BlueOptions 1416 Coverage Period: 01/01/2020 - 12/31/2020

Bronze
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage for: Individual and/or Family | Plan Type: PPO/EPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage,
www.floridablue.com/plancontracts/individual. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment,
deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.floridablue.com/plancontracts/individual or call 1-800-352-2583
to request a copy.
Important Questions Answers Why This Matters:
In-Network: $7,700 Per Generally, you must pay all of the costs from providers up to the deductible amount before this
What is the overall Person/$15,400 Family. Out-of- plan begins to pay. If you have other family members on the plan, each family member must meet
deductible? Network: $15,400 Per their own individual deductible until the total amount of deductible expenses paid by all family
Person/$30,800 Family. members meets the overall family deductible.7
This plan covers some items and services even if you haven’t yet met the deductible amount. But
Are there services
a copayment or coinsurance may apply. For example, this plan covers certain preventive services
covered before you meet Yes. Preventive care.
without cost sharing and before you meet your deductible. See a list of covered preventive
your deductible?
services at www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other
deductibles for specific No. You don’t have to meet deductibles for specific services.
services?
Yes. In-Network: $8,150 Per
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other
What is the out-of-pocket Person/$16,300 Family. Out-Of-
family members in this plan, they have to meet their own out-of-pocket limits until the overall
limit for this plan? Network: $16,300 Per
family out-of-pocket limit has been met.
Person/$32,600 Family.
Premium, balance-billed charges,
What is not included in
and health care this plan doesn't Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
the out-of-pocket limit?
cover.
Yes. See This plan uses a provider network. You will pay less if you use a provider in the plan’s network.
https://providersearch.floridablue.c You will pay the most if you use an out-of-network provider, and you might receive a bill from a
Will you pay less if you
om/providersearch/pub/index.htm provider for the difference between the provider’s charge and what your plan pays (balance
use a network provider?
or call 1-800-352-2583 for a list of billing). Be aware your network provider might use an out-of-network provider for some services
network providers. (such as lab work). Check with your provider before you get services.
Do you need a referral to
No. You can see the specialist you choose without a referral.
see a specialist?
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SBCID: 1907225
 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common What You Will Pay Limitations, Exceptions, & Other Important
Services You May Need Network Provider Out-of-Network Provider
Medical Event Information
(You will pay the least) (You will pay the most)
Primary Care Visits: $0
Copay - Visits 1-3 Primary Care Visits:
$45 Copay for Deductible + 50%
Primary care visit to treat an remaining Visits/ Virtual Coinsurance/ Virtual Visits Physician administered drugs may have higher
injury or illness Visits (Telemedicine): (Telemedicine): Not cost shares.
$10 Copay per Visit/ Covered/ Value Choice
If you visit a health Value Choice Provider: Provider: Not Covered
care provider’s office No Charge
or clinic Deductible + 50% Physician administered drugs may have higher
Specialist visit $65 Copay per Visit
Coinsurance cost shares.
Physician administered drugs may have higher
cost shares. You may have to pay for services
Preventive care/screening/
No Charge 50% Coinsurance that aren’t preventive. Ask your provider if the
immunization
services needed are preventive. Then check
what your plan will pay for.
Independent Clinical
Lab: $25 Copay per
Diagnostic test (x-ray, blood Visit/ Independent Deductible + 50% Tests performed in hospitals may have higher
work) Diagnostic Testing Coinsurance cost-share.
Center: Deductible +
If you have a test
50% Coinsurance
Prior Authorization may be required. Your
Deductible + 50% Deductible + 50% benefits/services may be denied. Tests
Imaging (CT/PET scans, MRIs)
Coinsurance Coinsurance performed in hospitals may have higher cost-
share.

