recovery or settlement amount you are able to obtain even if you or your attorney believes that you ha ve not been made whole for your loss es or damages b y the amount of the recovery or s e ttlement. You mus t do nothing to prejudice our right of s ubrogation hereun der a nd no waiver, release o f liability, or other documents executed by you, w ithou t notice to us and our wr itten cons ent, w ill be b indin g up on us . Subrog ation 18-1 Section 19: Rig ht of R eim bu rsemen t If any payment under this Book let is made to you or on yo ur b ehalf with respect to any in jury or illness res ulting from the intentional act, neg ligence, or fault of a third person or entit y, w e will have a right to b e re imburs ed by you (out of an y settlement or judgment proceeds you recover) o ne dollar ($1.00) for each dollar paid under the terms of this Book let minus a pro rata s hare for any cos ts and attorney fees incurred in purs u ing and recovering s uch proceeds . Our right of reimbursement w ill b e in ad dition to any s ubroga tion right or claim available to us, and you mus t execute and deliver such instruments or papers pertaining to any s e ttlement or claim, s ettlement nego tiations , or litigation as may be requested b y us to exercise our right of reimbursement hereunder. You or your law yer must notify us, by certified or registered mail, if you intend to claim damages from so meone for injuries o r illness . You must do n o thing to prejudice our right of reimbursement hereun der and no waiver, release of liability, or other documents executed by you, without notice to us and our written cons en t, will be binding up on us. Right of Reimbu rsement 19-1 Section 20: Claim s Process ing I ntroduction plan administrator is the e mployer who es tablishes and maintains the plan . Th is s ection is intend ed to: Ł help yo u understand w hat you or your Types of Claims treating Providers must do, under the terms For purposes of this Benefit Booklet, there are of this Bene fit Booklet, in order to obtain three types of claims: 1) Pre-Service Claims; payment for e xpenses for Covered Services 2) Pos t-Service C laims; and 3) Claims Involving they have rendered or will render to you; Urgent Care. It is important that you become and familiar with the t ypes of c laims that can be Ł provide you w ith a general description of the s ubmitted to us and the timeframes and other app licable procedures w e w ill use for requirements that apply. making Adverse Benefit Determinations, Concurren t Care Decisions and for notifying Post-Service Claims you whe n we den y bene fits. How to File a Post-Service Claim If your Group Plan is subject to the Emplo yee Retirement Income Security Act of 1974 We have d efined and described the three types ( ERISA), your pla n a dministrator is s o lely of claims tha t may be submitted to us. Our res pons ible for complying w ith ERISA. While the experience show s that the mos t common type of benefit determination timeliness s tandards s et claim we will rece ive from you or your treating forth in this s ectio n are ge nerally consistent with Providers w ill likely be Post-Service Claims . ERISA, we are not legally r es pons ible for In-Network Providers have agreed to file Post- notifying you of an y rights you may have under Service Claims for Services the y render to you. ERISA. If you are not s ure of your rights under In the e vent a Provider wh o renders Services to ERISA, you s ho uld contact your plan you do es not file a Post-Service Claim for such administrator or a n attorney of your choice. We Services, it is your respons ibility to file it with us. w ill follow the claim determination procedures and not ice req uirements s et forth in this s ection We must receive a Post-Service C laim w ithin 90 even if your Group Plan is not subject to ERISA. days of the date the H ealth Care Service was rendered or, if it was not reas onably pos s ib le to Under no circumstances w ill we be held file within s uch 90-da y p eriod, as s oon as res pons ible for, nor will we accept liability pos s ible. In any event, no Post-Service Claim relating to, the failure of your Group Plan™s w ill be cons idered for payment if we do not s pons or or plan administrator to: 1) comply with receive it at the address ind icated on yo ur ERISA™s d isclos ure requ irements ; 2) provid e you Identification Card w ithin one year of the date w ith a Summary Plan Description (SPD) as that the Service was rend ered unless you w ere term is defined by ERISA; or 3) comply w ith any legally incapacitated. other legal re qu irements . You s hould contact For Post-Service Claims , w e must receive an your plan s po ns or or administrator if you have itemized statement from the he alth care Provider ques tions relating to your Group Plan™s SPD. for the Service r endered along with a completed We are not yo ur Group Plan™s s pons or or plan claim form. The itemized s tatement must administrator. In mos t cas es , a plan™s s pons or or contain the following information: Claims Processing 20-1 1. the date the Service was pr ovided; receive n otice of payment for paper claims w ithin 30 days of receipt. If w e are unable to 2. a description of the Service including any determine whether the c laim or a portion of the app licable procedure code(s); claim is pa yab le b ecaus e w e need more or 3. the amount actually charg ed b y the add itional information, we may contest the claim Provider; w ithin the timeframes set forth below. 4. the diagnos is including any applicable Ł Contested Pos t-Service Claims diagnosis code(s ); In the e vent w e co ntest an electronically 5. the Provider™s name and address ; s ubmitted Post- Service Claim, or a portion o f s uch a claim, we w ill us e o ur best efforts to 6. the name of the individual who received the provide notice, within 20 days of receipt, that the Service; and claim or a portion of the claim is contested. In 7. the Covered Employee™s name and contract the event we contest a Pos t-Service Cla im number as they appear on the Identification s ubmitted on a paper claim form, or a portion of Card. s uch a claim, we w ill us e o ur best efforts to provide notice, within 30 days of receipt, that the The itemized statement and cla im form must be claim or a portion of the claim is contested. Our received by us at the address indicated on your notice may identify: 1) the contested portion or Identification Card. portio ns of the claim; 2) the reason(s ) for Note: If your Grou p purch as ed retail ph armacy contest ing the claim or a portion of the claim; pres cription drug coverage, p leas e refer to the and 3) the date that we reas onably expect to pharmacy program Endorsement for information notify you of the decis ion. The notice may also on the process ing of pres cription drug claims. indicate whether add itional information is Further, special claims pro cess ing rules may needed in order to complete process ing of the appl y for Health Care Services you receive claim. If we request additional information, we ® outside the state of F lorida under the BlueCard mus t receive it within 45 days of our req uest for ® Program (See the BlueCard ( Out-of- State) the information. If we do not receive the Program s ection of this Book let). re quested information, the claim or a portion The Process ing of Pos t-Service Claims of the claim will be adjudicated based on the information in our possession at the time We w ill use our bes t efforts to p a y, c ontest, or and may be denied. Upon receip t of the den y a ll Post-Service Claims for which we have reques ted in formation, we w ill use our b est all of the necess ary information, as determined efforts to complete the proces sing o f the Pos t- by us . Pos t-Service Cla ims w ill be p a id, Service Claim within 15 days of receipt of the contested, or denied w ithin the timeframes information. des cribed below. Ł Denial of Post-Service Claims Ł Payment for Post-Service Claims In the e vent w e den y a Pos t-Service Claim When pa yment is due und er the terms of this s ubmitted electronically, we w ill use our best Ben efit Booklet, we w ill use our bes t efforts to efforts to provide notice, within 20 da ys of pay (in who le or in part) for electronically receipt, that the c laim or a portion of the cla im is s ubmitted Post- Service Claims within 20 days of den ied. In the event we d en y a pa per Post- receipt. Likewise, w e w ill use our best efforts to Service Claim, w e w ill use our best efforts to pay (in who le or in part) for paper Post-Service provide notice, within 30 days of receipt, that the Claims w ithin 4 0 days of re ceipt. You may claim or a portion of the claim is denied. The Claims Processing 20-2 a Pre-Service Claim as that term is defined notice may identify the denied p ortion(s ) of the herein. In order to determine whether we must claim and the reason(s ) for denial. I t is your receive a Pre-Service Claim for a particular res pons ibility to ens ure that w e receive all Covered Service, please refer to the fWhat Is information determined b y us as necess ar y to Covered?f s ection and oth er applicable s ections adjudicate a Pos t-Service Claim. If we do not of this Bene fit Booklet. You may also call the receive t he necessar y information, the claim or a portion of the c laim may be denied. cus tomer s ervice number on your ID card for as sistance. A Post-Service Cla im denial is a n Adverse We are not required to render an o pinion or Ben efit Determination and is s ubject to the make a coverage or benefit determination with Adverse Benefit Determination standards and res pect to a Service that h as not actually been appeal proced ures described in this s ec tion. provided to you unless the terms of this Benefit Add itional Proces sing Information for Post- Booklet require (or condition pa yment upon) Service Claims approval by us for the Service before it is In any event, we w ill use our bes t efforts to pay received. or deny all: 1) electro nic Pos t-Service Claims Ben efit Determinations on Pre-Service Claims w ithin 90 days of receipt of the completed claim; Involving Urgent Care and 2) Post- Service paper claims w ithin 120 days of receipt of the completed c laim. C laims For a Pre-Service Claim Involving Urgent C are, proces s ing sh all be deemed to have been w e will use our best efforts to provide n otice of completed as of the date the notice of the cla ims our determination ( whe ther adverse or n o t) as decision is depos ited in the mail by us or s oon as pos sible, but n o t later than 72 ho urs otherw ise electronically transmitted. An y claims after receipt of the Pr e-Service Cla im unles s payment relating to a Post-Service Claim that is add itional information is required for a coverage not made by us within the applicable timeframe decision. If additional information is necess ar y is s ubject to the payment of simple interest at to make a determination, we w ill use our bes t the rate establ ished b y the Florida Insurance efforts to provide notice within 24 hours of: 1) Code. the need for additional information; 2) the s pecific information that you or your Provider We w ill investigate any allega tion of improper may need to provide; and 3 ) the date that we billing by a Provider upon receipt of w ritten reas onably expect to provide notice o f the notification from you. If we determine that you decision. If we re ques t ad ditional information, w ere b illed for a Service that was n ot actually w e must receive it w ithin 48 hours of our performed, any pa yment amount will be adjusted reques t. We will use o ur b es t efforts to provide and , if applicable, a refund will be reques ted. In notice of the decision o n your Pre-Service Claim s uch a cas e, if pa yment to the Pro vider is w ithin 48 hours after the earlier of: 1) receipt of reduced due s olely to the notification from you, the requested information; or 2) the end of the w e will pay you 20 percent of the amount of the period you w ere afforded to provide the reduc tion, up to a total of $500. s pecified a dditional information as des cribed abo ve. Pr e-Service Claims Ben efit Determinations on Pre-Service Claims How to File a Pre-Service Claim that D o No t Involve Urg en t Care Th is Benefit Booklet may condition coverage, We w ill use our bes t efforts to pro vide notice of a benefits, or pa yment ( in whole or in part), for a decision on a Pre-Service Claim not involving s pecific Covered Service, on the receipt b y us of Claims Processing 20-3 urgent care within 15 days of receipt provided Ł the reduction or terminatio n of co verage or add itional information is not required for a benefits by us was not due to an co verage d ecision. Th is 1 5-day determination amendment o f this Benefit Booklet or period may be extended by us one time for up to termination of your coverage as provided b y an a dditional 1 5 da ys. If such an extension is this Benefit Booklet. neces s ar y, we w ill use our bes t efforts to provide We w ill use our bes t efforts to n o tify you of such notice of the extension and reasons for it. We reduc tion or termination in advance so that you w ill use our b es t efforts to provide n otification of w ill have a reas onable amount of time to have the decisio n o n your Pre-Service claim within a the reduction or terminatio n reviewed in total of 30 da ys of the initial receipt of the claim, accordance w ith the Advers e Benefit if an extension of time was taken b y us. Determination s tandards and procedures If additional information is neces s ar y to make a des cribed below. In no event s hall we b e determination, we w ill use our best efforts to: required to pro vide more than a reas onable 1) provide notice of the need for additional period of time within which yo u may develop information, prior to the expiration o f the initial your appeal before w e actually terminate or 15-da y p er iod; 2) identify the specific information reduce coverage for the Services. that you or your Provid er may need to pro vide; Reques ts for Extens ion o f Services and 3) inform you of the date that we reason ably expect to notify you of our decision. If we Yo ur Provider may requ es t an extens ion of reques t additional information, we mus t receive co verage or bene fits for a Service beyond the it within 45 days of our re ques t for the approved period of time or number of approved information. We w ill use our bes t efforts to Services. If the r eques t for an e xtension is for a provide notification of the decision on your Pre- Claim Involving Ur gent Care, w e w ill use our Service Claim within 15 days of receipt of the bes t efforts to notify you of the approval or denial reques ted in formation. of s uch reques ted extension within 24 ho urs after receipt of your reques t , provided it is A Pre-Service Claim denial is an Adverse received at least 24 hours prior to the expir ation Ben efit Determination and is s ubject to the of the pre viously approved number or length of Adverse Benefit Determination standards and co verage for s uch Services. We w ill us e our appeal proced ures described in this s ec tion. bes t efforts to notify yo u w ithin 24 hours if: 1) we Concur ren t Care Decisions need additional information; or 2) you or your repres en tative failed to follow proper procedures Reduction or Termination of Coverage or in your request for an extension. If w e reques t Ben efits for Services add itional information, you w ill have 48 hours to provide the reques ted information. We may A reduction or termination of coverage or notify you orally or in writing , unless you or your benefits for Services w ill be cons idered a n repres en tative specifically request that it be in Adverse Benefit Determination whe n: writing . A denial of a reque st for extension of Ł w e ha ve ap proved in wr iting coverage or Services is cons idered an Adverse Benefit benefits for an ongoing course of Services to Determination a nd is s ubject to the Adverse be provided over a period of time or a Ben efit Determination review procedure be low . number of Services to be rendered; and Ł the reduction or terminatio n occurs before the end of such previous ly approved time or number of Services; and Claims Processing 20-4 Standards for Adverse Ben efit How to Appeal an Adverse Ben efit De termin ations De termin ation Mann er and Co ntent of a Notification of an You, or a representative designated by you in Adverse Benefit Determination writing , have the right to a ppea l an Adverse Ben efit Determination. We w ill revie w your We w ill use our bes t efforts to pro vide notice of appeal through the review process des cribed any Adverse Be nefit Determination in w riting. belo w. Your appea l mus t be submitted in writing Notification of an Adverse Benefit Determination to us w ithin 365 da ys of the original Adverse w ill inclu de (or will b e made available to you free Ben efit Determination, except in the case o f of charge upon reques t): Concurren t Care Decisions w h ich may, Ł the specific reason or reasons for the depend ing upon the circumstances , require you Adverse Benefit Determination; to file within a s horter period of time from notice of the de nial. The followin g guidelines are Ł a reference to the s p ecific Benefit Booklet app licable to reviews of Adverse Benefit provisions upon w hich the Adverse Benefit Determinations : Determination is bas ed, as w ell as a ny intern al r ule, gu ideline, protocol, or other Ł We must receive your appeal of an Adverse s imilar criterion that was relied upon in Ben efit Determination in person or in writing; making the Adverse Benefit Determination; Ł You ma y req ues t to review pertin ent Ł a description of any a dditional information documents , such as an y internal r ule, that might change the determination and guideline, protocol, or similar criterion relied w hy that information is neces s ar y; upon to make the determination, a nd su bmit iss ues or comments in writing; Ł a description of the Adverse Be nefit Determination review proce dures an d the Ł If the Adverse Benefit Determination is time limits applicable to such proced ures; bas ed on the lack of Medical Necess ity of a and particular Service or the Experimental or Investigational limitatio ns and exclus ions or Ł if the Adverse Benefit Determination is other similar exclusions or limitations, you bas ed on the Medical Neces s ity or may request , free of charge, an explanation Experimental or Invest igational limitations of the s cientific or clinical judgment relied and e xclus ions, a s tatement telling you how upon, if any, for the determination, that you can obtain the spec ific explanation of app lies the terms of this Benefit Book let to the scientific or clinical judg ment for the your medical circumstances ; determination. Ł During the revie w process , the Services in If your claim is a Claim Involving Urge nt Care, ques tion w ill be reviewe d w ithout regard to w e may notify yo u orally within the proper the decisio n reached in the initial timeframes, provided we follow-up w ith a written determination; or electronic notification meetin g the requirements of this s ubs ection no later than Ł We may consult with appropriate three days after the oral notification. Physicians , as n eces sary; Ł Any independen t medical consultant who reviews your Adverse Benefit Determination on o ur behalf will be identified upon reques t; and Claims Processing 20-5 Ł If your claim is a Claim Involving Urge nt claim denial. The ap peal may be directed to an Care, you may reques t an exped ited ap peal emplo yee of BCB SF who is a licens ed Ph ysician orally or in writing in wh ich case all res pons ible for Medical Neces s ity reviews . The neces s ar y information on r e view may be appeal may b e by telephone and the Ph ysician transmitted between you and us b y w ill respond to you, within a reasonable t ime, not telephone, facsimile or other available to exceed 15 business days . expeditious method. Additional Claims P r ocessing Your request for appeal should be sent to the Pr ovisions address below: 1. Releas e of Information/Cooperation: Blue Cross and B lue Shield of Florida, Inc. In order to process claims, w e may need Attention PPO Appeals / D C4 P.O. Box 44197 certain information, including information Ja cks onville, Florida 32231-4197 regarding other health care coverage yo u may have. You must cooperate with us in Timing o f Our Appea l Review on Adverse our e ffort to obtain such information by, Ben efit Determinations among other wa ys, s igning an y r eleas e of We w ill use our bes t efforts to re view your information form at our reques t. Failure by appeal of an Adverse Benefit Determination and you to fully cooperate with us may result in a communicate the decision in accordance w ith den ial of the pending claim and we w ill ha ve the follow ing time frames: no liability for such claim. Ł Pre-Service Claims -- within 30 da ys of the 2. Physical Examination: receipt of your appeal; or In order to make coverage and benefit Ł Post-Service Claims-- w ithin 60 days of the decisions, we may, at our expense , require receipt of your appeal; or you to be examined b y a h ealth care Provider o f our choice as often as is Ł Claims Involving Urgent Care (and reques ts reas onably necess ar y while a claim is to extend concurrent care Services made pending. Failure b y you to fully co operate w ithin 24 hours prior to the termination of the w ith such examination shall result in a den ial Services)-- w ithin 72 h ours of receipt o f your of the pending claim and we s hall have no reques t. If ad ditional in formatio n is liability for s uch claim. neces s ar y we w ill notify you within 24 ho urs and w e must receive the reques ted 3. Legal Actions : add itional information within 48 hours of our No legal action arising out of or in reques t. After we receive the ad ditional connec tion with coverage u nder this Benefit information, w e w ill have an addition al 48 Booklet ma y be brou ght agains t us w ithin hours to make a final determination. the 60-day p eriod following our receipt of the Note: The nature of a claim for Services (i.e. completed c laim as required here in. w hether it is furge nt caref o r not) is judged as of Add itionally, no s uch action may be brough t the time of the benefit determination on review, after expiration of the applicable statute of not as of the time the Service was in itially limitations . reviewed or provided. Yo u, or a Provider acting on your be ha lf, w ho has ha d a claim denied as not Medically Neces s ary has the opportunity to ap peal the Claims Processing 20-6 4. Fraud, Misrepres entation or Omiss ion in s pecific explanation of the scientific or App lying for Benefits: clinical judgment for the determination. 6. Circumstances Beyond Our Control: We rely on the information provided on the itemized statement and the claim form when To the extent that natura l disas ter, w ar, riot, proces s ing a claim. All such information, civil ins urrection, epidemic, or other therefore, mus t be accurate, truthful and emergency or similar event not within our complete. An y fraudulent statement, control, res u lts in facilities , pers onnel or our omiss ion or concea lment of facts, financial resources b eing unable to process misrepres en tation, or incorrect information claims for Covered Services , we will have no may result, in addition to any other legal liability or obligation for any delay in the remed y we ma y have, in denial of the claim payment of claims for Covered Services, or cancellation or resciss ion of your except that we w ill make a good faith effort co verage. to make payment for s uch Services, taking into account the impact of the e vent. For the 5. Expla nation of Benefits Form: purpos es of this para graph, an event is not All claims decisions, including denial and w ithin our control if we can not effectively claims review decisions , will be exercise influence or dominion over its communicated to you in writing either on an occurrence or non-occurrence. explanation of benefits form or some other ERI S A Ci vil Action P rovision written corres pondence. This form may indicate: A federal law know n as the Employee a) The s pecific reason or reas ons for the Retirement Security Act of 1974 (ERISA), as Adverse Benefit Determination; amended, may apply to the Group Plan. If ERISA applies to the Group Plan, you or your b) Reference to the specific Benefit Covered Dependents are entitled, after Booklet provisio ns upon w hich the exhaus tion of the appea l procedures provided Adverse Benefit Determination is bas ed for in this section, to pursue civil action under as w ell as an y internal rule, guideline, Section 502(a) of ERISA in connection with an protocol, or other similar criterion that Adverse Benefit Determination or any o ther lega l w as relied upon in making the Adverse or equitable remedy otherw ise available. Ben efit Determination; c) A description of an y additional information that would c hange the initial determination and w h y that information is necess ar y; d) A description of the applicable Adverse Ben efit Determination review procedures and the time limits app licable to such procedures ; and e) If the Adverse Benefit Determination is bas ed on the Medical Neces s ity or Experimental or Invest igational limitations an d exclus ions, a statement telling you how you can obtain the Claims Processing 20-7 Section 21: Relations hips Betw een th e Parties liable for any acts or omiss ions , or thos e of the BCBSF and Health Car e Pr oviders Group, its agents , servants, e mployees, or any Neither BCBSF nor any o f its o fficers, directors pers on or organ ization with which the Group has or employees pro vides Hea lth Care Services to entered into any agreement or arrangement. B y you. Ra ther, we are engaged in making acceptance of coverage and benefits here under, co verage and benefit decisions un der this you agre e to the foregoing. Booklet. By accepting our coverage and Medical Treatment Decisions - benefits, you agree that making s uch coverage and benefit dec isions does not const itute the Responsibility of Your P h ysician, Not rendering of Health C are Services a nd that BCBSF hea lth care Providers rendering those Services are not our employees or agents . In this Any and all decisions that require or pertain to re gard, we hereby expressly disclaim any independent profess ional medical judgment or agency relationship, actual or implied, with training, or the n eed for medical s ervices or an y health care Provider. We do not, by virtue s upplies, must be made s olely by your family of making coverage, be ne fit, and payment and your treating Physician in accordance with decisions, exercise an y control or direction over the patient/phys ician relations hip. It is pos s ible the medical judgment or clinical decisions of any that you or your treating Phys ician may conclude hea lth care Provider. An y decisions we make that a particular procedure is needed, concerning appropr iatenes s of s etting, or appropriate, or des irab le, even though s uch w hethe r any Service is Medically Neces s ary, procedure may not b e covered. s hall be deemed to be made solely for purposes of determining whether s uch Services are co vered, and not for purpos es of recommending any treatment or non-treatment. Neither BCBSF nor the Group will ass ume liability for any los s or damage arising as a res ult of acts or omiss ions of an y health care Provider. BCBSF and the Group Neither the Group nor an y pers on covered under this Booklet is our agent or representative, and neither s hall be liab le for any acts or omiss ions by our agents, servants, employees, or us. Add itionally, we w ill not be liable, whether in tort or contract or o therw ise, for any acts or omiss ions of an y other pers on or organization w ith which we ha ve made or hereafter make arrangements for the provision of Covered Services. We are not your agent, servant, or repres en tative nor are w e an agent, servant, or repres en tative of the Grou p and we w ill not b e Relationships Bet ween The Parties 21-1 Section 22: General Provis ions Master Policy, or to bind us in any manner not Access to Informati on express ly des cribed herein, including but not We have the right to receive, from you and any limited to the making of any promise or hea lth care Provider rendering Services to you, repres en tation, or by giving or receiving a ny information that is reas ona bl y neces s ar y, as information. The terms of coverage and benefits determined by us , in order to administer the to be provided by us may not be amended by co verage a nd benefits w e provide, subject to all the Group; unless s uch amendment is app licable confidentiality r equirements listed evidenced in wr iting and signed b y a duly belo w. By accepting coverage, you a uthorize authorized officer o f BCBSF. The Group s ha ll every health care Provider who renders Services immediately no tify you of any s uch amendment to you, to d isclose to us or to entities affiliated and/or shall as s ist us in notifying you at our w ith us, up on reques t, all facts, records, and reques t. reports pertaining to your care, treatment, and Assignmen t and Delegation phys ical or mental Condition, and to per mit us to copy any s uch records and reports s o obtained. Your obligations arising hereunder may not be as signed, delegated or otherw ise transferred by Right to Receive Necessar y you withou t the written cons ent of BCBSF. We I nformati on may as sign our coverage and/or b ene fit In order to administer coverage and benefits, we obligations to our s uccess or in in terest or an may, witho ut the consent of, or notice to, any affiliated ent ity without the cons ent of the Group pers on, plan , or organization, obtain from any at any time. Any assignment, delegation, or transfer made in v iolation of this provision pers on, plan , or organization any information w ith respect to any p ers on covered un der this shall be void. Booklet or applican t for enrollment which we Chan ges in P rem ium dee m to be neces s ar y. We may modify the Rates at any time, w ithout Am endmen t your consent, upon a t least 45 days prior notice The terms of coverage and benefits to be to the Group. It is the Group™s respo nsibility to provided by us may be amended at renew al of immediately no tify you if your financial the Group Mas ter Policy, without the consent of contribution requirement is change d d ue to a the Group, you or any other person, upon 4 5 change in Rates. days prior w ritten no tice to the Group. In the Right to Recovery event the amendment is unacceptable to the Group, the Group ma y terminate the Group Whenever we have made payments in exces s o f Master Policy upon at least ten days prior written , the maximum provided for under this Booklet notice to us . An y s uch amendment will be w e will have the righ t to recover any s uch w ithou t prejudice to claims filed with us an d payments, to the extent of such exces s, from related to Covered Services prior to the date of you or an y person, plan, or other organization s uch amendment. No agent or other pers on, that received such payments. except a duly authorized officer of BCBSF, has the authorit y to modify the terms of the Group General Prov isions 22-1 Compliance with State and Federal Evidence o f Covera ge Laws and Regula tions You have been provided with this Benefit Booklet and an Identification Card as evidence The terms of coverage and benefits to be of coverage under the Group Master Po lic y provided by us und er the Group Master Policy iss ued b y us to the Group. s hall be deemed to have been modified and s hall be interpreted , so as to co mply with G overnin g Law app licable s tate or federal laws and regulations dea ling w ith Rates, benefits , eligibility, The terms of coverage and benefits to be enrollment, termination, con version, or other provided hereunder, and the rights of the parties r ights and duties. hereunder, sh all be construed in accordance w ith the laws of th e s tate of Florida a nd/or the Confidentiality United States, when app licable. Except as otherw ise specifically provide d her ein, I dentification Car ds and e xcept as ma y be required in order for us to administer coverage an d b enefits, s pec ific The Identificatio n Cards iss ued to you in no wa y medical information concerning you, received b y creates, or s erves to verify, eligibility to receive Providers , shall be kept confidential b y us in co verage a nd benefits und er this Booklet. conformity with applicable law. Such information Identification cards are our propert y and must be may be disclosed to third parties for use in des troyed or r eturned to us immediately connec tion with bo na fide medical research an d following termination of your coverage. education, or as re as onably neces sar y in connec tion with the ad ministration of co verage Modification of Provider Network and and benefits, specifically including our q uality the Par ticipation Sta tus as surance and Blueprint for Health Programs . Add itionally, we may disclos e s uch information Network Blue, and the participation s tatus of to entities affiliated with us or other pers ons or individua l Providers a vailable u nder this Booklet, entities w e utilize to ass ist in providing coverage, are s ubject to change at any time without prior benefits or ser vices und er this Booklet. Further, notice to you or your approval or that of the any documents or information, which are Group. Add itiona lly, we may, at any time, properly s u bpoena ed in a judicial proceeding, or terminate or modify the terms of an y Provider by order of a regulatory agency, shall n ot be contract and may enter into add itional Provider s ubject to this provision. contracts w ithout prior notice to, or approval of, Our arrangements w ith a Provider may r equire the Group or you. It is your res pons ibility to that we releas e certain cla ims and medical determine whether a health care Provider is an information about pers ons covered under this In-Network Provider at the time the Health Care Booklet to that Provider even if treatment has Service is rendered. Und er this Booklet, your not been s oug ht b y or through that Provider. By financial respons ibility may vary depending upon accepting co verage, you hereby authorize us to a Provider™s participation status . release to Providers claims information, including related medical information, pertainin g to you in order for any s uch Provider to evaluate your financial res pons ibility under this Booklet. General Prov isions 22-2 If to Group: Cooperation Required of You and Your Cover ed Dependents To the addres s indicated on the Group App lication. You mus t coopera te w ith us, and must execute and s u bmit to us an y co ns ents, releas es, Our Obligations upon Termin ation as signments , and other documents w e may reques t in order to administer, and exercise o ur Upon terminatio n of yo ur coverage for any r ights hereun der. Failure to do s o may res ult in reas on, we w ill have no further liability or the den ial of c laims and w ill constitute grounds res pons ibility to you under the Group Mas ter for termination for cause b y us (See the Policy, except as s pecifically des cribed herein. Te rmination of an Individual™s Coverage for Caus e subs ection in the fTermination of ERI S A Coveragef s ection). We are not the plan spons or or pla n Non-Waiver of Defaults administrator, as defined b y ERISA. If the group hea lth plan under which you are covered is Any failure by us at a ny time, or from time to s ubject to the Employee Retirement Income time, to enforce or to require the strict Security Act (ERISA), the Group, as e ither plan adherence to any of the terms or cond itions s pons or or plan administrator of an emplo yee des cribed herein, will in no event constitute a w elfare b enefit plan s ubject to ERISA, is w aiver of an y s uch ter ms or conditions. Further, res pons ible for ens ur ing compliance with it will no t affect our right at any time to enforce or ERISA. avail ourselves of an y s uch re medies as w e ma y be e n title d to under applicable law , the Group Pr omissory Estoppel Master Policy, or this Benefit Booklet. No oral s tatements , representations , or Notices unders tanding b y any pers on can change , alter, delete, add, or otherw ise modify the e xpress Any notice requ ired or permitted hereunder w ill written terms of this Booklet. be d eemed given if han d d e livered or if mailed by United States Mail, postage prepa id, and Florida Agency for Health Care addres s ed as listed below . Such notice will be Admin istration ( AHCA) Performan ce dee med effective as of the date de livered or s o Outc ome and Financial Data depos ited in the ma il. The performance outcome and financial d ata If to us: pub lishe d by AHCA, pursuant to Florida Statute To the addres s printed on the Group 408.05, or any s ucces s or s tatute, located at the Application and /or the Identification Card. w eb s ite address w w w.floridahealthstat.com, If to you: may be access ed through the link provided on the Blue Cross and Blue Shie ld of Florida™s To the latest ad dres s pro vided by you or to corporate web s ite at w w w.bcbs fl.com . your latest ad dres s on Enro llment Forms ac tually de livered to us. Third Par ty Beneficiary You must notify us immediately of any The Group Mas ter Policy under which this address change. Ben efit Booklet was iss ued w as entered into General Prov isions 22-3 s o lely and s pecifically for the be ne fit of BCBSF and the Group. The terms and provisions of the Group Master Policy s hall be binding so lely upon, and inure s o lely to the benefit of, BCBSF and the Group, and no other person s hall have any rights, interest or claims thereunder, or under this Benefit Book let, or be entitled to sue for a breach thereof as a third-party beneficiary or otherwise. BCBSF and the Group hereby s pecifically expr ess their intent that health care Providers that have not entered into contracts w ith BCBSF to participate in BCBSF™s Provider network s s hall not be third-party beneficiaries under the Group Master Policy or this Benefit Booklet. General Prov isions 22-4 Section 23: Def in itions The following definitions are used in this Benefit generally be establishe d in accordance w ith Booklet. Other definitions may be found in the the negotiated price that the on-site Blue particular sect ion or su bsection where the y are Cros s and/or Blue Shield Plan (fHost Blu ef) us ed. pas s es on to us, except when the Hos t Blue is una ble to pass on its nego tiated price due Ac cident means an unintentiona l, unexpected to the terms of its Provider contracts. See ® event, other than the acute ons et of a bodily the BlueCard ( Out-o f-State) Program infirmity or dise as e, which resu lts in traumatic s ection for more details. injur y. This term does not include injuries 3. In the case o f Out-of-Network Providers caus ed b y surger y or treat ment for diseas e or located in Florida wh o participate in the illnes s. Trad itional Program, this amount will be es tablished in accordance with the Ac cidental Dental Injury means an injury to applicable agreement between that Provider s ound natural teeth (not pr evious ly and BCBSF. compromised by decay) caus ed by a sudden, unintentional, and unexpected event or force. 4. In the case o f Out-of-Network Providers Th is term does not include injuries to the mouth, located o utside of Florida w ho participate in ® s tructures w ithin the oral ca vit y, or injuries to the BlueCard (Out-of-State) Traditional natural teeth caused b y biting or chew ing, Program, this amount will generally b e s urgery, or treatment for a diseas e or illness . es tablished in accordance w ith the negotiated price that the Hos t Blue pas ses A dver se Be nefit Determination means any on to us , except when the Host Blue is den ial, reduction or termination of coverage, unable to pas s on its negot iated price due to benefits, or pa yment (in whole or in part) under the terms of its Provider contracts. See the the Benefit Book let with res pect to a Pre-Service ® BlueCard (Out-of-State) Program section Claim or a Post-Service Claim. Any reduction or for more details. termination of coverage, benefits , or payment in 5. In the case of Out-of-Netwo rk Providers that connec tion with a Concurre nt Care Decision, as have not entered into any a greement with des cribed in this s ect ion, shal l also constitute an BCBSF, or with another Blue Cross and/or Adverse Benefit Determination. Blue Shield org anization to provide acces s ® Allowed Amount means the maximum amount to Provider discounts und er the BlueCar d upon w hich pa yment will be based for Covered Program, the Allowe d Amount will be the Services. The Allowed Amount may be changed less er of the Provider™s actual ch arge or an at any time without notice to you or your amount es tablishe d b y BCBSF based on cons en t. s e veral factors including (but not necess arily limited to): BCBSF™s medical, payment, 1. In the case o f an In-Netw ork Provider and/or administrative guidelines; pre- located in Florida, this amount will b e negot iated payment amounts; diagnos tic es tablished in accordance w ith the related gro uping(s) (DRG); payment for such applicable agreement betw een that Provider s ervices under the Medicare program; and BCBSF. relative value scales ; the charge(s ) of the 2. In the case o f an In-Netw ork Provider Provider; the charge(s ) of s imilar Providers located o utside of Florida, this amount will w ithin a particular geographic area Definitions 23 -1 Benefit Booklet or Bookle t means the es tablished b y BCBSF; and/or the cost of certificate of coverage, wh ich is e vidence of providing the Covered Service. co verage u nder the Group Master Policy. If a particular Covered Service is not a vailable from any provider that is in NetworkBlue, as Birth Center means a facility or inst itution, other determined by us , the Allow ed Amount, than a Hosp ital or Ambulatory Surgical Center, w henever Florida Statute § 627.6471 applies , w hich is prop erl y licensed purs uant to Chapter means the usual and customary ch arge(s ) of 383 o f the Florida Statutes, or a similar s imilar Providers in a geograph ical area app licable law of another state, in which births es tablished b y us . are planned to occur aw ay from the mother™s us ual res idence following a normal, You ma y o btain an est imate of the Allowed uncomplicated, low -risk pregnanc y. Amount for particular s ervices b y ca lling the ® cus tomer s ervice telephone number included in BlueCard (Out-of-State) PPO Program this Booklet or on your Ide ntification Car d. The means a national Blu e Cros s and Blue Shield fact that we may provide you with such Ass ociation program available through Blue information does not mean that the particular Cros s and B lue Shield of Florida, Inc. Subject to ® Service is a Co vered Service. All ter ms and any applicable BlueCard (Out-of-State) conditions included in your Booklet a pply. You Program rules and protocols, you ma y have ® s hould refer to the fWhat is Covered?f section o f acces s to the BlueCard (Out-of-State) PPO your Booklet and the Sche dule of Benefits to Program d iscounts of other participating Blue determine what is co vered and how much w e Cros s and/or Blue Shield plans. w ill pay. ® BlueCard (Out-of-State) PPO Program Ambulance means a ground or w ater vehicle, Provider means a Provider designated as a airplane or helicopter prop erly licens ed pursuant ® BlueCard ( Out-o f-State) PPO Program Provider to Chapter 401 of the Florida Statutes, or a by the Hos t Blue. s imilar applicable law in another s tate. ® BlueCard (Out-of-State) Program means a Ambulatory Surgical C enter means a facility national Blue Cross a nd Blue Shield As soc iation properly licensed purs uant to Ch apter 395 of the program available through Blue Cross an d Blue Florid a Statutes, or a s imilar appl icable law of Shield of F lorida, Inc. Subject to any applicable another s tate, the primary purpose of which is to ® BlueCard ( Out-o f-State) Program rules and provide elective s urg ical care to a patient, protocols, you ma y ha ve access to the Provider admitted to, and discharge d from such facility discounts of other participating Blue Cross and/or w ithin the same working day. Blue Shield plans. Anniversary Date means the date, one ye ar ® BlueCard (Out-of-State) Traditional Program after the Effective Date, s tated o n the Group means a national Blu e Cros s and Blue Shield App lication and subs equ ent annua l Ass ociation program available through Blue ann iversar ies. Cros s and B lue Shield of Florida, Inc. Subject to ® any applicable BlueCard (Out-of-State) Art ificial Insemination ( AI) means a medical Program rules and protocols, you ma y have procedure in which sperm is placed into the ® acces s to the BlueCard (Out-of-State) female reproductive tract by a qualified health Traditional Program discou nts of other care provider for the p urpos e o f producing a participating Blue Cross and/or Blue Shield pregnanc y. plans . Definitions 23 -2 ® BlueCard (Out-of-State) Traditional Program and w ho is certified to practice midw ifery by the Provider means a Provider designated as a American College of Nurs e Midwives. ® BlueCard ( Out-o f-State) Traditional Program Certified Registered Nurse Anesthetist Provider b y the Host Blue. means a person w ho is a properly licensed Bone M arrow Transplant means human blood nurs e wh o is a certified advanced registered precurs or cells adm inistered to a patie nt to nurs e practitioner within the nurse anes thetist res tore normal hematological a nd immunological ca tegory pursuant to Chapter 464 of the Florida functions following ablative therapy. Human Statutes, or a s imilar applicable law of another blood precursor cells ma y be obtained from the s tate. patient in an autologous trans p lant, or an Claim Involving Urgent Care means any allogeneic transp lant from a medically reques t or application for coverage or be ne fits acceptab le related or unrelated donor, a nd may for medical care or treatment that has not yet be d erived from bone marrow , the circulating been pro vided to you with respect to wh ich the blood, or a combination of bone marrow an d app lication of time periods for making non- circulating blood. If chemotherap y is an integral urgent care benefit d eterminations: (1) could part of the treatment in volving bone marrow s erious ly jeopardize your life or he alth or your transplantation, the term "Bone Marrow ability to regain maximum function; or (2) in the Trans plant" includes the trans plantation as we ll opinion of a Phys ician w ith k nowledge of your as the administration of chemotherapy a nd the Cond ition, would subject you to s evere pain that chemotherapy drugs . The term "Bone Marrow cannot be ade quately managed without the Trans plant" also includes a ny services or propos ed Services be ing r endered. s upplies relating to a ny treatment or therapy involving the use o f high dos e or intensive dose Coinsuranc e means the sharing of health care chemotherapy and human blood precursor cells expens es for Covered Services between BCBSF and includes an y and all H ospital, Physician or and you. After your Deductible req uirement is other health care Provider Health C are Services met, BCBSF will pa y a percentage of the w hich are ren dered in order to treat the effects Allow ed Amount for Covered Services, as listed of, or complications arising from, the use of high in the Schedule of Benefits. The percentage dos e or intensive dose chemo therapy or human you are res pons ible for is your Coinsurance. blood precursor cells (e.g. , Hosp ital room and Concurrent C are Decision means a d ec ision board and ancillary s ervices). by us to deny, reduce, or terminate coverage, Calendar Yea r begins Jan uary 1s t an d e nds benefits, or pa yment ( in whole or in part) with December 31st. res pect to a course of treatment to be pro vided over a period of time, or a s pecific number of Car diac Therapy means Health Care Services treatments, if w e had previously appro ved or provided under the s upervision of a Ph ysician, authorized in wr iting coverage, benefits, or or an appropriate Provider trained for Cardiac payment for that course of treatment or number Therapy, for the purp ose of aiding in the of treatments. res toration of normal he art function in connec tion with a m yocardial infarction, As defined herein, a Concurrent Care Decision coronary occlusio n or coronary bypas s surger y. s hall not include any decision to den y, reduce, or terminate coverage, benefits , or payment Certified Nurse Midwife means a person w ho under the persona l cas e manage ment Program is licensed purs uant to Chapter 46 4 o f the as des cribed in the fBlueprint For Health Florid a Statutes, or a s imilar applicable law of Programsf s ection of this Bene fit Booklet. another state, as an advanced nurse prac titioner Definitions 23 -3 Condition Cov ered Services means a d iseas e, illness , ailment, means those Health Care injur y, or pregnancy. Services wh ich meet the criteria listed in the fWhat Is Covered?f s ect ion. Convenient Care Center means a properly Custodial or Custodial C are means care that licensed ambulatory ce n ter that: 1) treats a s erves to assist an in dividual in the activities o f limited n umber of common, low-intensity daily living, such as as sistance in walking, illnes ses when read y access to the patient's getting in and out o f bed, bathing, dress ing, primar y physician is not p os sible; 2) s hares feeding, and us ing the toilet, preparation of clinical information about the treatment with the s pecial diets, and supervision of medication that patient's primary p hysic ian; 3) is usu ally housed us ually c an be s elf-administered. Cus todia l in a retail busines s; and 4) is s taffed b y at leas t Care ess ent ially is person al care that does not one master™s level nurse ( ARNP) who operates require the cont inuing attention of trained under a set of clinical pr otocols that strictly medical or paramedical personne l. In circums cribe the conditions the ARNP can treat. determining w hether a person is receiving Although no p hys ician is pr es ent at the Cus todial Care, consid eration is given to the Convenien t Care Center, medical oversight is frequency, intensity and le vel of care a nd bas ed on a written collaborative agreement medical super vision required and furnished . A betwe en a s upervis ing phys ician and the ARNP. determination that care received is Cus todial is Copayment means the dollar amount not based on the patient's d iagnosis, t ype of es tablished s olely b y us, which is required to b e Cond ition, degree of functional limitation, or paid to a health care Provider by you at the time rehabilitation po tential. certain Covered Services are rendered b y that Provider. Deductible means the amount of charges , u p to the Allo w ed Amount, for Covered Services, Cov ered Dependent means an Eligible w hich you must actually pay to an appropriate Depende nt who meets and continues to meet all licensed health care Provider, who is recognized app licable elig ibility r equirements and w ho is , for pa yment under this Book let be fore our enrolled, and actually covered, u nder the Group payment for Co vered Services begins . Master Policy other than as a Co vered Detoxification Employee (See the Eligibility Requ irements for means a proces s w hereb y an Depende nt(s) s ubsection of the Eligibility for alcohol or drug intoxicated, or alcohol or drug Coverage section). depende nt, individual is as s isted through the period of time necess ary to eliminate, b y Cov ered Employee means an E ligible metabolic or other means, the intoxicating Employee or other individual who meets and alcohol or drug, alcohol or drug d ependent continues to meet all ap plicable eligibility factors or alcohol in combinatio n w ith drugs as requirements and wh o is enrolled, and actual ly determined by a license d Physician or co vered, under the Group Master Policy other Ps ycholo gist, while keeping the physiological than as a C overed D epend en t (See Eligib ility r isk to the individual at a minimum. Requ irements for Co vered Emplo yees s ubs ection of the fEligibility for Coveragef Diabetes Educat or means a pers on wh o is s ection). properly certified pursuan t to Florida law , or a s imilar applicable law of an other state, to Cov ered Person means a Covered Employee s uper vise diabetes o utpatient s elf-management or a Covered Dependent. training and educational s ervices. Definitions 23 -4 Dialysis Center means an outpatient facility 3. a child for whom the Covered Employee has certified by the Centers for Medicare and been court-appointed as lega l guardia n or Medicaid Services (CMMS) and the Florida legal cus todian; Age ncy for Health Care Administration (or a w ho meets and continues to meet all of the s imilar regulatory agency of another s tate) to eligibility re quirements des cribed in the provide hemodialys is and p eriton eal dialysis f Eligibility for Co veragef s ec tion in this Benefit s ervices and s upport. Booklet. Dietitian means a perso n w ho is prop erly Eligible De pendent also includes a ne wbor n licensed purs uant to Florida law or a similar ch ild of a Covered Dependent child. Coverage app licable law of another state to provide for such new born child will automatically nutrition counse ling for d iabetes outpatient self- terminate 