Welcome. Benefits Eligibility

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1 Welcome Introduction Suwannee River Water Management District understands that your benefits are important to you and your family. Helping you understand the benefits available to you is important. This Benefits Guide will provide you a description of the District's benefit program. Included in this guide are summary explanations of the benefits and costs as well as contact information for each carrier. It is important to remember that only those benefit programs for which you are eligible and have enrolled in apply to you. We encourage you to review each section and to discuss your benefits with your family members. Be sure to pay close attention to applicable co-payments and deductibles, how to file claims, pre-authorization requirements, participating networks, and services that may be limited or not covered (exclusions). This guide is not an employee/employer contract. It is not intended to cover all provisions of all plans but rather is a quick reference to help answer most of your questions. Please see your Summary Plan Description and/or carrier certificates for complete details. We hope this guide will give you an overview of your benefits and help you be better prepared for the enrollment process. Enrolling in Benefits If you are an eligible employee, you can enroll in benefits on the 1st of the month following your date of hire, the date you become benefit eligible due to a change in status, or the date of a qualifying event. You can also enroll or change benefits during our annual Open Enrollment period each year. Effective Date of Benefits (Open Enrollment): Benefits Eligibility Employee Eligibility Benefit eligible employees are provided an opportunity to participate in the Suwannee River Water Mangement District sponsored benefits program after satisfying the new hire waiting period and annually during Open Enrollment. Please refer to the following guidelines regarding eligibility and election changes. Dependent Eligibility Medical Only A dependent is defined as a covered employee s legal spouse, or dependent child of the employee or employee s spouse. Dependent children will be covered through the end of the calendar year in which they turn age 30. A dependent child is defined as: A natural child A step-child A legally adopted child A child placed for adoption A child for whom legal guardianship has been awarded to the covered employee or the employee s spouse. FL Statute Dependent Coverage: Health insurance coverage is available for dependents ages 26 to 30. Please contact your Human Resources Department for more information. Dependent Eligibility Dental and Vision Only A dependent is defined as a covered employee s legal spouse or an unmarried dependent child of the employee or employee s spouse. Dependent children will be covered through the end of the month in which they turn age 26. October 1, 2016 Termination of Benefits: Your coverage terminates on the last day of the month in which you leave employment or on the date of a qualifying event. 1

2 Medical Options Administered by Florida Blue Florida Blue is our medical healthcare carrier again this plan year. You now have three new plans for the Plan Year. BlueOptions Plan BlueOptions HSA Compatible Plan 05192/05193, and Blue Care HMO Plan 55. In addition to the new plans...for employees enrolling in BlueOptions HSA Compatible Plan 05192/05193 the District will contribute $1,000 toward your Health Savings Account (HSA) [setup by employee]. For employees enrolling in BlueOptions Plan or Blue Care HMO Plan 55 the District will contribute $1,000 toward your Health Reimbursement Account (HRA) [setup by the District]. Blue Options Plan offers a $250 deductible and co-payments for visits to your In-Network primary care physicians. A 30 day RX benefit for Generic/Preferred Brand/Non-Preferred copays and Mail Order copays. BlueCare HMO Plan 55 offers a $0 deductible with co-payments to your In- Network physicians. A 30 day