For more information about limitations and exceptions, see the plan or policy document at www.floridablue.com/plancontracts/individual.
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SBCID: 1907225
 Common What You Will Pay Limitations, Exceptions, & Other Important
Services You May Need Network Provider Out-of-Network Provider
Medical Event Information
(You will pay the least) (You will pay the most)
Preventive: No Charge
(retail)/ Condition Care Up to 30 day supply for retail, 90 day supply
Rx: $4 Copay per for mail order at 2 ½ times the retail amount.
If you need drugs to Generic drugs Prescription (retail)/ All Not Covered Responsible Rx programs such as Prior
treat your illness or Other Generic: $25 Authorization may apply. See Medication guide
condition Copay per Prescription for more information.
More information about (retail)
prescription drug Condition Care Rx: $30
coverage is available at Copay per Prescription
www.floridablue.com/to (retail)/ All Other Up to 30 day supply for retail, 90 day supply
Preferred brand drugs Not Covered
ols- Preferred Brand: for mail order at 2 ½ times the retail amount.
resources/pharmacy/me Deductible + 50%
Coinsurance (retail)
dication-guide
Deductible + 50% Up to 30 day supply for retail, 90 day supply
Non-preferred brand drugs Not Covered
Coinsurance (retail) for mail order at 2 ½ times the retail amount.
Deductible + 50% Up to 30 day supply for retail. Not covered
Specialty drugs Not Covered
Coinsurance through Mail Order.
Facility fee (e.g., ambulatory Deductible + 50% Deductible + 50%
If you have outpatient ––––––––none––––––––
surgery center) Coinsurance Coinsurance
surgery
Physician/surgeon fees Deductible In-Network Deductible ––––––––none––––––––
Deductible + 50% In-Network Deductible +
Emergency room care ––––––––none––––––––
Coinsurance 50% Coinsurance
Emergency medical Deductible + 50% In-Network Deductible +
––––––––none––––––––
transportation Coinsurance 50% Coinsurance
If you need immediate Urgent Care Visits: $65
medical attention Copay per Visit/ Value Urgent Care Visits:
Choice Provider: $0 Deductible + $65 Copay per
Urgent care ––––––––none––––––––
Copay - Visits 1-2 Visit/ Value Choice
$65 Copay for Provider: Not Covered
remaining Visits
Inpatient Rehab Services limited to 30 days.
If you have a hospital Deductible + 50% Deductible + 50%
Facility fee (e.g., hospital room) Inpatient Habilitation Services limited to 30
stay Coinsurance Coinsurance
days.

For more information about limitations and exceptions, see the plan or policy document at www.floridablue.com/plancontracts/individual.
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SBCID: 1907225
 Common What You Will Pay Limitations, Exceptions, & Other Important
Services You May Need Network Provider Out-of-Network Provider
Medical Event Information
(You will pay the least) (You will pay the most)
Physician/surgeon fees Deductible In-Network Deductible ––––––––none––––––––
Physician Office: $65
Copay per Visit /
Deductible + 50%
Outpatient services Hospital Opt 1: ––––––––none––––––––
If you need mental Coinsurance
Deductible + 50%
health, behavioral
Coinsurance
health, or substance
Physician Services: Physician Services: In-
abuse services
Deductible / Hospital Network Deductible/ Prior Authorization may be required. Your
Inpatient services
Opt 1: Deductible + 50% Hospital: Deductible + 50% benefits/services may be denied.
Coinsurance Coinsurance
Maternity care may include tests and services
$65 Copay on initial Deductible + 50%
Office visits described elsewhere in the SBC (i.e.
Visit Coinsurance
ultrasound.)
If you are pregnant Childbirth/delivery professional
Deductible In-Network Deductible ––––––––none––––––––
services
Childbirth/delivery facility Deductible + 50% Deductible + 50%
––––––––none––––––––
services Coinsurance Coinsurance
Deductible + 50%
Home health care No Charge Coverage limited to 30 visits.
Coinsurance
Coverage limited to 35 visits, including 35
manipulations. Services performed in hospital
Deductible + 50%
Rehabilitation services $65 Copay per Visit may have higher cost-share. Prior
Coinsurance
Authorization may be required. Your
benefits/services may be denied.
If you need help
Services performed in hospital may have
recovering or have
Deductible + 50% higher cost share. Prior Authorization may be
other special health Habilitation services $65 Copay per Visit
Coinsurance required. Your benefits/services may be
needs
denied.
Deductible + 50% Deductible + 50%
Skilled nursing care Coverage limited to 60 days.
Coinsurance Coinsurance
Motorized Wheelchairs: Excludes vehicle modifications, home
Deductible + 50%
Durable medical equipment $500 Copay per Visit/ modifications, exercise, bathroom equipment
Coinsurance
All Other: No Charge and replacement of DME due to use/age.
Hospice services No Charge Deductible + 50% ––––––––none––––––––
For more information about limitations and exceptions, see the plan or policy document at www.floridablue.com/plancontracts/individual.
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SBCID: 1907225
 Common What You Will Pay Limitations, Exceptions, & Other Important
Services You May Need Network Provider Out-of-Network Provider
Medical Event Information
(You will pay the least) (You will pay the most)
Coinsurance
Children’s eye exam No Charge Not Covered One exam every 12 months.
If your child needs One pair every 12 months. Additional cost
Children’s glasses No Charge Not Covered
dental or eye care shares may apply for Non-Collection Frame.
Children’s dental check-up Not Covered Not Covered Not Covered
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
 Acupuncture  Infertility treatment  Private-duty nursing
 Bariatric surgery  Long-term care  Routine eye care (Adult)
 Cosmetic surgery  Non-excepted abortions (i.e., not medically  Routine foot care unless for treatment of diabetes
 Dental care (Adult) necessary)  Weight loss programs
 Hearing aids  Pediatric dental check-up
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
 Chiropractic care - Limited to 35 visits  Most coverage provided outside the United  Non-emergency care when traveling outside the
States. See www.floridablue.com. U.S.

