<p> The District School Board of Sumter County, FL Benefits Match-Up Exhibit Item 4c – 47 HMO Plan BENEFIT HIGHLIGHTS IN-NETWORK Write “Match” or Fill In Differences Plan Name: Florida Blue Plan 47 - HMO</p><p>MEDICAL</p><p>Lifetime Max imum Unlimited</p><p>Cale n dar Y ea r De d u ctible Individual / Family Maximum $1,500 / $4,500</p><p>Out-of-Pocket Maximum Individual / Family Maximum $4,500 / $9,000 </p><p>Out-of-Pocket Limit What is included: Deductible Coinsurance Copayments Prescription Drugs Coinsurance 20%</p><p>Medical Pharmacy In-Network Monthly OOP $200 In-Network 20% coins Out-of-Network Not Covered Physician’s Services</p><p>Primary Care Visit – Office visits $30 copay and minor surgical procedures</p><p>Specialist Visit $55 copay</p><p>Urgent Care $60 copay</p><p>Independent Clinical Lab $0 Required Lab Provider? Services Quest – Exclusive In-Network Provider Advanced Imaging Services $250 copay</p><p>Preventive Care</p><p>Per Benefit Period Unlimited</p><p>Adult Wellness Services $0 Routine Adult Physical Exams and Immunizations Family Physician</p><p>Page 1 The District School Board of Sumter County, FL Benefits Match-Up Exhibit Item 4c – 47 HMO Plan BENEFIT HIGHLIGHTS IN-NETWORK Write “Match” or Fill In Differences Plan Name: Florida Blue Plan 47 - HMO</p><p>Specialist $0</p><p>Mammograms $0</p><p>Routine Colonoscopy $0 (50+)</p><p>Well Child Care $0 Services Family Physician Specialist $0</p><p>Other Types of Facility and Provider Services</p><p>Inpatient CYD + 20%</p><p>Physician and other CYD + 20% health care professional Outpatientservices Facility CYD + 20%</p><p>Physician and other CYD + 20% health care professional services</p><p>Emergency Room Visits $250 copay Facility In/Out-of- Network</p><p>Physician and other CYD + 20% health care professional services Ambulance – Ground/Air & CYD + 20% / CYD + 20% Water Ambulatory Surgical Center $200 copay Facility Services</p><p>Radiology, Pathology, Family Physician - $30 copay Anesthesiology Provider Services Specialist - $55 copay at an Ambulatory Surgical Center</p><p>Page 2 The District School Board of Sumter County, FL Benefits Match-Up Exhibit Item 4c – 47 HMO Plan BENEFIT HIGHLIGHTS IN-NETWORK Write “Match” or Fill In Differences Plan Name: Florida Blue Plan 47 - HMO</p><p>Therapy Services Cardiac Rehabilitation, Occupational, Speech, Physical, Massage & Spinal Manipulations</p><p>Outpatient Rehab Therapy Center $55 copay In-Network </p><p>$55 copay Outpatient Hospital Facility Services (per visit) Calendar Year 35 visits Maximums:</p><p>Home Health Care $0</p><p>Calendar Year Maximum: 20 visits</p><p>Skilled Nursing Facility CYD + 20%</p><p>Calendar Year Maximum: 60 days</p><p>Hospice CYD + 20%</p><p>Calendar Year Maximum: Unlimited</p><p>Durable Medical Equipment & Prosthetics and Orthotics Motorized Wheelchair $500 copay All Other $0</p><p>Allergy Injections $10 copay</p><p>Mental Health and Substance Abuse Services</p><p>Page 3 The District School Board of Sumter County, FL Benefits Match-Up Exhibit Item 4c – 47 HMO Plan BENEFIT HIGHLIGHTS IN-NETWORK Write “Match” or Fill In Differences Plan Name: Florida Blue Plan 47 - HMO</p><p>Mental Health and Substance Dependency Care and Treatment Services Inpatient / Outpatient Facility Services $0</p><p>Emergency Room $0 / $0</p><p>Physician Services at $0 Hospital and ER</p><p>Physician and Other $0 Health Care Professionals Family Physician Office</p><p>Specialist Office $0</p><p>Prescription Drug Benefits</p><p>RETAIL – 30 DAY SUPPLY</p><p>Pharmacy Deductible $100 – both retail and mail</p><p>Retail Preferred Generic $20 copay</p><p>Retail Preferred Brand $50 copay</p><p>Retail Non-Preferred Brand $80 copay</p><p>MAIL ORDER – 90 DAY SUPPLY Mail Order Generic $40 Copay</p><p>Mail Order Brand Preferred $100 Copay</p><p>Mail Order Brand Non- $160 Copay Preferred</p><p>Page 4</p>