18 months after the b irth of the management services. new born child. Refer to the fEligibility for Cov eragef section for limits on eligibility. Durable Medical Equipment means equ ipment furnished b y a s upplier or a Home Health Eligible Employee means an individual who Age ncy that: 1) can withstand repeated us e; meets and continues to meet all of the e ligibility 2) is primarily and customarily used to s er ve a requirements described in the Eligibility medical purpose; 3) not for comfort or Requ irements for Co vered Emplo yees conven ience; 4) ge nerally is no t use ful to an s ubs ection of the fEligibility for Coveragef individua l in the abse nce of a Condition ; and s ection in this Benefit Booklet and is eligible to 5) is appropriate for use in the home. enroll as a Co vered Employee. An y individual Durable Medical Equipment Provider means a w ho is an E ligible Employee is n ot a Covered pers on or entity that is properly licens ed, if Employee until such individual has actually app licable, under F lorida law (or a s imilar enrolled wi th, and been accepted for coverage app licable law of another state) to provide h o me as a Covered Employee by us. medical equipment, oxygen therap y s ervices, or Endorsement means an amendment to the dialysis s upplies in the patient™s ho me under a Group Master Policy or this Booklet issued b y Physician™s prescription. . BCBSF Effective Date means, wi th res pect to the Enrollment Date means the date of enro llment Group, 1 2:01 a.m. on the date specified on the of the individual under the Group Mas ter Policy Group Application. With res pect to individuals or, if earlier, the first day of the Waiting Period o f co vered under this Group Mas ter Policy, 12:01 s uch enrollment. a.m. on the date the group specifies that the co verage w ill commence as further described in Enrollment Forms means thos e BCBSF forms, the fEnrollment and Effective Date of Coveragef electronic ( wher e a vailable) or paper, which are s ection of this Benefit Booklet. us ed to maintain accurate enrollment files under the Group Mas ter Policy. Eligible Dependent means a Covered Employee™s : Experimental or Investigational means any evaluation, treatment, ther apy, or device which 1. legal spous e und er a leg ally valid, existing involves the app lication, a dministration or use, of marriage; or procedures , techniqu es, equipment, s upp lies, 2. natural, newb orn, adopted , Foster, or step products , remedies , vaccines , biological ch ild(ren); or products , drugs , pharmaceuticals, or chemical compounds if, as determined solely by us : Definitions 23 -5 1. s uch evalu ation, treatment, therapy, or Canada, or Great Britain, us ing g enerally device can not be la wfully marketed without accepted scientific, medical, or public health approval of the United States Food and methodologies or s tatistical practices; or Drug Administration or the Florida 7. there is no cons ensus among practicing Department of Hea lth and approval for Physicians that the treatment, therapy, or marketing has not, in fact, been given at the device is s afe and effective for the Con dition time s uch is furnished to you; or in q ues tion; or 2. s uch evalu ation, treatment, therapy, or 8. s uch evalu ation, treatment, therapy, or device is pro vided purs uant to a written device is not the standard treatment, protocol which d es cribes a s among its therapy, or device utilized by practicing objectives the following: determinations of Physicians in treating other patients w ith the s a fety, efficacy, or efficacy in comparison to s ame or similar Condition. the standard evaluation, treatment, therap y, "Reliable evidence" sh all mean (as determined or device; or by us ): 3. s uch evalu ation, treatment, therapy, or 1. records maintained b y Phys icians or device is de livered or s ho uld be delivered Hos pitals ren dering care or treatment to you s ubject to the approval an d s upervision of or other patients with the s ame or similar an institutional review boar d or other e n tity Cond ition; as required and defined by federal regulations; or 2. reports , articles , or written as s es sments in authoritative medical and scientific literature 4. reliable e vidence show s that such pub lishe d in the United States, Canada, or evaluation, treatment, ther apy, or device is Great Britain; the subject of an ongoing Phase I or II clinical in vestigation, or the experimental or 3. pub lishe d reports , articles , or other literature res earch arm of a Phase I II clinical of the Un ited States Departmen t of Hea lth investigation, or under study to determine: and H u man Services or the Un ited States maximum tolerated dos age(s ), toxicity, Pub lic Health Service, including any of the s a fety, efficacy, or efficacy as compared National Institutes of Health, or the Un ited w ith the s tandard means for treatment or States Office of Technology Ass es s men t; diagnosis of the Condition in question; or 4. the w ritten protocol or protocols re lied upon 5. reliable e vidence show s that the consens us by the treating physician or inst itution or the of opinion among experts is that further protocols of another Physician or institution s tudies, rese arch, or clinical investigations s tud ying s ubs tantially the s ame evaluation, are necess ar y to determine: maximum treatment, therapy, or device; tolerated dosa ge(s) , toxicit y, s afety, e fficacy, 5. the w ritten informed consent used b y the or efficacy as compared w ith the standard treating Physician or institution or by an other means for treatment or diagnosis of the Physician or institution s tud ying s ubs tantially Cond ition in question ; or the same evaluation, treatment, therapy, or 6. reliable e vidence show s that such device; or evaluation, treatment, ther apy, or device has 6. the records (including any reports) of any not been pro ven s afe and effective for institutiona l review b oard of an y institution treatment of the Condition in question, as w hich has re view ed the evaluation, evidenced in the mos t recently published Medical Literature in the Un ited States, Definitions 23 -6 treatment, therapy, or device for the and through w hich you and your Covered Cond ition in question . Depende nts become entitled to coverage and benefits for the Covered Services des cribed Note: Health Care Serv ices , which are herein. determined by BCB SF to be Experimental or Investigational, are excluded (see the fWhat Group Application means the BCBSF form, Is Not Covered?f section). In determining electronic ( wher e a vailable) or paper, including whether a Health Care Service is the underwr iting q ues tionn aire form, if any, that Experimental or Investigational, BCBSF may the Group mus t submit to BCBSF w hen also rely on the predominant opinion among reques ting the iss uance o f the Group Master experts, as expressed in the published Policy. authoritative literature, that usage of a Group M aster Policy means the written particular evaluation, treatment, therapy, or document, wh ich is the agreement betw een the device should be substantially confined to Group and us w hereby co verage and benefits resear ch settings or that further studies are w ill be provided to you an d any Covered necessary in order to define safety, toxicity, Depende nts . The Group Mas ter Policy includes effective ness, or effectiveness compared this Benefit Booklet (including the Schedu le of with standard alternatives. Ben efits), the Group Application, Enrollment Foster Child means a p erson wh o is place d in Forms, and an y Endors ements to this Benefit your residence and care un der the Foster Care Booklet or the Group Mas ter Policy. Program b y the Florida Department of Health & Group P lan means the e mploye e welfare Rehabilitative Services in c ompliance w ith benefit plan established b y the Group. Florid a Statutes or b y a similar regulator y agenc y of another state in compliance with that Health Ca re Se rvice or Services includes s tate™s a pplicable laws . treatments, therapies, devices, procedures, techniques, equ ipment, supplies, products, Gamete Intrafallopian Transfer (GIFT) means remedies, vaccines, biological products, drugs, the direct transfer of a mixture of s perm and pharmaceuticals, chemical compounds, and eggs in to the fallopian tube by a qua lified health other ser vices rendered or s upplied, by or at the care provider. Fertilization takes place inside direction of, Providers . the tube. Home Health Agency means a properly Gestational Surrogate means a w oman, licensed agenc y or organization, w hich provides regardless of age, w ho contracts, orally or in hea lth ser vices in the h o me pursuant to C hapter writing , to beco me pregnant by means o f Florida Statutes 400 o f the , or a similar Ass isted R eproductive Technology without the app licable law of another state. us e of an e gg from her body. Home Health Care or Home Health Care Gestational Surrogacy Contract or Services means Physician-directed Ar rangement means an oral or w ritten profess ional, technical an d related medical and agreement, regardless of the state or jurisd iction pers onal care Services provided on an w here executed, betw een the Gestational intermittent or part-time bas is directly by (or Surrogate and the intended parent or parents. indirectly throug h) a Home Health Agency in Group means the employer, labor union, trust, your home or residence. For purposes of this as soc iation, partners hip, or corporation, definition, a Hospital, Skilled Nurs ing Facility, department, other organization or en tity throug h w hich coverage and benefits are iss ued b y us, Definitions 23 -7 Services c a n be performed for coverage nurs ing home or other facility will n ot be cons idered an individuals home or residence. purposes. Hospice Identification (ID) Card means a pub lic agenc y or private means the card(s) we organization, which is duly licens ed by the state iss ue to Covered Employees . The card is our of Florida under applicable law, or a similar property, a nd is not transferable to another app licable law of another s tate, to provide pers on. Poss ess ion o f such card in no wa y hos pice ser vices. In addition, s uch licens ed verifies that a particular individual is eligible for, entity mus t be pr incipally e ngaged in provid ing or covered under, the Group Master Policy. pain relief, s ymptom management, and Independent Clinical Laboratory means a s upportive s ervices to terminally ill pers ons and laboratory pro perly licensed purs uant to Chapter their families. Florida Statutes 483 o f the , or a similar Hospital means a facility properly licensed app licable law of another state, where purs uant to Chapter 395 of the Florida Statutes, examinations are p er formed on materials or or a s imilar applicable law of another s tate, that: s pecimens taken from the human body to offers ser vices w hich are more in tensive than provide information or materials use d in the those required for room, board, perso nal diagnosis, pre vention, or treatment of a s ervices and gener al nursing care; offers Cond ition. facilities and be ds for use b eyond 24 h ours ; and Independent Diagnostic Testing Facility regularly makes available at leas t clinical means a facility, inde pendent of a Hos p ital or laboratory s er vices, d iagnos tic x-ray ser vices Physician's office, w h ich is a fixed location, a and treatment facilities for s urgery or obs tetrical mobile entity, or an ind ividual n on-Phys ician care or other definitive medical treatment of practition er where diagnostic tests are s imilar extent. performed b y a licensed Phys ician or by The term Hospital does no t include: an licensed, certified non-Phys ician personne l Ambulatory Surgical Center; a Skilled Nursing under appropria te Physician super vision. An Facility; a s tand-alone B irthing Center; a Independent Diagnos tic Tes ting Facility must be Ps ychiatric Facility; a Subs tance Abuse Facility; appropriately registered w ith the Agency for a convalescent, rest or nurs ing h ome; or a Health C are Administration and mus t comply facility which primarily provides Cus todial, w ith all a pplicable Florida law or laws of the educational, or Rehabilitative Therapies. s tate in wh ich it operates. Further, s uch an entity mus t meet our criteria for eligibility as an Note: If services specifically for the Independent Diagnos tic Tes ting Facility. treatment of a physical disability are provided i n a licensed Hospital which is In-Network means, w hen u sed in reference to accred ited by the Joint Commission on the Covered Services, the level of benefits p ayable Ac creditation of Health C are Organizations, to an In-Network Provider as des ignated on the t he American Osteopathic Association, or Schedule of Benefits under the head ing fIn- t he Commission on the Accreditation of Network f. O therwise, In-Network means, when Rehabilitative Fac ilities, pa yment for these us ed in reference to a Provider, that, at the time services will not be denied solely because Covered Services are r endered, the Provider is such Hospital lacks major surgical fa cilities an In-Network Provider under the terms o f this and is primarily of a rehabilitative nature. Ben efit Booklet. Recognition of these facilities does not In-Network Provider means an y he alth care expand the scope of Covered Services. It Provider who , at the time Covered Services only expands the setting where Covered Definitions 23 -8 Med ical Literature means s cie ntific studies w ere rendered to you, was under contract w ith pub lishe d in a United States peer-re viewed BCBSF to participa te in BCBSF™s Netw orkBlue national profess ional journal. and included in the p anel of providers des ignated b y BCBSF as fIn-Networkf for your Med ically Necessary or Medical Necessity s pecific plan . (Pleas e refer to yo ur Schedu le of means, in accordance w ith our gu idelines a nd Ben efits). For payment purpos es un der this criteria then in effect, for coverage and payment Ben efit Booklet only, the term In-Netw ork purpos es o nl y, that a Health Care Service is Provider a lso refers, w hen applicable, to an y required for the identification, treatment, or hea lth care Provider located outs ide the state of management of a Conditio n, and is, in the Florid a who or which, at the time Health Care opinion of BCBSF: Services were rendered to you, participated as a ® 1. cons istent w ith the symptom, diagnosis, and BlueCard ( Out-of-State) PPO Program Provider treatment of the Condition being treated ; under the Blue Cross Blue Shield Ass ociation™s ® BlueCard ( Out-of-State) Program. 2. w idely accepted b y the practitioners ' pe er group as efficacious and reas onably s afe In Vitro Fertilization (IVF) means a process in bas ed upon s cientific e vidence; w hich an egg and s perm are combined in a 3. universally accepted in clinical use s uch that laboratory d ish to facilitate fertilization. If omiss ion of the s er vice in these fertilized, the resulting embryo is trans ferred to circums tances raises ques tions regarding the w oman's uterus. the accuracy of diagnos is or the appropriateness of the treatment; Licensed Practica l Nurse means a pers on properly licensed to practice practical n urs ing 4. not Experimental or Invest igational; purs uant to Chapter 464 of the Florida Statues, 5. not for cos metic purposes ; or a s imilar applicable law of another s tate. 6. not primarily for the convenience of, the Covered Person™s family, the Physician or Massage Therapist means a person proper ly other provider; licensed to practice Mass a ge, pursuant to Chapter 480 of the Florida Statutes , or a similar 7. the most appropr iate level of s ervice or care app licable law of another state. w hich can s a fely be provided to the Covered Person; and Massage or M assage Therapy means the 8. in the case of inpatient care, the Health Care manipulation of superficial tiss ues of the human Service(s) cannot be pro vided safely in an bod y us ing the hand, foot, arm, or elbow. For altern ative s etting. purpos es of this Benefit Booklet, the term Mass age or Mass ag e Therapy does not include Note: It is important to remember that any the app lication or use of the follow ing or s imilar review o f Med ical Necess ity b y us is s olely for techniques or items for the purpos e of aiding in the purposes of de termining coverage or the manipulation of s uperficial t issues : hot or benefits under this Booklet and no t for the co ld p acks ; h ydro therapy; colonic irrigatio n; purpos e of reco mmending or providing medical thermal therap y; chemical or herbal care. In this res pect, we may revie w specific preparations; paraffin baths; infrared light; medical facts or information pertaining to you . ultraviolet light; Hubb ard tank; or contrast baths. Any s uch re view, howe ver, is s trictly for the purpos e of determining, among other things, Mastectomy means the removal of all or part of w hether a Service provided or proposed meets the breast for Medically Necess ar y reasons as the definition of Medical Necess ity in this determined by a Phys ician. Booklet as determined by us . In applying the Definitions 23 -9 , Occupational Therapist definition of Medical Neces s ity in this Booklet means a person w e may apply our coverage and pa yment properly licensed to practice Occupational guidelines then in effect. You are free to obtain Therapy pursuant to Chapter 468 of the Florida Statutes a Service even if we den y coverage becaus e the , or a s imilar applicable law of another Service is not Medically Ne ces s ary; how ever, s tate. you will be s o lely r es pons ible for paying for the Occupational Therapy means a treatment that Service. follows a n illness or injury a nd is designed to Med icare means the federal health insura nce help a patient le arn to use a new ly res tored or provided under Title XVIII o f the Soc ial Security previously impaired function. Act and a ll amendments thereto. Orthotic Device means any rigid or s emi-rigid Mental Health Professional means a person device n eeded to s upport a w eak or deformed properly licensed to provide Mental Hea lth bod y p art or restrict or eliminate body Services, p urs uant to C hapter 491 of the Florida movement. Statutes , or a s imilar applicable law of another Out-of-Network means, w hen us ed in reference s tate. This profess ional may be a clinical s oc ial to Covered Services, the level of ben e fits w orker, mental he alth couns elor or marriage a nd payable to an Out-of-Netwo rk Provider as family therapist. A Mental Health Profess ional des ignated on the Schedu le of Benefits und er does n ot include members of any religious the heading fOut-of-Networkf. Other wise, Out- denomination who provide counseling s ervices. of-Network means, when us ed in reference to a Mental and Nervous Disor der means an y a nd Provider, that, at the time Co vered Services are all disorders listed in the diagnostic categories of rendered, the Provider is n o t an In-Network the most recently pu blishe d edition of the Provider under the terms of this Benefit Booklet. American Psychiatric As soc iation's Diagnos tic Out-of-Network Provider means a Provider and Statistical Manu al of Mental Disorders , w ho, at the time Health Car e Services w ere regardless of the underlying cause, or effect, of rendered: the disorder. 1. did not have a contract with us to participate Midwife means a person p roperly licensed to in N etworkBlue but w as p articipa ting in o ur practice midw ifery purs uant to Chapter 467 of Traditional Program; or the Florida Statutes, or a s imilar applicable law 2. did not have a contract with a Host Blue to of another s tate. participate in its local PPO Program for ® purpos es of the BlueCard (Out-of-State) Morbid Obesity is a Con dition where an PPO Program but was participating, for individua l is 1 00 pounds over their id eal bod y ® purpos es of the BlueCard (Out-of-State) w eight a nd/or Bod y Mass Inde x (BMI) of equ a l ® Program, as a BlueCard (Out-of-State) to or greater than 40. Traditional Program Provider; or NetworkBlue means, or refers to, the preferred 3. did have a contract to participate in provider network es tablishe d and so des igna ted Network Blue but was n o t included in the by BCBSF, which is available to BlueOptions panel of Providers des ignated b y us to be members under this Benefit Booklet. Please In-Network for your Plan; or note that BCBSF™s Preferred Patient C are (PPC) 4. did not have a contract with us to p articipate preferred provid er network is not available to in N etworkBlue or our Tradition al Program; BlueOptions members under this Benefit or Booklet. Definitions 23 -10 Statutes 5. did not have a contract with a Host Blue to or a s imilar app licable law of another ® participate for purposes o f the BlueCard s tate. Such therapy may include traction, active ® ( Out-of-State) Program as a BlueCard or pass ive exercises , or heat therapy. ( Out-of-State) Traditional Program Provider. Physical Therapist means a person properly Outpatient Rehabilitation Facility means an licensed to practice Ph ysica l Therapy pursuant Florid a Statutes entity wh ich renders, through providers properl y to Chapter 486 of the , or a licensed purs uant to Florida law or the similar s imilar applicable law of an other state. law or laws of another s tate: outpatient Physic al Physician means an y individual who is prop erly Therapy; o utpatient Speec h Therap y; outpatient licensed b y the state of Florida, or a similar Occupational Therapy; outpatient cardiac app licable law of another state, as a Doctor of rehabilitation therapy; and outpatient Mas sage Medicine (M.D.), Doctor of Osteopathy (D.O.), for the primary purpose of res toring or improving Doc tor of Pod iatry (D.P.M.), Doctor of a bod ily function impaired or eliminated by a Chiropractic (D.C.), D octor of Dental Surger y or Cond ition. Further, s uch a n entity mus t meet Dental Med icine (D.D.S. or D.M.D.), or Doctor of our criteria for eligibility as an Outpatient Optometry (O.D.). Rehabilitation Facility. The term Outpatient Rehabilitation Facility, as us ed herein, s hall not Physician Assistant means a person proper ly include any Hosp ital including a general acute licensed purs uant to Chapter 458 of the Florida care Hospi tal, or any s eparately organ ized unit Statutes, or a s imilar applicable law of another of a Hos pital, which provides comprehensive s tate. medical rehabilitation inpatient ser vices, or Post-Service Claim means an y paper or rehabilitation ou tpatien t services, including, but electronic reques t or application for coverage, not limited to, a C lass III fs pecialty reh abilitation benefits, or pa yment for a Service actually hos pitalf described in Chapter 59A, Florida provided to you (not just proposed or Administrative Code or the similar law or law s of recommended) that is received b y us on a another state. properly completed claim form or electronic Pain Management includ es, but is not limited format acceptable to us in accordance with the to, Services for pain ass ess ment, medication, provisions of the fClaims Process ingf sec tion. phys ical thera py, biofeedback, and/or Pre-Service Claim means any requ est or couns e ling . Pain reh abilitation programs are app lication for coverage or benefits for a Service programs featuring multidisciplinary Services that has not yet been provided to you and with directed tow ard helping thos e w ith chronic pain res pect to w hich the terms of this Benefit to reduce or limit their pain. Booklet conditio n p ayment for the Service (in Partial Hospitalization means treatment in w hole or in part) on approval by us of coverage w hich an individua l receives at leas t s even or benefits for the Service before you receive it. hours of institutional car e during a p ortion of a A Pre-Service Claim may b e a Claim Involving 24-hour period and returns home or leaves the Urgent Care. As defined herein, a Pre-Service treatment facility during an y period in which Claim s hall not include a r eques t for a d ecision treatment is not s cheduled. A H os pital sh all not or opinion by us regard ing coverage, b enefits , or be considered a "ho me" for purposes of this payment for a Service that has not actually been definition. rendered to you if the terms of this Benefit Booklet do not require (or condition payment Physical Therapy means the treatment of upon) appro val by us of coverage or benefits for diseas e or injury by physical or mechanical the Service before it is rece ived. means as defined in Chapter 486 of the Florida Definitions 23 -11 Prem ium Florida Statutes means the amount required to be paid purs uant to Chapter 464 of the , by the Group to BCBSF in order for there to be or a s imilar applicable law of another s tate. co verage u nder the Group Master Policy. Registered Nurse First Assistant (RNFA) Prior/Concurrent Coverage Affidavit means means a person properly licens ed to perform the form that an Eligible Employee can submit to s urgical first ass isting services purs uant to Florida Statutes us as proof of the amount of time the Eligible Chapter 464 of the or a s imilar Employee was covered under Creditable app licable law of another state. Coverage. Rehabilitation Services means Services for the Prosthetist/Orthotist means a person or entity purpos e of res toring function lost due to illness , that is prop erly licensed, if applicable, under injur y or surgica l proce dures including b ut not Florid a law , or a s imilar app licable law of limited to Cardiac Rehabilitation, Pulmonary another s tate, to provide s e r vices cons isting of Rehabilitation, Occupa tional Therapy, Speech the desig n and fabrication of medical devices Therapy, Physical Therapy and Mass age s uch as braces , s plints, and art ificial limbs Therapy. pres cribed by a Phys ician. Rehabilitative Therapies means therapies the Prosthetic Device means a de vice, wh ich primar y purpose of which is to restore or replaces all or p art of a bod y part or an internal improve bod ily or mental functions impaired or bod y org an or replaces all or part of the eliminated by a Co ndition, and include, but are functions of a permanently inopera tive or not limited to, Phys ical The rapy, Speech malfunctioning body part or organ. Therapy, Pain Management, pulmonary therap y or Cardiac Therapy. Provider means an y facility, pers on or entity recognized for pa yment b y BCBSF under this Self-Administered Injectable Prescription Booklet. Drug means an FDA-approved injectable Prescription Drug that you may administer to Psychiatric Facility means a facility properly yourse lf, as recommended b y a Ph ysician, by licensed under Florida la w, or a similar means of injection, excluding Insu lin. app licable law of another state, to provide for the care and treatment of Mental and Nervous Skilled Nursing Facility means an inst itution or Disorders . For purpos es of this Booklet, a part thereof which mee ts BCBSF™s criteria for Ps ychiatric Facility is n ot a Hos pital or a eligibility as a Skilled Nursing Facility and wh ich: Subs tance Abuse Facility, as defined herein. 1) is licensed as a Sk illed Nursing Facility b y the s tate o f Florida or a similar applicable la w of Psychologist means a pers on prop erly licens ed another s tate; and 2) is accredited as a Skilled to practice ps ychology purs uan t to C hapter 49 0 Nurs ing Facility by the Joint Commission on of the Florida Statutes, or a s imilar applicable Accreditation of Hea lthcare Organizations or law of another s tate. recognized as a Sk illed Nurs ing Facility by the Secretary of Health and Human Services of the Rate means the amount BCBSF charges the United States under Medicare, unless such Group for each type of coverage under the accreditation or recognition requirement has Group Master Policy (e.g., Emplo yee Only been w aived by BC BSF. Coverage). Sound Natural Teeth means teeth that are Registered Nurse means a pers on properly w hole or properly restored (restoration w ith licensed to practice profes sional nursing amalgams, resin or composite only); are without Definitions 23 -12 impairment, periodontal, or other conditions ; and app licable in Florida or in certain counties are not in need of Services provided for any outside of Flor ida when s uch programs exist. reas on other than an Acciden tal Dental Injury. Urgent Ca re Center means a facility properly Teeth previously r es tored with a crown, inlay, licensed that: 1) is a vailable to provide services onla y, or porcelain res toration, or treated w ith to patients at least 60 hours per w eek w ith at endodon tics , are not Sound Na tural Teeth. least twent y-five (25) of tho s e available hours Speech Therapy means the treatment of after 5:00 p.m. on weekda ys or on Saturd ay or s peech a nd language disorders by a Speech Sun day; 2) posts instructions for individuals Therapist includ ing language as s essment and s eeking Health Care Services , in a consp icuous language restorat ive therapy services. pub lic place, as to w here to obtain such Services when the Urg ent Care Center is Speech Therapist means a person prop erl y clos ed; 3) employs or contrac ts w ith at least one licensed to practice Sp eech Therapy pursuant to or more Board Certified or Board Eligible Chapter 468 of the Florida Statutes , or a similar Physicians an d Re gistered Nurs es (RNs ) wh o app licable law of another s tate. are ph ys ically pres ent during al l hours of operation. Phys icians, RNs , and other medical Standard Reference Compendium means: profess ional staff mus t have appropriate training 1) the U nited States Pharmacopoe ia Drug and s k ills for the care of ad ults and ch ildren; and Information; 2) the American Medical 4) maintains and opera tes bas ic diagnos tic Ass ociation Drug Evaluation; or 3) the American radiology and la boratory equipment in Hos pital Formulary Service Hos pital Drug compliance with a pplicable state and/or feder al Information. laws and regu lations . Substance Abuse Facility means a facility For purposes of this Benefit Booklet, an Ur gent properly licensed und er Florida law, or a similar Care Ce nter is not a Hospital, Ps ychiatric app licable law of another state, to provide Facility, Substance Abus e Facility, Skilled neces s ar y care and treatment for Su bstance Nurs ing Facility or Outpatient Rehabilitation Depende ncy. For the purpos es of this Book let a Facility. Subs tance Abuse Facility is not a Hos pital or a Ps ychiatric Facility, as defined herein. Waiting Per iod means the length of time s pecified o n the Group App lication, which must Substance Dependency means a Condition be met by an individual before that individual w here a pers on™s a lcohol or drug use injures his becomes eligible for coverage under this Benefit or her health; interferes w ith his or her s ocial or Booklet. economic functioning; or causes the individual to lose self-control. Zygote I ntrafallopian Transfer (ZIFT) means a proces s in wh ich an egg is fertilized in the Traditional Program means, or refers to, laboratory an d the res ulting zygote is trans ferred BCBSF ‚s provider contracting programs called to the fallopian tube at the pronuclear stage Payment for Physician Services (PPS) and (before cell division tak es place). The e ggs are Payment for Hospital Services ( PHS). retrieved and fertilized on one day and the Traditional Program Providers means, or zygote is trans ferred the follow ing da y. refers to, thos e hea lth care Providers w ho are not Netw orkBlue Providers, but who, or w hich, have e ntered into a contract, then in effect, to participate in BCBSF™s Trad itional Program as Definitions 23 -13 BlueOptions Endorsements/Notices ~ (I BlueCross BlueShield ~ ' ® ~~e:,~~~~~:fthe Blue Cross and Blue Shield Association ® Script Pharmacy Progr am Endors em ent Bl ue Th is Endors ement and the BlueScript Pharmacy expens es by: 1) using Participatin g Program Schedule of Benefits are to be Pharmacies; 2) choosing Preferred Prescription attached to, and made a p art of, your Blue Cross Drugs rather than No n-Preferred Prescrip tion and Blue Shield of Florida, Inc. (fBCBSFf) Drugs ; and 3) choos ing Pr eferred Generic Ben efit Booklet. The Benefit Booklet is hereb y Prescription Drugs or Covered OTC Drugs. amended b y a dding the follo wing Blue Script To verify if a Pharmacy is a Participating Pharmacy Program provisions . Pharmacy, you may access the Pharmacy If you have any ques tions concerning this Program Provider D irector y on our w ebs ite at End orsement, please ca ll Blue Cross and Blue w w w .bcbsfl.com, call the cus tomer service Shield of F lorida toll free at 800-FL A-BLUE. phone number on your Ide ntification Card, or refer to the Pharmacy Program Provider References to fyouf or fyourf throughout refer to Directory then in effect. you as the Co vered Employee and to your Covered D ependents, u nless expres sly stated Covered Pr escri ption Dru gs and otherw ise or unless , in the context in wh ich the Su pplies and Covered OTC Drugs term is us ed, it is clearly intended otherwise. Any reference that refers s o lely to you as the A Prescription Drug, Covered OTC Drug or Self- Covered Employee or solely to your Co vered Administered Injectable Prescription Drug is Depende nt(s) w ill be noted as s uch. only co vered under this Endors ement if it is: References to f wef, fusf, and fourf throug hout 1. pres cribed by a Phys ician or other health refer to BCBSF. care profess ional (except a Pharmacist) ac ting within the scope of his or her licens e ; I ntroduction 2. dispens ed b y a Pharmacist; Under this Endorsement, w e provide coverage 3. Medically Necess ary; to you for certain Prescription Drugs and 4. in the case of a Self-Administered Injectable Sup plies and select Over-the-Counter (fOTCf) Prescription Drug, listed in the Medication Drugs purchas ed at a Pharmacy. In order to Guide with a s p ecial symbol des ignating it obtain benefits und er this Endors ement, you as a Covered Self-Administered Injectable mus t pay, at the t ime of purchase, the Pharmacy Prescription Drug; Deductible, if an y, and the app licable Copa yment or percentage of the Participating 5. in the case of a Spec ialty Drug, Prescription Pharmacy Allowance or Non- Participating Drugs that are iden tifie d as Spec ialty Drugs Pharmacy Allowance, as a pplicable, ind icated in the Medication Guide; on the BlueScript Pharmacy Program Schedule 6. a Prescription Drug contained in a n of Benefits. anaph ylactic kit (e.g., Epi-Pen, Epi-Pen Jr., In the Medicatio n Gu ide, you w ill find lists of Ana-Kit); Preferred Generic Prescription Drugs, Preferred 7. authorized for coverage by us , if prior Brand Name Prescription D rugs , Non-Preferred co verage a u thorization is required by us as Prescription Drugs and Covered OTC Drugs. You ma y b e a ble to reduce your out-of-pocket BlueScript for BlueOptions II LG (3 -tier) 1 24220 0709 BCA indicated with a un ique iden tifier in the Cov ered Ov er-the-Counter (OTC) Drugs Medication Guide , then in effect; Select OTC Drugs, listed in the Medication 8. not specifically or generally limited or Guide, may be covered when you obtain a excluded herein or b y the Benefit Booklet; Prescription for the OTC Drug from your and Physician. In order for there to be coverage under this Endors ement for OTC Drugs, you 9. approved by the FDA, a nd as s igned a mus t pay, at the t ime of purchase, the Pharmacy National Drug Code. Deductible, if an y, and the Preferred Generic A Supply is co vered under this Endors e ment Prescription Drug Copayment or percentage of only if it is: the Participating Pharmacy Allo w ance or the Non-Participating Phar macy Allowa nce, as 1. a Covered Pres cription Supply; app licable, indicated on the B lueScript 2. pres cribed by a Phys ician or other health Pharmacy Program Schedule of Bene fits. Only care profess ional (except a Pharmacist) those OTC Drugs listed in the Medic ation Guide ac ting within the scope of his or her licens e; are covered. 3. Medically Necess ary; and A list o f Covered OTC Drugs is published in the mos t current Med ication Guid e an d can be 4. not specifically or generally limited or viewed on our w ebs ite at w w w .bcbs fl.com , or excluded herein or b y the Benefit Booklet. you may ca ll the cus tomer s ervice p hone Coverage and Benef it Guidelines for number on your Identification Card an d one w ill be mailed to you up on reques t. Covered Pr escri ption Dru gs and Su pplies and Covered OTC Drugs Diabetic Coverage In providing b ene fits under this Endors ement, All Co vered Prescription Drugs and Supplies w e may apply the benefit guidelines s e t forth us ed in the tre atment of diabetes are co vered belo w, as w ell as any other applicable payment s ubject to the limitations and exclusions listed in rules s pec ific to particular Co vered Services this Endorsement. listed in the Benefit Book let. Insulin is only co vered if pres cribed by a Contraceptive Coverage Physician or other hea lth care profess ional (except a Pharmacist) acting w ithin the scope of All Pres cription diaphragms, oral co ntracep tives his or her license. S yringes and need les for and contraceptive patches w ill be covered injecting insulin are covered on ly whe n unles s indicated as n ot covered on the pres cribed in co njunction with insu lin. BlueScript Pharmacy Program Schedule of Ben efits and s ubject to the limitations and The following Supp lies and equ ipment us ed in exclusions listed in this Endors ement. the treatment of diabetes are covered u nder this End orsement: blood g lucose testing strips and Exclusion tablets, lancets, b lood glucose meters, and Contrace ptive injectable Pres cription Drugs acetone test tablets a nd s yringes and ne ed les. and implants (e.g., Norplant, IUD) inserted Exclusion for any p urpos e , are excluded from co verage u nder this Endors ement. All Supp lies us ed in the treatment of diabetes except thos e that are Covered BlueScript for BlueOptions II LG (3 -tier) 2 24220 0709 BCA Prescription Supplies are excluded from as indicated in your BlueOptions Schedule co verage u nder this Endors ement. of Benefits. Mineral Supplements, Fluoride or Vitamins 3. Prescription refills be yond the time limit s pecified b y state and/or federal law are not only The following Dru gs are covered w hen co vered. s tate or federal law requ ires a Prescription and w hen prescribed by a Ph ys ician or other health 4. Certain Co vered Prescription Drugs and care profess ional (except a Pharmacist) acting Sup plies and Covered OTC Drugs require w ithin the scope of his or her license: prior co verage a u thorization in order to be co vered. 1. prenatal vitamins; 5. Specialty Drugs (s elf-administered and 2. oral s ingle-product fluoride (non-vitamin Provider-administered), as des ignated in the s upplementation); Medication Guide , are not covered when 3. s us tained release niacin; purchas ed through the Mail Order Pharmacy. 4. folic acid; 6. Retin-A or it™s generic or therapeutic 5. oral h ematinic a gents; equ ivalent is excluded after age 26. 6. dihydrotachysterol; or Exclusions 7. ca lcitriol. Expenses for the following are excluded: Exclusion 1. Prescription Drugs and OTC Drugs that are Prescription vitamin or m ineral s up plements co vered and p ayab le under a s pec ific not listed above, non-pres cription mineral s ubs ection of the fWhat Is Covered?f s upplements and n on-pres cription vitamins s ection of your Benefit Boo k let, wh ich this are e xclu ded from coverage. End orsement amends (e.g., Prescription Drugs wh ich are disp ensed and billed b y a Lim itation s and E xclusions Hos pital). Limitations 2. Except as covered in the C overed Prescription Drugs and Supplies and Coverage and benefits for Covered Prescription Covered OTC Drugs s ubs ection, any Drugs an d Supp lies and Co vered OTC Drugs Prescription Drug obtained from a Pharmacy are s ubject to the following limitations in ad dition w hich is disp ens ed for administrat ion by to all other provisions and e xclus ions of your intravenous infus ion or injection, regardles s Ben efit Booklet: of the s etting in w hich such Prescription 1. We w ill not cover more than the Maximum Drug is administered or type of Provider s upply, as s et forth in the BlueScript administering such Prescription Drug. Pharmacy Program Schedule of Bene fits, 3. Any Drug or Supply which can be purchase d per Prescription for Covered Pres cription over-the-counter witho ut a Prescription, Drugs an d Supp lies or Covered OTC Drugs. even though a wr itten Prescription is 2. We w ill not cover amounts in excess of the provided (e.g., Drugs which do not requ ire a lifetime maximum and/or Benefit Period Prescription) except for insulin and Covered maximum for your BlueOptions he alth p lan, OTC Drugs listed in the Medication Guide. BlueScript for BlueOptions II LG (3 -tier) 3 24220 0709 BCA 4. All Supp lies other than Covered Prescription des cribed in exclus ion number 11 does Sup plies . not app ly to s exual d ysfunction Drugs excluded under this p aragraph; 5. Any Drugs or Supplies dispens ed prior to the Effective Date or after the termination k. purchas ed from any source (includ ing a date of coverage for this Endors ement. pharmacy) outside of the United States; 6. Therapeutic devices, a ppliances, medical or l. pres cribed by any health care other Supplies a nd equipment (e.g., air and profess ional not licensed in any s tate or w ater purifiers, s upp ort garments, creams, territory (e.g., Puerto Rico, U.S. Virgin gels, oils, and wa xes); regardless of the Islands or Guam) o f the United States of intended us e ( except for Covered America; Prescription Supplies). m. OTC Drugs not listed in the Medication 7. Prescription Drugs and Supplies and OTC Guide; and Drugs that are: n. Self-Administered Injectable a. in excess of the limitations s pecified in Prescription Drugs us ed to increase this Endorsement or on the BlueScript height or bone grow th (e.g., growth Pharmacy Program Schedule of hormone) except for Cond itions of Ben efits; grow th hormone deficiency documented w ith two abnor mally low s timulation b. furnished to you w ithout cos t; tests of les s than 10 ng/ml and one c. Experimental or Invest igational; abnormally low grow th hormone depende nt peptide or for C onditions of d. indicated or us e d for the tr eatment o f grow th hormone deficiency ass ociated infertility, except when indicated as w ith loss of p ituitary function du e to co vered on the BlueScript Pharmacy trauma, s urgery, tumors, radiation or Program Schedule of Benefits ; diseas e, or for s tate mandated use as in e. us ed for cosmetic purposes including patients w ith AIDS. but not limited to Minoxidil, Rogaine, Continuation of gro w th hor mone therapy Reno va; w ill not b e covered except for Conditions f. pres cribed by a Pharmacist; as soc iated with significant gro wth hormone deficiency when there is g. us ed for smoking cess ation (e.g., evidence of continu ed respons iveness Zyban), except when ind icated as to treatment. Treat ment is considered co vered on the BlueScript Pharmacy res pons ive in ch ildren less than 21 Program Schedule of Benefits ; years of age , when the grow th hormone h. listed in the Homeopathic dependa nt peptide (IGF-1) is in the Pharmacopoeia; normal range for age and Tanner i. not Medically Necess ar y; development stage; the growth velocity is at leas t 2 cm per year, and studies j. indicated or us ed for s exual d ysfunction demonstrate open epiphyses . (e.g., Cia lis, Levitra, Viagra, Caverject), Treatment is cons idered respons ive in except w hen indicated as covered on both adolescents with closed epiphyses the BlueScript Pharmacy Program and for adults, who continue to evidence Schedule of Benefits. The exception BlueScript for BlueOptions II LG (3 -tier) 4 24220 0709 BCA grow th hormone deficiency and the IGF- 13. Drugs that do not have a valid Nationa l Drug 1 remains in the n ormal range for age Code. and gender. 14. Drugs that are compounded except those 8. Mineral s u pplements , fluoride or vitamins that have a t least o ne active ingredient that except for those items listed in the Co verage is an FDA-approved Prescription Drug with a and Benefit Guidelines for Covered valid National Drug Code. Prescription Drugs and Supplies and 15. Any Drug pres cribed in exces s of the Covered OTC Drugs s ubs ection. manufacturer's rec ommended s pecifications 9. Any appetite s uppress ant, Pres cription Drug for dosages , frequency of u s e , or dura tion of and/or OTC Drug indicated, or used, for administration as set forth in the purpos es of w eight reduction or control, manufacturer's ins ert for such Drug. This except w hen indicated as covered on the exclusion does not apply if: BlueScript Pharmacy Program Schedule of a. the dosages , frequency of use, or Ben efits. duration of administration of a Drug has 10. Immunization agents , biological s era, b lood been s how n to be sa fe a nd effective as and b lood plasma . evidenced in published peer-review ed medical or ph armacy literature; 11. Drugs pres cribe d for uses other than the FDA-approved label indications. This b. the dosages , frequency of us e, or exclusion does not apply to an y Drug that duration of administration of a Drug is has be en pr oven s afe, effective an d part of an estab lish ed nationally accepted for the treatment of the s pecific recognized therapeutic clinical guideline medical Condition for which the Drug has s uch as those pub lished in the U nited been pres cribed, as evidenced b y the States by: 1) American Med ical res ults of goo d qua lity controlled cl inical Ass ociation; 2) National Heart Lung a nd s tudies pub lished in at leas t two or more Blood Institute; 3) American Cancer peer reviewed full length articles in Socie ty; 4) American H eart Ass ociation; res pected national profess ional medical 5) Nation al Ins titutes of He a lth; 6) journals. This exclus ion also does not apply American Gastroenterological to any Drug pres cribed for the treatment of Ass ociation; 7) Agency for Health Care cancer that has been ap proved by the FDA Policy an d Res e arch; or for at least one indication, provided the Drug c. w e, in our sole discretion, waive this is recogn ized for treatment of cancer in a exclusion with respect to a particular Standard Reference Compendium or Drug or therapeutic class es of Drugs. recommended for s uch treatment in Medical 16. Any Drug pres cribed in exces s of the Litera ture. Drugs pres cribed for the dos ages , frequency of us e, or duration of treatment of cancer that have not been administration sho w n to be safe and approved for any indication are a lso effective for such Drug as e videnced in excluded. pub lishe d peer-re viewed medical or 12. Drugs that have not been a pproved by the pharmacy literature or nationally recognized FDA as required by federal law for therapeutic clinical guidelines s uch as those distribu tion or delivery in to interstate pub lishe d in the United States by: commerce. BlueScript for BlueOptions II LG (3 -tier) 5 24220 0709 BCA a. American Medical Ass ociation; d. the Drug has a preferred formular y altern ative; b. National Heart L ung and Blood Institute; e. the Drug has a w idely available/ c. American Cancer Society; distribu ted AB rated gener ic equivalen t d. American Heart As soc iation ; formulation; e. National Institutes of Health; f. the Drug has sh own limited effectiveness in relation to alternative f. American Gastroenterological Drugs on the formulary; or Ass ociation; or g. the n umber of members affected by the g. Age ncy for Health Care Policy and change. Res earch; Refer to the Medication Guide to determine if a unles s w e, in our sole discretion, d ecide to particular Prescription Drug is excluded under w aive this exclusio n with respect to a this Endorsement. particular Dru g or therapeut ic class es o f Drugs . Pa yment Rules 17. Any amount you are req uired to pay under Under this Endorsement, the amount you must this Endorsement as indicated on the pay for Co vered Prescription Drugs and BlueScript Pharmacy Program Schedule of Sup plies or Covered OTC Drugs may vary Ben efits. depend ing on: 18. Any benefit penalt y red uctions or any 1. the participation s tatus of the Pharmacy charges in excess of the Participating w here p urchas ed ( i.e., Participating Pharmacy Allowance or Non- Participating Pharmacy versus Non-Participating Pharmacy Allowance. Pharmacy); 19. Self-prescribed Drugs or Supp lies and 2. the terms of our agreement w ith the Drugs or Supplies pres cribed b y any pers on Pharmacy s elected; related to yo u by blood or marriage. 3. w hether you have satisfied the Pharmacy 20. Any OTC Drug that is not listed in the Deductible, if an y, and the amount of Medication Guide as a Covered OTC Drug. Copa yment or percentage of the 21. Food or medical food pr oducts , wh ether Participating Pharmacy Allow ance or Non- pres cribed or not. Participating Pharmacy Allow ance set forth in the BlueScript Pharmacy Program 22. Prescription Dru gs des ignated in the Schedule of Benefits; Medication Guide as not covered bas e d o n (but not limited to) the follow ing criteria: 4. w hether the Prescription Dr ug is a Generic Prescription Drug or a Brand Name a. the Drug is n o longer marketed; Prescription Drug or C overed OTC Drug; b. the Drug has been s how n to ha ve 5. w hether the Prescription Dr ug is on the exces sive adverse effects and/or s afer Preferred Medication List; altern atives; 6. w hether the Prescription Dr ug is purchas ed c. the Drug is a vailable Over-the-Counter from the Mail Order Pharmacy; a nd ( OTC); BlueScript for BlueOptions II LG (3 -tier) 6 24220 0709 BCA 7. w hether the OTC Drug is des ignated in the To verify if a Pharmacy is a Participating Medication Guide as a Covered OTC Drug. Pharmacy, you may access the Pharmacy Program Provider D irector y on our w ebs ite at A Brand N ame Prescription Drug inclu ded on w w w .bcbsfl.com, call the cus tomer service the Preferred Medication L ist then in effect will phone number includ ed in your Benefit Booklet be reclass ified as a Non-Preferred Pres cription or on your Identification Card, or refer to the Drug on the date the FDA approves a Pharmacy Program Provider Directory then in bioequivalent Generic Prescription Drug. No n- effect. Preferred Prescription Drugs are subject to a higher Cost Share amount, as s e t forth in the Prior to purchas e, you must present your BlueScript Pharmacy Program Schedule of BCBSF Identification C ard to the Participating Ben efits. Pharmacy. The Participating Pharmacy mus t be able to verify that we, in fact, cover you. We reser ve the right to add, remove or reclass ify any Pres cription Drug in the Medicatio n Guide at When charges for Covered Prescription Drugs any time. and Supplies or C o vered OTC Drugs by a Participating Pharmacy are less than the Ph armacy Altern atives required Copa yment, the amount you w ill pay depends on the agreement then in effect For purposes of this Endors ement, there are two betwe en the Pharmacy an d us and will be one of types of Pharmacies: Participating Ph armacies the follow ing: and N on-Participating Pharmacies. 1. The usual and customary charge of such Participating Pharmacies Pharmacy as if it w ere not a Participating Participating Pharmacies are Pharmacies Pharmacy; participating in our BlueScript Pharmacy 2. The charge under the Pharmacy™s Program, or a National Network Pharmacy agreement with us; or belonging to our Pharmacy Benefit Manag er, at the time you purchase Co vered Prescription 3. The Copayment if less than the us ual and Drugs an d Supp lies and/or Covered OTC Drugs . cus tomary charge of such Pharmacy. Participating Pharmacies have agreed not to Specialty Pharmacy charge, or collect from you, for each Co vered Certain medicatio ns, such as injectable, oral, Prescription Drug, Covered Prescription Supply inhaled a nd infused therapies used to treat and/or Covered OTC Drug, more than the complex medical Co nditions are t ypically more amount s et forth in the BlueScript Pharmacy difficult to maintain, administer and monitor Program Schedule of Benefits . w hen compared to traditional Drugs . Specialty With BlueScript, there are four types of Drugs may require frequent dosage Participating Pharmacies: adjus tments, s pecial s torage and ha ndling and 1. Pharmacies in Florida that have signed a may not be readily a vailab le at local ph armacies BlueScript Participating Pharmacy Provider or routinely stocked by Physicians' offices, Agreement with us; mos tly d ue to the h igh cos t and complex handling they require . 