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is: Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or
www.dol.gov/ebsa/contactEBSA/consumerassistance.html, State consumer assistance program www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/,
Office of Personnel Management Multi State Plan Program: www.opm.gov/healthcare-insurance/multi-state-plan-program/externalreview/. Or Healthcare.gov
www.HealthCare.gov or call 1-800-318-2596 OR state health insurance marketplace or SHOP. Other coverage options may be available to you too, including buying
individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-
2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also
provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,
contact the insurer at 1-800-352-2583. You may also contact your State Department of Insurance at 1-877-693-5236. Additionally, a consumer assistance program
can help you file your appeal. Contact U.S. Department of Labor Employee Benefits Security Administration at 1-866-4-USA-DOL (866-487-2365) or
www.dol.gov/ebsa/consumer_info_health.html .

Does this plan provide Minimum Essential Coverage? Yes

For more information about limitations and exceptions, see the plan or policy document at www.floridablue.com/plancontracts/individual.
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SBCID: 1907225
If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the
requirement that you have health coverage for that month.

Does this plan meet Minimum Value Standards? Yes

If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

For more information about limitations and exceptions, see the plan or policy document at www.floridablue.com/plancontracts/individual.
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SBCID: 1907225
About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up
hospital delivery) controlled condition) care)
 The plan’s overall deductible $7,700  The plan’s overall deductible $7,700  The plan’s overall deductible $7,700
 Specialist Copayment $65  Specialist Copayment $65  Specialist Copayment $65
 Hospital (facility) Coinsurance 50%  Hospital (facility) Coinsurance 50%  Hospital (facility) Coinsurance 50%
 Other Copayment $25  Other No Charge $0  Other Coinsurance 50%

This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical
Childbirth/Delivery Professional Services disease education) supplies)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches)
Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)

Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900
In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $7,700 Deductibles $4,600 Deductibles $1,300
Copayments $100 Copayments $1,200 Copayments $300
Coinsurance $400 Coinsurance $0 Coinsurance $0
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $60 Limits or exclusions $60 Limits or exclusions $0
The total Peg would pay is $8,260 The total Joe would pay is $5,860 The total Mia would pay is $1,600

Note: These numbers assume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program, you may be able to
reduce your costs. For more information about the wellness program, please contact: www.floridablue.com.

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SBCID: 1907225
Health insurance is offered by Florida Blue. HMO coverage is offered by Florida Blue HMO, an affiliate of Florida Blue. Dental insurance is offered by Florida Combined Life
Insurance Company, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association.
Health insurance is offered by Florida Blue. HMO coverage is offered by Florida Blue HMO, an affiliate of Florida Blue. Dental insurance is offered by Florida Combined Life
Insurance Company, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association.
Health insurance is offered by Florida Blue. HMO coverage is offered by Florida Blue HMO, an affiliate of Florida Blue. Dental insurance is offered by Florida Combined Life
Insurance Company, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association.