RX benefit for Generic/Preferred Brand/Non-Preferred copays and Mail Order copays. BlueOptions HSA Compatible Plan 05192/05193 offers employees the options to open and contribute to a Health Savings Account. This plan has a deductible of $2,500 for employee only coverage, or $5,000 for employee and dependent coverage. A 30 day RX benefit for Generic/Preferred Brand/Non- Preferred copays and Mail Order copays, After your in-network Calendar Year Deductible is met. It is important to remember that this deductible is a family aggregate deductible, not per covered individual. The deductible may be met by one person, or a combination of everyone covered under your plan. For more information on Health Savings Accounts visit Please see the plan details on the following pages for more information about the three medical plans you have to choose from. This information will help you make the medical plan selection that is best for you and your family. Florida Blue s Member Portal is available for all subscribers and gives you quick and convenient access to all the information you need to take control of your health right at your fingertips! All you need to log-in is your member number. Some of the information available includes: The option to review your plan benefits and find out where you stand with your deductible. Shop, compare and estimate your costs for office visits, imaging services and surgeries so you know before you go. Compare drug prices with the Pharmacy Shopping Tool. View claim activity. Print a temporary ID card or request a replacement ID card. Access to Member Discounts such as gym memberships, weight loss programs, vision and hearing care. Florida Blue Provider Directory Remember, it is always in your best interest to use In-Network providers. Visit Florida Blue s website at and click Find a Doctor to search for providers. You have the option to search for a specific provider by name, by provider type or by location. Remember, BlueOptions plans (Plan 05192/05193 and Plan 03768) and Blue Care plans (Plan 55) utilize a different network of providers. 9

3 Suwannee River Water Management District BlueOptions BlueOptions BlueCare BlueOptions HSA-Compatible HSA-Compatible Plan 55 Plan Plan (Individual) Plan (Family) Calendar Year Deductible (CYD) Per Person/Family Aggregate In-Network $2,500 $5,000 / $5,000 $0/$0 $250 / $750 Out-of-Network $5,000 $10,000 / $10,000 Not Covered $1,000 / $3,000 Coinsurance (Coins) Percentage of covered services paid by member In-Network 20% 20% 0% 0% Out-of-Network 40% 40% Not Covered 50% Out-of-Pocket Maximum Per Person/Family Aggregate Includes CYD, Coins & Rx Includes CYD, Coins & Rx Includes CYD, Coins, Copays Includes CYD, Coins, Copays In-Network $5,800 / N/A $6,850 / $11,600 $2,500 / $7,500 $3,000 / $6,000 Out-of-Network $11,600 / N/A $23,200 / $23,200 Not Covered $6,000 / $12,000 Office Services Office visits In-Network Family Physician/PCP (FP) CYD + 20% Coins CYD + 20% Coins $10 $20 In-Network Specialist (SP) CYD + 20% Coins CYD + 20% Coins $10 $45 Advanced Imaging Services (MRI, MRA, PET, CT, Nuclear Medicine) In-Network CYD + 20% Coins CYD + 20% Coins $75 $200 Maternity In-Network Specialist CYD + 20% Coins CYD + 20% Coins $10 $45 Allergy Injections (by In-Network Family Physician) CYD + 20% Coins CYD + 20% Coins $5 $10 Physician-Administered Drugs or Medical Pharmacy Does not apply to allergy injections and immunizations. Separate member cost-share for the RX is in addition to the office visit cost share In-Network Monthly Out-of-Pocket Maximum $200 $200 $200 $200 In-Network Provider CYD + 20% Coins CYD + 20% Coins 10% 20% Coins Out-of-Network Provider CYD + 50% Coins CYD + 50% Coins 30% CYD + 50% Coins Hospital/Surgical Ambulatory Surgical Center In-Network CYD + 20% Coins CYD + 20% Coins $100 $200 Inpatient Hospital Facility Services (per admit) In-Network Opt. 1 - CYD + 20% Coins Opt. 1 - CYD + 20% Coins $250 Option 1 - $700 Opt. 2 - CYD + 25% Coins Opt. 2 - CYD + 25% Coins Option 2 - $1,000 Out-of-Network $500 + CYD + 