2. National Netw ork Pharmacies ; Us ing a Specialty Pharmacy to pro vide these 3. Specialty Pharmacies; and Specialty Drugs s hould low er the amount you 4. the Mail Order Pharmacy. BlueScript for BlueOptions II LG (3 -tier) 7 24220 0709 BCA have to pay for these medications, w h ile he lping You ma y b e respo ns ible for paying the full cos t to preser ve your benefits. of the Co vered Prescription Drugs and Supplies and C o vered OTC Drugs at the t ime of purchase The Specialty Pharmacies des ignated , solely b y and must s ubmit a claim to us for us , are the only fIn-Networkf s uppliers for reimbursement. Our reimbursement for Specialty Drugs. With B lueScript, you may Covered Prescription Drugs and Supplies a nd choos e to obtain Specialty Drugs from any Covered OTC Drugs will be bas ed on the N on- Pharmacy; how ever any Pharmacy not Participating Pharmacy Allow ance les s the des ignated b y us as a Specialty Pharmacy is Pharmacy D eductible, if an y, a nd the cons idered Out-of-Network for payment Copa yment or percentage of the Non- purpos es , even if such Pharmacy is a Participating Pharmacy Allow ance set forth in Participating Pharmacy for other Covered the fNon-Participating Pharmacyf C os t Share Prescription Drugs under this BlueScript co lumn in the BlueScript Pharmacy Program Pharmacy Program. Schedule of Benefits. For additional d etails on h ow to obta in Covered In order to be reimbursed for Covered Prescription Specia lty Drugs from a Specialty Prescription Drugs and Supplies an d Co vered Pharmacy, refer to the Med ication Guide. OTC Drugs purchas ed at a Non-Participating Mail Order Pha rmacy Pharmacy, you must obtain an itemized paid receipt and submit it w ith a properly comp leted For details on h ow to obta in Covered claim form (with any re quired documentation) to: Prescription Drugs an d Sup plies and OTC Drugs from the Mail Order Pharmacy, refer to the Blue Cross and B lue Shield of Florida, Inc. Medication Guide or the Mail Order Pharmacy Attention: Prescription Dru g Program Brochure. P. O. Box 1798 Ja cks onville, Florida 32231 Note: Spec ialty Drugs are not available through the Mail Order Pharmacy. Ph armacy Utilization Review Non-Participating Pharmacies Pr ograms A Non-Participating Pharmacy is a Pharmacy Our pharmacy utilization review pro grams are that has not agreed to p articipate in our intended to enco urage the res pons ible us e of BlueScript Participating Pharmacy Program and Prescription Drugs and Supplies an d OTC is not a Na tiona l Network Pharmacy, Specialt y Drugs . Pharmacy or the Mail Order Pharmacy. We may, at our s ole discretion, require that Our paymen t to you for Co vered Pres cription Prescriptions for s elect Pres cription Drugs and Drugs an d Supp lies and Co vered OTC Drugs is Sup plies or OTC Drugs be reviewed under our bas ed upon our Non-Participating Pharmacy pharmacy utilization review programs , then in Allow ance. Non- Participating Pharmacies have effect, in order for there to be coverage for them. not agreed to accept our Participating Pharmacy Under these programs there may b e limitations Allow ance or our Pharmacy Benefit Manager™s or conditions on co verage for select Prescription Participating Pharmacy Allow ance as pa yment Drugs an d Supp lies and OTC Drugs, depend ing in full les s any applicable Cost Share amounts on the quantity, frequenc y or type of Prescription due from you. Drug, Supply or OTC Drug Prescribed. BlueScript for BlueOptions II LG (3 -tier) 8 24220 0709 BCA Note: If coverage is not available, or is limited, prior co verage a u thorization are des ignated in this does not mean that yo u cannot obtain the the Medication Guide. Prescription Drug, Sup ply o r OTC Drug from the For additional d etails on h ow to obta in prior Pharmacy. It o nly means that we will not cover co verage a u thorization refer to the Me dication or pa y for the Prescription Drug, Suppl y or OTC Guide. Drug. You are alw ays free to purchas e the Information on our pharmacy utilization review Prescription Drug, Sup ply o r OTC Drug at yo ur programs is published in the Medication Guide at s o le expens e. w w w .bcbsfl.com, or you may c all the cus tomer Our pharmacy utilization review programs s ervice phone number on your Identification include the follow ing: Card. Your Pharmacist may also a d vise you if a Responsible Steps Prescription Drug requires prior co verage authorization. Under this program, we may exclude from co verage certain Prescription Drugs and OTC Ultimate Responsibility for Medical Drugs un less you have first tried designated Decisions Drug(s ) iden tifie d in the Medication Guide in the order indicated. In order for there to be The pharmacy utilization review programs ha ve co verage for s uch Prescription Drugs a nd OTC been es tablished s olely to determine whe ther Drugs pres cribe d b y your Phys ician, we must co verage or bene fits for Prescription Drugs, receive written documentation from you and Sup plies and OTC Drugs w ill be provided under your Ph ysician that the designated Drugs in the the app licable terms of the Benefit Book let. Medication Guide are not appropriate for you Ultimately, the final decision concerning whether becaus e of a documented allergy, a Prescription Drug, Supply or OTC Drug s hou ld ineffectiveness or s id e effects. be prescribed must be made by yo u and the pres cribing Phys ician. Decisions made by us in Prior to filling your Prescription, your Ph ysician authorizing coverage are made only to may, bu t is n o t requir ed to, contact us to reques t determine whether coverage or benefits are co verage for a Prescription Drug or OTC Drug available u nder the Be nefit Booklet and not for s ubject to the Respons ible Steps program b y the purpose o f providing or recommending care following the procedures for prior coverage or treatment. We reser ve the right to modify or authorization outlined in the Medication Gu ide. terminate these programs at an y time. Dose Optimization Program Any and all dec isions that require or pertain to Under this program, we may exclude from independent profess ional medical judgment or co verage an y Prescription Drug or OTC Drug training, or the n eed for a Prescription Drug, pres cribed in exces s o f the Maximum specified Sup ply or OTC Drug, mus t be made solely by in the Medication Guide. you an d your trea ting Ph ysician in accordance w ith the patient/Physician relatio nsh ip. It is Prior Coverage Authorization Pr ogram pos s ible that you or your treating Physician may You are required to obta in prior coverage conclude that a particular Prescription Drug, authorization from us in order for certain Sup ply or OTC Drug is nee ded , appropriate, or Prescription Drugs and Supplies an d OTC Drugs des irable, even though suc h Pres cription Drug, to be covered. Failure to obtain authorization Sup ply or OTC Drug may not be authori zed for will result in denial of covera ge. Pr escription co verage b y us. In s uch ca s es , it is your right Drugs an d Supp lies and OTC Drugs requiring and resp ons ibility to decide w hether the BlueScript for BlueOptions II LG (3 -tier) 9 24220 0709 BCA Prescription Drug, Sup ply o r OTC Drug shou ld 1. Prescription diaphragms ; be p urchas ed even if w e ha ve indicated that 2. s yringes an d ne edles pres cribed in co verage a nd pa yment will not be made for s uch conjunction with insu lin, or a covered Self- Prescription Drug, Sup ply o r OTC Drug. Administered Injectable Prescription Drug w hich is authorized for coverage by us; De finitions 3. s yringes an d ne edles pres cribed in Certain important terms applicable to this conjunction with a Pres cription Drug End orsement are set forth below. For additional authorized for coverage by us ; app licable definitions, pleas e refer to the 4. s yringes an d ne edles w hich are contained in definitions in the Benefit Book let that this anaph ylactic kits (e.g ., Epi-Pen, Epi-Pen, Jr., End orsement amends. Ana Kit); and Av erage W holes ale Price (fAWPf) means the 5. Prescription Supplies us e d in the treatment average who lesa le price of a Prescription Drug of d iabetes limited to on ly blood glucose at the time a cla im is process ed as es tablish ed testing strips and tab lets, lancets , blood by BCBSF bas ed upon its utilization of a glucose meters, and acetone test tablets. national drug database as determined b y BCBSF, provided that any s uch national drug Day Supply means a Maximum quantity per databas e must be accepte d in the industry as a Prescription as defined b y the Drug provider of average who lesale price, or similar manufacturer™s daily dosing reco mmendations pricing, d ata on a national s cale. for a 24-hour period. Bra nd Na me Pre scription Drug means a Dispensing Fee means the fee a Pharmacy is Prescription Drug which is marketed or s old b y a paid for filling a Prescription in addition to manufacturer using a trademark or proprietary payment for the Dr ug. name, an original or pioneer Drug, or a Drug that Drug means any medicinal subs tance, remedy, is licensed to another company by the Brand vaccine, biological product, drug, Name Drug manufacturer for distribution or s ale, pharmaceutical or chemical compound that has w hether or not the other company markets the at least o ne active ingredient that is FDA- Drug under a generic or other non-proprietary approved and has a valid National Drug Cod e. name. FDA means the United States Food and Drug Cov ered OTC Drug means an Over-the- Administration. Counter Drug that is des ig nated in the Medication Guide as a Covered OTC Drug. Generic Pres cription Drug means a Prescription Drug containing the same active Cov ered Prescription D rug means a Drug, ingredients as a Brand Na me Prescription Drug w hich, under federal or s tate law, requires a that either: 1) has be en approved by the FDA for Prescription and which is covered by this s a le or distribution as the bioequivalent of a End orsement. Brand Name Prescription D rug through an Cov ered Prescription D rug(s) and abbreviated new drug application under 21 Supply(ies) means Covered Prescription Drugs U.S.C. 355 ( j); or 2) is a Pres cription Drug that is and C o vered Prescription Supp lies. not a Brand N ame Prescription Drug, is legally marketed in the Un ited States and, in the Cov ered Prescription Supply(ies) means only judgment of BCBSF, is marketed and sold as a the follow ing Su pplies: BlueScript for BlueOptions II LG (3 -tier) 10 24220 0709 BCA generic competitor to its Brand N a me digits), product code (middle four dig its), a nd the Prescription Drug equivalent. All Generic package code (last two digits) . Prescription Drugs are identified by an National Network Pharmacy means a "established name" un der 2 1 U.S.C. 3 52 (e), by Pharmacy located outside o f Florida tha t is p ar t a generic na me ass igned by the United States of the national network o f Pharmacies Ado pted Names Council, or by an official or non- es tablished b y o ur contracting Pharmacy Benefit proprietary name, and may not n eces s arily h ave Mana ger. the same inactive ingredie nts or appearance as Non-Participating Pharmacy means a the Brand Name Prescription Drug. Pharmacy that has n ot agreed to p articipate in Mail Order Copayment means, w hen our B lueScript Pharmacy Program and is not a app licable, the amount pa yab le to the Mail Order National Netw ork Pharmacy, Specialty Pharmacy for each Covered Prescription Drug Pharmacy or the Mail Order Pharmacy. and C o vered Prescription Supp ly as set forth in Non-Participating Pharmac y A llowance the BlueScript Pharmacy Program Schedule o f means the amount upon w h ich p ayme nt in such Ben efits. s ituations w ill b e bas ed for Covered Prescription Mail Order Pha rmacy means the Pharmacy Drugs an d Supp lies and Co vered OTC Drugs: that has signed a Mail Services Prescription 1. In the case of Generic Prescription Drugs Drug Agreement with us. and Supplies and OTC Drugs , the Non- Maximum means the amount des ignated in our Participating Pharmacy Allow ance shall be Medication Guide as the Maximum, including but approximately 3 3 p ercent of AWP plus a not limited to, frequency, dosage and durat ion o f $1.00 Disp ensing Fee or, if the amount therapy. bille d for the applicable Dru g is les s, the Med ication Guide means the guide then in amount billed. effect issued b y us that may des ignate the 2. In the case of Brand Name Prescription following categories of Pres cription Drugs: Drugs an d Supp lies, the Non-Participating Preferred Generic Prescription Drugs; Preferred Pharmacy Allowance s hall be a pproximately Brand Name Prescription D rugs ; and Non- 82 p ercent of AWP p lus a $1.00 Dispens ing Preferred Prescription Drugs . The Medication Fee or, if the amount b illed for the app licable Guide do es not list all Non-Preferred Drug is less , the amount b illed. Prescription Drugs due to space limitations , bu t It is further provided, howe ver, that if either: 1) a s ome Non-Preferred Pres cription Drugs a nd national drug database then us ed by BCBSF poten tial alternatives are provided for your makes a fmaterial modificationf to its AWP data Note: information. The Medication Guide is (as determined by BCBSF), or; 2) BCBSF elects s ubject to change at any time. Please refer to to utilize a new national drug database , BCBSF our webs ite at ww w .bcbs fl.com for the most may modify the 33 p ercen t of AWP figure and/or current guide or you may call the cus tomer the 82 percent of AWP figure s et out above so s ervice phone n umber on your Identification that the applicable modified figure sets ou t a Card for current information. replacement percent figure that is betw een: 1) National D rug Code (NDC) means the the percent fig ure calculated to approximate the universal code that identifies the Drug app licable Non-Participating Pharmacy dispens ed. There are three parts of the NDC, Allo w ance in effect immediately prior to the w hich are as follows : the labeler code (first five app licable AWP database chang e, and; 2) the BlueScript for BlueOptions II LG (3 -tier) 11 24220 0709 BCA 33 p ercent of AWP figure or the 82 percent of Pharmacy Benefit Manager means an AWP figure, whichever is app licable. organization that has es tablished, and manages , a pharmacy network and other pharmacy Non-Prefe rred Prescription Drug means a management programs for third party payers Generic Prescription Drug or Brand Name and e mployers, wh ich has entered into an Prescription Drug that is no t included o n the arrangement with us to make such network Preferred Medication List then in effect. and/or programs availab le to you. One-Month S upply means a Maximum quantity Pharmacy Ded uctible means the amoun t of per Prescription up to a 30-Day Supply as allowe d charg es for Covered Pres cription Drugs defined by the Drug manufacturer™s dos ing and Supplies and Covered OTC Drugs you must recommendations . Certain Drugs , e.g. Specialty ac tually pa y per Benefit Period, in addition to Drugs , may be dispe ns ed in less er q uantities any applicable C opa yment or percentage of the due to manufacturer package s ize or cours e of Participating Pharmacy Allow ance or Non- therapy. Participating Pharmacy Allow ance, to a Over-the-Counter (OTC) Drug means a Drug Pharmacy, who is recognized for payment under that is s afe and effective for use by the genera l this Endorsement, before our payment for pub lic, as determined by the FDA, and can be Covered Prescription Drugs and Supplies and obtained without a Prescription . Covered OTC Drugs begins . Participating Pharmacy means a Phar macy Pharmacy Out-of-Pocket Maximum means the that has signed a Participating Pharmacy maximum amount you will be required to pay per Provider Agreement with u s to participate in the Ben efit Period for Covered Prescription Drugs BlueScript Pharmacy Program. National and Supplies and Covered OTC Drugs. An y Network Pharmacies , Specialty Pharmacies and benefit pena lty reductions , non-covered charges the Mail Order Pharmacy are a lso Participating or any charges in excess of the Participatin g Pharmacies. Pharmacy Allowance or Non- Participating Pharmacy Allowance w ill not accumulate tow ard Participating Pharmacy A llowance means the the pharmacy o ut-of-pocket maximum. maximum amount allowed to be charged b y a Participating Pharmacy per Prescription for a Prefe rred Br and Nam e Pr escription Drug Covered Prescription Drug, Covered means a Brand Name Prescription Drug that is Prescription Supply or Covered OTC Drug under included on the Preferred Medication List then in this Endorsement. effect. The Preferred Medication List is contained within the Medica tion Guide. A Pharmacist means a person properly licens ed Preferred Brand N ame Prescription Drug on the to practice the profes sion of Pharmacy purs ua nt Preferred Medication List then in effect will be Florid a Statutes to Chapter 465 of the , or a reclass ified as a Non-Preferred Prescription s imilar law of another state that regulates the Drug on the date the FDA approves a profess ion of Pharmacy. bioequivalent Generic Prescription Drug. Pharmacy means an estab lish ment licensed as Prefe rred Generic Prescription Drug means a a Pharmacy p urs uan t to Ch apter 465 of the Generic Prescription Drug on the Preferred Florid a Statutes, or a s imilar law of another Medication List then in effect. The Preferred s tate, where a Pharmacist dispe ns es Medication List is contained within the Prescription Drugs. Medication Guide. BlueScript for BlueOptions II LG (3 -tier) 12 24220 0709 BCA Prefe rred M edication List means a list of us as a Specialty Drug due to requirements s uch Preferred Prescription Drugs then in effect, as s pecial ha nd ling, storage, training, w hich have b een des igna ted b y us as preferred distribu tion, and management of the therap y. and for wh ich we pro vide c overage and benefits, Specialty Drugs are identified with a s pecial s ubject to the exclusions and limitations of this s ymbol in the Medication Guide. End orsement. The Preferred Medication List is Specialty Pharm acy means a Pharmacy that contained within the Medica tion Guide. has s igned a Participating Pharmacy Provider Prefe rred Prescription Drug means a Agreement with us to p articipate in the Prescription Drug that app ears on the Preferred BlueScript Pharmacy Program, to provide Medication List then in effect. A Preferred s pecific Prescription Dr ug p roducts, as Prescription Drug may be a Brand Name determined by us . The fact that a Pharmacy is a Prescription Drug or a Generic Prescription Participating Pharmacy does not mean that it is Drug. The Preferred Medication L ist is a Specialty Pharmacy. contained within the Medica tion Guide. Supply(ies) means an y Prescription or n on- Prescription means an order for Drugs , or Prescription device, appliance or equipment Sup plies by a Ph ys ician or other h ealth care including, but not limited to, s yringes, needles, profess ional authorized by law to pres cribe such test s trips, lancets, monitors , bandages, co tton Drugs or Supplies. s wa bs, and similar items and any birth control device. Prescription Drug means any medicinal s ubs tance, remedy, vaccine, biological product, Three-Month Supply means a Maximum Drug, pharmaceutical or chemical compound quant ity per Prescription u p to a 90-Day Supply w hich can only be d ispens ed purs uant to a as define d b y the Dru g manufacturer™s dos ing Prescription and/or wh ich is required by s tate recommendations . law to bear the following s tatement or s imilar s tatement on the label: "Caution: Federa l law Th is Endors ement shall n ot e xtend, vary, alter, prohibits dispens ing wi thout a Pres cription". For replace, or waive any of the provisions, bene fits, purpos es of this Endors ement, ins ulin is exclusions , limitations, or conditions contained in cons idered a Prescription Drug becaus e, in the Benefit Book let, other than as s pecifically order to be covered, w e require that it b e s tated in this Endors ement. In the e ven t of an y pres cribed by a Phys ician or other health care inconsistenc ies betw een the provisions profess ional (except a Pharmacist) acting within contained in this Endors ement a nd the the scope of his or her license. provisions contained in the Ben efit Booklet, the provisions contained in this Endors ement s hall Self-Administered Injectable Prescription control to the exten t necess ary to effectuate the Drug means an FDA-approved injectable intent of Blue Cross and B lue Shield of Florida, Prescription Drug that you may administer to Inc. as expres sed herein. yourse lf, as recommended b y a Ph ysician, by means of injection, excluding ins ulin. Covered Blue Cross and B lue Shield of Florida, Inc. Self-Administered Injectable Prescription Drugs are de noted w ith a symbol in the Me dication Guide. Patrick J. Geraght y Specialty Drug means an FDA-approved Chairman of the Board an d Chief Executive Prescription Drug that has been des ignated by Officer BlueScript for BlueOptions II LG (3 -tier) 13 24220 0709 BCA Option s 2008 Om n ibu s En dorsem en t Bl ue The Payment Guidelines for Physical and Th is Endors ement is to be attached to and made Massage Therapy s ubs ection is deleted in its a part of your Blue Cross and Blue Shield of entirety and replaced with the following: Florida, Inc. (herein "BCBSF") BlueOptions Benefit Booklet including any Endorsements Payment Guidelines for Massage and attached thereto. The Benefit Booklet is Physical Therapy amended as des cribed below: a. Payment for covered Mass age Services is If you have any questions concerning this limited to no more than four (4) 15-minute Endorsement, pleas e call Blue Cross and Blue Mass age treatments per day, not to exceed Shield of Florida toll free at 800-FLA-BLUE. the Outpatient Cardiac, Occupational, Physical, Speech, and Mass age Therapies Th is Endors ement is effective upon receipt and Spinal Manipulations benefit maximum unles s s pec ifically s tated otherwise w ithin this listed on the Schedule of Benefits. Endorsement. b. Payment for a combination of covered Mass age and Physical Therapy Services The fWh a t Is Covered?f section is rendered on the s ame day is limited to no amen ded as follows: more than four (4) 15-minute treatments per The Orthotic Devices ca tegory is amended by day for combined Mass age and Physical Exclusion Therapy treatment, not to exceed the deleting item number two in the Outpatient Cardiac, Occupational, Physical, provision in its entirety and replacing it with the Speech, and Mass age Therapies and Spinal following: Manipulations benefit maximum listed on the 2. Expenses for orthotic appliances or devices Schedule of Benefits. which straighten or re-s hape the c. Payment for covered Physical Therapy conformation of the head or bones of the s kull or cranium through cranial banding or Services rendered on the same day as s p inal manipulation is limited to one (1) molding (e.g. d ynamic orthotic cranioplasty Physical Therapy trea tment per day not to or molding helmets), except when the exceed fifteen (15) minutes in length. orthotic appliance or device is us ed as an alternative to an internal fixation device as a The Payment Guidelines for Spinal res ult of surgery for craniosynostosis; and Man ipulations s ubs ec tion is de leted in its Outpatient Cardiac, Occupational, The entirety and replaced with the following: Physical, Speech, Massage Therapies and Payment Guidelines for Spinal Manipulation Spinal Manipulation Services category is a. Payment for covered spinal manipulation is amended as follows : limited to no more than 26 s pinal or manipulations per Calendar Year, the maximum benefit listed in the Schedule of Benefits, whichever occurs first. b. Payment for covered Physical Therapy Services rendered on the same day as s p inal manipulation is limited to one (1) BlueOptions II Large Group 23013-1108R BCA 1 Physical Therapy trea tment per day, not to any drug that has been pro ven safe, exceed fifteen (15) minutes in length. effective and accepted for the treatment of the specific medical Condition for which the The Schedule of Benefits s ets forth the drug has been prescribed, as evidenced by maximum dollar amount that w e w ill pay for any the results of good quality controlled clinical co mbination of the outpatient therapies and s tudies published in at least two or more s p inal manipulation Services listed above. For peer-re viewed full length articles in example, even if you may have only been res pected national profess ional medical administered two (2) of your sp inal journals. This exclusion also does not apply manipulations for the Calendar Year, any to any drug prescribed for the treatment of add itional s pinal man ipulations for that Calendar cancer that has been approved by the FDA Year w ill not be covered if you have already met for at least one indication, provided the drug the combined therapy dollar maximum with other is recognized for treatment of your particular Services. cancer in a Standard Reference Compendium or recommended for treatment The s econd to the last paragraph of the of your particular cancer in Medical Preventive Child Healt h Supervision Services Literature. Drugs pres cribed for the ca tegory is deleted in its entirety and replaced treatment of cancer that have not been with the following: approved for any indication are excluded; In order to be covered, Services s hall be 4. Any drug which is indicated or us ed for provided in accordance with prevailing medical s e xual d ysfunction (e.g., Cialis, Levitra, s tandards cons istent w ith the Recommendations Viagra, Caverject). The exception described for Preventive Pediatric Health Care of the in exclusion number one above does not American Academy o f Pediatrics, the U.S. app ly to se xual d ysfunction drugs excluded Preventive Services Tas k Force, or the Advisory under this paragraph. Committee on Immunization Practices es tablished under the Public Health Service Act. Experimental or Investigational Services The exclusion is deleted in its entirety and replaced with the following: The fWh a t Is Not Covered?f section is amen ded as follows: Experimental or Investigational Services , except as otherwise covered under the Bone Introduction The paragraph is deleted in its Marrow Transp lant provision of the Transplant entirety and replaced with the following: Services category. Your Booklet express ly excludes expens es for The exclusion titled General Exclusions is the following Health Care Services, s upplies, amended by adding the following to item number drugs or charges . The following exclusions are s e ven: in addition to any exclusions s pecified in the f What Is Covered?f s ection or any other s ection f) Services that are not patient-specific, as of the Booklet. determined solely by us. The Dr ugs exclusion is amended by deleting The follow ing exclusions are added: item numbers one and four in their entirety and Immunizations except those co vered under the replacing them with the following: Preventive Ch ild Health Supervision Services or 1. Prescribed for us es other than the Food and Preventive Adult Wellness Services categories Drug Administration (FDA) approved label of the fWhat Is Covered?f sec tion. indications. Th is exclusion does not apply to BlueOptions II Large Group 23013-1108R BCA 2 Oversight of a medical laboratory b y a first occurred to a Hospital, and the benefits Physician or other health care Provider. which have been as signed are for transportation f Oversightf as us ed in this exclusion s hall, to care provided purs uant to s ect ion 395.1041, include, but is not limited to, the o versight of: Florida Statutes . A w ritten attestation of the as signment of benefits may be required. 1. the laboratory to ass ure timeliness , reliability, and /or usefulness of test results; The fBlueprin t for Health Pr ogramsf 2. the calibration of laboratory machines or sec tion is amended as follows: testing of laboratory equipment; Inpatient Facility Program The subs ection is 3. the preparation, review or updating of any amended by deleting the Provider Focused protocol or procedure created or reviewed by Ut ilization Management Program provision in a Physician or other health care Provider in its en tirety and replacing it with the following: connec tion with the operation of the laboratory; and Certain Netw orkBlue Providers ha ve agreed to participate in our focused utilization 4. laboratory equipment or laboratory personnel management program. Th is pre-s ervice review for any reas on. program is intended to promote the efficient Prescription Drug Copayments , Coinsurance delivery of medically appropriate Hea lth Care and Deductibles, or any part thereof, you are Services by NetworkBlue Providers. Under this obligated to pay under any p lan or policy. program we may perform focused pros pective review s o f all or s pecific Health Care Services propos ed for you. In order to perform the The fPh ysicians, Hospitals and Other review , we may require the Provider to submit to Pr ovider Optionsf section is us s pecific medical information relating to Health amen ded as follows: Care Services propos ed for you. Thes e Assignment of Benefits to Providers The Netw orkBlue Providers ha ve agreed not to bill, or s ubs ection is amended b y deleting the last co llect, any payment w hatsoever from you or us, paragraph in its entirety and replacing it with the or any other person or entity, with respect to a following: s pecific Health Care Service if: We spec ifically reserve the right to honor an 1. they fail to submit the Health Care Service as signment of benefits or payment b y you to a for a focused prospective review w hen Provider w ho: 1) is In-Network under your plan of required under the terms o f their agreement co verage; 2) is a NetworkBlue Provider even if with us; or that Provider is not in the panel for your plan of 2. we perform a focused review under the co verage; 3) is a Trad itional Program Provider; focused utilization management program ® 4) is a BlueCard (Out-of-State) PPO Program and w e determine that a Health Care ® Provider; 5) is a B lueCard ( Out-of-State) Service is not Medically Neces s ary in Traditional Program Provider; 6) is a licens ed accordance with our Medical Neces sity Hos pital, Physician, or dentist and the benefits criteria or inconsistent with our benefit which have been as signed are for care provided guidelines then in effect unless the following purs uant to sec tion 395.1041, Florida Statutes ; exception applies. or 7) is an Ambulance Provider that provides transportation for Services from the location Exception for Certain NetworkBlue Physicians where an "emergency medical condition", Certain Netw orkBlue Physicians licensed as defined in section 395.002(8) Florida Statutes, Doc tors of Medicine (M.D.) or Doctors of BlueOptions II Large Group 23013-1108R BCA 3 Osteopathy (D.O.) only may bill you for Services following guidelines are applicable to reviews of determined to be not Medically Necess ary b y Adverse Benefit Determinations: BCBSF under this focused utilization The third guideline is de leted in its ent irety and before management program if, you receive the replaced w ith the follow ing: Service: Ł If the Adverse Benefit Deter mination is a. they give you a written es timate of your bas ed on the lack of Med ical Neces s ity of a financial ob ligation for the Service; particular Service or the Experimental or b. they s pecifically identify the proposed Investigational exclusion, you may reques t, Service that BCBSF has de termined not to free of charge, an explanation of the be Medically Necess ary; and s cientific or clinical judgment relied upon, if any, for the determination, that applies the c. you agree to assume financial respons ibility terms o f this Benefit Booklet to your medical for such Service. circums tances. The follow ing guidelines are added: The fDuplica tion of Coverage Under O ther Health P lans/P rogramsf Ł If you wish to give someone else permission to appeal an Adverse Benefit Determination sec tion is amended as follows: on your behalf, w e must receive a completed The follow ing exclusion is added: Appointment of Representative form signed Coordination of Benefits Exclusion by you indicating the name of the person who will represent you with respect to the Prescription Drug Copayments , Coinsurance appeal. An Appointment of Repres entative and Deductibles, or any part thereof, you are form is not required if your Ph ysician is obligated to pay under any p lan or policy. appealing an Adverse Benefit Determination relating to a Claim Involving Urgent Care. The fClaims P rocessingf section is Appointment of Representative forms are amen ded as follows: available at www.bcbs fl.com or by calling the number on the back of your BCBSF ID Card. The How to Appeal an Adverse Benefit Determination s ubs ection is amended as Ł If the Adverse Benefit Determination is follows: bas ed on the lack o f Medical Necess ity of a particular Service, or the Experimental or The first paragraph is deleted in its entirety and Investigational nature of a Service, you ha ve replaced w ith the follow ing: the right to an independent external re view Except as des cribed below, only you, or a through the External Review Organization repres en tative designated by you in w riting, have des ignated in the How to Reques t External the right to appeal an Adverse Benefit Review o f Our Appeal Decision subs ection Determination. An appeal of an Adverse Benefit of this s ect ion. Your r ight to an External Determination will be reviewed using the review Review applies only when the Service is proces s des cribed below. Your appeal mus t be ac tually rendered by Physicians licensed as s ubmitted to us in writing for an internal appeal Doc tors of Medicine (M.D.) or Doctors of within 365 days of the original Adverse Benefit Osteopathy (D.O.). Determination, e xcept in the case of Concurrent Care Decisions which may, depending upon the circums tances, require you to file within a shorter period o f time from notice o f the denial. The BlueOptions II Large Group 23013-1108R BCA 4 The How to Appeal an Adverse Benefit The definition of Allowed Amount is amended Determination s ubs ection is further amended as follows : by rep lacing the addres s information with the Subparagraph number five is deleted in its following: entirety and replaced with the following: Requests for an internal appeal should be 5. In the case of an Ou t-of-Network Provider sent to the address below: that has not entered into an agreement with Blue Cross and Blue Shield of Florida, Inc. BCBSF to provide access to a discount from Attention: Member Appeals the billed amount of that Provider for the P.O. Box 44197 s pecific Covered Services pro vided to you, Jacks onville, Florida 32231-4197 the Allowed Amount w ill be the less er o f that Provider™s actual billed amount for the Effective April 21, 2009, the following subs ection s pecific Covered Services or an amount is added at the end of the How to Appeal an es tablished b y BCBSF that may be bas ed on Adverse Benefit Determination s ubs ec tion. s e veral factors including (but not necessarily How to Request External Review of Our limited to): (i) payment for s uch Services Appeal Decision under the Medicare and/or Medicaid If you are not s atisfied w ith our internal review of programs; (ii) payment often accepted for your appeal o f an Adverse Benefit Determination s uch Services by that Out-of-Network bas ed on the lack of Med ical Neces s ity or Provider and/or by other Providers, either in Experimental or Investigational nature o f a Florida or in other comparable mark et(s), Service you received from Physicians licensed that BCBSF determines are comparable to as Doctors of Medicine (M.D.) or Doctors of the Out-of-Network Provider that provided Osteopathy (D.O.), you may appeal our decision the specific Covered Services (wh ich may through an External Review Organization. Our include payment accepted by s uch Out-of- den ial letter will provide information regarding Netw ork Provider and/or by other Providers this External Review Organization. as participating providers in other provider Only Adverse Benefit Determinations bas ed on networks of third-party payers w h ich may the lack of Medical Neces s ity or Experimental or include, for example, other insurance Investigational nature of a Service you actually co mpanies and/or health maintenance received will be reviewed by the External Re view organizations); (iii) payment amounts w hich Organization. are cons istent, as determined b y BCBSF, with BCBSF™s provider network s trategies The External Review Organization™s (e.g., does not res ult in payment that determination with respect to your appeal s hall encourages Providers participating in a be binding upon you, your Physician, and us. BCBSF network to become non- participating); and/or, ( iv) the cost of The fDefinitionsf section is amen ded providing the specific Covered Services. In as follows: the cas e of an Out-of-Network Provider that The term freliable evidencef s hall be replaced has not entered into an agreement w ith with the w ords fcredible scientific evidencef in ano ther Blue Cross and/or Blue Shield Experimental the definition of or organization to provide access to d iscounts Investigational. from the billed amount for the s pecific Covered Services under the BlueCard (Out- BlueOptions II Large Group 23013-1108R BCA 5 likely to produce equivalent therapeutic or of-State) Program, the Allowed Amount for diagnostic resu lts as to the diagnosis or the specific Covered Services provided to treatment of your illnes s. you may be bas ed upon the amount provided to BCBSF by the other Blue Cross Note: It is important to remember that any and /or Blue Shield organization where the review of Medical Neces sity b y us is s olely for Services were provided at the amount such the purpose of determining coverage or benefits organization would pay non-participating under this Booklet and not for the purpos e of Providers in its geographic area for such recommending or providing medical care. In this Services. res pect, w e may review s pecific medical facts or information pertaining to you. Any such review, The follow ing paragraph is added at the end of however, is s trictly for the purpose of the definition of Allowed Amount: determining, among other things, w he ther a Please s pecifically note that, in the case of an Service provided or proposed meets the Out-of-Netw ork Provider that has not entered definition of Med ical Neces s ity in this Booklet as into an agreement with BCBSF to provide determined by us . In applying the definition of acces s to a discount from the billed amount of Medical Necess ity in this Booklet, we may apply that Provider, the A llowed Amount for particular our coverage and payment guidelines then in Services is often subs tantially below the amount effect. You are free to obtain a Service even if billed by s uch Out-of-Network Provider for such we deny coverage because the Service is not Medically Neces s ary; however, you will be s olely Services. You will be res pons ible for any res pons ible for paying for the Service. difference between such A llowed Amount and the amount billed for s uch Services by any s uch Mental and Nervous Disorder means any Out-of-Netw ork Provider. disorder listed in the diagnostic categories of the International Class ification of Diseas es , Ninth The follow ing definitions are deleted in their Edition, Clinical Mod ification (ICD-9 CM), or their entirety and replaced with the following: equ ivalents in the most recently published Med ically Necessary or Med ical Necessity version of the American Psychiatric Ass ociation's means that, with respect to a Health Care Diagnostic and Statistical Manual of Mental Service, a Physician, exercising prudent clinical Disorders , regardles s o f the underlying cause , or judgme nt, provided the Health Care Service to effect, of the disorder. you for the purpose of preventing, evaluating, The follow ing definitions are added: diagnosing or treating an illness , injury, disease or its s ymptoms, and that the Health Care External Review Organization means an Service was: external organization that is chos en by BC BSF in its s ole discretion to conduct external reviews as 1. in accordance with Generally Accepted des cribed herein. Standards of Medical Practice; Generally Accepted Standards of M edical 2. clinically appropriate, in terms o f type, Practice means s tandards that are based on frequency, extent, site and duration, and credible s cientific evidence published in peer- cons idered effective for your illness , injury or review ed medical literature generally recognized diseas e; and by the relevant medical community, Physician 3. not primarily for your convenience, or that of Specialty Society recommendations, and the your Physician or other health care Provider, views of Physicians practicing in relevant clinical and not more costly than an alternative areas and any other relevant factors. Service or sequence of Services at least as BlueOptions II Large Group 23013-1108R BCA 6 Physician Specialty Society means a United States medical specialty s ociety that represen ts diplomates certified by a board recognized by the American Board of Medical Specialties . Th is Endors ement shall not extend, vary, alter, replace, or waive any of the provisions, benefits, exclusions , limitations, or conditions contained in the Benefit Booklet, other than as s pecifically s tated in the provisions contained in this Endorsement. In the event of any inconsistencies be tween the provisions contained in this Endors ement and the provisions contained in the Benefit Booklet, the provisions contained in this Endors ement sha ll control to the extent necess ar y to e ffectuate the intent of Blue Cross and Blue Shield of Florida, Inc. as expres sed herein. Blue Cross and Blue Shield of Florida, Inc. Patrick J. Geraghty Chairman of the Board and Chief Executive Officer BlueOptions II Large Group 23013-1108R BCA 7 Option s Men tal Health S erv ices En dors em en t Bl ue Th is Endors ement is to be attached to and made Th is Endors ement shall not extend, vary, alter, a part of the current Blue Cross and Blue Shield replace, or waive any of the provisions, benefits, of Florida, Inc. (herein "BCBSF") Benefit Booklet exclusions , limitations, or conditions contained in including any Endors ements attached thereto. the Benefit Booklet, other than as specifically The Benefit Booklet is amended as described s tated in the provisions contained in this below: Endorsement. In the event of any inconsistencies be tween the provisions If you have any questions concerning this contained in this Endors ement and the Endorsement, pleas e call Blue Cross and Blue provisions contained in the Benefit Booklet, the Shield of Florida toll free at 800-FLA-BLUE. provisions contained in this Endors ement s ha ll control to the extent necess ar y to e ffectuate the The fWh a t Is Covered?f section is intent of Blue Cross and Blue Shield of Florida, amen ded as follows: Inc. as expres sed herein. Menta l Health Services The category is Blue Cross and Blue Shield of Florida, Inc. amended by deleting exclusion numbers one and four in their entirety and replacing them w ith the following: Patrick J. Geraghty 1. Services rendered in connection w ith a Chairman of the Board and Chief Executive Cond ition not clas sified in the diagnostic Officer ca tegories of the International Class ification of Diseas es , Ninth Edition, Clinical Modification (ICD-9 CM) or their equivalents in the most recently pub lished version of the American Psychiatric Ass ociation™s Diagnostic and Statistical Manual of Mental Disorders , regardles s o f the underlying caus e, or effect, of the disorder; 4. Services for marriage counseling, when not rendered in connection with a Condition clas sified in the diagnostic categories of the International Class ification of Diseas es , Ninth Edition, Clinical Modification (ICD-9- CM) or their equivalents in the most recently pub lished version of the American Psychiatric As soc iation™s Diagnostic and Statistical Manual of Mental Disorders ; BlueOptions I Large Group Menta l Health Services 23014-1108R BCA Pre- existin g C on dition s Exclu s ion Period Endors em en t 8. routine follow-up care of breas t cancer after Th is Endors ement is to be attached to, and the person w as determined to be free of made a part of, your current Blue Cross and breas t cancer; Blue Shield of Florida, Inc. (herein "BCBSF") Benefit Booklet including any Endorsements 9. Cond itions ar ising from domestic violence; attached thereto. The provisions of this 10. inherited diseas es of amino acid, organic Endorsement shall become effective and apply ac id, carbohydrate or fat metabolism as w ell to any paper or electronic Pos t-Service Claim for as ma labsorption originating from congenital benefits received and process ed by BCBSF on defects present at birth or acquired during or after December 1, 2007. the neonatal period; or The Introduction s ubsection of the Pre - 11. any Post- Service Claim for a Drug that existing Co nditions Exclusion Period s ection would otherwise be covered and payable is amended b y deleting the list of items where a under any retail pharmacy Endorsement Pre-existing Conditions does not apply in its iss ued w ith and part of this Benefit Booklet. entirety and replacing it with the following: For purposes o f this Endorsement, the term The Pre-existing Condition exclusionary period Drug s hall have the same definition as that se t does not apply to: forth in any retail pharmac y Endorsement issued with and part of this Benefit Booklet. 1. the Covered Employee and each Covered Dependent who was covered under the Th is Endors ement shall not extend, vary, alter, Group™s pr ior medical p lan on the date replace, or waive any of the provisions, benefits, immediately preced ing the Effective Date of exclusions , limitations, or conditions contained in co verage under this Booklet; the Benefit Booklet, other than as specifically 2. you if you w ere enrolled during the Initial s tated in the provisions contained in this Enrollment Period prior to the Effective Date Endorsement. In the event of any of the Group; or inconsistencies be tween the provisions contained in this Endors ement and the 3. you when the Group has e lected to w aive, in provisions contained in the Benefit Booklet, the writing, at the time o f Group Application the provisions contained in this Endors ement s ha ll Pre-existing Conditions exclusionary period control to the extent necess ar y to e ffectuate the for all s ubsequent Eligible Employees and/or intent of Blue Cross and Blue Shield of Florida, Eligible Dependents; Inc. as expres sed herein. 4. pregnancy; 5. a newborn child or an adopted newborn child Blue Cross and Blue Shield of Florida, Inc. properly enrolled under this Booklet; 6. an adopted child that has Cred itable Coverage; Patrick J. Geraghty 7. Genetic Information in the abs ence of a Chairman of the Board & Chief Executive Officer diagnosis o f the Condition; Large Group 23018-0807 BCA 1 Option s Bone Marrow En dorsem ent Bl ue other health care Provider Health Care Services Th is Endors ement is to be attached to and made which are rendered in order to treat the e ffects a part of your Blue Cross and Blue Shield of of, or complications arising from, the us e of high Florida, Inc. (herein "BCBSF") BlueOptions dos e or intensive dose chemotherapy or human Benefit Booklet, BlueOptions Hos pital and blood precursor ce lls (e.g., Hos pital room and Surgical Coverage Benefit Booklet and board and ancillary Services). BlueOptions with Integrated Prescription Drug Coverage Benefit Booklet (herein fBenefit Bookletf), including any Endorsements attached Th is Endors ement shall not extend, vary, alter, replace, or waive any of the provisions, benefits, thereto. The Benefit Booklet is amended as exclusions , limitations, or conditions contained in des cribed below : the Benefit Booklet, other than as specifically If you have any questions concerning this s tated in the provisions contained in this Endorsement, pleas e call Blue Cross and Blue Endorsement. In the event of any Shield of Florida toll free at 800-FLA-BLUE. inconsistencies be tween the provisions contained in this Endors ement and the The fDefinitionsf section is amen ded provisions contained in the Benefit Booklet, the as follows: provisions contained in this Endors ement s ha ll control to the extent necess ar y to e ffectuate the The Bone M arrow Transplant definition is intent of Blue Cross and Blue Shield of Florida, deleted in its entirety and replaced w ith the Inc. as expres sed herein. following: Bone M arrow Transplant means human blood Blue Cross and Blue Shield of Florida, Inc. precurs or cells administered to a patient to res tore normal hematological and immunological functions following ablative or non-ablative therapy w ith curative or life-prolonging intent. Patrick J. Geraghty Human blood precursor cells ma y be obtained Chairman of the Board and Chief Executive from the patient in an autologous trans plant, or Officer an allogeneic transplant from a medically acceptable related or unrelated donor, and may be derived from bone marrow, the circulating blood, or a combination of bone marrow and circulating blood. If chemo therapy is an integral part of the treatment involving bone marrow transplantation, the term "Bone Marrow Trans plant" includes the transplantation as w ell as the administration of chemotherapy and the chemotherapy drugs. The term "Bone Marrow Trans plant" also includes an y Services or s upplies relating to any treatment or therapy involving the us e of high dose or intensive dose chemotherapy and human blood precursor cells and includes any and a ll Hospital, Physician or BlueOptions Large Group 23488 1008 BCA 1 Options Dependen t Eligibility En dorsem ent Bl ue ch ild™s s tudent or marital s tatus , financia l Th is Endors ement is to be attached to and made depende ncy on the C o vered Employee, a part of your Blue Cross and Blue Shield of w hether the depen dent child resides w ith the Florid a, Inc. (herein "BCBS F") BlueOptions Covered Employee , or whether the Ben efit Booklet, BlueOptions Hos p ital a nd depende nt child is eligible for or enrolled in Surgical C overage Benefit Booklet a nd any other health plan . BlueOptions w ith Integrated Prescription Drug Coverage Bene fit Booklet ( herein fBenefit 3. The newborn child of a Covered Dependent Bookletf), including a ny Endorsements attached ch ild. Coverage for such ne wborn chi ld will thereto. The Benefit Book let is amended as automatically terminate 18 months a fter the des cribed below: birth of the newb orn child. If you have any ques tions c oncerning this Note: It is the Covered Employee™s s ole End orsement, please ca ll Blue Cross and Blue res pons ibility to es tablish that a child meets the Shield of F lorida toll free at 800-FL A-BLUE . app licable requirements for eligibility. Th is Endors ement is effective at the group Handicapped Children plan™s initial e ffective date or first Anniversar y In the case of a hand icapped d epende nt child, October 1, 2010 occurring on or after w h ichever s uch child is eligible to continue coverage as a occurs first. Covered D ependent, beyond the ag e of 30, if the child is: El igibility f or Co ver age 1. otherw ise eligible for coverage under the Eligibility Requirements for Group P lan; The Dependent(s) s ubs ec tion is deleted in its 2. incapable of self-sus taining employment by entire ty and rep laced w ith the following: reas on of mental retardation or phys ical handicap; and Eligibility Requirements f or Dependents 3. ch iefly dep endent upon the Covered An individual who meets the eligibility cr iteria Employee for s upport and maintenance s pecified b elow is an Eligible Dependen t and is provided tha t the s ymptoms or caus es of the eligible to apply for coverage under this Booklet: ch ild™s hand icap existed prior to the child™s t h 1. The Covered Employe e™s spous e und er a 30 birthday. legally valid existing marriage; Th is eligibility shall terminate on the last day of 2. the month in which the dependent child no The Covered Employe e™s natural, new born, longer meets the requirements for extended adopted, Foster, or s tep child(ren) (or a c hild eligibility as a hand icapped child. for w hom the Covered Employee has b een court-appointed as legal gu ardian or legal cus todian) who has not reached the end of the Calendar Year in wh ich he or s he reaches age 30 (or in the cas e of a Fos ter Child, is no longer eligible u nder the Foster Child Program), regardless of the depen dent 24708 0810R BCA End orsement. In the event of an y Enroll ment and Effec tive Date o f inconsistenc ies betw een the provisions Cove rage contained in this Endors ement a nd the provisions contained in the Ben efit Booklet, the The Dependent Enrollment subs ection is provisions contained in this Endors ement s hall amended b y dele ting the n o te at the end of the control to the exten t necess ary to effectuate the New born Child subs ection in its entirety and intent of Blue Cross and B lue Shield of Florida, replacing it with the follow ing: Inc. as expres sed herein. Note: Coverage for a new born child of a Blue Cross and B lue Shield of Florida, Inc. Covered D ependent child who h as not reached the end of the Calendar Year in wh ich he or s he becomes 30 w ill automatically terminate 18 months after the birth of the new born child. Patrick J. Geraght y Chairman of the Board an d Chief Executive Te r mination of Cov erage Officer Termination of a Covered D ependent™s The Cov erage s ubs ection is delet ed in its entirety and replaced w ith the following : A Covered Dependent's coverage w ill automatically terminate 1. a t 12:01 a.m. on the date the Group Master Policy terminates; 2. at 12:01 a.m. on the date the Covered Employee™s co verage terminates for any reas on; 3. If the Dependent becomes co vered under an altern ative he alth b enefits plan wh ich is offered through or in connection with the Group; 4. The last day of the Ca lenda r Year that the Covered D ependent child n o longer meets any of the app licable e ligibility requirements; 5. the Depe ndent™s coverage is terminated for caus e (see the Termination o f Individual Coverage for Cause subs ection). Th is Endors ement shall not extend, vary, alter, replace, or waive any of the provisions, bene fits, exclusions , limitations, or conditions contained in the Benefit Book let, other than as s pecifically s tated in the provisions con tained in this 24708 0810R BCA Option s Men tal Health S erv ices En dors em en t Bl ue Once we have received the necessary medical Th is Endors ement is to be attached to and made documentation from the Provider, we will review a part of your Blue Cross and Blue Shield of the information and make a prior coverage Florida, Inc. BlueOptions Benefit Booklet authorization decision, bas ed on our established including any Endors ements attached thereto. criteria then in e ffect. The Provider w ill be The Benefit Booklet is amended as described notified of the prior coverage authorization below: decision. If you have any questions concerning this Out-of-Network Providers Endorsement, pleas e call Blue Cross and Blue Shield of Florida toll free at 800-FLA-BLUE. It is your sole respons ibility to comply w ith our prior coverage authorization requirements w hen Th is Endors ement is effective upon your Group™s rendered or referred by an Out-of-Netw ork next renewal, w hich occurs on or after 10/15/09. before Provider Mental Health Services are provided. Your failure to obtain prior What is Covered? covera ge authorization will result in denial of covera ge for such Services. The Menta l Health Services s ubsection is For additional details on how to obtain prior amended as follows : co verage authorization for Mental Health The s econd paragraph is deleted in its entirety Services, please call the customer s er vice phone and replaced w ith the follow ing: number on the back of your ID Card. Partial Hos pitalization is a Covered Service w hen Once the necess ar y medical documentation has provided under the d irection of a Physician and been received from you and/or the Out-of- in lieu of inpatient hospitalization. Netw ork Provider, BCBSF will review the information and make a prior coverage Blueprint for Health Programs authorization decision, bas ed on our established criteria then in e ffect. You will be notified of the The follow ing new s ubs ection is added : prior coverage authorization decision. Pr ior Coverage Authorization/Pre - See the fClaims Process ingf s ection for Ser vice Notification Pr ograms for information on what you can do if prior coverage Men tal Health Services authorization is denied. You or your Physician w ill be required to obtain Note: Prior coverage authorization is not prior coverage authorization from us for Mental required when Covered Services are provided Health Services. for the treatment of a Medical Emergency. In-Network Providers It is the In-Network Provider™s s ole respons ibility to comply w ith our prior coverage authorization requirements, and therefore you w ill not be res pons ible for any benefit reductions if pr ior co verage authorization is not obtained before Medically Neces s ary Services are rendered. BlueOptions LG 24182 0709 BCA 1 Definitions The follow ing definition is added : Med ical Emergency means the sudden and une xpected onset of a medical or psychiatric Cond ition or an injury tha t in the absence of medical care could reasonably be expected to endanger your life or result in s er ious injury or disab ility. Th is Endors ement shall not extend, vary, alter, replace, or waive any of the provisions, benefits, exclusions , limitations, or conditions contained in the Benefit Booklet, other than as specifically s tated in the provisions contained in this Endorsement. In the event of any inconsistencies be tween the provisions contained in this Endors ement and the provisions contained in the Benefit Booklet, the provisions contained in this Endors ement s ha ll control to the extent necess ar y to effectuate the intent of Blue Cross and Blue Shield of Florida, Inc. as expres sed herein. Blue Cross and Blue Shield of Florida, Inc. Patrick J. Geraghty Chairman of the Board and Chief Executive Officer BlueOptions LG 24182 0709 BCA 2 Option s Su bs tan ce Depen den cy Care an d Treatmen t Bl ue En dorsem en t res pons ible for any benefit reductions if pr ior Th is Endors ement is to be attached to and made co verage authorization is not obtained before a part of your Blue Cross and Blue Shield of Medically Neces s ary Services are rendered. Florida, Inc. BlueOptions Benefit Booklet including any Endors ements attached thereto. Once we have received the necessary medical The Benefit Booklet is amended as described documentation from the Provider, we will review below: the information and make a prior coverage authorization decision, bas ed on our established If you have any questions concerning this criteria then in e ffect. The Provider w ill be Endorsement, pleas e call Blue Cross and Blue notified of the prior coverage authorization Shield of Florida toll free at 800-FLA-BLUE. decision. Th is Endors ement is effective upon your Group™s Out-of-Network Providers next renewal, w hich occurs on or after 10/15/09. It is your sole respons ibility to comply w ith our prior coverage authorization requirements w hen What is Covered? rendered or referred by an Out-of-Netw ork Provider before Substance Dependency Care The Substance Dependency Care and Your and Treatment Services are provided. Treatment s ubsection is amended by de leting failure to obtain prior coverage authorization item #2 in its entirety and replacing it with the will result in denial of coverage for such following: Services. 2. Physician, Psychologist and Mental Health For additional details on how to obtain prior Profess ional outpatient visits for the care co verage authorization for Subs tance and treatment of Subs tance Dependency. Dependency Care and Treatment, please call the cus tomer service phone number on the back Blueprint for Health Programs of your ID Card. Once the necess ar y medical documentation has The follow ing new s ubs ection is added : been received from you and/or the Out-of- Pr ior Coverage Authorization/Pr e- Netw ork Provider, BCBSF will review the Ser vice Notification Pr ograms for information and make a prior coverage Su bstance Dependency Care and authorization decision, bas ed on our established Treatment criteria then in e ffect. You will be notified of the prior coverage authorization decision. You or your Physician w ill be required to obtain See the fClaims Process ingf s ection for prior coverage authorization from us for information on what you can do if prior coverage Subs tance Dependency Care and Treatment. authorization is denied. In-Network Providers Note: Prior coverage authorization is not It is the In-Network Provider™s s ole respons ibility required when Covered Services are provided to comply w ith our prior coverage authorization for the treatment of a Medical Emergency. requirements, and therefore you w ill not be BlueOptions LG 24230 0709 BCA 1 Definitions The follow ing definition is added : Med ical Emergency means the sudden and une xpected onset of a medical or psychiatric Cond ition or an injury tha t in the absence of medical care could reasonably be expected to endanger your life or result in serious injury or disab ility. Th is Endors ement shall not extend, vary, alter, replace, or waive any of the provisions, benefits, exclusions , limitations, or conditions contained in the Benefit Booklet, other than as specifically s tated in the provisions contained in this Endorsement. In the event of any inconsistencies be tween the provisions contained in this Endors ement and the provisions contained in the Benefit Booklet, the provisions contained in this Endors ement s ha ll control to the extent necess ar y to e ffectuate the intent of Blue Cross and Blue Shield of Florida, Inc. as expres sed herein. Blue Cross and Blue Shield of Florida, Inc. Patrick J. Geraghty Chairman of the Board and Chief Executive Officer BlueOptions LG 24230 0709 BCA 2 Option s A u tis m Spectru m D isorder En dors em en t Bl ue 393 .17 of the Florida Statutes or licens ed Th is Endors ement is to be attached to and made under Chapters 490 or 491 of the Florida a part of your Blue Cross and Blue Shield of Statutes ; and Florida, Inc. BlueOptions Benefit Booklet including any Endors ements attached thereto. 3. Physical Therapy by a Physical Therapist, The Benefit Booklet is amended as described Occupational Therapy b y an Occupational below: Therapist, and Speech Therapy by a Speech If you have any questions concerning this Therapist. Covered therapies provided in Endorsement, pleas e call Blue Cross and Blue the treatment of Autism Spectrum Disorder Shield of Florida toll free at 800-FLA-BLUE. are covered even though they may be hab ilitative in nature (provided to teach a Th is Endors ement is effective upon your Group™s function) and are not necess arily limited to renewal, w hich occurs on or after 4/1/09. res toration of a function or skill that has been lost. Schedule of Benefits Payment Guidelines for Autism Spectrum The Schedule of Benefits is amended to the Disorder following benefit maximums: 1. All Covered Services for Autism Spectrum Disorder w ill be applied to the Benefit Period Autism Spectrum Disorder Services and lifetime benefit maximums for Autism Per BP––––––––––––––..$36,000 Spectrum Disorder Services indicated in Per Lifetime–––––––––––...$200,000 your Schedule of Benefits. 2. Upon your Group™s renew a l, which occurs on What Is Cov ered? or after 10/15/09, the Applied Behavior Analysis Services outlined in paragraph two The What is Covered? s ection of the Benefit abo ve will continue to be eligible for Booklet is amended as follows: co verage once the Benefit Period and/or lifetime benefit maximums for Autism The follow ing new s ubs ection is added : Spectrum Disorder have been met, up to the To tal Lifetime Maximum Benefit or Benefit Autism Spectrum Disorder Period maximum, w hen applicable, s et forth in your Schedule of Benefits. Autism Spectrum Disorder Services provided to a Covered Dependent w ho is under the age of 3. The covered therapies provided in the 18, or if 18 years of age or older, is attending treatment of Autism Spectrum Disorder high school and w as d iagnosed with Au tism outlined in paragraph three above will be th Spectrum Disorder prior to his or her 9 birthday app lied to the Benefit Period and lifetime cons isting of: benefit maximums for Autism Spectrum and Disorder the Outpatient Therapies 1. well-baby and w ell-child screening for the Benefit Period maximum s e t forth in your pres ence of Autism Spectrum Disorder; Schedule of Benefits. Once the lifetime 2. Applied Behavior Analysis, w hen rendered benefit maximum for Autism Spectrum by an individual certified pursuant to Section Disorder has been met, there w ill be no BlueOptions LG 24013 0709 BCA 1 co verage for therapies described in In-Network Providers paragraph three above. It is the In-Network Provider™s s ole respons ibility Exclusion: to comply w ith our prior coverage authorization requirements, and therefore you w ill not be Any Services for the treatment of Autism res pons ible for any benefit reductions if pr ior Spectrum Disorder other than as s pecifically co verage authorization is not obtained before identified as covered in this section. Medically Neces s ary Services are rendered. Note: In order to determine whether Autism Once we have received the necessary medical Spectrum Disorder Services are co vered under documentation from the Provider, we will review this Booklet, we reserve the right to request a the information and make a prior coverage formal written treatment plan s igned b y the authorization decision, bas ed on our es tablished treating physician to include the diagnos is, the criteria then in e ffect. The Provider w ill be propos ed treatment type, the frequency and notified of the prior coverage authorization duration of trea tment, the anticipated outcomes decision. s tated as goa ls, and the frequency with which the treatment p lan will be updated, but no less Out-of-Network Providers than every 6 months. It is your s ole respons ibility to comply w ith our You or your Physician w ill be required to obtain prior coverage authorization requirements w hen prior coverage authorization from us for Autism rendered or referred by an Out-of-Netw ork Spectrum Disorder Services before s uch Provider before Autism Spectrum Disorder Services are rendered. Refer to the fBlueprint Your failure to obtain Services are provided. for Health Programsf s ection of this Booklet for prior coverage authorization will result in add itional information. denial of coverage for such Services. Once the necess ar y medical documentation has The Menta l Health Services s ubsection is been received from you and/or the Provider, amended as follows : BCBSF w ill re view the information and make a Exclusion #7 is de leted in its ent irety and prior coverage authorization decision, based on replaced w ith the follow ing: BCBSF™s established criteria then in e ffect. You will be notified of the prior coverage authorization 7. Services for testing of aptitude, ability, decision. intelligence or interest except as covered under the Autism Spectrum Disorder For additional details on how to obtain prior s ubs ection; co verage authorization for Autism Spectrum Disorder Services please call the customer s ervice phone number on the back of your ID Blueprint for Health Programs Card. See the fClaims Process ingf s ection for The follow ing new s ubs ection is added : information on what to do if prior coverage Pr ior Coverage Authorization/Pr e- authorization is denied. Ser vice Notification Pr ograms for Note: Prior coverage authorization is not Autism Spectrum Disorder required when Covered Services are provided You or your Physician w ill be required to obtain for the treatment of a Medical Emergency. prior coverage authorization from us for Autism Spectrum Disorder Services. BlueOptions LG 24013 0709 BCA 2 contained in this Endors ement and the Definitions provisions contained in the Benefit Booklet, the provisions contained in this Endors ement s ha ll The Definitions s ection is amended by adding control to the extent necess ar y to e ffectuate the the following terms: intent of Blue Cross and Blue Shield of Florida, Inc. as expres sed herein. Applied Behavior Analysis means the design, implementation and evaluation of environmental Blue Cross and Blue Shield of Florida, Inc. modifications, using behavioral s timuli and cons equences to produce socially significant improvement in human behavior, including, but not limited to, the use of direct obser vation, Patrick J. Geraghty measuremen t and functional analysis o f the Chairman of the Board and Chief Executive relations be tween environment and behavior. Officer Autism Spectrum Disorder means an y of the following disorders as defined in the diagnostic ca tegories of the International Class ification of Diseas es , Ninth Edition, Clinical Modification ( ICD-9 CM), or their equivalents in the most recen tly pub lished version of the American Psychiatric As soc iation's Diagnostic and Statistical Manual of Mental Disorders : 1. Autistic disorder; 2. Asperger's s yndrome; 3. Pervasive developmental disorder not otherw ise s pecified; and 4. Childhood Disintegrative Disorder. Med ical Emergency means the sudden and une xpected onset of a medical or psychiatric Cond ition or an injury that in the absence of medical care could reasonably be expected to endanger your life or result in serious injury or disab ility. Th is Endors ement shall not extend, vary, alter, replace, or waive any of the provisions, benefits, exclusions , limitations, or conditions contained in the Benefit Booklet, other than as specifically s tated in the provisions contained in this Endorsement. In the event of any inconsistencies be tween the provisions BlueOptions LG 24013 0709 BCA 3 Option s A u tis m Spectru m D isorder A m en dm en t Bl ue Th is document amends the Blue Cross and Blue Shield of Florida, Inc. (herein fBCBSFf) BlueOptions Autism Spectrum Disorder Endorsement to the BlueOptions Benefit Booklet iss ued to you. The BlueOptions Autism Spectrum Disorder Endorsement is hereb y amended as des cribed below: If you have any questions concerning this amendment, please call Blue Cross and Blue Shield of Florida toll free at 800-FLA-BLUE. The Autism Spectrum Disorder Services benefit maximums added to your Schedule of Benefits with Endors e ment 24013 0709 BCA, are hereb y changed to unlimited. Th is amendment sha ll not extend, vary, alter, replace, or waive any of the provisions, benefits, exclusions , limitations, or conditions contained in the Benefit Booklet, other than as specifically s tated in the provisions contained in this amendment. In the event of an y inconsistencies between the provisions contained in this amendment and the provisions contained in the Benefit Booklet, the provisions contained in this amendment s ha ll contro l to the extent necess ary to effectuate the intent of Blue Cross and Blue Shield o f Florida, Inc. as express ed herein. Blue Cross and Blue Shield of Florida, Inc. Patrick J. Geraghty Chairman of the Board and Chief Executive Officer BlueOptions LG Autism Spectrum Disorder Amendment 24715 0910 BCA Option s Special En rollm en t Period En dorsem en t Bl ue dependen t), or coverage under other health Th is Endors ement is to be attached to and made insurance (except in the case o f loss of a part of your Blue Cross and Blue Shield of co verage under a Children™s Health Florida, Inc. BlueOptions Benefit Booklet Insurance Program (CHIP) or Medicaid, s ee including any Endors ements attached thereto. #3 below) , or COBRA continuation The Benefit Booklet is amended as described co verage that you w ere co vered under at the below. time of initial enrollment provided that: If you have any questions concerning this a) when offered coverage under this plan Endorsement, pleas e call Blue Cross and Blue at the time of initial eligibility, you stated, Shield of Florida toll free at 800-FLA-BLUE. in w riting, that coverage under a group hea lth plan or health ins urance coverage References to the fState Children™s Health was the reason for declining enrollment; Insurance Program (S-CHIP)f in your Benefit and Booklet are hereby changed to fChildren™s b) you lost your other coverage under a Health Insurance Program (CHIP).f group health benefit plan or health insurance coverage (except in the case Enrollment and Effective Date of The of los s of coverage under a CHIP or Cov erage s ection is amended by deletin g the Medicaid, s ee #3 below) as a res ult of f Special Enrollment Periodf subs ection in its termination of employment, reduction in entirety and replacing it with the following: the number of hours you work, reaching or exceeding the maximum lifetime of a ll Special Enroll ment Peri od benefits under other health coverage, the employer ceased o ffering group An Eligible Employee and/or the Employee™s hea lth coverage, death of your spous e , Eligible Dependent(s) may apply for coverage divorce, legal separation or employer outside of the Initial Enrollment Period and contributions toward such coverage was Annual Enrollment Period as a res ult of a s pecial terminated; and enrollment event. To apply for coverage, the Eligible Employee and/or the Employee™s Eligible c) you sub mit the applicable Enrollment Dependent(s) must complete the applicable Form to the Group w ithin 30 days of the Enrollment Form and forward it to the Group date your coverage was terminated within the time periods no ted below for each Note: Los s of coverage for failure to pay s pecial enrollment event. your portion of the required Premium on a An Eligible Employee and/or the Employee™s timely basis or for caus e (s uch as making a Eligible Dependent(s) may apply for coverage if fraudulent claim or an intentional one of the following s pecial enrollment events misrepres en tation o f a material fact in occurs and the applicable Enrollment Form is connec tion with the prior health coverage) is s ubmitted to the Group within the indicated time not a qualifying event for s pec ial enrollment. periods: or 1. If you lose your coverage under another group health benefit plan (as an employee or BlueOptions LG 24188 0709 BCA 1 2. If when offered coverage under this plan at control to the extent necess ar y to e ffectuate the the time of initial eligibility, you stated, in intent of Blue Cross and Blue Shield of Florida, writing, that coverage under a group health Inc. as expres sed herein. plan or health insurance coverage w as the reas on for declining enrollment; and you get Blue Cross and Blue Shield of Florida, Inc. married or obtain a dependent through birth, adoption or placement in anticipation of adoption and you s ubmit the applicable Enrollment Form to the Group w ithin 30 days Patrick J. Geraghty of the date of the event. Chairman of the Board and Chief Executive Officer or 3. If you or your E ligible Dependent(s) lose co verage under a CHIP or Medicaid due to loss of eligibility for s uch coverage or become eligible for the optional state premium ass istance program and you s ubmit the applicable Enrollment Form to the Group within 60 days of the date s uch co verage was terminated or the date you become eligible for the optional state premium ass istance program. The Effective Date of coverage for you and your Eligible Dependents added as a result of a s pecial enrollment event is the date of the s pecial enrollment event. E ligible Employees who do not enroll or change their coverage s e lection during the Special Enrollment Period mus t w ait until the next Annual Open Enrollment Period (See the Dependent Enrollment s ubs ection of this s ect ion for the rules relating to the enrollment of Eligible Dependents of a Covered Employee). Th is Endors ement shall not extend, vary, alter, replace, or waive any of the provisions, benefits, exclusions , limitations, or conditions contained in the Benefit Booklet, other than as specifically s tated in the provisions contained in this Endorsement. In the event of any inconsistencies be tween the provisions contained in this Endors ement and the provisions contained in the Benefit Booklet, the provisions contained in this Endors ement s ha ll BlueOptions LG 24188 0709 BCA 2 Option s Prior Cov erag e A u th orization an d Elig ibility Bl ue En dorsem en t depending on whether Services are rendered by Th is Endors ement is to be attached to and made an In-Network Provider or an Out-of-Network a part of your Blue Cross and Blue Shield of Provider, as des cribed below: Florida, Inc. BlueOptions Benefit Booklet including any Endors ements attached thereto. In-Network Providers The Benefit Booklet is amended as described It is the In-Network Provider™s s ole respons ibility below: to comply w ith our prior coverage authorization If you have any questions concerning this requirements, and therefore you w ill not be Endorsement, pleas e call Blue Cross and Blue res pons ible for any benefit reductions if pr ior Shield of Florida toll free at 800-FLA-BLUE. co verage authorization is not obtained before Medically Neces s ary Services are rendered. Th is Endors ement is effective upon your Group™s renewal, w hich occurs on or after 10/15/09. Once we have received the necessary medical documentation from the Provider, we will review the information and make a prior coverage Blueprint for Health Programs authorization decision, bas ed on our established criteria then in e ffect. The Provider w ill be Pr ior Coverage Authorization/Pr e- notified of the prior coverage authorization Ser vice Notification Pr ograms decision. It is important for you to understand our prior Out-of-Network Providers co verage authorization programs and how the 1. In the case of Provider-administered Provider you s elect and the type of Service you drugs , it is your s ole respons ibility to comply receive affects these requirements and with our prior coverage authorization ultimately how much you are respons ible for requirements w hen you us e an Out-of- paying under this Benefit Booklet. Netw ork Provider before the drug is You or your Physician w ill be required to obtain purchas ed or administered. Y our f ailure to prior coverage authorization from us for: obtain prior coverage authorization will result in denial of coverage for s uch 1. certain Provider-administered drugs , as drug, including any Service related to the denoted with a special s ymbol in the drug or its administration. Medication Guide; For additional details on how to obtain prior 2. advanced d iagnostic imaging Services , co verage authorization, and for a list of s uch as CT scans , MRIs, MRA and nuclear Provider-administered drugs that require imaging; and prior coverage authorization, pleas e refer to 3. other Health Care Services that are or may the Medication Guide. become subject to a prior coverage 2. In the case of a dvanced diagnostic authorization program or a pre-ser vice imaging Services s uch as CT scans , MRIs , notification program as defined and MRA and nuclear imaging, it is your sole administered by us . res pons ibility to comply with our prior Prior coverage authorization requirements vary, co verage authorization requirements when BlueOptions LG 24200 0709 BCA 1 rendered or referred by an Out-of-Netw ork notification program, including how you can Provider before the advanced diagnos tic obtain prior coverage authorization and/or imaging Services are pro vided. Your failure provide the pre-service notification for s uch t o obtain pr ior coverage authorization Service not already listed here. Th is information will result in denial of coverage for such will be provided to you upon enrollment, or at Services . least 30 days prior to such Out-of-Network Services becoming s ubject to a prior coverage For additional details on how to obtain prior authorization or pre-service notification program. co verage authorization for advanced diagnostic imaging Services, please call the See the fClaims Process ingf s ection for cus tomer s ervice phone number on the back information on what you can do if prior coverage of your ID Card. authorization is denied. other Health Care Services 3. In the case of Note: Prior coverage authorization is not under a prior coverage authorization or pre- required when Covered Services are provided s ervice notification program, it is your s o le for the treatment of a Medical Emergency. res pons ibility to comply with our prior co verage authorization or pre-service Eligibility for Coverage notification requirements when rendered or referred by an Out-of-Network Provider, The follow ing paragraph is added at the end of before the Services are pro vided. Failure the Eligibility Requirements for Dependent(s) t o obtain pr ior coverage authorization or s ubs ection: provide pre-service notification may result in denial of the claim or application Exception for Students on Medical Leave of Absence from School of a financial penalty assessed at the t ime the claim is presented for payment A Covered Dependent child w ho is a full-time or t o us. The penalty applied w ill be the less er part-time student at an accredited post- of $500 or 20% of the total Allowed Amount s econdary institution, w ho takes a phys ician of the claim. The decision to apply a penalty certified medically neces s ar y leave of abs ence or deny the claim w ill be made uniformly and from school, will still be considered a studen t for will be identified in the notice describing the eligibility purpos es under this Booklet for the prior coverage authorization and pre-s ervice earlier o f 12 months from the first day of the notification programs. leave of abs ence or the date the Covered Dependent would otherwise no longer be eligible Once the necess ar y medical documentation has for coverage under this Booklet. been received from you and/or the Out-of- Netw ork Provider, BCBSF or a designated vendor, w ill re view the information and make a Definitions prior coverage authorization decision, based on our es tablished criteria then in effect. You w ill be The follow ing definition is added : notified of the prior coverage authorization Med ical Emergency means the sudden and decision. une xpected ons et of a medical or psychiatric BCBSF w ill provide you information for any Out- Cond ition or an injury tha t in the absence of of-Network Hea lth Care Service subject to a medical care could reasonably be expected to prior coverage authorization or pre-ser vice BlueOptions LG 24200 0709 BCA 2 endanger your life or result in serious injury or disab ility. Th is Endors ement shall not extend, vary, alter, replace, or waive any of the provisions, benefits, exclusions , limitations, or conditions contained in the Benefit Booklet, other than as specifically s tated in the provisions contained in this Endorsement. In the event of any inconsistencies be tween the provisions contained in this Endors ement and the provisions contained in the Benefit Booklet, the provisions contained in this Endors ement s ha ll control to the extent necess ar y to e ffectuate the intent of Blue Cross and Blue Shield of Florida, Inc. as expres sed herein. Blue Cross and Blue Shield of Florida, Inc. Patrick J. Geraghty Chairman of the Board and Chief Executive Officer BlueOptions LG 24200 0709 BCA 3 Option s Product En h ancem en t Endorsem en t Bl ue Th is Endors ement is to be attached to and made Services are rendered. For example, we may a part of your Blue Cross and Blue Shield of determine w hether a proposed transp lant w ould Florida, Inc. BlueOptions Benefit Booklet be a Covered Service under this Booklet be fore including any Endors ements attached thereto. the transp lant is pro vided. We are not ob ligated The Benefit Booklet is amended as described to determine, in advance, whether any Service below: not yet provided to you w ould be a Covered Service unless w e have specifically des ignated If you have any questions concerning this that a Service is subject to a prior authorization Endorsement, pleas e call Blue Cross and Blue requirement as des cribed in the fBlueprint for Shield of Florida toll free at 800-FLA-BLUE. Health Programsf s ect ion. We are also not Th is Endors ement is effective beginning obligated to cover or pay for any Service that has January 1, 2010 and effective on your plan™s not actually been rendered to you. first Anniversary Date occurring after this date. Ambulatory Surgical Centers The ca tegory is All references to the terms or phras es in the amended as follows : chart below are changed as indicated throughout Item number seven is deleted in its entirety and the Benefit Booklet: replaced w ith the follow ing: Current New 7. administration and cost of whole blood or Calendar Year Deductible blood products (except as outlined in the Deductible Drugs exclusion o f the fWhat Is Not Covered?f section); Calendar Year Coinsurance Coinsurance The Hospital Services category is amended as follows: Per pers on per Per pers on per Calendar Year Benefit Period Item number eight is de leted in its ent irety and replaced w ith the follow ing: Calendar Year Benefit Period maximums maximums 8. administration and cost of whole blood or blood products (except as outlined in the Drugs exclusion of the fWhat Is Not What Is Cov ered? Covered?f section); The Introduction s ubsection is amended as Maternity Services The category is amended follows: by adding the following paragraph before the exclusion: The s econd to the last paragraph is deleted in its entirety and replaced with the following: Under Federal law, your Group Plan generally may not restrict benefits for any hosp ital length We will determine w hether Services are Co vered of s tay in connection w ith childbirth for the Services under this Booklet after you have mother or newborn child to less than 48 hours obtained the Services and we have received a following a vaginal de livery; or les s than 96 hours claim for the Services. In s ome circumstances following a cesarean s ec tion. However, Federal we may determine whether Services might be law generally does not prohibit the mother's or Covered Services under this Booklet before s uch 24736 0910 BCA BlueOptions II LG 24018 0210R BCA 1 newborn's attending Provider, after consulting mother or newborn child to less than 48 hours with the mother, from d ischarging the mother or following a vaginal de livery; or les s than 96 hours her newborn earlier than 48 hours (or 96 as following a cesarean s ec tion. However, Federal app licable). In any cas e, under Federal law, law generally does not prohibit the mother's or your Group Plan can only requ ire that a provider newborn's attending Provider, after consulting obtain authorization for prescribing an inpatient with the mother, from d ischarging the mother or hos pital stay that exceeds 48 hours (or 96 her newborn earlier than 48 hours (or 96 as hours ). app licable). In any cas e, under Federal law, your Group Plan can only requ ire that a provider The follow ing Cov ered Service Category is obtain authorization for prescribing an inpatient added: hos pital stay that exceeds 48 hours (or 96 Med ical Pharmacy hours ). Physician-administered Prescription Drugs w hich Self-Administered Injectable Prescription The are rendered in a Physician™s office are s ubject Drug category is deleted in its entirety and to a s eparate Cost Share amount that is in replaced w ith the follow ing: add ition to the office visit Cos t Share amount. Self-Administered Prescription Drugs The Medical Pharmacy Cos t Share amount app lies to the Prescription Drug and does not The following Self-Administered Drugs are include the administration o f the Prescription co vered: Drug. 1. Self-Administered Prescription Drugs us ed Your plan may also include a maximum monthly in the treatment of d iabetes, cancer, amount you will be required to pay out-o f-pocket Cond itions requiring immediate s tabilization for Medical Pharmacy, when such Services are (e.g. anaphylaxis), or in the administration of provided by an In-Netw ork Provider or Specialty dialysis; and Pharmacy. If your plan includes a Medical 2. Self-Administered Prescription Drugs Pharmacy out-of-pocket monthly maximum, it identified as Specialty Drugs with a special will be listed on your Schedule o f Bene fits and s ymbol in the Medication Guide when only applies after you have met your Deductible, delivered to you at home and purchased at a if applicable. Specialty Pharmacy or an Out-of-Network Please refer to your Schedule o f Benefits for the Provider that provides Specialty Drugs; and add itional Cost Share amount and/or monthly 3. Specialty Drugs us ed to increase height or maximum out-of-pocket applicable to Medical bone growth (e.g., growth hormone), must Pharmacy for your plan. meet the follow ing criteria in order to be Note: For purposes of this benefit, allergy co vered: injections and immunizations are not considered a. Must be pres cribed for Conditions of Medical Pharmacy. growth hormone deficiency documented The New born Care category is amended by with two abnormally low s timulation tests add ing the following paragraph at the end of the of les s than 10 ng/ml and one ca tegory: abnormally low grow th hormone dependen t peptide or for Conditions of Under Federal law, your Group Plan generally growth hormone deficiency as s ociated may not restrict benefits for any hosp ital length with loss of pituitary function due to of s tay in connection w ith childbirth for the 24736 0910 BCA BlueOptions II LG 24018 0210R BCA 2 trauma, s urgery, tumors, radiation or What Is Not Cov ered? diseas e, or for state mandated use as in patients w ith AIDS. The Dr ugs exclusion is amended as follows: b. Continuation of growth hormone therapy Exclusion numbers tw o and five are deleted in only covered for Conditions ass ociated their entirety and replaced with the following: with s ignificant growth hormone deficiency when there is evidence of 2. All drugs dispens ed to, or purchased by, you continued res pons iveness to treatment. from a pharmacy. This exclusion does not Treatment is cons idered respons ive in app ly to drugs dispens ed to you when: ch ildren les s than 21 years of age, when a. you are an inpatient in a Hospital, the growth hormone dependant peptide Ambulatory Surgical Center, Skilled ( IGF-1) is in the normal range for age Nurs ing Facility, Psychiatric Facility or a and Tanner development s tage; the Hos pice facility; growth velocity is at least 2 cm per year, b. you are in the outpatient department of a and stud ies demons trate open Hos pital; epiphyses . Treatment is cons idered res pons ive in both adoles cents w ith c. dispens ed to your Physician for clos ed epiphyses and for adults, who administration to you in the Physician™s continue to evidence growth hormone office and prior coverage authorization deficiency and the IGF-1 remains in the has been obtained (if required); normal range for age and gender. d. you are receiving Home Health Care The Skilled Nursing Facilities category is according to a plan o f treatment and the amended as follows : Home Health Care Agency bills us for s uch drugs, including Self-Administered Item number five is de leted in its ent irety and Prescription Drugs that are rendered in replaced w ith the follow ing: connec tion with a nursing visit; and 5. administration and cost of whole blood or e. defined by, and covered under, a blood products (except as outlined in the BCBSF Pharmacy Program Drugs exclusion of the fWhat Is Not Endorsement to this Booklet. Covered?f section); The Surgical Assistant Services category is 5. Any Self-Administered Prescription Drug except when indicated as covered in the amended by deleting the following in its entirety: f What Is Covered?f s ection o f this Benefit Payment Guidelines for Surgical Assistant Booklet. Services exc lusions The follow ing are added: The Allowed Amount for surgical ass istant 6. Blood or blood products us ed to treat Services is limited to 20 percent of the Allowed hemophilia, except w hen provided to you for: Amount for the surgical procedure. a. emergency s tabilization; b. during a covered inpatient s tay, or c. when proximately related to a s urgical procedure. 24736 0910 BCA BlueOptions II LG 24018 0210R BCA 3 The exceptions to the exclusion for drugs credited toward the individual Deductible and purchas ed or dispens ed by a pharmacy only up to the applicable Allow ed A mount. des cribed in subparagraph number two do Please s ee your Schedule o f Benefits for more not apply to hemophilia drugs e xcluded information. under this s ubparagraph. Family Deductible 7. Drugs , which require prior coverage If your plan includes a family Deductible, a fter authorization when prior coverage the family Deductible has been met by your authorization is not obtained. family, neither you nor your Covered Dependents 8. Specialty Drugs us ed to increase height or will have any additional Deductible respons ibility bone growth (e.g., growth hormone) except for the remainder of that Benefit Period. The for Conditions of growth hormone deficiency maximum amount that any one Covered Person documented w ith two abnormally low in your family can contribute toward the family s timulation tests of les s than 10 ng/ml and Deductible, if applicable, is the amount applied one abnormally low growth hormone tow ard the individual Deduct ible. Please s ee dependen t peptide or for Conditions of your Schedule of Benefits for more information. growth hormone deficiency as s ociated w ith The Copayment Requirements subs ection is loss of pituitary function due to trauma, amended by deleting number one in its entirety s urgery, tumors, radiation or diseas e, or for and replacing it with the following: s tate mandated use as in patients with A IDS. 1. Office Services Copayment Continuation of growth hormone therapy will If your plan is a Copayment plan, the not be covered except for Conditions Copa yment for Covered Services rendered as soc iated with significant growth hormone in the office must be paid by you, for each deficiency when there is evidence of office visit before any payment will be made continued res pons iveness to treatment. (See by us. The o ffice Services Copayment f What Is Covered?f s ection for additional app lies regardless of the reason for the information.) office visit and applies to all Covered Services rendered during that visit, with the Understanding Your Share of exception of Durable Medical Equipment, Medical Pharmacy, Orthotics and Health Care Expenses Prosthetics, which may require Cos t Share amounts in addition to the Office Services Calendar Year Deductible The s ubsection is Copa yment, as s e t forth on your Schedule of deleted in its entirety and replaced w ith the Benefits. following: De ductible Requirem ent Individual Deductible Th is amount, w hen applicable, must be s atisfied by you and each of your Covered Dependents each Benefit Period, before an y payment w ill be made by us. On ly those charges indicated on claims we receive for Covered Services will be 24736 0910 BCA BlueOptions II LG 24018 0210R BCA 4 Out-of-Pocket Calendar Year Maximums Prior Coverage Credit The The subs ection is s ubs ection is deleted in its entirety and replaced deleted in its entirety and replaced w ith the with the following: following: Out-of-Pocket Maximu ms Pr ior Coverage Credit Individual out-of-pocket maximum We will give you credit for the s atisfaction or partial satisfaction of any Deductible and Once you have reached the individual out-of- Coinsurance maximums met by you under a pocket maximum amount listed in the Schedule prior group insurance, blanket insurance, of Benefits, you w ill have no additional out-of- franchise insurance or group Health pocket respons ibility for the remainder of that Maintenance Organization (HMO) policy Benefit Period and we will pay 100 percent o f the maintained by the Group if the Group Master Allowed Amount for Covered Services rendered Policy replaces s uch policy. This provision only during the remainder of that Benefit Period. app lies if the prior group ins urance, blanket Family out-of-pocket maximum insurance, franchise insurance or HMO co verage purchased by the Group w as in effect If your plan includes a family out-of-pocket immediately preced ing the Effective Date of this maximum, once your family has reached the Group policy. This provision is only applicable family out-of-pocket maximum amount listed in for you during the initial Bene fit Period of the Schedule of Benefits , neither you nor your co verage under the Group Mas ter Policy and the co vered family members w ill have any additional following rules apply: out-of-pocket respons ibility for the remainder of that Benefit Period and w e w ill pay 100 percen t Prior Covera ge Credit for Deductible of the Allowed Amount for Co vered Services For the initial Benefit Period of coverage under rendered during the remainder of that Benefit the Group Mas ter Policy only, charges credited Period. The maximum amount any one Covered by the Group™s prior insurer, toward your Person in your family can contribute toward the Deductible requirement, for Services rendered family out-of-pocket maximum, if applicable, is during the 90-day period immediately preceding the amount applied toward the individual out-of- the Effective Date of the Group Master Policy, pocket maximum. P lease see your Schedule of will be credited to the Deductible requirement Benefits for more information. under this Booklet. Note: The Deductible, any applicable Prior Covera ge Credit f or Coinsurance Copa yments and Coinsurance amounts w ill accumulate toward the out-of-pocket maximums. Charges cred ited by the Group™s pr ior insurer , Any benefit pena lty reductions, non-covered tow ard your Coinsurance maximum, for Services charges or any charges in excess of the Allowed rendered during the 90-day period immediately Amount will not accumulate toward the out-of- preceding the Effective Date of the Group pocket maximums. I f the Group has purchas ed Master Po licy, w ill be credited to your out-of- Prescription Drug coverage, any applicable Cos t pocket maximum under this Booklet. Share under the Prescription Drug coverage, will Prior coverage credit toward the Deductible or not apply to the Deductible or the out-of-pocket out-of-pocket maximums w ill only be g iven for maximums under this Booklet. Health Care Services, w hich would have been Covered Services under this Booklet. 24736 0910 BCA BlueOptions II LG 24018 0210R BCA 5 Prior coverage credit under this Booklet only Under the inpatient facility program, we may app lies at the initial enrollment of the entire review Hos pital s tays, Hos pice, Inpatient Group. You and/or the Group are res pons ible Rehabilitation, LTAC and Skilled Nursing Facility for providing us w ith any information necess ary ( SNF) Services, and other Health Care Services for us to apply this pr ior coverage credit. rendered during the course of an inpatient stay or treatment program. We may conduct this The How We Will Credit Calendar Year review w hile you are inpatient, after your Benefit M ax imums and the Total M aximum discharge, or as part of a review o f an episode of Benefit Per Person s ubs ec tion is amended as care w hen you are transferred from one level o f follows: inpatient care to another for ongoing treatment. The s ubsection title is hereby changed to: The review is conducted s olely to determine whether w e s hould provide coverage and/or fHow we will Credit Benefit M aximumsf payment for a particular admiss ion or Health Care Services rendered during that admiss ion. Physicians, Hospitals and Us ing our established criteria then in e ffect, a concurrent review of the inpatient s tay may occur Other Provider Options at regular intervals, including in advance of a transfer from one inpatient facility to another. The follow ing s ubs ect ion is added after the We will provide notification to your Physician Hospitals s ubsection: when inpatient coverage criteria are no longer Specialty Pharm acy met. In administering the inpatient facility program, w e may review s pecific medical facts Certain medications, such as injectable, oral, or information and ass es s , among other things, inhaled and infused therapies us ed to treat the appropriateness of the Services being co mplex medical Conditions are typically more rendered, health care s etting and/or the level of difficult to maintain, administer and monitor w hen care of an inpatient admission or other health co mpared to traditional drugs . Specialty Drugs care treatment program. Any s uch reviews by may require frequent dosage adjustments, us , and any reviews or ass ess ments of s pec ific s pecial s torage and handling and may not be medical facts or information which we conduct, readily available at local pharmacies or rou tinely are s olely for purposes of making coverage or s tocked by Physicians' o ffices, mos tly due to the payment decisions under this Benefit Booklet high cos t and complex handling they require. and not for the purpose of recommending or Us ing the Specialty Pharmacy to provide these providing medical care. Specialty Drugs, if applicable on your plan, s hould lower the amount you have to pay for these medications, while helping to pres erve your benefits. Pleas e refer to the Medication Guide for a list of Specialty Pharmacies. Blueprint for Health Program s Inpatient Facility Program The subs ection is amended by deleting the first paragraph it its entirety and replacing it with the following: 24736 0910 BCA BlueOptions II LG 24018 0210R BCA 6 The follow ing s ubs ect ion, added to your Benefit criteria then in e ffect. The Provider w ill be Booklet with Endorse ment 24200 0709 BCA, is notified of the prior coverage authorization deleted in its entirety and replaced w ith the decision. following: Out-of-Network Providers Pr ior Coverage Authorization/Pr e- Prescription Drugs 1. In the case of denoted Ser vice Notification Pr ograms with a s pecial s ymbol in the Medication Guide as requiring prior authorization, it is It is important for you to understand our prior your sole respons ibility to comply w ith our co verage authorization programs and how the prior coverage authorization requirements Provider you s elect and the type of Service you when you use an Out-of-Network Provider receive affects these requirements and before the Prescription Drug is purchas ed or ultimately how much you are respons ible for administered. Y our failure to obtain prior paying under this Benefit Booklet. covera ge authorization will result in You or your Provider w ill be required to obtain denial of coverage for such Prescription prior coverage authorization from us for: Drug, including any Service related to the Prescription Drug or its administration. 1. certain Prescription Drugs denoted with a s pecial s ymbol in the Medication Guide as Exception: Self-Administered Prescription requiring prior authorization; Drugs , identified as Specialty Drugs with a s pecial s ymbol in the Medication Guide, do 2. advanced d iagnostic imaging Services , not require prior authorization w hen s uch as CT scans , MRIs, MRA and nuclear purchas ed from an Out-of-Network Provider imaging; and for delivery to you at home. other Health Care Services 3. that are or may For additional details on how to obtain prior become s ubject to a prior coverage co verage authorization, and for a list of authorization program or a pre-ser vice Prescription Drugs that require prior notification program as defined and co verage authorization, please refer to the administered by us . Medication Guide. Prior coverage authorization requirements vary, 2. In the case of a dvanced diagnostic depending on whether Services are rendered by imaging Services s uch as CT scans , MRIs , an In-Network Provider or an Out-of-Network MRA and nuclear imaging, it is your sole Provider, as des cribed below: res pons ibility to comply with our prior In-Network Providers co verage authorization requirements when rendered or referred by an Out-of-Netw ork It is the In-Network Provider™s s ole respons ibility Provider before the advanced diagnos tic to comply w ith our prior coverage authorization Your failure imaging Services are pro vided. requirements, and therefore you w ill not be t o obtain pr ior coverage authorization res pons ible for any benefit reductions if pr ior will result in denial of coverage for such co verage authorization is not obtained before Medically Neces s ary Services are rendered. Services. For additional details on how to obtain prior Once we have received the necessary medical co verage authorization for advanced documentation from the Provider, we will review diagnostic imaging Services, please call the the information and make a prior coverage authorization decision, bas ed on our established 24736 0910 BCA BlueOptions II LG 24018 0210R BCA 7 cus tomer s ervice phone number on the back See the fClaims Process ingf s ect ion for of your ID Card. information on what you can do if prior coverage authorization is denied. other Health Care Services 3. In the case of under a prior coverage authorization or pre- Note: Prior coverage authorization is not s ervice notification program, it is your s o le required when Covered Services are provided res pons ibility to comply with our prior for the treatment of a Medical E mergency. co verage authorization or pre-service notification requirements when rendered or Eligibility for Cov erage referred by an Out-of-Network Provider, before the Services are pro vided. Failure The follow ing paragraph is added at the end of t o obtain pr ior coverage authorization or the Eligibility Requirements for Dependent(s) provide pre-service notification may s ubs ection: result in denial of the claim or application Exception for Students on Medical Leave of of a financial penalty assessed at the Absence from School t ime the claim is presented for payment t o us. The penalty applied w ill be the less er A Covered Dependent child w ho is a full-time or of $500 or 20% of the total Allowed Amount part-time student at an accredited post- of the claim. The decision to apply a penalty s econdary institution, w ho takes a phys ician or deny the claim w ill be made uniformly and certified medically neces s ar y leave of abs ence will be identified in the notice describing the from school, will still be considered a studen t for prior coverage authorization and pre-s ervice eligibility purpos es under this Booklet for the notification programs. earlier o f 12 months from the first day of the leave of abs ence or the date the Covered Once the necess ar y medical documentation has Dependent would otherwise no longer be eligible been received from you and/or the Out-of- for coverage under this Booklet. Netw ork Provider, BCBSF or a designated vendor, w ill re view the information and make a prior coverage authorization decision, based on Termination of Coverage our es tablished criteria then in effect. You w ill be notified of the prior coverage authorization The follow ing s entence is added to the third decision. Cert ification of Creditable paragraph of the BCBSF w ill provide you information for any Out- Cov erage s ubs ection: of-Network Hea lth Care Service subject to a You may call the call the cus tomer s ervice prior coverage authorization or pre-ser vice phone number indicated in this Booklet or on notification program, including how you can your ID Card to request the certification. obtain prior coverage authorization and/or provide the pre-service notification for s uch Service not already listed here. This information General Provisions will be provided to you upon enrollment, or at least 30 days prior to such Out-of-Network subsection The follow ing is added: Services becoming s ubject to a prior coverage Customer Rew ar ds Programs authorization or pre-service notification program. From time to time, we may o ffer programs to our cus tomers that provide rewards for following the 24736 0910 BCA BlueOptions II LG 24018 0210R BCA 8 terms o f the program. We will tell you about any iss ued b y us where you may find information available rewards programs in general mailings, about Specialty Drugs, Prescription Drugs that member news letters and/or on our w ebsite. require prior coverage authorization and Self- Your participation in these programs is Administered Prescription Drugs that may be co mpletely voluntary and w ill in no w a y affect the co vered under this plan. co verage available to you under this Benefit Note: The Medication Guide is s ubject to Booklet. We reserve the right to offer rewards in change at any time. Please re fer to our website exces s o f $25 per year as w e ll as the right to at ww w.bcbsfl.com for the most current guide or discontinue or modify any reward program you may call the cus tomer s ervice phone features or promotional offers at any time without number on your Identification Card for current your consent. information. Prescription Drug means any medicinal Definitions s ubs tance, remedy, vaccine, biological product , drug, pharmaceutical or chemical compound The following definitions are added: which can only be dispens ed with a Prescription and /or which is required by state law to bear the Benefit Period means a consecutive period o f following statement or similar statement on the time, specified by BC BSF and the Group, in label: "Caution: Federal law prohibits which benefits ac cumulate toward the dispens ing w ithout a Prescription". s a tisfaction of Deductibles, out-of-pocket maximums and any applicable benefit Specialty Drug means an FDA -approved maximums. Your Benefit Period is listed on your Prescription Drug that has been designated, Schedule of Benefits, and will not be less than s o lely by us, as a Specialty Drug due to s pecial 12 months unless indicated as s uch. handling, storage, training, distribution requirements and/or management of therapy. Cost Share means the dollar or percentage Specialty Drugs may be Provider administered or amount es tablished s olely by us , w hich must be s e lf-administered and are identified w ith a paid to a health care Provider by you at the time s pecial s ymbol in the Medication Guide. Covered Services are rendered by tha t Provider. Cos t Share may include, but is no t limited to Specialty Pharmacy means a Pharmacy tha t Coinsurance, Copayment, Deductible and/or Per has s igned a Participating Pharmacy Provider Admiss ion Deductible (PAD) amounts. Agreement with us to provide s pecific Applicable Cost Share amounts are identified in Prescription Drug products, as determined by us . your Schedule of Benefits. In-Network Specialty Pharmacies are listed in the Medication Guide. FDA means the United States Food and Drug Administration. The fact that a pharmacy is a participating pharmacy does not mean that it is a Specialty Med ical Emergency means the sudden and Pharmacy. une xpected onset of a medical or psychiatric Cond ition or an injury tha t in the absence of medical care could reasonably be expected to endanger your life or result in serious injury or disab ility. Med ication Guide for the purpose of this Benefit Booklet means the guide then in effect 24736 0910 BCA BlueOptions II LG 24018 0210R BCA 9 Self-Administered I njectable The definition of Prescription Drug is de leted in its ent irety and replaced w ith the follow ing: Self-Administered Prescription Drug means an FDA-approved Prescription Drug that you may administer to yourself, as recommended by a Physician. Th is Endors ement shall not extend, vary, alter, replace, or waive any of the provisions, benefits, exclusions , limitations, or conditions contained in the Benefit Booklet, other than as specifically s tated in the provisions contained in this Endorsement. In the event of any inconsistencies be tween the provisions contained in this Endors ement and the provisions contained in the Benefit Booklet, the provisions contained in this Endors ement s ha ll control to the extent necess ar y to e ffectuate the intent of Blue Cross and Blue Shield of Florida, Inc. as expres sed herein. Blue Cross and Blue Shield of Florida, Inc. Patrick J. Geraghty Chairman of the Board and Chief Executive Officer 24736 0910 BCA BlueOptions II LG 24018 0210R BCA 10 Option s Pre-ex istin g C on dition s En dors em ent Bl ue Th is Endors ement is to be attached to and made intent of Blue Cross and Blue Shield of Florida, a part of your Blue Cross and Blue Shield of Inc. as expres sed herein. Florida, Inc. BlueOptions Benefit Booklet Blue Cross and Blue Shield of Florida, Inc. including any Endors ements attached thereto. The Benefit Booklet is amended as described below: If you have any questions concerning this Patrick J. Geraghty Endorsement, pleas e call Blue Cross and Blue Chairman of the Board and Chief Executive Shield of Florida toll free at 800-FLA-BLUE. Officer Pre-existing Conditions Exclusion Period The s ection is amended as follows: Introduction Item number six w ithin the s ubs ection is deleted in its entirety and replaced with the following: 6. an adopted child or a child placed for adoption; The follow ing paragraph is added at the end of Proving Creditable Cov erage the s ubs ection: The Group must notify you of your right to show that you had prior Creditable Coverage to reduce the Pre-existing Condition exclusion period. You may ask tha t your Group as sist you in obtaining a certificate from any prior p lan, s uch as by a telephone call from your Group to a prior employer or insurer verifying Creditable Coverage. Th is Endors ement shall not extend, vary, alter, replace, or waive any of the provisions, benefits, exclusions , limitations, or conditions contained in the Benefit Booklet, other than as specifically s tated in the provisions contained in this Endorsement. In the event of any inconsistencies be tween the provisions contained in this Endors ement and the provisions contained in the Benefit Booklet, the provisions contained in this Endors ement s ha ll control to the extent necess ar y to e ffectuate the BlueOptions II LG 24078 0409 BCA Option s Hos pital Per A dm iss ion Dedu ctible Bl ue En dorsem en t Th is Endors ement is to be attached to and made provisions contained in this Endors ement s ha ll a part of your Blue Cross and Blue Shield of control to the extent necess ar y to e ffectuate the Florida, Inc. BlueOptions Benefit Booklet intent of Blue Cross and Blue Shield of Florida, including any Endors ements attached thereto. Inc. as expres sed herein. The Benefit Booklet is amended as described Blue Cross and Blue Shield of Florida, Inc. below: If you have any questions concerning this Endorsement, pleas e call Blue Cross and Blue Shield of Florida toll free at 800-FLA-BLUE. Patrick J. Geraghty Chairman of the Board and Chief Executive Officer Understanding Your Share of Health Care Expenses Understanding Your Share of Health The Care Expenses s ection is amended by adding the following new subsection: Hospital Per Admission De ductible The Hospital per admiss ion Deductible, when app licable to your plan, must be s atisfied by each you for each Hos pital admiss ion before any payment will be made b y us for any c laim for inpatient Services. The Hospital per admiss ion Deductible applies regardless of the reason for the admiss ion, is in addition to the Deductible requirement, and applies to all Hos pital admiss ions in or outside the State of Florida. Th is Endors ement shall not extend, vary, alter, replace, or waive any of the provisions, benefits, exclusions , limitations, or conditions contained in the Benefit Booklet, other than as specifically s tated in the provisions contained in this Endorsement. In the event of any inconsistencies be tween the provisions contained in this Endors ement and the provisions contained in the Benefit Booklet, the BlueOptions III LG 24108 0809 BCA Options Health C are Reform En dors emen t Bl ue Th is Endors ement is to be attached to and made Note: In order to determine whe ther such a part of your Blue Cross and Blue Shield of Services are co vered u nder this Bene fit Booklet, w e reser ve the right to reques t a formal w ritten Florid a, Inc. BlueOptions Benefit Booklet treatment plan s igned b y the treating ph ysician including a ny Endorsements attached thereto. If to include the diagnos is, the proposed treatment you ha ve any ques tions concerning this type, the frequenc y a nd duration of treatment, End orsement, please ca ll Blue Cross and Blue the anticipated outcomes s tated as go als, and Shield of F lorida toll free at 800-FL A-BLUE . the frequency w ith wh ich the treatment plan will The Benefit Booklet is amended as des cribed be u pdated, but no less than every 6 months. belo w to comply wi th the Patient Protection and The Hospice Services category is deleted in its Affordable Care Act (PPACA) , H.R. 3590, entire ty and rep laced w ith the following: otherw ise know n as the Affordable Care Act. Hospice Se rvices Th is Endors ement is effective at your gr oup Health C are Services provided in connection plan™s initial e ffective date or first Anniversar y w ith a Hospice treatment program ma y b e Date occurring on or after September 2 3, 2010 Covered Services, provided the Hosp ice w hichever occurs first . treatment program is: Emergency Serv ices All re ferences to the term 1. approved by your Physician; and and Car e are changed to Emergency Services 2. your doctor has certified to us in writing that throughout the Benefit Booklet. Additionally, all your life expectancy is 12 months or les s. Medical Emergency references to the term are changes to Emergency Medical Condition. Recertification is required every six months . The Outpatient Cardiac, Occupational, What I s Cov ere d? Physical, Speech, Massage Therapies and Spinal Manipulation Services s ubs ection is The Autism Spectrum Disorder C ategory is amended b y dele ting the last paragraph of the Payment Guidelines amended b y d eleting the Payment Guidelines for Spinal Manipulation f or Autism Spectrum Disorder in its entirety s ubs ection in its e n tirety and replacing it with the and replac ing it with the following: following: Cov erage Acce ss Rules for Autism Spectrum Your Schedule of Benefits s ets forth the Disorder maximum number of visits co vered under this Autism Spectrum Disorder Services must be plan for any c ombination of the outpatient authorized in accordance with criteria therapies a nd s pinal manipulation Services es tablished b y us , before s uch Services are listed ab ove. For e xample, even if you may rendered. Services performed without have o nly been administered two (2) of your authorization will be denied. Authorization for s p inal manipulations for the Benefit Period, a ny co verage is not required when Covered Services add itional spina l manipulations for that Benefit are provided for the treatment of an Emergency Period will not b e covered if you have already Medical Condition. met the combined therapy visit maximum w ith other Services. 24728 0810 BCA BlueOption s Large Group 1 24673 0810 BCA The Preventive Adult Wellness Services In order to be covered, Services s ha ll be ca tegory is deleted in its en tirety an d replace d provided in accordance with prevailing medical w ith the following. s tandards cons istent with: Preventive Adult Wellness Services 1. evidence-based items or Services that have in effect a rating of ‚A™ or ‚ B™ in the current Preventive adult wellnes s Services are covered recommendations of the U .S. Preventive under your plan. For purpos es o f this benefit, an Services Task Force established und er the adu lt is 17 years or old er. Pub lic Health Service Act; In order to be covered, Services s ha ll be 2. immunizations that h ave in effect a provided in accordance with prevailing medical recommendation from the Advisor y s tandards cons istent with: Committee on Immunization Practices of the 1. evidence-based items or Services that ha ve Centers for Diseas e Control and Prevention in effect a rating of ‚A™ or ‚ B™ in the current es tablished under the Pub lic Health Service recommendations of the U .S. Preventive Act with res pect to the individual involved; Services Task Force established under the and Pub lic Health Service Act; 3. w ith respect to infants, ch ildren, a nd 2. immunizations that h ave in effect a ado lescents , evidence- informed preventive recommendation from the Advisor y care and s creenings pro vided for in the Committee on Immunization Practices of the comprehens ive guidelines s upported b y the Centers for Diseas e Control an d Prevention Health R es ources an d Services es tablished under the Pub lic Health Service Administration. Act with res pect to the individual involved; The following new categor y is added: and Emergency Services 3. w ith respect to w omen, such additional preventive care and screenings not Emergency Services and care for an Emergency des cribed in paragraph (1) as provided for in Medical Condition are covered In-Network and comprehens ive guidelines s upported b y the Out-of-Netw ork without the need for any prior Health R es ources an d Services authorization determination by us. Administration. When Emergency Services and care for an Exclusion: Emergency Medical Condition are rendered by an Out-of-Network Provider, any Copayment Routine vision and hearing examinations and and/or Coinsurance amount applicable to In- s creenings are not covered, except as required Network Providers for Emergency Services and under paragraph number one above. care w ill also appl y to such Out-of-Network Preventive Child He alth Supervision The Provider. Services categor y is deleted in its entirety and replaced w ith the following: Preventive Child H ea lth Supervision Services Preventive Child Health Supervision Services t h from the moment o f birth up to the 17 birthda y are covered. 24728 0810 BCA BlueOption s Large Group 2 24673 0810 BCA 3. you whe n the Group has elected to waive, in What I s No t Cove re d? writing , at the time of Group Application the Pre-existing C onditions exclusionar y per iod The Dr ugs exclusion is amended by deleting for all s ubseque nt Eligible Employees and/or exclusion number three in its ent irety and Eligible De pendents replacing it with the follo w ing: 4. the Covered Dependent ch ild w ho is under 3. Any non-Prescription medicines, remedies , the age of 19 as of the e ffective date of this vaccines , biological products (e xcept End orsement, or if enrolled thereafter, is insulin), pharmaceuticals or chemical under the age of 19 at the time of compounds, vitamins, mineral s upp lements , enrollment; fluoride products, over-the-counter drugs, products , or health foods, e xcept as 5. pregnanc y; des cribed in the Preventive Adult Wellness 6. Genetic Information in the absence of a Services and Preventive C h ild Health diagnosis of the Condition; Sup ervision Services ca tegor ies of the 7. routin e follow-up care of breast cancer after fWhat Is Covered?f s ect ion. the person w as deter mined to be free o f The Genetic Screening exclusion is deleted in breas t cancer; its entirety and replaced w ith the follow ing: 8. Cond itions arising from domestic vio lence; Genetic screening , including the evaluation of or genes to determine if you are a carrier of an 9. inherited diseases of amino acid, organic abnormal gene that puts you at r isk for a ac id, carbohydrate or fat metabolism as w e ll Cond ition, except as pro vided under the as ma labsorptio n originating from congenital Preventive Adult Wellness Services and defects present at b irth or acquired during Preventive Child Health Supervision Services the neonatal p eriod. ca tegories of the fWhat Is Covered?f s ect ion. Te r mination of Cove rag e Pre-ex isting Conditions Ex clusion Perio d Rescission of Coverage We reser ve the right to R es cind the coverage The list of exceptions in the Introduction is under this Group Mas ter Policy for any individual deleted in its entirety and replaced w ith the co vered under this Group Master p olicy as following: permitted b y law. Th is Pre-existing Co ndition exclusionary period We may only Rescind the c overage under this does n ot apply to Group Master Policy if you, or another pers on on 1. the Covered Employee and each C overed your behalf commits fraud or intentional Depende nt who w as covered under the misrepres en tation of material fact in ap plying for co verage or bene fits. Group™s pr ior medical plan on the date immediately prece ding the Effective Date of We w ill provide at leas t 45 days advance written co verage under this Booklet; notice our intent to Resc ind coverage. 2. you if you wer e enrolled during the Initial Res ciss ion of coverage is c ons idered an Enrollment Period prior to the Effective Date Adverse Benefit Determination and is s ubject to of the Group; 24728 0810 BCA BlueOption s Large Group 3 24673 0810 BCA the Adverse Benefit Determination review time limits applicable to such proced ures; procedure des cribed in the fC laims Process ingf and, s ection of this Benefit Booklet. Ł if the Adverse Benefit Determination is bas ed on the Medical Neces s ity or Claims Process ing Experimental or Invest igational limitations and e xclus ions, a s tatement telling you how Standards for Adverse Benefit The to obtain the s pecific explanation of the Determinations subs ection is deleted in its s cientific or clinical judgment for the entire ty and rep laced w ith the following: determination. Mann er and Co ntent of a Notification of an If the claim is a Claim Involving Urgent Care, we Adverse Benefit Determination: may notify you orally within the proper timeframes, provided we follow-up w ith a written We will us e our best efforts to provide notice of or electronic notification meetin g the any Adverse Be nefit Determination in w riting. requirements of this s ubs ection no later than Notification of an Adverse Benefit Determination three days after the oral notification. w ill inclu de (or will b e made available to you free of charge upon reques t): How to Appeal an Adverse B enefit The Determination is amended b y deleting the Ł the date the Service or s up ply was provided; s ection in its en tirety and replacing it w ith the Ł the Provider™s name following: Ł the dollar amount of the claim, if applicable; You have the r ight to an independent external Ł the diagnos is codes includ ed o n the claim review throug h an external review organ ization (e.g., ICD-9, DSM-IV), including a for certain appeals, as provided in the Patient des cription of such codes ; Protection and Affordable Care Act of 2010. Ł the standardized procedure code included The How to Request External R eview of Our on the claim (e.g., Current Procedural Appe al Decision s ubs ection is de leted in its Te rminolog y), including a des cription of s uch entire ty and rep laced w ith the following: codes ; Ł the specific reason or reasons for the How to Request External Review of Adverse Benefit Determination, including Our Appeal Decision any applicable d enial code; If you are not satisfied w ith our in ternal review o f Ł a description of the specific Benefit Booklet your appeal of an Ad verse Benefit provisions upon w hich the Adverse Benefit Determination , pleas e refer to the Adverse Determination is bas ed, as w ell as an y Ben efit Determination notice or call the cus tomer intern al r ule, gu ideline, protocol, or other s ervice phone n umber on your ID Card for information on how to reques t an external s imilar criterion that was relied upon in review. making the Adverse Benefit Determination; Ł a description of any a dditional information that might change the determination and w hy that informatio n is nec es s ary; Ł a description of the Adverse Be nefit Determination review proce dures an d the 24728 0810 BCA BlueOption s Large Group 4 24673 0810 BCA The definition o f Medical Emergenc y is deleted Definitions in its entirety and replaced w ith the follow ing: Adverse Benef it The definition o f Emergency M e dical Condition means a Determination is de leted in its entirety and medical or ps ychiatric Condition or an injury replaced w ith the following: manifesting itse lf by acute symptoms of s u fficient se verit y ( including severe pain) such A dver se B e nefit Determination means any that a prud ent laypers on , who pos s es s es an den ial, reduction or termination of coverage, average k now ledge of health and medicine, benefits, or pa yment ( in whole or in part) under could reas onabl y expect the abs ence of the Contract in connection with: immediate medical attention to res ult in a 1. a Pre-Service Claim or a Post-Service condition described in claus e (i), (ii), or (iii) of Claim; Section 1867(e)(1)( A) of the Social Security Act. 2. a Concurren t Care Decision , as d es cribed in The following definitions are added: the fClaims Process ingf s ec tion; or 3. Res ciss ion of coverage, as des cribed in the Rescission Rescind or refers to BCB SF™s fTermination of Co veragef s ection; ac tion to retroactively cancel or discontinue co verage u nder the Group Hea lth. Plan. The definition o f Emergency Services and Res ciss ion d oes not include a cance llation or Care is dele ted in its entirety and replaced w ith discontinuance of co verage w ith only a the follow ing: pros pective effect or a cancellation or Emergency Services means, with respect to an discontinuance of co verage that is e ffective Emergency Medical Condition: retroactively due to non-payment of Premiums 1. a medical screening examination (as Stabilize s hall ha ve the same meaning w ith required under Section 1867 of the Social regard to Emergency Services as the term is Security Act) that is w ithin the capability of defined in Section 18 67 of the Soc ial Security the emergency department of a Hospital, Act. including a ncillary Services routinely available to the emergency department to The follow ing definition is deleted: evaluate s uch Emergenc y Medical Exte rnal R eview Organization Cond ition; and 2. w ithin the capabilities of the s taff and facilities available at the hos pital, s uch further medical examination and treatment as are required under Section 1867 of such Act to Stabilize the patient. 24728 0810 BCA BlueOption s Large Group 5 24673 0810 BCA Th is Endors ement shall n ot e xtend, vary, alter, replace, or waive any of the provisions, bene fits, exclusions , limitations, or conditions contained in the Benefit Book let, other than as s pecifically s tated in this Endors ement. In the e ven t of an y inconsistenc ies betw een the provisions contained in this Endors ement a nd the provisions contained in the Ben efit Booklet, the provisions contained in this Endors ement s hall control to the exten t necess ary to effectuate the intent of Blue Cross and B lue Shield of Florida, Inc. as expres sed herein. Blue Cross and B lue Shield of Florida, Inc. Patrick J. Geraght y Chairman of the Board an d Chief Executive Officer 24728 0810 BCA BlueOption s Large Group 6 24673 0810 BCA BlueOptions Health C are Reform A m en dmen t Th is Endors ement is to be attached to and made a part of the Blu e Cross and Blue Shield of Florida, Inc. (herein fBCBSFf) BlueOptions Benefit Booklet including any Endorsements attached thereto. If you h a ve any ques tions concerning this Endors ement, please ca ll us toll free at 800 -FLA-BLUE. CLA IMS PROCESSING The Standards for Adv erse Benefit D eterminations subs ection is amended as follo ws : The Manner and Co ntent of a Notification of an Adverse Benefit Determination is amended b y deleting the n umbered list in its e ntirety and replacing it with the following: Man ner and Content of a Notification of an Adverse Benefit Determination We w ill use our best efforts to pro vide notice of any Adverse Benefit Determination in writing. Notification of an Adverse Benefit Determination w ill include (or will be made available to you free of charge upo n reques t): 1. the date the Service or s up ply was provided; 2. the Provider™s name; 3. the dollar amount of the claim, if applicable; 4. the diagnos is codes includ ed o n the claim (e.g., ICD-9, DSM-IV), including a description of such codes ; 5. the standardized procedure code included on the claim (e.g., Current Procedural Terminology), including a des criptio n of such codes; 6. the specific reason or reasons for the Adverse Benefit Determination, includ ing any applicable denial code; 7. a reference to the s p ecific Booklet provisions up on which the Adverse Benefit Determination is bas ed, as w ell as an y internal rule, guideline, pr o tocol, or other s imilar criterion that was r elied upon in making the Adverse Benefit Determination; 8. a description of any a dditional information that might change the d e termination a nd w h y that information is neces s ar y; 9. a description of the Adverse Be nefit Determination review procedures and the time limits appl icable to s uch procedures; and 10. if the Adverse Benefit Determination is bas ed on the Medical Neces s ity or Experimental or Investigational limitatio ns and exclusions , a s tatement telling you how you can obtain the spec ific explanation of the scientific or clinical judgment for the determination. BlueOptions Large Group 24922 0312 BCA 1 Th is Endors ement shall n ot e xtend, vary, alter, rep lace, or w aive any of the pro visions , be nefits, exclusions , limitations, or conditions contained in the Benefit Book let, other than as s pecifically stated in this Endorsement. In the event of any inconsistencies betw een the provisions contained in this End orsement and the provisions contained in the Benefit Book let, the provisions con tained in this End orsement shall control to the extent necess ar y to effectuate the intent of Blue Cross and Blue Shield of Florida, Inc. as express ed herein. Blue Cross and B lue Shield of Florida, Inc. Patrick J. Geraght y Chairman of the Board and Chief Executive Officer BlueOptions Large Group 24922 0312 BCA 2 ® Script Con traceptiv e A m en dm en t Bl ue Th is amendment is to be attached to, and made a part of your Blue Cross an d B lue Shield of Florida, Inc. ® (fBCBSFf) Benefit Booklet (fBookletf). Your BlueScript Ph armacy Program Endors ement is amended as des cribed below. Th is amendment is effective at your Group plan™s initial effective date occurring on or after August 1, 2012 or first Anniversar y Date occurring o n or after August 1, 2012 w hichever occurs first . If you have any ques tions c oncerning this amendment, please call us toll free at 800-FLA-BLUE. COVERED P RESCRIP TION DRUGS AND SUP PLIES AND COV ERE D OTC DRUGS Number 1 is deleted in its e ntirety and replaced w ith the following: 1. Prescribed b y a Physician or other health care profes siona l (except a Pharmacist) acting wi thin the s cope of his or her license except for vaccines , which are covered when pres cribed and administered by a Pharmacist w ho is certified in immunization administration; COVE RAGE AN D BE NEFI T GUIDE LINES FOR COVERE D PRESCRI P TION DRUGS AND S UPP LIES AND COV ERE D OTC DRUGS Contraceptive Coverage The category is deleted in its entirety and replaced w ith the follow ing: Contraceptive Coverage All Pres cription diaphragms, oral co ntracep tives and contraceptive p atches are co vered u nder this ® End orsement unless indicated as not co vered on the BlueScript Ph armacy Program Schedule of Ben efits and s ubject to the limitations and exclusions listed in this Endors ement. The follow ing are covered at no cost to you when pres cribed by a Ph ysician or other he alth care profess ional (except a Pharmacist) act ing within the scope of his or her licens e and purchas ed at a Participating Pharmacy: 1. Generic Prescription oral contraceptives indicated as covered in the Medication Guide; Exceptions ma y be consid ered for Brand Name and/or Non-Preferred oral contraceptive Prescription Drugs whe n d es ignated Generic Prescription Drugs in the Medication Guide are not appropriate for you beca use of a d ocu mented allergy, ineffectiveness or s ide effects. In order for an exception to be cons idered, we must receive an fException R eques t Formf from your Ph ysician. You can obtain an Exception Request Form on our we bs ite at w w w .floridab lue.com, or you ma y ca ll the cus tomer s ervice p hone number on your ID Card and one w ill be mailed to you u pon r equest. 2. Diaphragms indicated as co vered in the Medication Guide; a nd 3. Emergency contraceptives indicated as covered in the Medication Guide. BlueScript for BlueOptio ns Large Group 24931 0312 BC A 1 Exclusion Contrace ptive injectable Pres cription Drugs, and implants (e.g., Norplant, IUD, etc.) inserted for any purpos e are excluded from coverage under this End orsement. LIMI TATIONS AND E XCLUSI ONS Limitations The s ubs ec tion is amended by deleting exclusion number 6 in its entirety and rep lacing it w ith the following: 6. Retinoids (e.g., Retin-A) and their generic or therapeutic equivalents are excluded after age 2 6. The Exclusions subs ection is amended by de leting exclusions 3, 11, and 22 in their e n tirety and replacing them w ith the following: 3. Any Drug or Supply which can be purchase d o ver-the-counter without a Prescription, e ven though a written Prescription is provided ( i.e., Drugs wh ich d o not require a Prescription) e xcept for e mergency contraceptives, ins ulin a nd Covered OTC Drugs listed in the Medicatio n Gu ide. 11. Immunization agents , biological s era, b lood and blood plasma, except as listed in the Covered Prescription Drugs and Supplies and Covered OTC Drugs subs ection. 22. Prescription Drugs des ignated in the Medication Guide as not covered based on (but n ot limited to) the follow ing criteria: a. the Drug is a Re packaged Drug; b. the Drug is n o longer marketed; c. the Drug has been s how n to ha ve excess ive adverse effects and/or s afer alternatives; d. the Drug is a vailable Over-the-Counter (OTC); e. the Drug has a preferred formular y a lternative; f. the Drug has a w idely available/ distribu ted AB rated generic equivalent formulation; g. the Drug has sh own limited effectiveness in relation to alternative Drugs o n the formulary; or h. the number of m embers affected b y the ch ange. Refer to the Medication Guide to determine if a particular Prescription Drug is excluded un der this End orsement. DEFI NI TIONS The Covere d Prescription Supply(ies) definition is deleted in its entirety and replace d with the follow ing: Cov ered Prescription Supply(ies) means only the follow ing Supplies: 1. diaphragms indicated as covered in the Medication Guide; 2. s yringes an d ne edles pres cribed in conjunction with Ins ulin , or a covered Self-Administered Injectable Prescription Drug which is authorized for coverage b y us; BlueScript for BlueOptio ns Large Group 24931 0312 BC A 2 3. s yringes an d ne edles pres cribed in conjunction with a Pres cription Drug authorized for coverage by us ; or 4. Prescription Supplies us e d in the treatment of diabe tes limited to only b lood glucos e tes ting strips a nd tablets, lancets, b lood glucose meters, and acetone tes t tablets (un less indicated as not covered on ® the BlueScript Pharmacy Program Schedule of Bene fits). The Non-Preferred Prescription Drug de finition is deleted in its entirety and replaced w ith the following: Non-Prefe rred Prescription Drug means a compound drug or Generic Pres cription Drug or Brand Name Prescription Drug that is not included on the Preferred Medication List then in effect. Prescription Drug The definition is deleted in its entirety and replaced with the follo w ing: Prescription Drug means any medicinal subs tance, remedy, vaccine, biolo gical product, Drug, pharmaceutical or chemical compound wh ich can only be dispens e d p urs uan t to a Pres cription and/or w hich is requ ired by s tate law to bear the follow ing statement or s imilar statement on the label: "Caution: Federal law pro hibits d ispens ing without a Prescription". For purposes of this Endors ement, emergency contraceptives and ins ulin are considered a Prescription Drug because, in order to be covered, we require tha t it be prescribe d by a Phys ician or other hea lth care profess ional (except a Pharmacist) acting w ithin the scope of his or her license. The following new definition is adde d: Repackaged Drug(s) means a ph armaceutical pro duct that is removed from the original manufacturer container (Brand Originator) and repackaged b y a nother manufacturer w ith a different NDC. Th is amendment s ha ll not extend, vary, alter, replace, or wa ive any of the provisions, benefits, exclusions , limitations, or conditions contained in the Booklet, other than as spec ifically stated in this amendment. In the event of any inconsistencies betw e en the provisions co ntained in this amendment and the provisio ns contain ed in the Booklet, the pro vis ions contained in this amendment shall co ntrol to the extent necess ar y to effectuate the intent of Blue C ros s and Blue Shield of Flo rida, Inc. as express ed herein. Blue Cross and Blue Shield of Florid a, Inc. Patrick J. Geraght y Chairman of the Board an d Chief Executive Officer BlueScript for BlueOptio ns Large Group 24931 0312 BC A 3 Options 2012 Health C are Reform En dorsemen t Bl ue Th is Endors ement is to be attached to and made a part of the Blu e Cross and Blue Shield of Florida, Inc. (herein fBCBSFf) BlueOptions Benefit Booklet including any Endorsements attached thereto. If you h a ve any ques tions concerning this Endors ement, please ca ll us toll free at 800 -FLA-BLUE. Except as otherw ise noted, your Book let is amended a s des cribed below to comply w ith the Patient Protection and Affordable Care Act (PPACA), H.R. 35 90, otherwise know n as the Affordable C are Act. The provisions conta ined in this End orsement are effective at your Group™s initial e ffective on or after August 1, 2012 August 1, 2012, or first Anniversary Da te occurring on or after w hichever occurs first. All re ferences to the f Prevent ive Adult Wellness Serv ices f and f Preventive Child Health Supervision Services fPreventive Health Service sf. f categories throughou t the Booklet are hereby re placed with WHA T IS C OVERED? Emergency Services The following is added a t the end of the categor y: Special Pa yment Rules for Non-Grandfathered Plans The Pa tient Protectio n an d Affordable Care Act ( PPACA) requ ires that n on-grandfathered health pla ns appl y a s pecific method for determining the allowed amount for Emergency Services rendered for an Emergency Medical Condition by Providers w ho do n ot ha ve a contract with us. Payment for Emergency Se rvices rendered b y an Out-of-Network Provid er that ha s not e ntered into an agreement with BCBSF to provide access to a discount from the billed amount of that Provider will be the greater of: 1. the amount equal to the median amount n egotiated w ith all BCBSF In-Network Providers for the s ame Services; 2. the Allowed A mount as defined in the Book let; 3. the usua l and cus tomar y Provider ch arges for similar Services in the community where the Services w ere provided; or 4. w hat Medicare wou ld h a ve paid for the Services rendered. In no event will Out-of-Network Provid ers be paid more than their charges for the Services rendered. If your plan is a grandfathered health plan under PPACA, these payment guidelines do not apply to your plan. If you are not s ure whe ther or not your health plan is grandfathered, pleas e contact yo ur Group. BlueOptions Large Group 24921 0312 BCA 1 The Preventive Adult Wellness Services and Pr eventive Child Health Supervision Services ca tegories are deleted in their entirety and replaced w ith the following: Preventive Health Services Preventive Services are covered for both adults a nd c hildren based on pre vailing medical s tandards and recommendations wh ich ar e explained further below. So me examples of preventive health Services include, but are n ot limited to, periodic routine he alth e xams, routine gynecological exams , immunizations and related preventive Services s uch as Prostate Specific Antigen (PSA), routine mammograms and pap smears . In order to be covered, Services s ha ll be provided in accordance with prevailing medical s tandards cons istent with: 1. evidence-based items or Services that have in effect a rating of ‚A™ or ‚ B™ in the current recommendations of the U .S. Preventive Services Tas k Force es tablishe d un der the Public Health Service Act; 2. immunizations that h ave in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Diseas e Con trol and Prevention es tablished un der the Public Health Service Act with respect to the individual in volved; 3. w ith resp ect to infants, children, and adolescents, e vidence- informed preventive care and screen ings provided for in the comprehens ive guidelines s upp orted b y the He alth Reso urces and Ser vices Administration; and 4. w ith respect to w omen, s uch additional preventive care and s creenings not des cribed in paragrap h number one as pr o vided for in comprehensive guidelines s upported by the Health Resources an d Services Administration. Women™s preventive co verage under this category includes: a. w ell-woman visits; b. s creening for gestational diabetes; c. human papillomavirus tes t ing; d. couns e ling for sexually tran smitted infections; e. couns e ling an d screening for human immune-deficiency virus ; f. contraceptive methods and couns eling un less indicated as covered under a BlueScript Pharmacy Program Endorsement; g. s creening and couns eling for interpersonal and domestic violence; and h. breas tfeeding s upport, s upplies an d counse ling. Breas tfeeding s upp lies are limited to one manual breas t pump per pregnanc y. Exclusion: Routine vision and hearing examinations and scree nings are not covered, except as required under paragraph number one above. Sterilization procedures covered un der this s ection are limited to tuba l ligations only. Contracept ive implants are limited to Intra-uterine d evices (IUD) only, includ ing ins ertion and removal. BlueOptions Large Group 24921 0312 BCA 2 CLA IMS PROCESSING The Standards for Adv erse Benefit Determinations subs ection is amended as follo ws (these changes are not related to the Affordable Care Act): The Manner and Co ntent of a Notification of an Adverse Benefit Determination is amended b y deleting the n umbered list in its e ntirety and replacing it with the following: Man ner and Content of a Notification of an Adverse Benefit Determination We w ill use our best efforts to pro vide notice of any Adverse Benefit Determination in writing. Notification of an Adverse Benefit Determination w ill include (or will be made available to you free of charge upo n reques t): 1. the date the Service or s up ply was provided; 2. the Provider™s name; 3. the dollar amount of the claim, if applicable; 4. the diagnos is codes includ ed o n the claim (e.g., ICD-9, DSM-IV), including a description of such codes ; 5. the standardized procedure code included on the claim (e.g., Current Procedural Terminology), including a des criptio n of such codes; 6. the specific reason or reasons for the Adverse Benefit Deter mination, includ ing any applicable denial code; 7. a reference to the s p ecific Booklet provisions up on which the Adverse Benefit Determination is bas ed, as w ell as an y internal rule, guideline, pr o tocol, or other s imilar criterion that was r elied upon in making the Adverse Benefit Determination; 8. a description of any a dditional information that might change the determination and wh y that information is neces s ar y; 9. a description of the Adverse Be nefit Determination review procedures and the time limits appl icable to s uch procedures; and 10. if the Adverse Benefit Determination is bas ed on the Medical Necess ity or Experimental or Investigational limitatio ns and exclus ions, a s tatement telling you how you can obtain the spec ific explanation of the scientific or clinical judgment for the determination. Th is Endors ement shall n ot e xtend, vary, alter, replace, or waive any of the provisions , benefits, exclusions , limitations, or conditions contained in the Benefit Book let, other than as s pecifically stated in this Endorsement. In the event of any inconsistencies betw een the provisions contained in this Endorsement and the provisions contained in the Ben efit Booklet, the provisions con tained in this End orsement shall control to the extent necess ar y to effectuate the intent of Blue Cross and Blue Shield of Florida, Inc. as express ed herein. BlueOptions Large Group 24921 0312 BCA 3 Blue Cross and Blue Shield of Florid a, Inc. Patrick J. Geraght y Chairman of the Board an d Chief Executive Officer BlueOptions Large Group 24921 0312 BCA 4 ® BlueCard Program Endorsement Th is Endors ement is to be attached to and made a part of your current Blue Cros s and Blue Shield of Florida, Inc. ("BCBSF") Benefit Booklet and any Endors ements attached thereto. If you have any ques tions concerning this Endorse ment, pleas e call us toll free at 800-FLA-BLUE. The Benefit Booklet is hereby amended by deleting the BlueCard ( Out-of-State) Program s ection in its entirety and replacing it with the following: BLUECARD PROGRAM Out-of-Area Ser vices We have a variety of relationships w ith other Blue Cross and/or B lue Shield L icensees referred to genera lly as fInter-Plan Programs f. Whenever you obtain Health Care Services outside of our s er vice area, the claims for thes e Services may be proces s ed through one of thes e Inter-Plan Programs, which include the B lueCard Program and may include negotiated National Account arrangements available between us and other Blue Cross and Blue Sh ield Licens ees. Typically, w hen access ing care outside our s er vice area, you will obtain care from health care Providers that have a contractual agreement (i.e., are fparticipating providersf) with the local Blue Cross and/or Blue Shield Licensee in that other geographic area (fHost Bluef). In s ome instances , you may obtain care from non-participating health care Providers. Our payment practices in both ins tances are des cribed below. BlueCar d Program Under the BlueCard Program, w hen you access Covered Services within the geographic area served by a Hos t Blue, we will remain respons ible for fulfilling our contractual obligations. However, the Host Blue is res pons ible for contracting w ith and generally handling all interactions w ith its participating health care Providers. Whenever you access Covered Services outside our s ervice area and the claim is proces s ed through the BlueCard Program, the amount you pa y for Covered Services is ca lculated bas ed on the lower of: Ł The billed covered charges for your Covered Services, or Ł The negotiated price that the Host Blue makes available to us . Often, this "negotiated price" w ill be a s imple discount that reflects the actual price that the Host Blue pays to your health care Provider. Sometimes, it is an estimated price that takes into account special arrangements with your health care Provider or Provider group that may include types of s e ttlements, incentive payments, and/or other credits or charges. Occasionally, it may be an average pr ice, based on a discount that res ults in expected average savings for s imilar types of health care Providers after taking into account the s ame t ypes of trans actions as w ith an es timated price. BlueCard Program BlueOptions Group 24978 L G 0612 BCA 1 Estimated pricing and average pricing, going forward, also take into account ad just ments to correct for over- or underes timation o f modifications of past pricing for the types of trans action modifications noted abo ve. How ever, such adjus tments w ill not affect the price we us e for your claim becaus e they will not be app lied retroactively to claims already paid. Laws in a s mall number of states may require the Hos t Blue to add a s urcharge to your ca lculation. If any s tate laws mandate other liability calculation methods, including a s urcharge, we would then calculate your liability for any Covered Services accord ing to applicable law. Out-of-Network P roviders Outside BCBSF™s Service Area Your Liability Calculation When Covered Services are provided outside o f our service area b y non - participating health care Providers, our payment w ill be bas ed on the Allowed Amount as defined in the Benefit Booklet. Th is Endors ement shall not extend, vary, alter, replace, or waive any o f the provisions, benefits, exclusions , limitations, or conditions contained in the Benefit Booklet, other than as specifically s tated in this Endorsement. In the event of any inconsistencies betw een the provisions contained in this Endorsement and the provisions contained in the Benefit Booklet, the provisions contained in this Endorsement shall control to the e xtent necess ary to effectuate the intent of Blue Cros s and Blue Sh ield of Florida, Inc. as express ed herein. Blue Cross and Blue Shield of Florida, Inc. Patrick J. Geraghty Chairman of the Board and Chief Executive Officer BlueCard Program BlueOptions Group 24978 L G 0612 BCA 2 ® Blue Sc ript Oral Chemotherapy D rug Amendment Th is amendment is to be attached to and made part of your Blue Cr os s and Blue Shield of Florida, Inc. (fBCBSFf) Blue Options Benefit Booklet (fBook letf), including any Endors ements attached thereto. This ® document specifically amends the BlueScript Phar macy Program Endorsem ent as des cribed b elow . Th is amendment is effective at your Group plan™s in itial Effective Date occurring on or after July 1, 2014 or first Anniversary Da te occurring on or after July 1, 2014 w hichever occurs first . If you have any ques tions or c omplaints concerning this amendment, ple ase call us toll free at 800-FL A- BLUE. COVER A GE AND BENEFIT GUIDELINES FOR COVERED PRESCRIPTI ON DRU GS A ND SUPPLIES AN D COVERED OTC DRUGS The follow ing subcategor y is added : Oral Chemotherapy Drugs Your Cost Share for oral Pres cription Drugs us ed to kill or s low the gro wth of cancerous cells (chemotherapy), as cons istent w ith nationally accepte d s tandards , shall not exceed $ 50 per One-Month Sup ply w hen purchas ed from a Participating Pharmacy. Th is amendment s ha ll not extend, vary, alter, rep lace, or wa ive any of the pro visions, benefits, exclusions , limitations, or conditions contained in the Booklet, other than as s pec ifically s tated in this amendment. In the event of any inconsistencies betw e en the provisions co ntained in this amendment and the provisions contained in the Booklet, the pro vis ions contained in this amendment shall co ntrol to the extent necess ar y to effectuate the intent of Blue C ros s and Blue Shield of Flo rida, Inc. as express ed herein. Blue Cross and B lue Shield of Florida, Inc. Patrick J. Geraght y Chairman of the Board an d Chief Executive Officer 24312 0214 BC A BlueScript for B lueOptions Large Group ® BlueS cr ipt Specialty Pharmacy : Split Fill O ption A mendment This amendment is to be attached to and made p art of your Blue Cross and Blue Shield of Florida, Inc. ® (fBCBSFf) BlueOptions Benefit Booklet (fBookletf). Your BlueScript Pharmacy Program Endorsement is amended as d escribed below. January 1, This amendment is effective at yo ur Group plan™s initial Effective Date occurring on or after 2014 Ja nuary 1 , 2014 or first Anniversary Date occurring o n or after w hichever occurs first. If you have any questions or complaints concerning this amendment, please call u s toll free at 800-FLA - BLUE . COVERGE A ND BENEFIT GUIDELINES FOR C OVERED PRESCRIPTION DRU G S A ND SUPPLIES A ND COVERED OTC DRUGS The follow ing s u bs ec tion is added : Specialty Pharm acy: Split Fill Option Some types of medication may be difficult to tolerate for patients who are new to certain forms of treatment, such as oral oncology medication. To reduce w aste and help avoid cost for medications that w ill go unused, the Specialty Pharmacy may split the first fill for certain medications identified in the Medication Guide. The applicable Cost Share would also be split between the two fills. This amendment s hall not extend, vary, alter, replace, or w aive any of the provisions, benefits, exclusions , limitations, or conditions contained in the Booklet, other than as s pec ifically stated in this amendment. In the event of any incons istencies be tween the provisions containe d in this amendment and the provisions contained in the Booklet, the provisions contained in this amendment s hall control to the extent necess ary to effectuate the intent of Blue Cross and Blue Shield of Florida, Inc. as express ed herein. Blue Cros s and B lue Shield of Florida, Inc. Patrick J. Geraghty Chairman of the Board and C h ief Executive Officer 24287 0613 BCA BlueScript for BlueOptions Large Group BlueO ptions 2014 Health Care Reform Endorseme nt Th is Endors ement is to be attached to and made a part of the current Blue Cross and B lue Shield of Florida, Inc. ("BCBSF") BlueOptions Benefit Booklet and an y Endors ements attached thereto. If you h ave any questions or complaints concerning this Endorse ment, please ca ll us toll free at 800-FLA -BL UE. Th is Endors ement is effective at your Group plan™s initial E ffective Date occurring on or after January 1, 2014 Ja nuary 1 , 2014 or first Anniversar y Date occurring o n or after w hichever occurs first. T A BLE OF C ONTENTS Table of Contents Pre-Existing Conditions Exclusion Period The is amended b y deleting in its entire ty. WHA T IS C OVERED? The Introduction is amended as follows : Item number s ix is deleted in its entire ty and rep laced w ith the followin g: 6. not specifically or generally limited or excluded u nder this Booklet. The Clinical Trials ca tegory is added: Clinical Trials Clinical trials are r es earch s tudies in which Phys icians and other res earchers wor k to find w a ys to improve care. Each s tud y tries to ans w er s cientific quest ions and to find better wa ys to pre vent, diagnose, or treat pa tien ts. Each trial has a protoco l which explains the purpos e of the trial, h ow the trial w ill be performed, w ho may part icipate in the trial, and the b eginning and end points of the trial. If you are eligible to p articipate in a n Approved Clinical Trial, routine patient care for Services furnished in connec tion with your participation in the Approved C linical Trial may be covered when: 1. An In-Network Provider has indicated such trial is appr opriate for you , or 2. you pro vide us w ith medical and scientific information establishing that your participation in such tr ial is appropriate. Routine patient care includes all Medically Necess ar y Services that wo u ld otherwise be covered under this Booklet, s uch as doctor vis its, lab tes ts, x-rays and s cans and hos pital s tays related to treatment of your Con dition and is s ubject to the applicable Cost Sh are(s ) on the Schedu le of Benefits. Even though benefits may be a vailable u nder this Booklet for routine patient care related to an Appro ved Clinical Trial you may not b e eligible for inclusion in thes e trials or there may not be any trials available to treat your Condition at the time you w ant to b e included in a clinical tria l. 24281.3 BlueOptions Large Group 24281 0613 BCA 1 Exclusion 1. Cos ts that are g enerally covered by the clinical trial, including, but not limited to: a. Res earch costs related to c onducting the clinical trial s uch as res earch Physician and nurs e t ime, anal ysis of res u lts, and clinical tes ts performed only for res earch purpos es . b. The investigational item, device or Service itse lf. c. Services inconsistent w ith wide ly accepted and es tab lished standards of care for a particular diagnosis. 2. Services related to an Approved Clinical Trial received outside of the Un ited States . The Special Payment R ules for Non-Grandfathered Plans at the end of the Emergency Services ca tegory is deleted in its en tirety an d replace d with the following: Special Payment R ules for Non-Grandfathered Plans The Pa tient Protectio n an d Affordable Care Act ( PPACA) requ ires that n on-grandfathered health pla ns appl y a s pecific method for determining the allowed amount for Emergency Services rendered for an Emergency Medical Condition by Providers w ho do n ot ha ve a contract w ith us. Payment for Emergency Services rendered b y an Out-of-Network Provid er that ha s not e ntered into an agreement with BCBSF to provide access to a discount from the billed amount of that Provider will be the greater of: 1. the amount equa l to the median amount negot iated with all BCBSF In-Network Providers for the sa me Services; 2. the Allowed Amount as defined in the Booklet; or 3. what Medicare wo uld have paid for the Services rendered. In no event will Out-of-Network Provid ers be paid more than their ch arges for the Services ren dered. If your plan is a grandfathered health plan under PPACA, these payment guidelines do not apply to your plan. If you are not su re w hether or not your health plan is grandfathered, p lease con tact your Group. Inpatient Rehabilitation The ca tegory is amended b y deleting numbers three and five in their entirely and replac ing them w ith the follow ing: 3. co verage is subject to our Medical Neces sity coverage criteria then in effect; 5. the Reha bilitation Services mus t be required at such intensity, freque ncy and dura tion that further progres s canno t be achieved in a less intensive setting. Menta l Health Services The category is amended by de leting the first tw o parag raphs in the ir entirety and replac ing them w ith the following: Diagnost ic evaluation, psychiatric treatment, individual therapy, and group therap y rendered to you by a Physician, Psychologist or Mental H ealth Profes siona l for the treatment of a Menta l and N ervous Disor der may be covered. Covered Services may include : 1. Physician office vis its; 2. Intensive Outpatient Treatment (rendered in a facility), as de fined in this Booklet; and 24281.3 BlueOptions Large Group 24281 0613 BCA 2 3. Partial Hospitalization, as defined in this Booklet, when provided u nder the direction of a Ph ysician. Exclusion The is amended by deleting numbers one through four in their entirely and replacing them w ith the follow ing: 1. Services rendered for a Cond ition that is not a Mental and N er vous Disor der as de fined in this Booklet, re gardless of the underlying ca us e , or effect, o f the d isorder; 2. Services for psychological testing ass ociated with the evaluation and diagnosis of learning disab ilities or intellectual disability; 3. Services beyond the period neces s ar y for evaluation and d iagnosis of learning dis ab ilities or intellectual disab ility; 4. Services for marriage cou nseling u n less related to a Mental a nd N ervous Disorder as defined in this Booklet, re gardless of the underlying ca us e , or effect, o f the d isorder; The Preventive Health Services categor y is amended b y deletin g the exclus ion in its entirety and replacing it with the follo w ing: Exclusion Routine vision and hearing examinations and scree nings are not covered as Preventive Health Services, except as required under paragrap h number one an d/or number three above. Sterilization procedures co vered under this category are limited to tubal ligations only. Contracept ive implants are limited to Intra- uterin e d evices (IUD) indicated as covered in the Medication Guide only, including insertion and removal. MEDICA L NECESSITY Item number three is deleted in its entirety a nd replaced w ith the following: 3. s taying in the H os p ital because s upervision in the h ome, or care in the home, is not available or is inconvenie nt; or be ing hosp italized for any Service which could have been provided ad equately in an altern ate s etting (e.g., Hospital outpatient department or at home w ith Home Health Care Services); or PRE-EXISTING CONDIT IONS EXCLUSION PERIOD Pre-Existing Conditions Exclusion Period The Section is deleted in its entirety. 24281.3 BlueOptions Large Group 24281 0613 BCA 3 BLUEPRINT FOR HEALT H PROGR A MS Prior Coverage Authorization/Pre- Service Notificaton Programs The subs ection is deleted in its entire ty and rep laced w ith the following: Pr ior Coverage Auth orization/ Pre-Service Notification Pr ograms It is important for you to u nders tand our pr ior coverage authorization programs and how the Pr ovider you s e lect and the t ype of Service you receive affects these requ irements and u ltimately how much you w ill have to pay u nder this Booklet. You or your Phys ician will be required to obtain prior co verage a u thorization from us for: Prescription Drugs 1. , as denoted w ith a s pecial s ymbol in the Medication Guide; 2. advanced d iagnostic imaging Services, such as CT scans , MRIs, MRA and nuclear imaging; 3. Aut ism Spe ctrum Disorder Services; and Substance Dependency Care and Treatment 4. Services ; and 5. Mental Health Services; and 6. Services rendered in connection with Approved Clinical Trials ; and 7. other Health Car e Services tha t are or may b ecome subject to a prior coverage authorization program or a pre-service no tification program as defined and administered by us . You are solely respons ible for getting any requ ired authorization before Services are rendered regardless of w hether the Service is b e ing rendered by an In-Network Provider or Out-of-Network Provider. 1. In the case of Prescription Drugs, it is your sole respons ibility to obta in our prior coverage before If you do not authorization when you use a Provider the drug is purchase d or administered. obtain prior coverage authorization, we will deny cov erage for the Prescription Drug and not make any payment for the drug or any Service related to the drug or its administration. All Pres cription Drugs co vered un der the Medical Pharmacy category in the WHAT IS COVERED? s ection, require prior authorization. For a list of other medications that req uire prior coverage authorization and details on how to get an au thoriza tion, please refer to the Medication Guide. 2. In the case of a dvanced diagnostic imaging Services such as CT s cans , MRIs, MRA and nuclear imaging, you must obtain authorization w hen rendere d or re ferred by a Provider before the a dvanced diagnostic imaging Services are provided . If you do not obtain pr ior coverage authorization we will deny coverage for the Se rvices and not make any payment for such Ser vices. For details on ho w to ob tain pr ior coverage authorization for advanced diagnos tic imaging Services, pleas e call the customer ser vice phone n umber on the back of your ID Card. Autism Spectrum Disorder Services 3. In the case of , yo u must obtain an authorization when before If you rendered or referred by a Provider Autism Spectrum Disorder Services are provided. do not obtain prior coverage authorization we will not make any payment for such Services. 24281.3 BlueOptions Large Group 24281 0613 BCA 4 For details on h ow to obta in prior coverage author ization for Autism Spectrum Disorder Services, pleas e call the customer ser vice p hone number on your ID Card. 4. In the case of Substance Dependency Ca re and Treatment Services, you must obtain an before authorization when rendere d or referred b y a Provider Subs tance Depend ency Care and If you do not obtain pr ior coverage authorization we will not Treatment Services are pro vided. make any payment for such Services. For details on h ow to obta in prior coverage author ization for Subs tance Depe nde ncy Care and Treatment Services, please call the cus tomer s ervice p hone number on your ID C ard. Mental Health Services 5. In the case of , you must obtain an authorization when rendere d or referred by a Provider before Mental Health Services are provided. If you do not o btain prior coverage authorization we will not make any payment for such Services. For details on h ow to obta in prior co verage author ization for Mental Hea lth Services , please call the cus tomer s ervice phon e n umber on your ID Card. Approved Clinical Trials 6. In the case of Services re ndered in connection with , you must obtain an authorization when rendere d or referred b y a Provider before you obtain routine patient care provided If you do not obtain prior coverage authorization in connection with an Approved Clinical Trial. we will not make any payment for such Services. 7. In the case of other H ealth Care Services under a prior coverage authorization or pre-service notification program, you must obtain an authorization or comp ly with an y pre-s ervice no tification requirements when rendered or referred by a Provider, before the Services are provided. If you do not o btain a uthor ization or provide pre-service notification, we may: 1. den y p ayment of the c laim; or 2. appl y a b enefit penalty whe n the claim is pres ented to us for payment consist ing of one of the following: a. $500 b. 20% of the total Allowed Amount of the claim;or c. The less er o f $500 or 20% of the total Amount o f the claim. The decision to apply a penalt y or den y the claim will be made uniformly and the applicable denial/pena lty w ill be identified in the notice describing the prior coverage authorization and pre-s er vice notification programs. We w ill inform you of any Health Care Service that is o r w ill become subject to a prior coverage authorization or pre-service notification program, including how you can obtain prior coverage authorization and/or provide the pre-ser vice notification for such Service. This information will be provided to you upon enro llment, or at leas t 30 da ys prior to such Services becoming subject to a prior co verage a u thorization or p re-s er vice notification program. Such information may be provided to you electronically, if you have e lected the delivery of notifications from us in that manner. Changes to the list 24281.3 BlueOptions Large Group 24281 0613 BCA 5 of other He a lth Care Services that re quire prior authorization shall occur no more frequently than tw ice in a Calendar Year. Once the necess ar y medical documentation has been received from you and/or the Pr ovider, BCBSF or a des ignated vendor, will review the in formation and make a prior coverage author ization decision, bas ed on o ur establish ed criteria then in effect. You will be notified of the prior coverage authorization decision. Note: Prior coverage authorization is no t required when Emergency Services ar e rendered for the treatment of an Emergency Medical Condition. See the CLAIMS PROCESSING s ection for information on what yo u can do if prior coverage authorization is denied. ENROLLMENT A N D EFFECTIVE D A TE OF COVERA GE The Dependent Enrollment subs ection is amended by deleting the first par agra ph of the Adopted/Foster Children s ubs ection in its entirety and replacing it with the following: Adopted/Foster Children Œ To enroll a n adopted child (other tha n an a dopted newborn child) or Foster Child, the Covered Employee must submit an Enrollment Form during the 30-day period immediately following the date of placement and pa y the add itional Premium, if any. The Effective Date for an adopted or Foster Child (other than an a dopted new bo rn child) s hal l be the date s uch adopted or Foster Child is placed in the reside nce of the Covered Employee pursuant to Florida law. If timely notice is given, no additional Premium w ill be ch arged for coverage of the adopted ch ild or Fos ter Child for the duration of the n o tice per iod. We ma y requ ire the Covered Employee to provide any information an d/or documents deemed necess ary b y us in order to properly administer this section. The Other Provisions R egarding Enrollment and Effective Date of Coverage s ubs ection is amended by deleting the Rehir ed Employees s ubs ect ion in its entirely and replac ing it with the follow ing : Rehired Employees Individuals w ho are rehired as emplo yees of the Group are considered new ly-hired employees for purpos es of this s ection. The pro vis ions of the Group Master Policy (which includes this Booklet), app licable to new ly-hired emplo yees a nd their Eligible Dependents (e.g., enrollment, Effective Dates of co verage a nd Waiting Period) are applicable to rehire d employees an d their Eligible Dependents . CLA IMS PROCESSING The Standards for Adverse Benefit Determinations s u bs ection is amended by deleting How to Request External R eview of Our Appeal Decision in its entirety and rep lacing it with the follo wing: How to Request External Review of Our Appeal Decision If we den y your appeal an d our decision involves a medical judgment, including , but not limited to, a decision based on Medical Necess ity, appropriatenes s, health care s etting, le vel of care or effectiveness 24281.3 BlueOptions Large Group 24281 0613 BCA 6 of the He alth Care Service or treatment you requested or a d etermination that the treatment is Experimental or Invest igational, you are entitled to req ues t an independent, e xternal review of our decision. Your reques t will be review ed b y an in dependen t third party w ith clinical and legal expertise (fExternal Reviewerf) w ho has no as s ociation w ith us. If you have any questions or concerns during the external review proces s , p lease contact us at the ph one number listed on yo ur ID card or visit w w w .floridablue.com . You may submit additional written comments to External R eview er. A letter with the mailing address w ill be sent to you wh en you file a n external revie w. Please note that if you provide any additional information during the external re view proces s it will be s h ared w ith us in order to gi ve us the opportun ity to reconsider the denial. Submit your reques t in writing on the External Revie w Reques t form w ithin four months after receipt of your denial to the b elow addres s : Blue Cross and B lue Shield of Florida Attention: Member External Re views DCC9-5 Post Office Box 44197 Ja cks onville, FL 3 2231-419 7 If you have a medical Condition where the timeframe for completion of a s tandard external review w ould s erious ly jeopard ize your life, he alth or ability to regain maximum function, you may file a request for an expedited external re view. Generally, a n urg ent situation is one in which your h ealth ma y be in serious jeopardy, or in the opinion of your Ph ysician, you may experience p ain that canno t be adequately controlled while you wait for a decision on the external review o f your claim. Moreover exped ited external reviews may be reques ted for an a dmiss ion, a vailability of care, continued stay or Health C are Service for w hich you received Emergency Services, but have not been discharge d from a facility. Please be s ure your treating Ph ysician completes the appropriate form to initiate this reques t t ype. If you ha ve any ques tions or concerns dur ing the external review proc ess , please contac t us at the ph one number listed on your ID card or visit w w w. floridablue.com. You may s ubmit add itional written comments to the External Reviewer. A letter with the mailing addres s wi ll be s en t to you when you file an external review. Pleas e n ote that if yo u pro vide any a dditional information during the externa l review proces s it will be s hared w ith us in order to g ive us the o pportunity to recons ider the denial. If you belie ve your situation is urgent, you may request a n expedited review b y s end ing your re ques t to the addr ess abo ve or by fax to 904-565-6637. If the External Review er d ecides to overturn our decision , we w ill pro vide co verage or pa yment for your hea lth care item or Service. You or someone you name to act for you may file a request for external review. To appoint s omeone to ac t on yo ur be half, please complete an Appo intment of Repres entative form. You are entitled to receive, upon written reques t and free of charge, reason able a ccess to, and copies of all documents relevant to your appeal including a copy of the actual benefit provision, guideline protocol or other s imilar criterion on w hich the appeal decision was bas ed. You ma y req ues t and we w ill pro vide the diagnos is and treatment codes, as we ll as their corresponding meanings, ap plicab le to this notice, if available. 24281.3 BlueOptions Large Group 24281 0613 BCA 7 GENERA L PRO VISIONS subsection The following is added : Care P rofile Program Œ A Payer -Based Health Record Pr ogram A care profile is a vailable to treating Phys icians for each person covered under this Booklet. This care profile allows a s ecur e, electronic view of s pec ific claims information for Services rendered by Physicians, Hos pitals, labs, pharmacies , and other hea lth care Providers. Un less you have chosen to opt out, here are a few of the be nefits of participation in the Care Profile Program: 1. All au thorized treating Physicians w ill have a cons olidated view Œ or history Œ of your Health Care Services, ass ist ing them in improved d ecision-making in the de livery of health care. 2. In times of catastrophic events or Emergency Services, the care profile will be access ible from any location by authorized Phys icians s o that appropriate treatment and Service can still be delivered. 3. Safe and s ecure transmiss ion of claim information. Only authorized hea lth care Providers or authorized members of the Provider™s s taff will have access to your information. 4. Coordination of care among your authorized treating hea lth care Providers . 5. More efficient health care delivery for you. Kee ping your health information private is extremely important, so your care profile will not include certain hea lth information that p er tains to fs ensitivef medical conditions, for which the law provides s pecial protection. Hea lth care Providers access the care profile us ing the same secure, electronic channel they us e to file claims. In addition, o nl y a uthor ized members of the Provider™s staff w ill have access to the information. Rem ember, this will help your Physician in obtainin g important information concerning your hea lth history. How ever, if for s o me reason you, or an y of your Covered Dependents , choose not to pro vide your treating Physician access to your claim history, the use of this information may be restricted. Shou ld you choos e not to participate call the cus tomer service phone number on your ID C ard a nd inform a service ass ociate of your d ecision. DEFINITIONS Apr oved Clinical Trial The definition o f is added: Approved Clinical Trial means a phas e I, phase II, p has e I II, or phas e IV clinical trial that is conducted in re lation to the prevention, detection, or treatment of cancer or other Life-Threatening D iseas e or Cond ition and meets on e of the follow ing criteria: 1. The s tudy or investigation is appro ved or funded b y one or more of the follow ing: a. The National Ins titutes of Health. b. The Centers for Diseas e Control and Prevention. c. The Agency for Health Care Research and Quality. d. The Centers for Medicare and Medicaid Services. 24281.3 BlueOptions Large Group 24281 0613 BCA 8 e. cooperative gro up or center of an y of the e ntities des cribed in claus es (i) through (iv) or the Department of Defense or the Department of Veterans Affairs. f. A qualified non-governmental research entity identified in the guidelin es issued b y the N ational Institutes of Health for center support grants. g. Any of the following if the conditions des cribed in paragraph (2) are met: i. The Department of Veterans Affairs. ii. The Department of Defense . iii. The Department of Energy. 2. The s tudy or investigation is conducted un der an investigational new drug application re viewed b y the Food and Drug Administration. 3. The s tudy or investigation is a drug trial tha t is exempt from having such an investigational new drug app lication . For a s tudy or investigation conducted b y a Dep ar tment the study or investigation must be re viewed and approved through a s ystem o f peer review that the Secretary determines: (1) to be comparable to the s ystem of peer review o f studies and investig ations us ed b y the N ational Institutes of Hea lth, an d (2) as sures unb iased r eview of the h ighest scien tific s tandards by qualified individuals w ho ha ve no interest in the outcome of the review. For purposes of this definition, the term fLife-Threatening D iseas e or Conditionf means a ny dise as e or condition from w hich the likelihood of de ath is probab le unless the cours e of the diseas e or condition is interrupted . The definition o f Intensive Outpatient Treatment is added : Intensive Outpatient Treatment means treatment in w hich an individual receives at least 3 clin ical hours of ins titutio nal care p er da y (24-hour period) for at least 3 da ys a w eek and returns home or is not treated as an inp atient during the remainder of that 24-hour period. A Hos pital s hall not be considered a "ho me" for purposes of this d efinition. The definition o f Medically Necessar y or Medical Necessity is de leted in its en tirety and replaced w ith the follow ing: Med ically Necessary or Medical Necessity means that, with resp ect to a Health Care Service, a Provider, exercising pru dent clinical judgment, provided, or is propos ing or recommending to provid e the Health C are Service to you for the purpose o f preventin g, evaluating, diagnos ing or treating an illness , injur y, dise ase or its s ymptoms, and that the Health Care Service was / is: 1. in accordance w ith Generally Accepted Standards of Medical Practice; 2. clinically appropriate, in terms of type, frequency, extent, site of Service, duration, and co ns idered effective for your illnes s, injury, or dise as e or s ymptoms; 3. not primarily for your convenience, your family™s convenience, your caregiver™s co nvenience or that of your Ph ysician or other health care Provider, and 24281.3 BlueOptions Large Group 24281 0613 BCA 9 4. not more costly than the s ame or similar Service provided by a d ifferent Provider, b y w ay of a different method of administration, an alternative location (e.g., office vs. inpatient), and/or an altern ative Service or s eq uence of Services at least as lik ely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your illness , injury, diseas e or s ymptoms. When determining w hether a Service is not more cost ly than the s ame or similar Service as referenced ab ove, we may, but are not required to, take into cons ideration various factors including, but not limited to, the follow ing: a. the Allo wed Amount for Service at the location for the de livery of the Service versus an a lternate s e tting; b. the amount we have to pa y to the propos ed particular Provid er versus the A llowe d Amount for a Service by another Provider includ ing Providers of the same and/or different licensure and/or s pecialty; and/or, c. an a nalysis of the therapeutic and/or diagnos tic outcomes of an alternate trea tment versus the recommended or performed procedure including a comparison to no treatment. Any such anal ysis may include the sh ort and/or long-term health outcomes of the recommended or performed treatment versu s alternate treatments includ ing an analys is of s uch outco mes as the ability of the proposed procedure to treat comorbidities, time to diseas e recurrence, the likelihood of additional Services in the future, etc. Note : The distance you have to travel to r eceive a Health Care Service, time off from w ork, overall recovery time, etc. are not factors that we are requ ired to consider when evaluating whether or not a Health C are Service is n ot more cost ly than an alternative Service or sequence of Services. Reviews w e perform of Medical Necess ity may be based o n comparative effectiveness res earch , w here a vailable, or on evidence show ing lack of s uperiority of a par ticular Service or lack of difference in outcomes with res pect to a particular Service. In performing Medical Necess ity reviews , w e may tak e into co ns idera tion an d us e cos t data which may be proprietary. It is important to remember that any review of Medical Necess ity by us is s olely for the purpose of determining coverage or be nefits under this Book let and not for the purpose of recommending or providing medical care. In this res pec t, we may review spec ific medical facts or information pertaining to you. Any such review , h ow ever, is s trictly for the purpos e o f determining, among other things, wh ether a Service provided or propos ed meets the definition of Medical Neces s ity in this Book let as de termined b y us . In app lying the definition of Medical Necess ity in this Bo oklet, we may apply our coverage and payment guidelines then in effect. You are free to ob tain a Service even if w e den y coverage because the Service is not Medically Necessar y; howe ver, you w ill be solely respons ible for pa ying for the Service. 24281.3 BlueOptions Large Group 24281 0613 BCA 10 Mental and Nervous Disorder The definition o f is deleted in its en tirety a nd replaced with the following: Mental and Nervous Disorder means an y d isorder listed in the diagnos tic categor ies of the Interna tional Class ification o f Diseas e (ICD-9 CM or ICD 10 C M), o r their equivalents in the most recently publish ed version of the American Psychiatric Ass ociation's Diagnostic a nd Statistical Manu al of Mental D isorders, regardless of the underlying cause, or effect, of the disorder. Pa rtial Hospitalization The definition o f is deleted in its entirety and replaced w ith the follow ing: Partial Hospitalization means treatment in which a n individual rece ives at least 6 clinica l hours of institutiona l care per day ( 24-hour p eriod) for at least 5 days per w eek and returns home or is no t treated as an inp atient during the r emainder of that 24-hour period. A Hos pital s hall not be considered a "ho me" for purposes of this d efinition. Th is Endors ement shall n ot e xtend, vary, alter, rep lace, or w aive any of the pro visions , be nefits, exclusions , limitations, or conditions contained in the Benefit Booklet other than as spec ifically s tated in the provisions contained in this Endorsement. In the event of any inconsistencies betw een the provisions contained in this Endors ement and the provision s contained in the Benefit Book let, the provisio ns contained in this Endors ement s ha ll control to the e xtent necess ar y to effectuate the inten t of Blue Cross and Blue Shield of Florida, Inc. as expres sed here in. Blue Cross and B lue Shield of Florida, Inc. Patrick J. Geraght y Chairman of the Board an d Chief Executive Officer 24281.3 BlueOptions Large Group 24281 0613 BCA 11 BlueO ptions 2014 Compliance Endorsem ent Th is Endors ement is to be attached to and made a part of the current Blue Cross and B lue Shield of Florida, Inc. ("BCBSF") BlueOptions Benefit Booklet and an y Endors ements attached thereto. If you h ave any ques tions or complaints concerning this Endorse ment, please ca ll us toll free at 800-FLA -BL UE. Th is Endors ement is effective at your Group plan™s initial Effective Date occurring on or a fter J uly 1, 20 14 July 1, 2014 or first Anniversary Da te occurring on or after w hichever occurs first . Substance Dependency Care and Treatment All re ferences to f f throughout this Booklet are rep laced w ith f Substance Dependency f. WHA T IS C OVERED? The Menta l Health Services and Substance Dependency Care and Treatment categories are deleted in their entirety and replaced with the following: Behavioral Health Serv ices Mental Health Services Diagnost ic evaluation, psychiatric treatment, individual therapy, and group therap y rendered to you by a Physician, Psychologist or Mental H ealth Profes sional for the treatment o f a Mental and Nervous Disorder may be covered. Covered Services may include : 1. Physician office vis its; 2. Intensive Outpatient Treatment (rendered in a facility), as de fined in this Booklet; 3. Partial Hospitalization, as defined in this Booklet, w hen provided under the direction of a Physician; and 4. Res idential Treatment Services, as defined in this Booklet. Exclusion 1. Services rendered for a Cond ition that is not a Mental and N er vous Disor der as de fined in this Booklet, re gardless of the underlying ca us e , or effect, o f the d isorder; 2. Services for ps ycholog ical tes ting ass ociated with the evaluation and d iagnos is of learning disab ilities or intellectual disability; 3. Services beyond the period neces s ar y for evaluation and d iagnosis of learning disabilities or intellectual disab ility; 4. Services for educatio nal purposes ; 5. Services for marriage couns eling unless related to a Mental and Nervous Disorder as defined in this Booklet, re gardless of the underlying ca us e , or effect, o f the d isorder; 6. Services for pre-marital cou nseling; 24318.2 NGF BlueOptions Large Group 24318 0214 BC A 1 7. Services for court-ordered care or testing, or required as a condition of parole or probation; 8. Services to test aptitude, a b ilit y, intelligence or interest; 9. Services required to maintain employment; 10. Services for cognitive remediation; and 11. inpatient s tays that ar e primarily intended as a chang e of environment. Subs tance Dependenc y Treatment Services When there is a s udden drop in consumption after prolon ged heavy us e o f a s ubs tance a person may experience withdrawa l, often causing both ph ysiologic and cognitive symptoms. The symptoms of w ithdraw al vary greatly, rang ing from minimal changes to po tentially life threatening states. Detoxification Services can be re ndered in different types of locations , depe nding on the s e verity of the withdraw a l s ymptoms. Care and treatment for Subs tance Dependenc y includ es the following: 1. Inpatient and outpatient Health Care Services rendere d b y a Physician, Psycho logist or Mental Health Profess ional in a program accredited by The Jo int Commiss ion or appro ved b y the s tate of Florida for Detoxification or Substance Depende ncy. 2. Physician, Psychologist a nd Men tal Health Profess ion al o u tpatient visits for the care and treatment of Subs tance Dependenc y. We may provide you with information on resources a vailable to you for non-medical ancillar y s ervices like vocational r ehabilitation or employment couns eling, when w e are able to. We don™t pay for any services that are provided to you by any of these res ources ; they are to b e provided solely at your expense. You acknow ledge that we do not have any Co ntractual or other formal arrangements w ith the Provider o f such s ervices. Exclusion Long term Services for alcoholism or drug add iction , including s pecia lized inpatie nt un its or inpat ient s tays that are primarily intended as a ch ange of en vironment. The Preventive Health Services categor y is amended b y deletin g nu mber h u nder item number 4 in its entire ty and rep lacing it with the follo w ing: h. breas tfeeding s upport, s upplies an d counse ling. Breas tfeeding s upp lies are limited to breas t pumps. You must obtain prior coverage authorization from us before you get the bre ast pump . Breas t pumps mus t be obtained through a Durable Medical Equipment Provider who m ust be ab le to verify that you are either scheduled for delivery or have delivered within 9 months. In-Network benefits are only a vailable through our pre ferred Durable Medical Equipment Provider. If you do not o btain prior co verage a u thorization we w ill not make any payment for such Service. 24318.2 NGF BlueOptions Large Group 24318 0214 BC A 2 The follow ing Note is adde d after number h: Note: From time to time medical standards that are bas ed on the recommendations of the entities listed in n umbers 1 through 4 above ch ange. Services may be added to the recommendations and sometimes may be r emoved. It is important to u nders tand that your coverage for these preventive Services is bas ed on wh a t is in effect on your Effective Date. If any of the recommendations or guide lines change after your Effective Date, your co verage w ill no t change until your Group™s first Anniversary Date one year after the recommendations or guidelines go into effect. For example, if the USPSTF adds a new r ecommendation for a preventive Servic e that we do not cover and you are alread y covered under this Benefit Booklet; that new Service will not b e a Covered Service under this categor y right aw ay. The coverage for a new Service will star t on yo ur Group™s Ann iversar y Date one year after the ne w recommendation goes into effect. The Exclusion is de leted in its entirety and replaced w ith follow ing: Routine vision and hearing examinations and s cree nings are no t covered as Preventive Services, except as required under paragrap h number one and/or number three above. Sterilization procedures covered under this categor y are limited to thos e procedures ind icated as covered in the Medication Guide only. Contraceptive implants are limited to Intra-uter ine devices (IUD) indicated as covered in the Medication Guide only, including ins ertion and removal. The following limitations ar e added after the Exclusion : Limitations Breast p umps are limited to: a. one manual or e lectric breas t pump per pregnancy, in connection with childbirth; b. the most cos t-effective pump, as determined by us (p leas e s ee the D urable Medical Equipment ca tegory in this s ection for additional information); c. hos pital-grade breast p u mps are not covered except when Medically Neces sar y during an inpatient s tay, in accordance with our Med ical N eces s ity co verage criteria in effect at the time Services are provided. DEFINITIONS The follow ing definitions ar e added: Psychiatric Facility means a facility properly licens ed under Flor ida law, or a s imilar applicable la w of another s tate, to provide for the Medically Neces s ary c are and treatment of Mental and Nervous Disorders . For purpos es of this Booklet, a ps ychiatric facility is not a Hospital or a Substance Abus e Facility, as de fined herein. Psychologist means a per s on prop erly licens ed to practice ps ycholog y p ursuant to Ch apter 49 0 of the Florid a Statutes, or a s imilar appl icable law of another s tate. 24318.2 NGF BlueOptions Large Group 24318 0214 BC A 3 Residential Treatment Facility means a facility properly licensed und er Florida law or a s imilar app licable law of another state, to provide care and treatment of Men tal and N ervous Disord ers and Subs tance Dependenc y a nd meets all of the following requirements: Ł Has Mental Health Profes siona ls on-site 24 hours per day and 7 days per w eek; Ł Provides acces s to necess ar y med ical s er vices 24 hours per da y and 7 days p er w eek ; Ł Provides acces s to at least w eekl y s es s ions w ith a beh avioral health profes sional fully licensed for independent practice for ind ividual ps ychotherap y; Ł Has individualized active trea tment plan directed tow ard the alleviation of the impairment that caus ed the admiss ion; Ł Provides a level of sk illed intervention cons istent with patient risk ; Ł Is not a wildernes s treatment program or any s uch related or similar program, school and/or education service. With regard to Su bstance Depende ncy trea tment, in addition to the ab ove, mus t mee t the following: Ł If Detoxification Services ar e necess ary, provides access to necess ar y o n-s ite medical services 24 hours per da y and 7 days p er w eek , w hich must be actively supervised b y a n attending p hys ician; Ł Ability to ass es s and recognize withdrawa l comp lications that threaten life or bodily func tion a nd to obtain needed Services e ither on s ite or externally; Ł Is s upervised b y an on-site Phys ician 24 hours per da y and 7 da ys p er week w ith evidence of close and freque nt obser vation. Residential Treatment Services means treatment in w hich an individual is admitted b y a Physician overnight to a H ospital, Ps ychiatric Hos pital or Residen tial Treatment Facility and receives daily face to face treatment by a Men tal Health Profess ional for at least 8 hours per da y, each day. The Ph ysician mus t perform the admiss ion e valuation with documentation and treatment orders within 48 h ours and provide evaluations at leas t week ly with documentation. A multidisciplinary treatment p lan must be develope d within 3 da ys of adm ission and mus t be updated w eekly. Th is Endors ement shall not extend, vary, alter, replace, or waive any of the provisions , benefits, exclusions , limitations, or conditions contained in the Benefit Booklet other than as spec ifically s tated in the provisions contained in this Endorsement. In the event of any incons istencies betwe en the provisio ns contained in this Endors ement a nd the provisions contained in the Benefit Book let, the provisio ns contained in this Endors ement s ha ll control to the e xtent necess ar y to effectuate the inten t of Blue Cross and Blue Shield of Florida, Inc. as expres sed here in. Blue Cross and B lue Shield of Florida, Inc. Patrick J. Geraght y Chairman of the Board an d Chief Executive Officer 24318.2 NGF BlueOptions Large Group 24318 0214 BC A 4 In the pursuit of health· Okaloosa County BOCC #41954 2015 BlueMedicare Group PPO* (Employer PPO) Health Benefits Benefits BlueMedicare Group PPO* Plan 2 Premium (per member, per month) $330.05 for PPO2Rx2 Annual Deductible (DED) $0 In-Network / $2,000 Out-of-Network Out-of Pocket Maximum (based on plan $2,000 In-Network / $4,000 Out-of-Network year) In-Network out-of-pocket maximum accumulates toward Out-of-Network out-of-pocket maximum Physician Office Primary Care (per visit) In-Network $35 Copayment Out-of-Network DED & 40% Coinsurance Specialist Care (per visit) In-Network $50 Copayment Out-of-Network DED & 40% Coinsurance e-Visit In-Network $5 Copayment Out-of-Network DED & 40% Coinsurance Convenient Care Center In-Network / Out-of-Network $50 Copayment Podiatry Services (per visit) In-Network $50 Copayment (routine foot care up to 6 visits per year) Out-of-Network DED & 40% Coinsurance Chiropractic Services (per visit) In-Network $20 Copayment For each Medicare-covered visit (manual Out-of-Network DED & 40% Coinsurance manipulation of the spine to correct subluxation) Outpatient Mental Health Care (per visit) In-Network $40 Copayment For individual or group therapy Out-of-Network DED & 40% Coinsurance (including partial hospitalization) Outpatient Substance Abuse Care (per visit) In-Network $40 Copayment Out-of-Network DED & 40% Coinsurance Part B drugs (including chemotherapy) In-Network 20% coinsurance Out-of-Network DED & 40% Coinsurance Allergy Injections In-Network $10 Copayment Out-of-Network DED & 40% Coinsurance Y0011_31875 0414R2 EGWP C: 06/2014 1 In the pursuit of health· Benefits BlueMedicare Group PPO* Plan 2 Other Services Outpatient Surgery In-Network $250 Copayment for each outpatient hospital facility visit $175 Copayment for each visit to an ambulatory surgical center Out-of-Network DED & 40% Coinsurance In-Network / Out-of-Network $0 Copayment for physician services Diagnostic Tests, X-Rays Office In-Network $50 Copayment Out-of-Network DED & 40% Coinsurance IDTF In-Network $100 Copayment Out-of-Network DED & 40% Coinsurance Lab Services Independent Clinical Lab In-Network $0 Copayment Outpatient Hospital In-Network $30 Copayment All Locations Out-of-Network DED & 40% Coinsurance Advanced Imaging (MRI, MRA, CT Scan, PET Scan and Nuclear Medicine): Office In-Network $175 Copayment Out-of-Network DED & 40% Coinsurance IDTF In-Network $175 Copayment Out-of-Network DED & 40% Coinsurance Outpatient Hospital In-Network $250 Copayment Out-of-Network DED & 40% Coinsurance Y0011_31875 0414R2 EGWP C: 06/2014 2 In the pursuit of health· Benefits BlueMedicare Group PPO* Plan 2 Outpatient Hospital Services (per visit): Occupational Therapy, Physical Therapy, In-Network $40 Copayment Speech & Language Therapy, Cardiac and Out-of-Network DED & 40% Coinsurance Pulmonary Rehab (including intensive cardiac rehab) Radiation Therapy In-Network $50 Copayment Out-of-Network DED & 40% Coinsurance Dialysis In-Network / Out-of-Network 20% Coinsurance Lab Only In-Network $30 Copayment Out-of-Network DED & 40% Coinsurance All Other Diagnostic Tests, X-Rays, In-Network $250 Copayment Advanced Imaging, etc. Out-of-Network DED & 40% Coinsurance Urgently Needed Care In-Network / Out-of-Network $50 Copayment (This is not emergency care, and in most cases is out-of-the-service area.) Emergency Services In-Network / Out-of-Network $65 Copayment Worldwide Coverage Dental, Hearing and Vision (Medicare- In-Network $50 Copayment Covered) Out-of-Network DED & 40% Coinsurance Home Health In-Network / Out-of-Network $0 Copayment Ambulance In-Network / Out-of-Network $150 Copayment for Medicare-covered ambulance services Y0011_31875 0414R2 EGWP C: 06/2014 3 In the pursuit of health· Benefits BlueMedicare Group PPO* Plan 2 Outpatient Medical Services and Supplies Durable Medical Equipment/Diabetic Supplies Diabetic Supplies (glucose meters, test In-Network $0 Copayment strips and lancets) Out-of-Network DED & 40% Coinsurance Note: needles, syringes and insulin for self- injection are covered under your Part D benefit Equipment: Plan-Approved Electric In-Network 20% Coinsurance Customized Wheelchairs, Electric Scooters Out-of-Network DED & 40% Coinsurance All Other Medicare-Covered Durable In-Network $0 Copayment Medical Equipment Out-of-Network DED & 40% Coinsurance Prosthetic Devices In-Network $0 Copayment for Medicare-covered items Out-of-Network DED & 40% Coinsurance Outpatient Rehabilitation Occupational Therapy, Physical Therapy, Speech & Language Therapy, Cardiac and Pulmonary Rehab (including intensive cardiac rehab) Office or Freestanding Facility In-Network $40 Copayment for each visit Services Out-of-Network DED & 40% Coinsurance Outpatient Hospital Services In-Network $40 Copayment for each visit Out-of-Network DED & 40% Coinsurance Dialysis In-Network/Out-of-Network 20% Coinsurance Inpatient Care Inpatient Hospital Care In-Network (including substance abuse treatment) $250 Copayment each day for day(s) 1-7 for a Medicare-covered stay in a network hospital After the 7th day, the plan pays 100% of covered expenses per stay Out-of-Network DED & 40% Coinsurance Y0011_31875 0414R2 EGWP C: 06/2014 4 In the pursuit of health· Benefits BlueMedicare Group PPO* Plan 2 Inpatient Mental Health Care In-Network $250 Copayment each day for day(s) 1-7 for a Medicare-covered stay in a network hospital $0 Copayment for day(s) 8-90 for a Medicare-covered stay in a network hospital 190-day lifetime limit in a psychiatric hospital Out-of-Network DED & 40% Coinsurance Skilled Nursing Facility In-Network (in a Medicare-certified skilled nursing $0 Copayment each day for days 1-20 per facility) benefit period $100 Copayment each day for days 21-100 per benefit period There is a limit of 100 days for each benefit period 3-day prior hospital stay is not required Out-of-Network DED & 40% Coinsurance Hospice Member must receive care from a Medicare-certified hospice Preventive Services Annual Screening Mammograms In-Network $0 Copayment for Medicare-covered (for women with Medicare, age 40 and older) screening mammograms Out-of-Network 40% Coinsurance Pap Smears and Pelvic Exams In-Network (for women with Medicare) $0 Copayment per Pap smear $0 Copayment per pelvic exam Out-of-Network 40% Coinsurance Bone Mass Measurement In-Network $0 Copayment for each Medicare- (for people with Medicare who are at risk) covered bone mass measurement Out-of-Network 40% Coinsurance Colorectal Screening Exams In-Network $0 Copayment for Medicare-covered (for people with Medicare age 50 and older) colorectal screening exams Out-of-Network 40% Coinsurance Prostate Cancer Screening Exams In-Network $0 Copayment for Medicare-covered (for men with Medicare age 50 and older) prostate cancer screening exams Out-of-Network 40% Coinsurance Y0011_31875 0414R2 EGWP C: 06/2014 5 In the pursuit of health· Benefits BlueMedicare Group PPO* Plan 2 Vaccines (Medicare-covered) In-Network / Out-of-Network $0 Copayment for influenza vaccine $0 Copayment for pneumococcal vaccine $0 Copayment for hepatitis B vaccine Supplemental Benefit Fitness Free membership through SilverSneakers BlueMedicare Group PPO out-of-pocket maximum includes all covered health services member cost share rendered in/out of network on a calendar year basis. Supplemental services and Part D costs are not applied to out-of-pocket maximum. Medicare Part B - the premium provided under this plan excludes the Medicare Part B premium payments. (Members must continue to pay the Medicare Part B premium unless paid by Medicaid or another third party.) Florida Blue is a PPO Plan with a Medicare contract. Enrollment in Florida Blue depends on contract renewal. Y0011_31875 0414R2 EGWP C: 06/2014 6 In the pursuit of health· Okaloosa County BOCC #41954 2015 BlueMedicare Group Rx * (Employer PDP) Benefits BlueMedicare Group Rx* Option 2 Included with PPO2Rx2 - current Premium Included with PPO1Rx2 – alternate $187.04 for Rx2 Stand-alone Annual Deductible $75 for Brand Drugs Only Retail 31-day Supply Tier 1 - Preferred Generics $15 Copayment Tier 2 - Non-Preferred Generics $15 Copayment Tier 3 - Preferred Brand $45 Copayment Tier 4 - Non-Preferred Brand $85 Copayment Tier 5 - Specialty Drugs 25% Coinsurance Mail Order 90-day Supply with PRIME Mail Order Tier 1 - Preferred Generics $8 Copayment Tier 2 - Non-Preferred Generics $8 Copayment Tier 3 - Preferred Brand $135 Copayment Tier 4 - Non-Preferred Brand $255 Copayment Tier 5 - Specialty Drugs 25% Coinsurance Gap 31-day Supply Tier 1 - Preferred Generics $15 Copayment Tier 2 - Non-Preferred Generics $15 Copayment Tier 3 - Preferred Brand $45 Copayment Tier 4 - Non-Preferred Brand $85 Copayment Tier 5 - Specialty Drugs 25% Coinsurance Greater of $2.65 Copayment or 5% Coinsurance for generic drugs Catastrophic Greater of $6.60 Copayment or 5% Coinsurance for brand drugs Florida Blue is an Rx (PDP) Plan with a Medicare contract. Enrollment in Florida Blue depends on contract renewal. Prescription drug copays do not accumulate towards the health plan calendar year out-of-pocket maximum. Y0011_31877 0414R1 EGWP C: 06/2014 In the pursuit of health· 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_31877 0414R1 EGWP C: 06/2014 STANDARD INSURANCE COMPANY A Stock Life Insurance Company 900 SW Fifth Avenue Portland, Oregon 97204-1282 (503) 321-7000 CERTIFICATE GROUP LIFE INSURANCE Policyholder: Okaloosa County Board of County Commissioners Policy Number: 649032-A Effective Date: October 1, 2014 A Group Policy has been issued to the Policyholder. We certify that you will be insured as provided by the terms of the Group Policy. If your coverage is changed by an amendment to the Group Policy, we will provide the Policyholder with a revised Certificate or other notice to be given to you. This policy includes an Accelerated Benefit. Death benefits will be reduced if an Accelerated Benefit is paid. The receipt of this benefit may be taxable and may affect your eligibility for Medicaid or other government benefits or entitlements. However, if you meet the definition of "terminally ill individual" according to the Internal Revenue Code Section 101, your Accelerated Benefit may be non-taxable. You should consult your personal tax and/or legal advisor before you apply for an Accelerated Benefit. Possession of this Certificate does not necessarily mean you are insured. You are insured only if you meet the requirements set out in this Certificate. If the terms of the Certificate differ from the Group Policy, the terms stated in the Group Policy will govern. "We", "us" and "our" mean Standard Insurance Company. "You" and "your" mean the Member. All other defined terms appear with the initial letter capitalized. Section headings, and references to them, appear in boldface type. This certificate provides life insurance for employees and dependents, if applicable, of Okaloosa County Board of County Commissioners, 601 A N Pearl St, Crestview FL, 32536, under 649032-A. The employee shall be given a copy of the group enrollment application. The benefits are payable to the beneficiaries of record designated by the employee. Chairman, President and CEO GC190---LIFE/S214 Retirees with a retirement date of 10/01/14 forward Table of Contents COVERAGE FEATURES ...... 1 GENERAL POLICY INFORMATION ...... 1 BECOMING INSURED ...... 1 PREMIUM CONTRIBUTIONS ...... 3 SCHEDULE OF INSURANCE ...... 4 REDUCTIONS IN INSURANCE ...... 5 OTHER BENEFITS ...... 5 OTHER PROVISIONS ...... 5 LIFE INSURANCE ...... 7 A. Insuring Clause ...... 7 B. Amount Of Life Insurance ...... 7 C. Changes In Life Insurance ...... 7 D. Repatriation Benefit ...... 7 E. Suicide Exclusion: Life Insurance ...... 7 F. When Life Insurance Becomes Effective ...... 8 G. When Life Insurance Ends...... 8 H. Reinstatement Of Life Insurance ...... 9 DEPENDENTS LIFE INSURANCE ...... 9 A. Insuring Clause ...... 9 B. Amount Of Dependents Life Insurance ...... 9 C. Changes In Dependents Life Insurance ...... 9 D. Suicide Exclusion: Dependents Life Insurance ...... 10 E. Definitions For Dependents Life Insurance ...... 10 F. Becoming Insured For Dependents Life Insurance ...... 10 G. When Dependents Life Insurance Ends ...... 11 ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE ...... 12 A. Insuring Clause ...... 12 B. Definition Of Loss For AD&D Insurance ...... 12 C. Amount Payable ...... 12 D. Changes In AD&D Insurance ...... 12 E. AD&D Insurance Exclusions ...... 12 F. Additional AD&D Benefits ...... 12 G. Becoming Insured For AD&D Insurance ...... 14 H. When AD&D Insurance Ends ...... 15 ACTIVE WORK PROVISIONS ...... 15 CONTINUITY OF COVERAGE ...... 15 PORTABILITY OF INSURANCE ...... 16 WAIVER OF PREMIUM ...... 17 ACCELERATED BENEFIT ...... 18 RIGHT TO CONVERT ...... 19 CLAIMS ...... 20 ASSIGNMENT ...... 23 BENEFIT PAYMENT AND BENEFICIARY PROVISIONS ...... 23 ALLOCATION OF AUTHORITY ...... 26 TIME LIMITS ON LEGAL ACTIONS ...... 26 INCONTESTABILITY PROVISIONS ...... 26 CLERICAL ERROR AND MISSTATEMENT ...... 27 TERMINATION OR AMENDMENT OF THE GROUP POLICY ...... 27 DEFINITIONS ...... 28 Index of Defined Terms Accelerated Benefit, 18 L.L.C. Owner-Employee, 29 Active Work, Actively At Work, 15 Leave Of Absence Period, 6 AD&D Insurance, 28 Life Insurance, 29 Air Bag System, 13 Loss, 12 Annual Earnings, 28 Any Occupation, 30 Maximum Conversion Amount, 5 Automobile, 13 Member, 1 Minimum Time Insured, 5 Beneficiary, 24 Noncontributory, 29 Child, 29 Class Definition, 1 P.C. Partner, 30 Contributory, 29 Physician, 30 Conversion Period, 20 Policyholder, 1 Pregnancy, 30 Dependent, 10 Prior Plan, 30 Dependents Life Insurance, 29 Proof Of Loss, 21 Disabled, 29 Qualifying Event, 20 Eligibility Waiting Period, 29 Qualifying Medical Condition, 18 Employer(s), 1 Evidence Of Insurability, 29 Recipient, 25 Right To Convert, 20 Family Status Change, 3 Seat Belt System, 13 Group Policy, 29 Sickness, 30 Group Policy Effective Date, 1 Spouse, 30 Group Policy Number, 1 Supplemental Life Insurance, 30 Guarantee Issue Amount (for Dependents Life Insurance), 2 Totally Disabled, 30 Guarantee Issue Amount (for Plan 2), 2 Waiting Period (for Waiver Of Premium), Injury, 29 17 Insurance (for Accelerated Benefit), 20 Waiver Of Premium, 17 Insurance (for Right to Convert), 20 War, 12 Insurance (for Waiver Of Premium), 17 You, Your (for Right To Convert), 20 COVERAGE FEATURES This section contains many of the features of your group life insurance. Other provisions, including exclusions and limitations, appear in other sections. Please refer to the text of each section for full details. The Table of Contents and the Index of Defined Terms help locate sections and definitions. GENERAL POLICY INFORMATION Group Policy Number: 649032-A Type of Insurance Provided: Life Insurance: Yes Supplemental Life Insurance: Not applicable Dependents Life Insurance: Yes Accidental Death And Dismemberment (AD&D) Insurance: Yes Policyholder: Okaloosa County Board of County Commissioners Employer(s): Okaloosa County Board of County Commissioners Clerk of Courts Property Appraiser Tax Collector Group Policy Effective Date: October 1, 2014 Policy Issued in: Florida BECOMING INSURED To become insured for Life Insurance you must: (a) Be a Member; (b) Complete your Eligibility Waiting Period; and (c) Meet the requirements in Life Insurance and Active Work Provisions. The Active Work requirement does not apply to Members who are retired on the Group Policy Effective Date. The requirements for becoming insured for coverages other than Life Insurance are set out in the text. Definition of Member: You are a Member if you are one of the following: 1. An active elected official employee of the Employer; 2. An active employee of the Employer who is regularly working at least 30 hours each week; or 3. An employee of the Employer who retired under the Employer's retirement program. You are not a Member if you are: 1. A temporary or seasonal employee. 2. A leased employee. 3. An independent contractor. 4. A full time member of the armed forces of any country. Class Definition: Retirees with a retirement date of 10/01/14 forward This Summary Plan Description applies to the class listed above. Other classes are also covered under the Plan. Contact your Plan Administrator for further information. Printed 11/04/2014 - 1 - 649032-A Eligibility Waiting Period: You are eligible on one of the following dates: If you are a Member on the Group Policy Effective Date, you are eligible on that date. If you become a Member after the Group Policy Effective Date, you are eligible on the first day of the calendar month coinciding with or next following 30 consecutive days as a Member. Evidence Of Insurability: Required: a. For late application for Contributory insurance. b. For reinstatements if required. c. For Members and Dependents eligible but not insured under the Prior Plan. d. For any Plan 2 Life Insurance Benefit in excess of the Guarantee Issue Amount of $300,000. However, this requirement will be waived on the Group Policy Effective Date for an amount equal to the amount of additional life insurance under the Prior Plan on the day before the Group Policy Effective Date, if you apply on or before the Group Policy Effective Date. e. For any Dependents Life Insurance Benefit for your Spouse in excess of the Guarantee Issue Amount of $25,000. However, this requirement will be waived on the Group Policy Effective Date for an amount equal to the amount of dependents life insurance under the Prior Plan on the day before the Group Policy Effective Date, if you apply on or before the Group Policy Effective Date. f. For any increase resulting from a plan or option change you elect. Printed 11/04/2014 - 2 - 649032-A Certain Evidence Of Insurability Requirements Will Be Waived. Your insurance is subject to all other terms of the Group Policy. For A Family Status Change In the event of a Family Status Change certain Evidence Of Insurability requirements will be waived with respect to Plan 2 Life Insurance. 1. If you are eligible but not insured for Plan 2 Life Insurance and AD&D Insurance, requirement(s) a. and c. above will be waived if you apply for Plan 2 Life Insurance and AD&D Insurance within 31 days of a Family Status Change. 2. If you are insured for an amount less than $300,000, requirement(s) d. above will be waived if you apply for an increase in your Plan 2 Life Insurance and AD&D Insurance up to $300,000 within 31 days of a Family Status Change. Family Status Change means any of the following events: 1. Your marriage, divorce or legal separation or dissolution of your Domestic Partner relationship. 2. The birth of your Child. 3. The adoption of a Child by you. 4. The death of your Spouse and/or Child. 5. The commencement or termination of your Spouse's employment. 6. A change in employment from full-time to part-time by you or your Spouse. You may increase your Life Insurance due to any of the event(s) above. LI.EV.01 PREMIUM CONTRIBUTIONS Life Insurance: Plan 1: Contributory Plan 2: Not applicable AD&D Insurance: Member: Plan 1: Not applicable Plan 2: Not applicable Dependents Life Insurance: Spouse: Not applicable Child: Not applicable The cost of insurance may be funded by contributions to an IRC Section 125 Cafeteria Plan. Printed 11/04/2014 - 3 - 649032-A SCHEDULE OF INSURANCE SCHEDULE OF LIFE INSURANCE For you: Life Insurance Benefit: You will become insured under Plan 1 if you meet the requirements to become insured under the Group Policy. If you are insured under Plan 1, you may also become insured under Plan 2 if you meet the requirements to become insured under Plan 2 Life Insurance under the Group Policy. Plan 2 is a Contributory plan requiring premium contributions from Members. Plan 1 (basic): $10,000 A Member may not be insured as both an active Member and a retired Member. Plan 2 (additional): None The Repatriation Benefit: The expenses incurred to transport your body to a mortuary near your primary place of residence, but not to exceed $5,000 or 10% of the Life Insurance Benefit, whichever is less. Dependents Life Insurance Benefit: If you are insured under Plan 2 Life Insurance, you may apply for Dependents Life Insurance for your Dependents. You may elect to insure your Spouse, your Child(ren), or both. For your Spouse: None The amount of Dependents Life Insurance for your Spouse may not exceed 100% of the amount of your Plan 2 Life Insurance. For your Child: None The amount of Dependents Life Insurance for your Child may not exceed 100% of the amount of your Plan 2 Life Insurance. SCHEDULE OF AD&D INSURANCE For you: AD&D Insurance Benefit: None Seat Belt Benefit: The amount of the Seat Belt Benefit is the lesser of (1) $10,000 or (2) the amount of AD&D Insurance Benefit payable for loss of life. Air Bag Benefit: The amount of the Air Bag Benefit is the lesser of (1) $5,000; or (2) the amount of AD&D Insurance Benefit payable for Loss of your life. Career Adjustment Benefit: The tuition expenses for training incurred by your Spouse within 36 months after the date of your death, exclusive of board and room, books, fees, supplies and other expenses, but not to exceed $5,000 per year, or the cumulative total of $10,000 or 25% of the AD&D Insurance Benefit, whichever is less. Printed 11/04/2014 - 4 - 649032-A Child Care Benefit: The total child care expense incurred by your Spouse within 36 months after the date of your death for all Children under age 13, but not to exceed $5,000 per year, or the cumulative total of $10,000 or 25% of the AD&D Insurance Benefit, whichever is less. Higher Education Benefit: The tuition expenses incurred per Child within 4 years after the date of your death at an accredited institution of higher education, exclusive of board and room, books, fees, supplies and other expenses, but not to exceed $5,000 per year, or the cumulative total of $20,000 or 25% of the AD&D Insurance Benefit, whichever is less. Line of Duty Benefit: The Lesser of (1) $50,000; or (2) 100% of the amount of the AD&D Insurance Benefit otherwise payable for the Loss. AD&D TABLE OF LOSSES The amount payable is a percentage of the AD&D Insurance Benefit in effect on the date of the accident and is determined by the Loss suffered as shown in the following table: Loss: Percentage Payable: a. Life 100% b. One hand, one foot or sight of one 50% eye c. Two or more of the Losses listed 100% in b. above No more than 100% of your AD&D Insurance will be paid for all Losses resulting from one accident. REDUCTIONS IN INSURANCE Your insurance is not subject to reductions due to age. OTHER BENEFITS Waiver Of Premium: No Accelerated Benefit: No OTHER PROVISIONS Limits on Right To Convert if Group Policy terminates or is amended: Minimum Time Insured: 5 years Maximum Conversion Amount: $10,000 Printed 11/04/2014 - 5 - 649032-A Suicide Exclusion: Applies to: a. Plan 2 Life Insurance b. Dependents Life Insurance on your Spouse c. AD&D Insurance Leave Of Absence Period: 60 days Continuity Of Coverage: Yes Insurance Eligible For Portability: If as a retired Member you are insured or eligible for insurance under the Group Policy, you are not eligible to buy portable group insurance coverage. Annual Earnings based on: Earnings in effect on your last full day of Active Work. Printed 11/04/2014 - 6 - 649032-A LIFE INSURANCE A. Insuring Clause If you die while insured for Life Insurance, we will pay benefits according to the terms of the Group Policy after we receive Proof Of Loss satisfactory to us. B. Amount Of Life Insurance See the Coverage Features for the Life Insurance schedule. C. Changes In Life Insurance 1. Increases You must apply in writing for any elective increase in your Life Insurance. Subject to the Active Work Provisions, an increase in your Life Insurance becomes effective as follows: a. Increases Subject To Evidence Of Insurability An increase in your Life Insurance subject to Evidence Of Insurability becomes effective on the date we approve your Evidence Of Insurability. b. Increases Not Subject To Evidence Of Insurability An increase in your Life Insurance not subject to Evidence Of Insurability becomes effective on: (i) The first day of the calendar month coinciding with or next following the date you apply for an elective increase or the date of change in your classification, age or Annual Earnings. (ii) The later of the date you apply or the date of the Family Status Change, if you apply within 31 days of a Family Status Change. 2. Decreases A decrease in your Life Insurance because of a change in your classification, age or Annual Earnings becomes effective on the first day of the calendar month coinciding with or next following the date of the change. Any other decrease in your Life Insurance becomes effective on the first day of the calendar month coinciding with or next following the date the Policyholder or your Employer receives your written request for the decrease. D. Repatriation Benefit The amount of the Repatriation Benefit is shown in the Coverage Features. We will pay a Repatriation Benefit if all of the following requirements are met. 1. A Life Insurance Benefit is payable because of your death. 2. You die more than 200 miles from your primary place of residence. 3. Expenses are incurred to transport your body to a mortuary near your primary place of residence. E. Suicide Exclusion: Life Insurance If your death results from suicide or other intentionally self-inflicted Injury, while sane or insane, 1 and 2 below apply. 1. The amount payable will exclude the amount of your Life Insurance which is subject to this Printed 11/04/2014 - 7 - 649032-A suicide exclusion and which has not been continuously in effect for at least 2 years on the date of your death. In computing the 2-year period, we will include time you were insured under the Prior Plan. 2. We will refund all premiums paid for that portion of your Life Insurance which is excluded from payment under this suicide exclusion. F. When Life Insurance Becomes Effective The Coverage Features states whether your Life Insurance is Contributory or Noncontributory. Subject to the Active Work Provisions, your Life Insurance becomes effective as follows: 1. Life Insurance subject to Evidence Of Insurability Life Insurance subject to Evidence Of Insurability becomes effective on the date we approve your Evidence Of Insurability. 2. Life Insurance not subject to Evidence Of Insurability a. Noncontributory Life Insurance Noncontributory Life Insurance not subject to Evidence Of Insurability becomes effective on the date you become eligible. b. Contributory Life Insurance You must apply in writing for Contributory Life Insurance and agree to pay premiums. Contributory Life Insurance not subject to Evidence Of Insurability becomes effective on: (i) The date you become eligible if you apply on or before that date. (ii) The date you apply if you apply within 31 days after you become eligible. (iii) The later of the date you apply or the date of the Family Status Change, if you apply within 31 days of a Family Status Change. Late application: Evidence Of Insurability is required if you apply more than 31 days after you become eligible. 3. Takeover Provision a. If you were insured under the Prior Plan on the day before the effective date of your Employer's coverage under the Group Policy, your Eligibility Waiting Period is waived on the effective date of your Employer's coverage under the Group Policy. b. You must submit satisfactory Evidence Of Insurability to become insured for Life Insurance if you were eligible under the Prior Plan for more than 31 days but were not insured. G. When Life Insurance Ends Life Insurance ends automatically on the earliest of: 1. The date the last period ends for which a premium was paid for your Life Insurance; 2. The date the Group Policy terminates. However, if you are Totally Disabled on that date, we will continue your Life Insurance for 12 months, unless you are eligible for Waiver Of Premium. The Life Insurance Benefit payable during this 12 month extension period will be reduced by any amount payable under a replacement group life insurance plan; 3. The date your employment terminates, unless you are eligible for benefits as a retired Member; and 4. The date you cease to be a Member. However, if you cease to be a Member because you are working less than the required minimum number of hours, your Life Insurance will be continued with premium payment during the following periods, unless it ends under 1 through Printed 11/04/2014 - 8 - 649032-A 3 above. a. While your Employer is paying you at least the same Annual Earnings paid to you immediately before you ceased to be a Member. b. While your ability to work is limited because of Sickness, Injury, or Pregnancy. If you are Totally Disabled and you are not eligible for Waiver Of Premium (see Waiver Of Premium), your Life Insurance will continue, while you remain Totally Disabled, for a period of six months, but not beyond the date the Group Policy terminates. This applies even if your employment terminates. c. During the first 60 days of: (1) A temporary layoff; or (2) A strike, lockout, or other general work stoppage caused by a labor dispute between your collective bargaining unit and your Employer. d. During a leave of absence if continuation of your insurance under the Group Policy is required by a state-mandated family or medical leave act or law. e. During any other scheduled leave of absence approved by your Employer in advance and in writing and lasting not more than the period shown in the Coverage Features. H. Reinstatement Of Life Insurance If your Life Insurance ends, you may become insured again as a new Member. However, 1 through 4 below will apply. 1. If your Life Insurance ends because you cease to be a Member, and if you become a Member again within 90 days, the Eligibility Waiting Period will be waived. 2. If your Life Insurance ends because you fail to make a required premium contribution, you must provide Evidence Of Insurability to become insured again. 3. If you exercised your Right To Convert, you must provide Evidence Of Insurability to become insured again. 4. If your Life Insurance ends because you are on a federal or state-mandated family or medical leave of absence, and you become a Member again immediately following the period allowed, your insurance will be reinstated pursuant to the federal or state-mandated family or medical leave act or law. (REPAT_SUIC ALL_FAM STAT) LI.LF.FL.3X DEPENDENTS LIFE INSURANCE A. Insuring Clause If your Dependent dies while insured for Dependents Life Insurance, we will pay benefits according to the terms of the Group Policy after we receive Proof Of Loss satisfactory to us. B. Amount Of Dependents Life Insurance See the Coverage Features for the amount of your Dependents Life Insurance. C. Changes In Dependents Life Insurance 1. Increases You must apply in writing for any elective increase in your Dependents Life Insurance. Printed 11/04/2014 - 9 - 649032-A Subject to the Active Work Provisions, an increase in your Dependents Life Insurance becomes effective as follows: a. Increases Subject To Evidence Of Insurability An increase in your Dependents Life Insurance subject to Evidence Of Insurability becomes effective on the date we approve that Dependent's Evidence Of Insurability. b. Increases Not Subject To Evidence Of Insurability An increase in your Dependents Life Insurance not subject to Evidence Of Insurability becomes effective on the first day of the calendar month coinciding with or next following the date you apply for an elective increase. An increase in your Dependents Life Insurance because of an increase in your Life Insurance becomes effective on the date your Life Insurance increases. 2. Decreases A decrease in your Dependents Life Insurance because of a decrease in your Life Insurance becomes effective on the date your Life Insurance decreases. D. Suicide Exclusion: Dependents Life Insurance If a Dependent's death results from suicide or other intentionally self-inflicted Injury, while sane or insane, 1 and 2 below will apply. 1. The amount payable will exclude the amount of Dependents Life Insurance which has not been continuously in effect for at least 2 years on the date of death. In computing the 2-year period, we will include time insured under the Prior Plan. 2. We will refund all premiums paid for Dependents Life Insurance which is excluded from payment under this suicide exclusion which we determine are attributable to that Dependent. E. Definitions For Dependents Life Insurance Dependent means your Spouse or Child. Dependent does not include a person who is a full-time member of the armed forces of any country. F. Becoming Insured For Dependents Life Insurance 1. Eligibility You become eligible to insure your Dependents on the later of: a. The date you become eligible for Life Insurance; and b. The date you first acquire a Dependent. A Member may not be insured as both a Member and a Dependent. A Child may not be insured by more than one Member. 2. Effective Date The Coverage Features states whether your Dependents Life Insurance is Contributory or Noncontributory. Subject to the Active Work Provisions, your Dependents Life Insurance becomes effective as follows: a. Dependents Life Insurance Subject To Evidence Of Insurability Dependents Life Insurance subject to Evidence Of Insurability becomes effective on the later of: 1. The date your Life Insurance becomes effective; and Printed 11/04/2014 - 10 - 649032-A 2. The first day of the calendar month coinciding with or next following the date we approve the Dependent's Evidence Of Insurability. b. Dependents Life Insurance Not Subject To Evidence Of Insurability 1. Noncontributory Dependents Life Insurance Noncontributory Dependents Life Insurance not subject to Evidence Of Insurability becomes effective on the later of: i. The date your Life Insurance becomes effective; and ii. The date you first acquire a Dependent. 2. Contributory Dependents Life Insurance You must apply in writing for Contributory Dependents Life Insurance and agree to pay premiums. Contributory Dependents Life Insurance not subject to Evidence Of Insurability becomes effective on the latest of: i. The date your Life Insurance becomes effective if you apply on or before that date; ii. The date you become eligible to insure your Dependents if you apply on or before that date; and iii. The date you apply if you apply within 31 days after you become eligible. Late Application: Evidence Of Insurability is required for each Dependent if you apply more than 31 days after you become eligible. c. While your Dependents Life Insurance is in effect, each new Child becomes insured immediately. d. Takeover Provision Each Dependent who was eligible under the Prior Plan for more than 31 days but was not insured must submit satisfactory Evidence Of Insurability to become insured for Dependents Life Insurance. G. When Dependents Life Insurance Ends Dependents Life Insurance ends automatically on the earliest of: 1. Five months after you die (no premiums will be charged for your Dependents Life Insurance during this time); 2. The date your Life Insurance ends; 3. The date the Group Policy terminates, or the date Dependents Life Insurance terminates under the Group Policy; 4. The date the last period ends for which you made a premium contribution, if your Dependents Life Insurance is Contributory; 5. For your Spouse, the date of your divorce; 6. For any Dependent, the date the Dependent ceases to be a Dependent; and 7. For a Child who is Disabled, 90 days after we mail you a request for proof of Disability, if proof is not given. (SP & CH_SUIC ALL) LI.DL.OT.4 Printed 11/04/2014 - 11 - 649032-A ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE A. Insuring Clause If you have an accident, while insured for AD&D Insurance, and the accident results in a Loss, we will pay benefits according to the terms of the Group Policy after we receive Proof Of Loss satisfactory to us. B. Definition Of Loss For AD&D Insurance Loss means loss of life, hand, foot, sight which meets all of the following requirements: 1. Is caused solely and directly by an accident. 2. Occurs independently of all other causes. 3. Occurs within 365 days after the accident. 4. With respect to Loss of life, is evidenced by a certified copy of the death certificate. 5. With respect to all other Losses, is certified by a Physician in the appropriate specialty as determined by us. With respect to a hand or foot, Loss means actual and permanent severance from the body at or above the wrist or ankle joint. With respect to sight, Loss means entire, uncorrectable, and irrecoverable loss of sight. C. Amount Payable See Coverage Features for the AD&D Insurance schedule. The amount payable is a percentage of the AD&D Insurance Benefit in effect on the date of the accident and is determined by the Loss suffered. See AD&D Table Of Losses in the Coverage Features. D. Changes In AD&D Insurance Changes in your AD&D Insurance will become effective on the date your Life Insurance changes. E. AD&D Insurance Exclusions No AD&D Insurance benefit is payable if the accident or Loss is caused or contributed to by any of the following: 1. War or act of War. War means declared or undeclared war, whether civil or international, and any substantial armed conflict between organized forces of a military nature. 2. Suicide or other intentionally self-inflicted Injury, while sane or insane. 3. Committing or attempting to commit an assault or felony, or actively participating in a violent disorder or riot. Actively participating does not include being at the scene of a violent disorder or riot while performing your official duties. 4. The voluntary use or consumption of any poison, chemical compound, alcohol or drug, unless used or consumed according to the directions of a Physician. 5. Sickness or Pregnancy existing at the time of the accident. 6. Heart attack or stroke. 7. Medical or surgical treatment for any of the above. F. Additional AD&D Benefits Seat Belt Benefit The amount of the Seat Belt Benefit is shown in the Coverage Features. Printed 11/04/2014 - 12 - 649032-A We will pay a Seat Belt Benefit if all of the following requirements are met: 1. You die as a result of an Automobile accident for which an AD&D Insurance Benefit is payable for Loss of your Life; and 2. You are wearing and properly utilizing a Seat Belt System at the time of the accident, as evidenced by a police accident report. Seat Belt System means a properly installed combination lap and shoulder restraint system that meets the Federal Vehicle Safety Standards of the National Highway Traffic Safety Administration. Seat Belt System will include a lap belt alone, but only if the Automobile did not have a combination lap and shoulder restraint system when manufactured. Seat Belt System does not include a shoulder restraint alone. Automobile means a motor vehicle licensed for use on public highways. Air Bag Benefit The amount of the Air Bag Benefit is shown in the Coverage Features. We will pay an Air Bag Benefit if all of the following requirements are met: 1. You die as a result of an Automobile accident for which a Seat Belt Benefit is payable for Loss of your life. 2. The Automobile is equipped with an Air Bag System that was installed as original equipment by the Automobile manufacturer and has received regular maintenance or scheduled replacement as recommended by the Automobile or Air Bag manufacturer. 3. You are seated in the driver's or a passenger's seating position intended to be protected by the Air Bag System and the Air Bag System deploys, as evidenced by a police accident report. Air Bag System means an automatically inflatable passive restraint system that is designed to provide automatic crash protection in front or side impact Automobile accidents and meets the Federal Vehicle Safety Standards of the National Highway Traffic Safety Administration. Automobile means a motor vehicle licensed for use on public highways. Career Adjustment Benefit The amount of the Career Adjustment Benefit is shown in the Coverage Features. We will pay a Career Adjustment Benefit to your Spouse if all of the following requirements are met: 1. You are insured for AD&D Insurance under the Group Policy. 2. You die as a result of an accident for which an AD&D Insurance Benefit is payable for Loss of your life. 3. Your Spouse is, within 36 months after the date of your death, registered and in attendance at an accredited institution of higher education or trades training program for the purpose of obtaining employment or increasing earnings. No Career Adjustment Benefit will be paid if you have no surviving Spouse. Child Care Benefit The amount of the Child Care Benefit is shown in the Coverage Features. We will pay a Child Care Benefit to your Spouse if all of the following requirements are met: 1. You are insured for AD&D Insurance under the Group Policy. 2. You die as a result of an accident for which an AD&D Insurance Benefit is payable for Loss Printed 11/04/2014 - 13 - 649032-A of your life. 3. Your Spouse pays a licensed child care provider who is not a member of your family for child care provided to your Child(ren) under age 13 within 36 months of your death. 4. The child care is necessary in order for your Spouse to work or to obtain training for work or to increase earnings. No Child Care Benefit will be paid if you have no surviving Spouse. Higher Education Benefit The amount of the Higher Education Benefit is shown in the Coverage Features. We will pay a Higher Education Benefit to your Child if all of the following requirements are met: 1. You are insured for AD&D Insurance under the Group Policy. 2. You die as a result of an accident for which an AD&D Insurance Benefit is payable for Loss of your life. 3. Your Child is, within 12 months after the date of your death, registered and in full-time attendance at an accredited institution of higher education beyond high school. The Higher Education Benefit will be paid to each Child who meets the requirements of item 3 above, for a maximum of 4 consecutive years beginning on the date of your death. No Higher Education Benefit will be paid if there is no Child eligible to receive it. Line Of Duty Benefit The amount of the Line Of Duty Benefit is shown in the Coverage Features. We will pay a Line Of Duty Benefit if all of the following requirements are met: 1. You are a Public Safety Officer. 2. You suffer a Loss for which an AD&D Insurance Benefit is payable. 3. The Loss is the result of a Line Of Duty Accident. Public Safety Officer means a Member whose primary job duties include controlling or reducing crime or juvenile delinquency, criminal law enforcement, or fire suppression. Public Safety Officer includes police officers, firefighters, corrections officers, judicial officers, and officially recognized or designated volunteer firefighters, if they otherwise meet the definition of Public Safety Officer. Line of Duty Accident means an accident, including accidental exposure to adverse weather conditions, that occurs while you are taking any action which by rule, regulation, law, or condition of employment you are obligated or authorized to perform as a Public Safety Officer in the course of controlling or reducing crime or criminal law enforcement, including such action taken in response to an emergency while off duty. If you are a Public Safety Officer, whose primary job duties are controlling or reducing crime, criminal law enforcement, or fire suppression, Line of Duty Accident includes a Line Of Duty Accident that occurs while you are on duty at social, ceremonial, or athletic functions to which you are assigned or for which you are paid as a Public Safety Officer by your Employer. G. Becoming Insured For AD&D Insurance 1. Eligibility You become eligible for AD&D Insurance on the date your Life Insurance is effective. 2. Effective Date Printed 11/04/2014 - 14 - 649032-A The Coverage Features states whether AD&D Insurance is Contributory or Noncontributory. Subject to the Active Work Provisions, AD&D Insurance becomes effective as follows: a. Noncontributory AD&D Insurance Noncontributory AD&D Insurance becomes effective on the date you become eligible. b. Contributory AD&D Insurance You must apply in writing for Contributory AD&D Insurance and agree to pay premiums. Contributory AD&D Insurance becomes effective on the later of: (i) The date you become eligible if you apply on or before that date. (ii) The first day of the calendar month coinciding with or next following the date you apply, if you apply after you become eligible. H. When AD&D Insurance Ends AD&D Insurance ends automatically on the earlier of: 1. The date your Life Insurance ends. 2. The date your Waiver Of Premium begins. 3. The date AD&D Insurance terminates under the Group Policy. 4. The date the last period ends for which a premium was paid for your AD&D Insurance. (FB NO DEP REQD_LINE DUTY BEN_ALCOHL EXCL_SEAT AIR COMBO) LI.AD.OT.5 ACTIVE WORK PROVISIONS If you are incapable of Active Work because of Sickness, Injury or Pregnancy on the day before the scheduled effective date of your insurance or an increase in your insurance, your insurance or increase will not become effective until the day after you complete one full day of Active Work as an eligible Member. Active Work and Actively At Work mean performing the material duties of your own occupation at your Employer's usual place of business. You will also meet the Active Work requirement if: 1. You were absent from Active Work because of a regularly scheduled day off, holiday, or vacation day; 2. You were Actively At Work on your last scheduled work day before the date of your absence; and 3. You were capable of Active Work on the day before the scheduled effective date of your insurance or increase in your insurance. LI.AW.OT.1 CONTINUITY OF COVERAGE A. Waiver Of Active Work Requirement If you were insured under the Prior Plan on the day before the effective date of your Employer's coverage under the Group Policy, you can become insured on the effective date of your Employer's coverage without meeting the Active Work requirement. See Active Work Provisions. B. Payment Of Benefit Printed 11/04/2014 - 15 - 649032-A The benefits payable before you meet the Active Work requirement will be: 1. The benefits which would have been payable under the terms of the Prior Plan if it had remained in force; reduced by 2. Any benefits payable under the Prior Plan. LI.CC.FL.1 PORTABILITY OF INSURANCE A. Portability Of Insurance If your insurance under the Group Policy ends because your employment with your Employer terminates, you may be eligible to buy portable group insurance coverage as shown in the Coverage Features for yourself and your Dependents without submitting Evidence Of Insurability. To be eligible you must satisfy the following requirements: 1. On the date your employment terminates, you must be able to perform with reasonable continuity the material duties of at least one gainful occupation for which you are reasonably fitted by education, training and experience. (If you are unable to meet this requirement, see the Right To Convert and Waiver Of Premium provisions for other options that may be available to you under the Group Policy.) 2. On the date your employment terminates, you are under age 65. 3. On the date your employment terminates, you must have been continuously insured under the Group Policy for at least 12 consecutive months. In computing the 12 consecutive month period, we will include time insured under the Prior Plan. 4. You must apply in writing and pay the first premium directly to us at our Home Office within 31 days after the date your employment terminates. You must purchase portable group life insurance coverage for yourself in order to purchase any other insurance eligible for portability. This portable group insurance will be provided under a master Group Life Portability Insurance Policy we have issued to the Standard Insurance Company Group Insurance Trust. If approved, the certificate you will receive will be governed under the terms of the Group Life Portability Insurance Policy and will contain provisions that differ from your Employer's coverage under the Group Policy. B. Amount Of Portable Insurance The minimum and maximum amounts that you are eligible to buy under the Group Life Portability Insurance Policy are shown in the Coverage Features. You may buy less than the maximum amounts in increments of $1,000. The combined amounts of insurance purchased under this Portability Of Insurance provision and the Right To Convert provision cannot exceed the amount in effect under the Group Policy on the day before your employment terminates. C. When Portable Insurance Becomes Effective Portable group insurance will become effective the day after your employment with your Employer terminates, if you apply within 31 days after the date your employment terminates. Printed 11/04/2014 - 16 - 649032-A If death occurs within 31 days after the date insurance ends under the Group Policy, life insurance benefits, if any, will be paid according to the terms of the Group Policy in effect on the date your employment terminates and not the terms of the Group Life Portability Insurance Policy. AD&D benefits, if any, will be paid according to the terms of the Group Policy or the Group Life Portability Insurance Policy, but not both. In no event will the benefits paid exceed the amount in effect under the Group Policy on the day before your employment terminates. (WITH DL REF_WITH ADAD REF) LI.TP.OT.1 WAIVER OF PREMIUM A. Waiver Of Premium Benefit Insurance will be continued without payment of premiums while you are Totally Disabled if: 1. You become Totally Disabled while insured under the Group Policy and under age 60; 2. You complete your Waiting Period; and 3. You give us satisfactory Proof Of Loss. However, continuation of insurance without payment of premium is limited to 12 months if you become Totally Disabled on or after age 60. We may have you examined at our expense at reasonable intervals. Any such examination will be conducted by specialists of our choice. B. Definitions For Waiver Of Premium 1. Insurance means all your insurance under the Group Policy, except AD&D Insurance and Dependents AD&D Insurance. 2. Waiting Period means the 180 consecutive day period beginning on the date you become Totally Disabled. Waiver Of Premium begins when you complete the Waiting Period. C. Premium Payment Premium payment must continue until the later of: 1. The date you complete your Waiting Period; and 2. The date we approve your claim for Waiver Of Premium. D. Refund Of Premiums We will refund up to 12 months of the premiums that were paid for Insurance after the date you become Totally Disabled. E. Amount Of Insurance The amount of Insurance eligible for Waiver Of Premium is the amount in effect on the day before you become Totally Disabled. However, the following will apply: 1. Insurance will be reduced or terminated according to the Group Policy provisions in effect on the day before you become Totally Disabled. 2. If you receive an Accelerated Benefit, Insurance will be reduced according to the Accelerated Benefit provision. 3. The amount of Supplemental Life Insurance on your Spouse will be the lesser of: a. The amount in effect on the day before you become Totally Disabled; and b. The amount in effect one year before the date you become Totally Disabled. Printed 11/04/2014 - 17 - 649032-A F. Effect Of Death During The Waiting Period If you die during the Waiting Period and are otherwise eligible for Waiver Of Premium, the Waiting Period will be waived. G. Termination Or Amendment Of The Group Policy Insurance will not be affected by termination or amendment of the Group Policy after you become Totally Disabled. H. When Waiver Of Premium Ends Waiver Of Premium ends on the earliest of: 1. The date you cease to be Totally Disabled; 2. Twelve months after the date you become Totally Disabled if you become Totally Disabled on or after age 60; 3. 90 days after the date we mail you a request for additional Proof Of Loss, if it is not given; 4. The date you fail to attend an examination or cooperate with the examiner; 5. With respect to the amount of Insurance which an insured has converted, the effective date of the individual life insurance policy issued to the insured; and 6. The date you reach age 65. However, if on the date the Group Policy terminates you are age 64 and you are eligible for Waiver Of Premium, Insurance will continue for an additional 12 months, subject to all other terms of the Group Policy. (ELIG 60_TERMS 65) LI.WP.FL.2 ACCELERATED BENEFIT A. Accelerated Benefit If you qualify for Waiver Of Premium and give us satisfactory proof of having a Qualifying Medical Condition while you are insured under the Group Policy, you may have the right to receive during your lifetime a portion of your Insurance as an Accelerated Benefit. You must have at least $10,000 of Insurance in effect to be eligible. If your Insurance is scheduled to end within 24 months following the date you apply for the Accelerated Benefit, you will not be eligible for the Accelerated Benefit. Qualifying Medical Condition means you are terminally ill as a result of an illness or physical condition which is reasonably expected to result in death within 12 months. We may have you examined at our expense in connection with your claim for an Accelerated Benefit. Any such examination will be conducted by one or more Physicians of our choice. B. Application For Accelerated Benefit You must apply for an Accelerated Benefit. To apply you must give us satisfactory Proof Of Loss on our forms. Proof Of Loss must include a statement from a Physician that you have a Qualifying Medical Condition. C. Amount Of Accelerated Benefit You may receive an Accelerated Benefit of up to 75% of your Insurance. The maximum Accelerated Benefit is $500,000. The minimum Accelerated Benefit is $5,000 or 10% of your Insurance, whichever is greater. If the amount of your Insurance is scheduled to reduce within 24 months following the date you apply for the Accelerated Benefit, your Accelerated Benefit will be based on the reduced amount. Printed 11/04/2014 - 18 - 649032-A The Accelerated Benefit will be paid to you once in your lifetime in a lump sum. If you recover from your Qualifying Medical Condition after receiving an Accelerated Benefit, we will not ask you for a refund. D. Effect On Insurance And Other Benefits For any purpose other than premium payment, the amount of your Insurance after payment of the Accelerated Benefit will be the greater of the amounts in (1) and (2) below; however, if you assign your rights under the Group Policy, the amount of your Insurance will be the amount in (2) below. (1) 10% of the amount of your Insurance as if no Accelerated Benefit had been paid; or (2) The amount of your Insurance as if no Accelerated Benefit had been paid; minus The amount of the Accelerated Benefit; minus An interest charge calculated as follows: A times B times C divided by 365 = interest charge. A = The amount of the Accelerated Benefit. B = The monthly average of our variable policy loan interest rate. C = The number of days from payment of the Accelerated Benefit to the earlier of (1) the date you die, and (2) the date you have a Right To Convert. The amount of your AD&D Insurance, if any, is not affected by payment of the Accelerated Benefit. AD&D is not continued under Waiver Of Premium. Note: If you assign your rights under the Group Policy, the amount of your Insurance after payment of the Accelerated Benefit will be the amount in (2) above. E. Exclusions No Accelerated Benefit will be paid if: 1. All or part of your Insurance must be paid to your Child(ren), or your Spouse or former Spouse as part of a court approved divorce decree, separate maintenance agreement, or property settlement agreement. 2. You are married and live in a community property state unless you give us a signed written consent from your Spouse. 3. You have made an assignment of all or part of your Insurance unless you give us a signed written consent from the assignee. 4. You have filed for bankruptcy, unless you give us written approval from the Bankruptcy Court for payment of the Accelerated Benefit. 5. You are required by a government agency to use the Accelerated Benefit to apply for, receive, or continue a government benefit or entitlement. 6. You have previously received an Accelerated Benefit under the Group Policy. F. Definitions For Accelerated Benefit Insurance means your Life Insurance Benefit and Supplemental Life Insurance Benefit, if any, under the Group Policy. LI.AB.OT.5 RIGHT TO CONVERT A. Right To Convert Printed 11/04/2014 - 19 - 649032-A You may buy an individual policy of life insurance without Evidence Of Insurability if: 1. Your Insurance ends or is reduced due to a Qualifying Event; and 2. You apply in writing and pay us the first premium during the Conversion Period. Except as limited under C. Limits On Right To Convert, the maximum amount you have a Right To Convert is the amount of your Insurance which ended. B. Definitions For Right To Convert 1. Conversion Period means the 31-day period after the date of any Qualifying Event. 2. Insurance means all your insurance under the Group Policy, including insurance continued under Waiver Of Premium, but excluding AD&D Insurance. 3. Qualifying Event means termination or reduction of your Insurance for any reason except: a. The Member's failure to make a required premium contribution. b. Payment of an Accelerated Benefit. 4. You and your mean any person insured under the Group Policy. C. Limits On Right To Convert If your Insurance ends or is reduced because of termination or amendment of the Group Policy, 1 and 2 below will apply. 1. You may not convert Insurance which has been in effect for less than the Minimum Time Insured. See Coverage Features. 2. The maximum amount you have a Right To Convert is the lesser of: a. The amount of your Insurance which ended, minus any other group life insurance for which you become eligible during the Conversion Period; and b. The Maximum Conversion Amount. See Coverage Features. D. The Individual Policy You may select any form of individual life insurance policy we issue to persons of your age, except: 1. A term insurance policy; 2. A universal life policy; 3. A policy with disability, accidental death, or other additional benefits; or 4. A policy in an amount less than the minimum amount we issue for the form of life insurance you select. The individual policy of life insurance will become effective on the day after the end of the Conversion Period. We will use our published rates for standard risks to determine the premium. E. Death During The Conversion Period If you die during the Conversion Period, we will pay a death benefit equal to the maximum amount you had a Right To Convert, whether or not you applied for an individual policy. The benefit will be paid according to the Benefit Payment And Beneficiary Provisions. LI.RC.OT.1 CLAIMS A. Filing A Claim Printed 11/04/2014 - 20 - 649032-A Claims should be filed on our forms. If we do not provide our forms within 15 days after they are requested, the claim may be submitted in a letter to us. B. Time Limits On Filing Proof Of Loss Proof Of Loss must be provided within 90 days after the date of the loss. If that is not possible, it must be provided as soon as reasonably possible, but not later than one year after that 90-day period. Proof Of Loss for Waiver Of Premium must be provided within 12 months after the end of the Waiting Period. We will require further Proof Of Loss at reasonable intervals, but not more often than once a year after you have been continuously Totally Disabled for two years. If Proof Of Loss is filed outside these time limits, the claim will be denied. These limits will not apply while the Member or Beneficiary lacks legal capacity. C. Proof Of Loss Proof Of Loss means written proof that a loss occurred: 1. For which the Group Policy provides benefits; 2. Which is not subject to any exclusions; and 3. Which meets all other conditions for benefits. Proof Of Loss includes any other information we may reasonably require in support of a claim. Proof Of Loss must be in writing and must be provided at the expense of the claimant. No benefits will be provided until we receive Proof Of Loss satisfactory to us. D. Investigation Of Claim We may have you examined at our expense at reasonable intervals. Any such examination will be conducted by specialists of our choice. We may have an autopsy performed at our expense, except where prohibited by law. E. Time Of Payment We will pay benefits within 60 days after Proof Of Loss is satisfied. F. Notice Of Decision On Claim We will evaluate a claim for benefits promptly after we receive it. With respect to all claims except Waiver Of Premium claims (or other benefits based on disability), within 90 days after we receive the claim we will send the claimant: (a) a written decision on the claim; or (b) a notice that we are extending the period to decide the claim for an additional 90 days. With respect to Waiver Of Premium claims (or other benefits based on disability), within 45 days after we receive the claim we will send the claimant: (a) a written decision on the claim; or (b) a notice that we are extending the period to decide the claim for 30 days. Before the end of this extension period we will send the claimant: (a) a written decision on the Waiver Of Premium claim (or other benefits based on disability); or (b) a notice that we are extending the period to decide the claim for an additional 30 days. If an extension is due to the claimant's failure to provide information necessary to decide the Waiver Of Premium claim (or other benefits based on disability), the extended time period for deciding the claim will not begin until the claimant provides the information or otherwise responds. If we extend the period to decide the claim, we will notify the claimant of the following: (a) the reasons for the extension; (b) when we expect to decide the claim; (c) an explanation of the standards on which entitlement to benefits is based; (d) the unresolved issues preventing a decision; and (e) any additional information we need to resolve those issues. Printed 11/04/2014 - 21 - 649032-A If we request additional information, the claimant will have 45 days to provide the information. If the claimant does not provide the requested information within 45 days, we may decide the claim based on the information we have received. If we deny any part of the claim, we will send the claimant a written notice of denial containing: 1. The reasons for our decision. 2. Reference to the parts of the Group Policy on which our decision is based. 3. A description of any additional information needed to support the claim. 4. Information concerning the claimant's right to a review of our decision. G. Review Procedure If all or part of a claim is denied, the claimant may request a review. The claimant must request a review in writing: 1. Within 180 days after receiving notice of the denial of a claim for Waiver Of Premium (or other benefits based on disability); 2. Within 60 days after receiving notice of the denial of any other claim. The claimant may send us written comments or other items to support the claim. The claimant may review and receive copies of any non-privileged information that is relevant to the request for review. There will be no charge for such copies. Our review will include any written comments or other items the claimant submits to support the claim. We will review the claim promptly after we receive the request. With respect to all claims except Waiver Of Premium claims (or other benefits based on disability), within 60 days after we receive the request for review we will send the claimant: (a) a written decision on review; or (b) a notice that we are extending the review period for 60 days. With respect to Waiver Of Premium claims (or other benefits based on disability), within 45 days after we receive the request for review we will send the claimant: (a) a written decision on review; or (b) a notice that we are extending the review period for 45 days. If an extension is due to the claimant's failure to provide information necessary to decide the claim on review, the extended time period for review of the claim will not begin until the claimant provides the information or otherwise responds. If we extend the review period, we will notify the claimant of the following: (a) the reasons for the extension; (b) when we expect to decide the claim on review; and (c) any additional information we need to decide the claim. If we request additional information, the claimant will have 45 days to provide the information. If the claimant does not provide the requested information within 45 days, we may conclude our review of the claim based on the information we have received. With respect to Waiver Of Premium claims (or other benefits based on disability), the person conducting the review will be someone other than the person who denied the claim and will not be subordinate to that person. The person conducting the review will not give deference to the initial denial decision. If the denial was based on a medical judgement, the person conducting the review will consult with a qualified health care professional. This health care professional will be someone other than the person who made the original medical judgement and will not be subordinate to that person. The claimant may request the names of medical or vocational experts who provided advice to us about a claim for Waiver Of Premium (or other benefits based on disability). If we deny any part of the claim on review, the claimant will receive a written notice of denial containing: 1. The reasons for our decision. Printed 11/04/2014 - 22 - 649032-A 2. Reference to the parts of the Group Policy on which our decision is based. 3. Information concerning the claimant's right to receive, free of charge, copies of non-privileged documents and records relevant to the claim. (2ND REV PUB WRDG_NEW WOP WRDG) LI.CL.OT.5 ASSIGNMENT You may make an absolute or collateral assignment of all your Life and AD&D Insurance, subject to 1 through 7 below. 1. All insurance under the Group Policy, including AD&D Insurance, is assignable. Dependents Life Insurance is not assignable. 2. An absolute assignment must be irrevocable. It must transfer all rights, including: a. The right to change the Beneficiary; b. The right to buy an individual life insurance policy on your life under Right To Convert; and c. The right to receive accidental dismemberment benefits. d. The right to apply for and receive an Accelerated Benefit. 3. The assignment will apply to all of your Life and AD&D Insurance in effect on the date of the assignment or becoming effective after that date. 4. The assignment may be to any person permitted by law. 5. The assignment will have no effect unless it is: made in writing, signed by you, and delivered to the Policyholder or Employer in your lifetime. Neither we, the Policyholder, nor the Employer are responsible for the validity, sufficiency or effect of the assignment. 6. All accidental dismemberment benefits will be paid to the assignee. All death benefits will be paid according to the beneficiary designation on file with the Policyholder or Employer, and the Benefit Payment And Beneficiary Provisions. 7. The assignment will not change the Beneficiary, unless the assignee later changes the Beneficiary. Any payment we make according to the beneficiary designation on file with the Policyholder or Employer or the Employer, and the Benefit Payment And Beneficiary Provisions will fully discharge us to the extent of the payment. You may not make an assignment which is contrary to the rules in 1 through 7 above. (ALLOWED) LI.AS.FL.2 BENEFIT PAYMENT AND BENEFICIARY PROVISIONS A. Payment Of Benefits 1. Except as provided in item 6 below, benefits payable because of your death will be paid to the Beneficiary you name. See B through E of this section. 2. AD&D Insurance benefits payable for Losses other than Loss of Life will be paid to the person who suffers the Loss for which benefits are payable. Any such benefits remaining unpaid at that person's death will be paid according to the provisions for payment of a death benefit. 3. The benefits below will be paid to you if you are living. a. AD&D Insurance benefits payable because of the death of your Dependent. b. Dependents Life Insurance benefits. c. Supplemental Life Insurance benefits payable because of the death of your Spouse. Printed 11/04/2014 - 23 - 649032-A d. Accelerated Benefits. 4. Dependents Life Insurance benefits and AD&D Insurance benefits payable because of the death of your Dependent which are unpaid at your death will be paid in equal shares to the first surviving class of the classes below. a. The children of the Dependent. b. The parents of the Dependent. c. The brothers and sisters of the Dependent. d. Your estate. 5. Supplemental Life Insurance benefits payable because of the death of your Spouse which are unpaid at your death will be paid in equal shares to the first surviving class of the classes below. a. The children of your Spouse. b. The parents of your Spouse. c. The brothers and sisters of your Spouse. d. Your estate. 6. Additional Benefits will be paid as follows: The Child Care Benefit will be paid to your surviving Spouse. No Child Care Benefit will be paid if you have no Spouse. The Career Adjustment Benefit will be paid to your Spouse. No Career Adjustment Benefit will be paid if you have no Spouse. The Higher Education Benefit will be paid to each eligible Child. No Higher Education Benefit will be paid if there is no Child eligible to receive it. The Repatriation Benefit will be paid to the person who incurs the transportation expenses. B. Naming A Beneficiary Beneficiary means a person you name to receive death benefits. You may name one or more Beneficiaries. If you name two or more Beneficiaries in a class: 1. Two or more surviving Beneficiaries will share equally, unless you provide for unequal shares. 2. If you provide for unequal shares in a class, and two or more Beneficiaries in that class survive, we will pay each surviving Beneficiary his or her designated share. Unless you provide otherwise, we will then pay the share(s) otherwise due to any deceased Beneficiary(ies) to the surviving Beneficiaries pro rata based on the relationship that the designated percentage or fractional share of each surviving Beneficiary bears to the total shares of all surviving Beneficiaries. 3. If only one Beneficiary in a class survives, we will pay the total death benefits to that Beneficiary. You may name or change Beneficiaries at any time without the consent of a Beneficiary. We will provide a form on which you can designate your Beneficiary(ies). This form will typically be provided in a hardcopy format. However, at the Policyholder's request, and subject to our approval, the form may instead be provided electronically or telephonically. Printed 11/04/2014 - 24 - 649032-A Your Beneficiary designation must be the same for Life Insurance and AD&D Insurance death benefits. Your Beneficiary designations for Life Insurance and your Supplemental Life Insurance may be different. You may name or change Beneficiaries in writing. Writing includes a form signed by you; or a verification from us, or our designated agent, the Policyholder, the Policyholder's designated agent, the Employer, or the Employer's designated agent of an electronic or telephonic designation made by you. Your designation: 1. Must be dated; 2. Must be delivered to us, our designated agent, the Policyholder, the Policyholder's designated agent, the Employer, or the Employer's designated agent; during your lifetime. 3. Must relate to the insurance provided under the Group Policy; and 4. Will take effect on the date it is delivered or, if a telephonic or electronic designation, verified by us, our designated agent, the Policyholder, the Policyholder's designated agent, the Employer, or the Employer's designated agent. If we approve it, a designation, which meets the requirements of a Prior Plan, will be accepted as your Beneficiary designation under the Group Policy. C. Simultaneous Death Provision If a Beneficiary or a person in one of the classes listed in item D. No Surviving Beneficiary dies on the same day you die, or within 15 days thereafter, benefits will be paid as if that Beneficiary or person had died before you, unless Proof Of Loss with respect to your death is delivered to us before the date of the Beneficiary's death. D. No Surviving Beneficiary If you do not name a Beneficiary, or if you are not survived by one, benefits will be paid in equal shares to the first surviving class of the classes below. 1. Your Spouse. (See Definitions) 2. Your children. 3. Your parents. 4. Your brothers and sisters. 5. Your estate. E. Methods Of Payment Recipient means a person who is entitled to benefits under this Benefit Payment and Beneficiary Provisions section. 1. Lump Sum If the amount payable to a Recipient is less than $25,000, we will pay it in a lump sum. 2. Standard Secure Access Checking Account If the amount payable to a Recipient is $25,000, or more, we will deposit it into a Standard Secure Access checking account which: a. Bears interest at a rate equal to the 13-week Treasury Bill (T-Bill) auction rate, but not to exceed 5%; b. Is owned by the Recipient; Printed 11/04/2014 - 25 - 649032-A c. Is subject to the terms and conditions of a confirmation certificate which will be given to the Recipient; and d. Is fully guaranteed by us. 3. Installments Payment to a Recipient may be made in installments if: a. The amount payable is $25,000 or more; b. The Recipient chooses; and c. We agree. To the extent permitted by law, the amount payable to the Recipient will not be subject to any legal process or to the claims of any creditor or creditor's representative. (FB_REPAT_ELECT/TEL DESIG_WITH DEF SP_WITH REV SSA_SPOUSE DEF TERM_THIRD PARTY DESIG) LI.BB.FL.6 ALLOCATION OF AUTHORITY Except for those functions which the Group Policy specifically reserves to the Policyholder, we have full and exclusive authority to control and manage the Group Policy, to administer claims, and to interpret the Group Policy and resolve all questions arising in the administration, interpretation, and application of the Group Policy. Our authority includes, but is not limited to: 1. The right to resolve all matters when a review has been requested; 2. The right to establish and enforce rules and procedures for the administration of the Group Policy and any claim under it; 3. The right to determine: a. Eligibility for insurance; b. Entitlement to benefits; c. Amount of benefits payable; d. Sufficiency and the amount of information we may reasonably require to determine a., b., or c., above. Subject to the review procedures of the Group Policy any decision we make in the exercise of our authority is conclusive and binding. LI.AL.OT.1 TIME LIMITS ON LEGAL ACTIONS No action at law or in equity may be brought until 60 days after we have been given Proof Of Loss. No such action may be brought more than five years after the earlier of: 1. The date we receive Proof Of Loss; and 2. The time within which Proof Of Loss is required to be given. LI.TL.FL.1 INCONTESTABILITY PROVISIONS A. Incontestability Of Insurance Printed 11/04/2014 - 26 - 649032-A Any statement made to obtain or to increase insurance is a representation and not a warranty. No misrepresentation will be used to reduce or deny a claim unless: 1. The insurance would not have been approved if we had known the truth; and 2. We have given you or any other person claiming benefits a copy of the signed written instrument which contains the misrepresentation. We will not use a misrepresentation to reduce or deny a claim after the insured's insurance has been in effect for two years during the lifetime of the insured. B. Incontestability Of Group Policy Any statement made by the Policyholder or Employer to obtain the Group Policy is a representation and not a warranty. No misrepresentation by the Policyholder or Employer will be used to deny a claim or to deny the validity of the Group Policy unless: 1. The Group Policy would not have been issued if we had known the truth; and 2. We have given the Policyholder or Employer a copy of a written instrument signed by the Policyholder or Employer which contains the misrepresentation. The validity of the Group Policy will not be contested after it has been in force for two years, except for nonpayment of premiums. LI.IN.OT.2 CLERICAL ERROR AND MISSTATEMENT A. Clerical Error Clerical error by the Policyholder, your Employer, or their respective employees or representatives will not: 1. Cause a person to become insured; 2. Invalidate insurance under the Group Policy otherwise validly in force; or 3. Continue insurance under the Group Policy otherwise validly terminated. B. The Policyholder and your Employer act on their own behalf as your agent, and not as our agent. C. Misstatement Of Age If a person's age has been misstated, we will make an equitable adjustment of premiums, benefits, or both. The adjustment will be based on: 1. The amount of insurance based on the correct age; and 2. The difference between the premiums paid and the premiums which would have been paid if the age had been correctly stated. LI.CE.OT.2 TERMINATION OR AMENDMENT OF THE GROUP POLICY The Group Policy may be terminated by us or the Policyholder according to its terms. It will terminate automatically for nonpayment of premium. The Policyholder may terminate the Group Policy in whole, and may terminate insurance for any class or group of Members, at any time by giving us written notice. Printed 11/04/2014 - 27 - 649032-A Benefits under the Group Policy are limited to its terms, including any valid amendment. No change or amendment will be valid unless it is approved in writing by one of our executive officers and given to the Policyholder for attachment to the Group Policy. If the terms of the Certificate differ from the Group Policy, the terms stated in the Group Policy will govern. The Policyholder, your Employer, and their respective employees or representatives have no right or authority to change or amend the Group Policy or to waive any of its terms or provisions without our signed written approval. We may change the Group Policy in whole or in part when any change or clarification in law or governmental regulation affects our obligations under the Group Policy, or with the Policyholder's consent. Any such change or amendment of the Group Policy may apply to current or future Members or to any separate classes or groups thereof. LI.TA.OT.1 DEFINITIONS AD&D Insurance means accidental death and dismemberment insurance, if any, under the Group Policy. Annual Earnings means your annual rate of earnings from your Employer. Your Annual Earnings will be based on your earnings in effect on your last full day of Active Work unless a different date applies (see the Coverage Features). Annual Earnings includes: 1. Contributions you make through a salary reduction agreement with your Employer to: a. An Internal Revenue Code (IRC) Section 401(k), 403(b), 408(k), or 457 deferred compensation arrangement; or b. An executive nonqualified deferred compensation arrangement. 2. Amounts contributed to your fringe benefits according to a salary reduction agreement under an IRC Section 125 plan. Annual Earnings does not include: 1. Bonuses. 2. Commissions. 3. Overtime pay. 4. Shift differential pay. 5. Stock options or stock bonuses. 6. Your Employer's contributions on your behalf to any deferred compensation arrangement or pension plan. 7. Any other extra compensation. Child means: 1. Your child from live birth through age 20 (through age 24 if a registered student in full time attendance at an accredited educational institution); or 2. Your child who meets either of the following requirements: a. The child is insured under the Group Policy and, on and after the date on which insurance would otherwise end because of the Child's age, is continuously Disabled. b. The child was insured under the Prior Plan on the day before the effective date of your Employer's coverage under the Group Policy and was Disabled on that day, and is continuously Disabled thereafter. Printed 11/04/2014 - 28 - 649032-A Child includes any of the following, if they otherwise meet the definition of Child: i. Your adopted child; or ii. Your stepchild, if living in your home. Your child is Disabled if your child is: 1. Continuously incapable of self-sustaining employment because of mental retardation or physical handicap; and 2. Chiefly dependent upon you for support and maintenance, or institutionalized because of mental retardation or physical handicap. You must give us proof your Child is Disabled on our forms within 31 days after a) the date on which insurance would otherwise end because of the Child's age or b) the effective date of your Employer's coverage under the Group Policy if your child is Disabled on that date. At reasonable intervals thereafter, we may require further proof, and have your Child examined at our expense. Contributory means you pay all or part of the premium for insurance. Dependents Life Insurance means dependents life insurance, if any, under the Group Policy. Eligibility Waiting Period means the period you must be a Member before you become eligible for insurance. See Coverage Features. Evidence Of Insurability means an applicant must: 1. Complete and sign our medical history statement; 2. Sign our form authorizing us to obtain information about the applicant's health; 3. Undergo a physical examination, if required by us, which may include blood testing; and 4. Provide any additional information about the applicant's insurability that we may reasonably require. Group Policy means the group life insurance policy issued by us to the Policyholder and identified by the Group Policy Number. Injury means an injury to your body. Life Insurance means life insurance under the Group Policy. L.L.C. Owner-Employee means an individual who owns an equity interest in an Employer and is actively employed in the conduct of the Employer's business. Noncontributory means the Policyholder or Employer pays the entire premium for insurance. P.C. Partner means the sole active employee and majority shareholder of a professional corporation in partnership with the Policyholder. Physician means a licensed M.D. or D.O., acting within the scope of the license. Physician does not include you or your spouse, or the brother, sister, parent or child of either you or your spouse. Pregnancy means your pregnancy, childbirth, or related medical conditions, including complications of pregnancy. Prior Plan means your Employer's group life insurance plan in effect on the day before the effective date of your Employer's coverage under the Group Policy and which is replaced by the Group Policy. Sickness means your sickness, illness, or disease. Spouse means a person to whom you are legally married. However, for purposes of insurance under the Group Policy, Spouse does not include a person who is a full-time member of the armed forces of any country or a person from whom you are divorced. Printed 11/04/2014 - 29 - 649032-A Supplemental Life Insurance means supplemental life insurance, if any, under the Group Policy. Totally Disabled means you are unable to perform with reasonable continuity the Material Duties of Any Occupation as a result of Sickness, accidental Injury, or Pregnancy. Any Occupation means any gainful occupation for which you are reasonably fitted by education, training and experience. (BASE_NO STOCK_WITH STAT TOT DIS) LI.DF.FL.5 ALIC99X Printed 11/04/2014 - 30 - 649032-A Milliman Actuarial Valuation Milliman Okaloosa County, Florida Actuarial Valuation of Postretirement Benefits Under GASB 45 as of September 30, 2017 Prepared by Milliman, Inc. Michael McGrath, FSA Principal Sebastian Jaramillo, ASA Consulting Actuary 3424 Peachtree Road NE Suite 1900 Atlanta, GA 30326 Tel +1 404 254 6700 Fax +1 404 237 6984 milliman.com Issued: October 2, 2017 3424 Peachtree Road NE ll Milliman Suite 1900 Atlanta, GA 30326-1123 USA October 2, 2017 Main + 1 404 237 7060 Fax + 1 404 237 6984 Okaloosa County, Florida milliman.com 302 N Wilson Street, Suite 203 Crestview, FL 32536-3474 Okaloosa County, Florida Pursuant to your request, we have completed an actuarial valuation of the benefit cost and funded status relating to the future retiree medical benefits provided by Okaloosa County, Florida for the fiscal period ending September 30, 2017. The resulting liabilities and cost presented as for the current year are “rolled forward” from the results of the valuation as of the year ending September 30, 2016, as permitted under GASB 45. The results of our calculations are set forth in the following report, as are the actuarial assumptions, methods and brief summary of the retiree eligibility and benefits upon which our calculations have been made. Our determinations reflect the procedures and methods as prescribed in Statement 45 of the Governmental Accounting Standards Board, “Accounting and Financial Reporting by Employers for Postemployment Benefits Other than Pensions” (“Statement”). Actuarial computations under the Statement are for purposes of fulfilling certain employer accounting requirements. The calculations reported herein have been made on a basis consistent with our understanding of the Statement. Determinations for purposes other than meeting the employer financial accounting requirements of the Statement may differ significantly from the results reported herein. In preparing our calculations for this report, we have relied without audit, on the employee data, plan provisions, and other plan financial information as provided by Okaloosa County, Florida. If any of this information, as summarized in this report, is inaccurate or incomplete, the results shown could be materially affected and this report may need to be revised. If there are material defects in the data, it is possible that they would be uncovered by a detailed, systematic review and comparison of the data to search for data values that are questionable or for relationships that are materially inconsistent. Such a review was beyond the scope of our assignment. Milliman’s work is prepared solely for the internal use of Okaloosa County, Florida (the “Plan Sponsor”) and the Plan’s Trustees and may not be provided to third parties without our prior written consent. Milliman does not intend to benefit or create a legal duty to any third party recipient of its work product. Milliman’s consent to release its work product to any third party may be conditioned on the third party signing a release, subject to the following exceptions: . The Plan Sponsor may provide a copy of Milliman’s work, in its entirety, to the Plan’s professional service advisors who are subject to a duty of confidentiality and who agree to not use Milliman’s work for any purpose other than to benefit the Plan. . The Plan Sponsor may distribute certain work product that Milliman and the Plan Sponsor mutually agree is appropriate as may be required by law. Any third party recipient of this work product who desires professional guidance should not rely upon Milliman’s work product, but should engage qualified professionals for advice appropriate to its own specific needs. Future actuarial measurements may differ significantly from the current measurements presented in this report due to such factors as the following: plan experience differing from that anticipated by the economic or demographic assumptions; changes in economic or demographic assumptions; increases or decreases expected as part of the natural operation of the methodology used for these measurements (such as the end of an amortization period or additional cost or contribution requirements based on the plan's funded status); and changes in plan provisions or applicable law. Due to the limited scope of our assignment, we did not perform an analysis of the potential range of future measurements. In our opinion, each assumption used, other than those assumptions mandated by law and regulations thereon, is individually reasonable (taking into account the experience of the Plan and reasonable expectations) and, in combination, such other assumptions offer our best estimate of anticipated experience under the Plan. On the basis of the foregoing, we hereby certify that to the best of our knowledge and belief, this report is complete and accurate and has been prepared in accordance with generally recognized and accepted actuarial principles and practices which are consistent with the principles prescribed by the Actuarial Standards Board and the Code of Professional Conduct and Qualification Standards for Actuaries Issuing Statements of Actuarial Opinion in the United States promulgated by the American Academy of Actuaries. We are members of the American Academy of Actuaries and meet its Qualification Standards to render the actuarial opinion contained herein. Please contact us if you have questions about our report or would like additional information. Respectfully submitted, ______Michael McGrath Sebastian Jaramillo Fellow, Society of Actuaries Associate, Society of Actuaries Milliman Actuarial Valuation Table of Contents Introduction and Purpose Exhibits Summary of Participant Data ...... 1 Actuarial Present Value of Total Projected Benefits ...... 2 Unfunded Actuarial Accrued Liability ...... 3 Annual Required Contribution ...... 4 Projected Benefit Payments ...... 5 Financial Statement Disclosures ...... 6 Schedule of Funding Progress ...... 7 Appendices A – Summary of Actuarial Assumptions and Methods ...... A-1 B – Summary of Principal Plan Provisions ...... B-1 Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 Okaloosa County, Florida Milliman Actuarial Valuation Introduction and Purpose Historically, governmental entities offering postretirement medical plans – especially those that are self- funded – have accounted for such plans on essentially a cash basis. Consequently, the cost for such plans is attributed to the period of time that an employee is retired and not performing substantial work for the employer. In 2004, the Governmental Accounting Standards Board issued Statement No. 45 entitled “Accounting and Financial Reporting by Employers for Postemployment Benefits Other Than Pensions” (“GASB 45”) to address the accounting of these plans. The major change under GASB 45 is to attribute the cost of postretirement benefits to the time during which the employee is working for the employer. Reasons provided by GASB for this change include: . Recognize the cost of benefits in periods when the related services are received by the employer. . Provide information about the actuarial liabilities for promised benefits associated with past services and to what extent those benefits are funded. . Provide information that is useful to assess potential demands on the employer’s future cash flows. While GASB 45 allocates the costs of a postretirement benefit plan over the years of active employment (when the promise of future benefits is potentially motivating an employee), it does not require the funding of such benefits. There are two key points that need to be noted in this regard. First, the choice of the discount rate used in measuring the liabilities of the benefits is tied to the funding vehicle or lack thereof. GASB 45 requires the use of a discount rate that is related to the long-term investment yield on investments used to finance the payments of benefits. An unfunded plan must use a discount rate equal to what the sponsor earns on its general assets. Since a lower discount rate leads to higher liabilities, a funded plan will have lower liabilities than an unfunded plan with identical provisions and membership. While the discount rate issue provides some encouragement for funding plans, there is a second key point. GASB 45 requires that assets can only be considered if they are: (1) held in an irrevocable trust, (2) dedicated solely to provide benefits under the plan to retirees and their beneficiaries, and (3) are protected from creditors. This restriction may limit what can be funded, depending upon legal restraints and tax issues. Since the plan is unfunded, results are shown using a discount rate of 4.00%. These pages estimate the cost of the entity’s current retiree health program and the potential impact of GASB 45. The intended purpose of this information is to provide actuarial cost information to the entity to help with financial and benefit planning. Milliman does not intend to benefit and assumes no duty or liability to other parties who receive this work. The report should only be used in its entirety to assure complete understanding of the estimates and the methodology and assumptions underlying the estimates. In preparing this report, we relied on the overall employee census information provided by the entity. We reviewed the information for reasonableness, but we did not audit the information. To the extent that any of this data or information is incorrect, the results of this report may need to be revised. Per capita claims were developed from our understanding of the Plan and Milliman’s Health Cost Guidelines. A number of assumptions have been made in projecting retiree health costs that should be reviewed prior to interpreting the results shown in this report. These assumptions, as well as the actuarial methodology, are described in this report. The projections in this report are estimates and, as such, the entity’s actual liability will vary from these estimates. The actual liability will not be known until such time that all eligibility is exhausted and all benefits are paid. The projections and assumptions should be updated as actual costs under this program develop. Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 Okaloosa County, Florida Milliman Actuarial Valuation Exhibits Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 Okaloosa County, Florida Milliman Actuarial Valuation Exhibit 1 Summary of Participant Data As of June 2016 Number of Active Members by Age and Service Groups Age <1 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40 & Up Total 0-24 110 11 25-29 934 10 53 30-34 2 33 12 11 58 35-39 8 23 12 1013 1 67 40-44 8 35 12 1711 6 89 45-49 5 23 19 2410 9 9 4 103 50-54 4 20 18 3010 9 10 7 2 110 55-59 3 26 10 3031 11 7 7 3 128 60-64 2 13 15 1215 12 7 5 2 83 65-69 2 3 3 2 3 3 16 70&Up 1 2 1 4 Total 42 220 111 139 93 51 36 23 7 0 722 Number of Retirees with Medical Coverage by Age and Gender r Age Male Female Total <50 0 50-54 1 1 2 55-59 4 3 7 60-64 10 5 15 65-69 2 2 70-74 1 1 75 & Up 1 1 l TotalI 17 11 28 The retiree count above does not include 6 retirees with coverage under the County sponsored Medicare Advantage Plan. It also does not include 33 retirees with County sponsored dental coverage who do not receive medical coverage through the County. Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 Okaloosa County, Florida Milliman Actuarial Valuation Exhibit 2 Actuarial Present Value of Total Projected Benefits Current Plan at 4.00% Discount Rate as of 10/1/2016 Actives Retirees Total Medical and Rx $6,141,890 $1,446,373 $7,588,263 Total $6,141,890 $1,446,373 $7,588,263 Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 Okaloosa County, Florida Milliman Actuarial Valuation Exhibit 3 Unfunded Actuarial Accrued Liability Actuarial Accrued Liability (AAL) at 4.00% Discount Rates as of 10/1/2016 Actives Retirees Total Medical and Rx $3,349,405 $1,446,373 $4,795,778 Total $3,349,405 $1,446,373 $4,795,778 Unfunded Actuarial Accrued Liability (UAAL) AAL MV Asse ts U AAL As of October 1, 2016 $4,795,778 $0 $4,795,778 Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 Okaloosa County, Florida Milliman Actuarial Valuation Exhibit 4 Annual Required Contribution The amortization of the Unfunded Actuarial Accrued Liability for Fiscal Year Ending September 30, 2017 is calculated as a level dollar amount. GASB 45 allows for these payments to be calculated as a level percentage of payroll. If this were done, the FYE 2017 ARC would be lower, but the ARC in future years would be higher in later years as payroll increases. The UAAL is amortized over an open 30 year amortization period. Fiscal Year End # 9/30/2016 9/30/2017 1. Normal Costs a. Current Year Normal Cost as of October 1 $245,119 $254,924 b. Assumed Interest to the End of the Fiscal Year 9,805 10,197 c. Current Year Normal Cost as of September 30 [(1a) + (1b)] 254,924 265,121 2. Determination of Current Year Amortization Payment a. Unfunded Actuarial Accrued Liability 4,613,497 4,795,778 b. Effective Amortization Period 30 30 c. Level Dollar Amortization Factor 17.9837 17.9837 d. Amortization Amount as of FYE [(2a) / (2c)] 256,537 266,673 e. Assumed Interest to the End of the Plan Year 10,261 10,667 f. Amortization Amount as of FYE [(2d) + (2e)] 266,798 277,340 3. Determination of Annual Required Contribution a. Normal Cost for Benefits Attributable to Service in the Year (1c) 254,924 265,121 b. Amortization of Unfunded Actuarial Accrued Liability (2f) 266,798 277,340 c. Annual Required Contribution (ARC) [(3a) + (3b)] 521,722 542,461 Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 Okaloosa County, Florida Milliman Actuarial Valuation Exhibit 5 Projected Benefit Payments Total net claims include expected medical and prescription drugs claims paid on behalf of retirees and their covered dependents, less the contributions those retirees make towards the cost of their coverage. This projection is based on the population used in this valuation and makes no provision for future hires. In addition, it will only be realized if all assumptions are met. Year Total 2017 - 2018 $258,000 2018 - 2019 $242,000 2019 - 2020 $268,000 2020 - 2021 $324,000 2021 - 2022 $372,000 2022 - 2023 $404,000 2023 - 2024 $374,000 2024 - 2025 $333,000 2025 - 2026 $330,000 2026 - 2027 $313,000 Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 Okaloosa County, Florida Milliman Actuarial Valuation Exhibit 6 Financial Statement Disclosures The following table shows the calculation of the Annual Required Contribution and Net OPEB Obligation. The end of year Net OPEB obligation will need to reflect actual contributions. Fiscal Year Ending September 30, 2016 September 30, 2017 Determination of Annual Required Contribution Normal Cost at fiscal year end $254,924 $265,121 Amortization of UAAL 266,798 277,340 Annual Required Contribution (ARC) $521,722 $542,461 Determination of Net OPEB Obligation Annual Required Contribution $521,722 $542,461 Interest on prior year Net OPEB Obligation 50,128 60,015 Adjustment to ARC (72,472) (86,767) Annual OPEB Cost $499,378 $515,709 Assumed Contributions made (252,188) (263,491) * Estimated Increase in Net OPEB Obligation $247,190 $252,218 Estimated Net OPEB Obligation - beginning of year $1,253,195 $1,500,385 Estimated Net OPEB Obligation - end of year $1,500,385 $1,752,603 * - The contributions made for the 12 months ending September 30, 2017 reflect assumed contributions. This item is defined in GASB 45 (assuming no additional funding to a qualified trust) as actual benefit payments on behalf of retirees and dependents less any contributions paid by retirees or dependents for coverage. The following table shows the annual OPEB cost and net OPEB obligation for the prior two years and estimated amounts for the current year. Percentage of Fiscal Year Discount Annual OPEB Net OPEB OPEB Cost Ended Rate Cost Obligation Contributed 9/30/2015 4.0% $450,001 68.3% $1,253,195 9/30/2016 4.0% $499,378 50.5% $1,500,385 9/30/2017 4.0% $515,709 51.1% $1,752,603 Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 Okaloosa County, Florida Milliman Actuarial Valuation Exhibit 7 Schedule of Funding Progress Unfunded Actuarial UAAL as a Actuarial Actuarial Actuarial Discount Accrued Covered % of Funded Valuation Value of Accrued Rate Liability Payroll Covered Ratio Date Assets Liabilities (AAL) (1) Payroll (UAAL)(2) Oct. 1, 2014 0 4.00% 4,615,780 4,615,780 17,466,290 26.43% 0.0% Oct. 1, 2015 0 4.00% 4,613,497 4,613,497 29,190,777 15.80% 0.0% Oct. 1, 2016 0 4.00% 4,795,778 4,795,778 Not Reported N/A 0.0% (1) Actuarial Accrued Liability determined under the projected unit credit cost method. (2) Actuarial Accrued Liability less Actuarial Value of Assets. Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 Okaloosa County, Florida Milliman Actuarial Valuation Appendices Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 Okaloosa County, Florida Milliman Actuarial Valuation Appendix A Summary of Actuarial Assumptions and Methods Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 Okaloosa County, Florida Milliman Actuarial Valuation Summary of Actuarial Methods The actuarial cost method determines, in a systematic way, the incidence of plan sponsor contributions required to provide plan benefits. It also determines how actuarial gains and losses are recognized in OPEB costs. These gains and losses result from the difference between the actual experience under the plan and what was anticipated by the actuarial assumptions. The cost of the Plan is derived by making certain specific assumptions as to rates of interest, mortality, turnover, etc. which are assumed to hold for many years into the future. Since actual experience may differ somewhat from the long term assumptions, the costs determined by the valuation must be regarded as estimates of the true costs of the Plan. Actuarial liabilities and comparative costs shown in this Report were computed using the Projected Unit Credit Actuarial Cost Method, which consists of the following cost components: . The Normal Cost is the Actuarial Present Value of benefits allocated to the valuation year. . The Actuarial Accrued Liability is the Actuarial Present Value of benefits accrued as of the valuation date. . Valuation Assets are equal to the market value of assets as of the valuation date, if any. . Unfunded Actuarial Accrued Liability is the difference between the Actuarial Accrued Liability and the Valuation Assets. It is amortized over the maximum permissible period under GASB 45 of 30 years. It should be noted that GASB 45 allows a variety of cost methods to be used. We elected this method because it is generally easy to understand and is widely used for the valuation of postemployment benefits other than pensions. Other methods used do not change the ultimate liability, but do allocate it differently between what has been earned in the past and what will be earned in the future. If a different method was used, either the normal cost would decrease and the unfunded amortization would increase, or the normal cost would increase and the amortization decrease. Please note that the net effect of the change may result in an increase or decrease in the Annual Required Contribution (ARC). If desired, we can provide more details. Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 Okaloosa County, Florida Milliman Actuarial Valuation Summary of Actuarial Assumptions In addition to the actuarial method used, actuarial cost estimates depend to an important degree on the assumptions made relative to various occurrences, such as rate of expected investment earnings by the fund, rates of mortality among active and retired employees, rates of termination from employment, and retirement rates. In the current valuation, the actuarial assumptions used for the calculation of costs and liabilities are as shown below. Please note that the demographic assumptions are consistent with those used by the Florida Retirement System actuary and adopted by the Florida Retirement System Board. In the current valuation, the actuarial assumptions used for the calculation of costs and liabilities are as follows: Measurement Date Benefit liabilities and costs are valued as of October 1, 2016. The liabilities and costs presented as of the measurement date are “rolled forward” from the prior valuation as of October 1, 2015, as permitted under GASB 45. Discount Rate for Valuing Liabilities 4.00% per annum, compounded annually Assumed Inflation Rate 2.30% per annum, compounded annually Mortality Rates Males – RP 2000 system table with floating Scale AA projections for Males Females – RP 2000 system table with floating Scale AA projections for Females Employee mortality is projected to valuation year plus 15 years Annuitant mortality is projected to valuation year plus 7 years Disability Rates Sample rates of disability: Age Male Females 20 0.002% 0.000% 25 0.002% 0.001% 30 0.003% 0.001% 35 0.005% 0.003% 40 0.009% 0.005% 45 0.014% 0.008% 50 0.022% 0.010% 55 0.034% 0.016% 60 0.048% 0.022% Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 Okaloosa County, Florida Milliman Actuarial Valuation Withdrawal Rates Sample rates of Termination: Attained Age - Male Service 20 30 40 50 60 0 .328 .258 .244 .234 .274 3 .184 .132 .107 .094 .093 5 .117 .088 .074 .060 .068 7 .111 .071 .062 .053 .051 10+ .098 .047 .030 .030 .053 Attained Age – Female Service 20 30 40 50 60 0 .303 .254 .244 .232 .232 3 .174 .116 .100 .088 .087 5 .135 .094 .070 .062 .061 7 .113 .081 .063 .055 .054 10+ .116 .054 .033 .030 .030 Rates of early (reduced) retirement are included in the above rates of withdrawal. Participants retiring with a reduced benefit prior to age 55 are assumed to decline retiree medical coverage through the County. Retirement Rates Sample rates of Retirement based on year first eligible for unreduced retirement and subsequent retirement dates for participants hired prior to 7/1/2011. Male Male Female Female First Year Subsequent First Year Subsequent Age Eligible Years Eligible Eligible Years Eligible 45 18.4% 3.0% 23.7% 1.7% 50 39.5% 9.5% 35.9% 6.2% 55 49.9% 9.1% 44.8% 7.6% 60 63.0% 10.4% 57.7% 14.6% 65 37.9% 11.0% 49.3% 19.0% 80 100.0% 100.0% 100.0% 100.0% Sample rates of Retirement based on year first eligible for unreduced retirement and subsequent retirement dates for participants hired subsequent to 6/30/2011. Male Male Female Female First Year Subsequent First Year Subsequent Age Eligible Years Eligible Eligible Years Eligible 45 18.4% 3.0% 23.7% 1.7% 50 39.5% 9.5% 35.9% 6.2% 55 49.9% 9.1% 44.8% 7.6% 60 63.0% 10.4% 57.7% 14.6% 65 47.0% 11.0% 58.4% 19.0% 80 100.0% 100.0% 100.0% 100.0% In determining these rates, “retirement” includes election into the Florida Retirement System’s Deferred Retirement Option Program (DROP). 75% of participants retiring on an unreduced basis are assumed to elect to enter the DROP for a period of 3 years Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 Okaloosa County, Florida Milliman Actuarial Valuation Participation Assumption Currently active employees are expected to elect retiree medical coverage with a 50.00% likelihood at retirement. Current and future retirees are expected to continue coverage after age 65 at a 10.00% rate. Marriage Assumption For employees retiring after the valuation date, it is assumed that husbands are three years older than their wives. For employees retiring after the valuation date, 33.33% are assumed to elect to cover their spouse under the medical plan at retirement. Current retirees are valued using their current spousal election under the retiree medical plan in which they are currently enrolled. Medical Inflation (Trend Assumption) The trend assumptions for medical and pharmacy costs and retiree premiums are summarized below: Year younger than 65 65 and older 2016 4.50% 6.20% 2017 4.80% 5.70% 2018 5.40% 5.20% 2019 5.60% 4.90% 2020 5.40% 4.90% 2021 5.40% 4.90% 2022 5.30% 4.90% 2023 5.30% 4.80% 2024 5.20% 4.80% 2025 5.20% 4.80% 2026 5.20% 4.80% An ultimate rate of 4.1% is reached for the first time in the year 2085 for costs associated with participants younger than age 65. An ultimate rate of 4.2% and the year 2079 for costs associated with participants older than age 65. Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 Okaloosa County, Florida Milliman Actuarial Valuation Annual Claims Costs at Sample Ages Participants retiring in the future are assumed to elect coverage in the available medical plans under a distribution that matches the current retiree distribution. Expected annual claims as of the valuation date are as follows: Retirees Spouses Age Male Female Male Female 50 13,122 14,808 10,676 12,496 55 13,845 14,536 12,427 13,728 60 16,876 16,495 15,052 15,482 64 21,049 19,013 18,443 17,465 65 5,280 5,381 5,280 5,381 70 5,949 5,934 5,949 5,934 75 6,507 6,404 6,507 6,404 80 6,857 6,718 6,857 6,718 The claims cost above represent medical and prescription claims. Expected Retiree Premium Contribution The expected annual retiree premium contribution is based on a weighted average of the current retiree plan election. The expected future retiree premium contribution is as follows: Retirees Retiree and Spouses Annual Premium prior to age 65 9,753 14,886 Annual Premium after age 65 5,656 11,312 Blue Medicare PPO, Dental and Life Insurance Liability The County sponsored Blue Medicare PPO, group rated dental, and life insurance coverages are reflected as having 0 implicit liabilities in the valuation. Changes in Assumptions since Prior Valuation There have been no changes to the assumptions from the previous valuation as of October 1, 2015. Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 Okaloosa County, Florida Milliman Actuarial Valuation Appendix B Summary of Principal Plan Provisions Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 Okaloosa County, Florida Milliman Actuarial Valuation Appendix B – Summary of Principal Plan Provisions Retiree Medical Plan Eligibility A participant is eligible to receive benefits from the Plan upon retirement under Florida Retirement System plan provisions, as shown below. To be eligible for retiree benefits, the participant must be covered under the medical plan as an active employee immediately prior to retirement. Employees enrolled in FRS prior to July 1, 2011: Unreduced Retirement under FRS: Age 62 with 6 years of service, or any age with 30 years of service. Early Retirement under FRS: Any age and 6 years of service. Employees enrolled in FRS on or after to July 1, 2011: Unreduced Retirement under FRS: Age 65 with 8 years of service, or any age with 33 years of service. Early Retirement under FRS: Any age and 8 years of service. Participants qualifying for retirement are eligible to elect to enter a deferred retirement option (DROP) feature of the FRS for a period of up to 60 months. For the purposes of this valuation, medical claims incurred while a retiree participates in the DROP are not considered a liability under GASB 45. Participants not eligible for retirement at the time of their termination are not eligible for immediate or future benefits from the Retiree Medical plan. Premiums Due From Retirees for Coverage through the County Medical Coverage for retirees and spouses younger than age 65 2015-16 Monthly Premium 2016-17 Monthly Premium Plan Retiree Family Retiree Family PPO 3769 760.49 1,160.76 806.12 1,230.41 PPO 3559 812.76 1,240.53 861.53 1,314.96 Medical Coverage for retirees and spouses older than age 65 2015-16 Monthly Premium 2016-17 Monthly Premium Plan Retiree Retiree + 1 Retiree Retiree + 1 PPO 3769 441.18 882.40 467.65 935.34 PPO 3559 471.33 942.70 499.61 999.26 Blue Medicare 330.05 660.10 355.81 882.40 Dental Coverage for retirees and spouses 2015-16 Monthly Premium 2016-17 Monthly Premium Plan Retiree Retiree & Spouse Retiree Retiree & Spouse Met Life 21.88 63.47 27.35 79.34 The County sponsors a group rated life insurance coverage. Retirees may participate for $10,000 of coverage for $10 premiums monthly. Coverage Coverage is provided for the lifetime of the participant. Coverage is also provided to eligible spouse of retirees. Retired employees are responsible for the full cost of their medical, dental, and life insurance coverages. Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 B-1 Okaloosa County, Florida Milliman Actuarial Valuation Appendix B – Summary of Principal Plan Provisions Retiree OPEB Plan Provision Summaries: BlueOptions 03769 Coverage Period: 10/01 /2015-09/30/2016 w,th Rx $15 50 $80 S11mm:uy of Benefits and Coverage : Whal th is Pl an Covers & Whm it Costs Co,·erage fo r : Individual and/or Family I Pl:tn Type: PPO This is only a summary. If you want more de!Jlil abou t your coverage and costs, you can get the complete terms in the policy or plan document at ww,, .floridabluc.com or by call ing 1-800-.352-25~3. In the event there is a conAict between this summary and your Florida Blue coverage documents the rerrns and condittons of the coverage documents will control. Important Questions I Answers I Why this Matters: In-Network: $500 Per Pei:son/ $ 1,500 You must pay al l the costs up Lo the deductible amount before this plan begins Family. Out-Of-Network: $1 500 Per to pay for covered serv,ces you use. C heck your policy or plan docum ent to sec Whal is the overall Pecson/ $4,500 Family. when the deducrible s!Jl rts over (usually. but not aJways,January I st). See the deductible? Does not apply Lo In- etwork preventive chart s!Jlrting on page 2 for how much you pay for covered services after you ca re. meet the d eductible. Are th ere otl, cr You don' t have to meet d eductibles for specific services, but see the chart de ductibles fo r s pecific No. starti11g on page 2 for o ther costs fo r services this plan co\lers. services? Yes. In-Network: $3,000 Per ls there an Ql!.l::Qf:: 17,e om-of-noc ke, limit is the most you could pay during a coverage period Person/ $6,000 Family. O ut-Of- p ocket limit o n nl)' (usually o ne yea r) fo r you r share of the cost of covered services. This limit helps Network: $6,000 Per Person/ $12,000 expenses? you phn fo r hea ld1 care expenses. Family. Wha t is n ot included in Pcemium, balanc;e-billed cha rges, and Even though you pay these expenses, they don't count toward the out-of-pocket the out-of::pock e t health care this pla11 doesn't cover. limic. limit? Is the re an ovc ra.11 The chart starting o n page 2 describes any limits o n what the plnn will pay fo r annua l lj mit oo wbat o. .rpecijic covered services, such as o ffi ce visits. th e plan pays? Jf you use an in-network doctor o r o ther health care ~ . this plan will pay Yes. For a list of pa rticipati.n g some or all of th costs of covered services. Be aw1tre, your in-network doctor or Docs ti, is p Ian use a pro,tj d ers, see www. floridnblue.com o r hospital may use an out-of-network ~ for some services. Phns use tl1e ne two rk of provide rs? ca.It 1-800-352-2583. re on in-network, ~ . or participating for Of.!!rid= in tl1eir JJ.Cm:filk. Sec the chort s!Jlrtini,: on page 2 fo r how t.his ph n pays different kinds of nroviders. Do I need a referral to o. You can see the s p ecia lis t you choose wlthout permission from this p )g.n _ see a s ne:cia li st? Are there sen rices this Some of the servi es this plan doesn't cover are listed on page 4. See your policy Yes. olan d oesn't cover? or olan document for additional 1nfoanation abo ut excluded services. BlueOptions 03559 Coverage Period: 10/01/2015 - 09/30/2016 w,th R..~ SI 5 $50, $80 Sumnmry of !Jenefits and Covem ge: What thi s Plan Covers & What i-i Costs Coverage for: Individual and/or Famil y Plan T. pe: PPO Th is is only a summary. If )'OU wont more demi! about your coverage and costs, you ca n get the complete terms in tlie policy or plRn document at ww" .floriddbluc.com or by c•lling 1-800-352-2583. In the event there is a connict between this summary and you r Florida Blue coverage documents the terms and co nditions of the coverag-e documents will control. Important Questions I Answers I Why this Matters: In- 1etwork: $500 Per Person/ $ 1,500 You must pay all the costs up to the deduc1ihle •mount before th is pion begins Family. Out-Of- etwork: $750 Per to pay fo r covered services you use. Check your policy or pion document to see W hat is d1 c ovc.rall Person/ $2,250 Family. when the d eductible starts over (usually, but not always,January 1st). See the d ed ucrihle ? Does not apply to ln-Netwock preven ive chart starting on page :? for how much you pay for covered services nfter you care. meet tl1e deductihlc. Are there other You do n' l hA.ve to meet deductibles foe specific services. but see the chart deductibles for s pecific o. stMting on pnge 2 for other costs fo r services this plan covers. services? Yes. In-Network: $2,500 Per ls there an o u, ---of- The nm-of-p ocket limit is the most you could p•y during a coverage period Person/ $5,000 Pamily. O ut-Of- p ocket limit o n n1 y (usually o ne year) for yo ur share of the cost of covered services. This limit helps ecwork: $5,000 Per Person/ $10,000 expens es ? you plan for hcaltl1 care expenses. Family. W bat is n ot included i.n Premium, b•lance-b ill ed chnrgcs, nnd Even though you pay these expenses, d1ey don't count toward the out-of-pocket the o u1-of=Pockc t health c.1re this plan doesn't cover. .li.m.i!? Ii.mi!.- ls the re an overall The chart starting on page 2 describes any limits on what th e plan will pay fo r annua l limit ou what No. specijie covered secvicest such as office visits. the plan navs? If you use an in-network doctor or other hen Ith care pmvidcr, this plan will pay Yes. For• list of pa rti cipating some or all of the costs of covered services. Be aware, your in-network doctor or Does th is p la u use a providers, see www.E1oridablue.com or hospirnl may use an out-of-network provider for some services. Plans use the n etwork of providers? ca ll 1-800-352-2583. term in-network, fl!Cfea:cd., o r part,cipacing fo r p rovid ers in their network. See the chart starting on p•ge 2 foe how d1is plan pays different kinds of p roviders. Do l need a rcfcrr.U ta o. You cAn s~e the s pecia li st you choose without permission from th is pla n. s ec a speciali s t? Are there scnriccs this Some of the services this plan doesn't cover arc listed o n page 4. See your policy Yes. n,l a11 d oesn't cover? or plan document fo r nddit:ional in formation About ~~~ludt d ~,~isa~~. Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 B-2 Okaloosa County, Florida Milliman Actuarial Valuation Appendix B – Summary of Principal Plan Provisions 2015 BlueMedicare Group Rx" (Employer PDP) Benefits BlueMedicare Group Rx* Option 2 Included with PPO2Rx2 - current Premium Included with PPO1 Rx2 - alternate $187.04 for Rx2 Stand-alone Annual Deductible $75 for Brand Drugs Only Retail 31-day Supply Tier 1 - Preferred Generics $15 Copayment Tier 2 - Non-Preferred Generics $15 Copayment Tier 3 - Preferred Brand $45 Copayment Tier 4 - Non-Preferred Brand $85 Copayment Tier 5 - Specialty Drugs 25% Coinsurance Mail Order 90-day Supply with PRIME Mail Order Tier 1 - Preferred Generics $8 Copayment Tier 2 - Non-Preferred Generics $8 Copayment Tier 3 - Preferred Brand $135 Copayment Tier 4 - Non-Preferred Brand $255 Copayment Tier 5 - Specialty Drugs 25% Coinsurance Gap 31-day Supply Tier 1 - Preferred Generics $15 Copayment Tier 2 - Non-Preferred Generics $15 Copayment Tier 3 - Preferred Brand $45 Copayment Tier 4 - Non-Preferred Brand $85 Copayment Tier 5 - Specialty Drugs 25% Coinsurance Greater of $2.65 Copayment or 5% Coinsurance for generic drugs Catastrophic Greater of $6.60 Copayment or 5% Coinsurance for brand drugs Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 B-3 Okaloosa County, Florida Milliman Actuarial Valuation Appendix B – Summary of Principal Plan Provisions Network: PDP Plus The Preferred Dentist Program was designed to help you get the dental care you need and help lower your costs. You get benefits for a wide range of covered services - both in and out of the network. The goal is to deliver affordable protection for a healthier smile and a healthier you. In Network Out of Network Coverage Type %of Negotiated Fee %of R&CFee1 Type A- Preventive 100% 100% Type B- Basic Restorative 80% 80% Type C- Major Restorative 50% 50% Type D- Orthodontia 50% 50% Deductible: Per Individual $50 $50 Applies to Type B& Cservim only Applies 10 Type 8 & Cservices only Deductible: Per Family $150 $150 Applies to Type B&C services only Applies to Type 8 &C ser,~es only Annual Maximum Benefits: $1200 $1200 Per Individual Orthodontia Lifetime Maximum: $1000 $1000 Per Individual Ortho applies to Child Only (Up to age 19) Dependent Age: Eligible for benefits until the day that he or she turns 26. Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 B-4 Okaloosa County, Florida Milliman Actuarial Valuation Appendix B – Summary of Principal Plan Provisions Appendix D Glossary The following is an explanation of many of the terms referenced by the Statement of the Governmental Accounting Standards Board, “Accounting and Financial Reporting by Employers for Postemployment Benefits Other than Pensions”. 1. Actuarial Cost Method. This is a procedure for determining the Actuarial Present Value of Benefits and allocating it to time periods to produce the Actuarial Accrued Liability and the Normal Cost. The Statement assumes a closed group of employees and other participants unless otherwise stated; that is, no new entrants are assumed. Six methods are permitted – Unit Credit, Entry Age Normal, Attained Age, Aggregate, Frozen Entry Age, and Frozen Attained Age. 2. Actuarial Accrued Liability. This is the portion of the Actuarial Present Value of Benefits attributable to periods prior to the valuation date by the Actuarial Cost Method (i.e., that portion not provided by future Normal Costs). 3. Actuarial Present Value of Benefits. This is the value, as of the applicable date, of future payments for benefits and expenses under the Plan, where each payment is: (a) Multiplied by the probability of the event occurring on which the payment is conditioned, such as the probability of survival, death, disability, termination of employment, etc.; and (b) Discounted at the assumed discount rate. 4. Actuarial Value of Assets. This is the value of cash, investments and other property belonging to the Plan, as used by the actuary for the purpose of an Actuarial Valuation. 5. Amortization Payment. This is the amount of the contribution required to pay interest on and to amortize over a given period the Unfunded Actuarial Accrued Liability or the Unfunded Frozen Actuarial Accrued Liability. A closed amortization period is a specific number of years counted from one date and reducing to zero with the passage of time; an open amortization period is one that begins again or is recalculated at each actuarial valuation date. 6. Annual Required Contributions (“ARC”). This is the employer’s periodic required contribution to a defined benefit OPEB plan, calculated in accordance with the set of requirements for calculating actuarially determined OPEB information included in financial reports. 7. Attribution Period. The period of an employee’s service to which the expected postretirement benefit obligation for that employee is assigned. The beginning of the attribution period is the employee’s date of hire and costs are spread across all employment. 8. Benefit Payments. The monetary or in-kind benefits or benefit coverage to which participants may be entitled under a post employment benefit plan, including health care benefits and life insurance not provided through a pension plan. 9. Funding Excess. This is the excess of the Actuarial Value of Assets over the actuarial accrued liability. 10. Normal Cost. This is the portion of the Actuarial Present Value of Benefits allocated to a valuation year by the Actuarial Cost Method. Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 B-5 Okaloosa County, Florida Milliman Actuarial Valuation Appendix B – Summary of Principal Plan Provisions 11. Net OPEB obligation. This is the cumulative difference since the effective date of this statement between annual OPEB cost and the employer’s contributions to the plan, including the OPEB liability (asset) at transition, if any, and excluding (a) short-term differences and (b) unpaid contributions that have been converted to OPEB-related debt. 12. Other Postemployment Benefits (“OPEB”). This refers to postemployment benefits other than pension benefits, including healthcare benefits regardless of the type of plan that provides them, and all other postemployment benefits provided separately from a pension plan, excluding benefits defined as termination benefits or offers. 13. Return on Plan Assets. This is the actual investment return on plan assets during the fiscal year. 14. Substantive Plan. The terms of the postretirement benefit plan as understood by an employer that provides postretirement benefits and the employees who render services in exchange for those benefits. The substantive plan is the basis for the accounting for the plan. 15. Unfunded Actuarial Accrued Liability. This is the excess of the actuarial accrued liability over the Actuarial Value of Assets. Actuarial Valuation of Postretirement Benefits Under GASB 45 for the Period ending September 30, 2017 B-6 Okaloosa County, Florida