40% Coins $500 + CYD + 40% Coins Not Covered CYD + 50% Coins Outpatient Hospital Facility Services (per visit) In-Network Opt. 1 - CYD + 20% Coins Opt. 1 - CYD + 20% Coins $150 Option 1 - $300 Opt. 2 - CYD + 25% Coins Opt. 2 - CYD + 25% Coins Option 2 - $600 Therapy at Outpatient Hospital In-Network Opt. 1 - CYD + 20% Coins Opt. 1 - CYD + 20% Coins $30 Option 1 - $45 Opt. 2 - CYD + 25% Coins Opt. 2 - CYD + 25% Coins Option 2 - $60 Emergency Room Facility Services (per visit; waived if admitted) In-Network CYD + 20% Coins CYD + 20% Coins $100 $200 Out-of-Network CYD + 20% Coins CYD + 20% Coins $100 $200 Preventive Care Routine Physical Exams and Immunizations In-Network Family Physician/PCP $0 $0 $0 $0 In-Network Specialist $0 $0 $0 $0 Out-of-Network Provider 40% Coins (No CYD) 40% Coins (No CYD) Not Covered 50% Coins (No CYD) Well Woman Exam (e.g., Annual GYN) In-Network Family Physician/PCP $0 $0 $0 $0 In-Network Specialist $0 $0 $0 $0 Out-of-Network Provider 40% Coins (No CYD) 40% Coins (No CYD) Not Covered 50% Coins (No CYD) Mammograms (member cost; In- and Out-of-Network) $0 $0 $0 (In-Network Only) $0 Colonoscopy BlueOptions: Routine screening only for age 50+ covered at 100% of allowed amount; In- and Out-of-Network. With diagnosis, subject to applicable deductible, coinsurance or copays. $0 (See note far left column) $0 (See note far left column) $0 (In-Network Only) (See note far left column) $0 (See note far left column) Well Child (No CYM) In-Network Family Physician/PCP $0 $0 $0 $0 In-Network Specialist $0 $0 $0 $0 Out-of-Network Provider 40% Coins (No CYD) 40% Coins (No CYD) Not Covered 50% Coins (No CYD) 10

4 Prescription Drugs Retail (30 days) Deductible In-Network CYD In-Network CYD Generic/Preferred Brand/Non-Preferred $10 / $30 / $50 $10 / $30 / $50 $10 / $30 / $50 $10 / $30 / $50 Mail Order (90 days) Generic/Preferred Brand/Non-Preferred $25 / $75 / $125 $25 / $75 / $125 $25 / $75 / $125 $25 / $75 / $125 Specialty Pharmacy (30 day supply limit) In Network CareMark exclusively Out of Network any pharmacy other than CareMark Same as Retail RX Benefit above Subject to In-Network CYD, then 50% of RX allowance; balance billing may occur Same as Retail RX Benefit above Subject to In-Network CYD, then 50% of RX allowance; balance billing may occur Same as Retail RX Benefit above $300 RX Ded applies, then 50% of RX allowance; balance billing may occur Same as Retail RX Benefit above $300 RX Ded applies, then 50% of RX allowance; balance billing may occur Emergency Medical Care Urgent Care Centers In-Network CYD + 20% Coins CYD + 20% Coins $10 $50 Out-of-Network CYD + 20% Coins CYD + 20% Coins Not Covered $50 after CYD Emergency Room Facility Services (per visit; waived if admitted) In-Network CYD + 20% Coins CYD + 20% Coins $100 $200 Out-of-Network CYD + 20% Coins CYD + 20% Coins $100 $200 Ambulance In-Network CYD + 20% Coins CYD + 20% Coins $500 CYD Out-of-Network In-Network CYD + 20% Coins In-Network CYD + 20% Coins $500 In-Network CYD Outpatient Diagnostic Services Independent Diagnostic Testing Facility Advanced Imaging Services (MRI, MRA, PET, CT, Nuclear Medicine) In-Network CYD + 20% Coins CYD + 20% Coins $50 $200 Other IDTF Services (ex. X-rays) In-Network CYD + 20% Coins CYD + 20% Coins $10 $50 Independent Clinical Lab In-Network CYD CYD $0 $0 Outpatient Hospital Facility Services (per visit) In-Network Opt. 1 - CYD + 20% Coins Opt. 1 - CYD + 20% Coins $150 Option 1 - $300 Opt. 2 - CYD + 25% Coins Opt. 2 - CYD + 25% Coins Option 2 - $600 Out-of-Network CYD + 40% Coins CYD + 40% Coins Not Covered CYD + 50 % Coins Mental Health and Substance Abuse Mental Health & Substance Dependency Care & Treatment Inpatient Hospital Facility Services (per admit) In-Network CYD + 20% Coins CYD + 20% Coins $0 $0 Out-of-Network In-Network CYD + 20% Coins In-Network CYD + 20% Coins Not Covered 50% Coins (No CYD) Outpatient Office Visit In-Network Family Physician/PCP (FP) CYD + 20% Coins CYD + 20% Coins $0 $0 In-Network Specialist (SP) CYD + 20% Coins CYD + 20% Coins $0 $0 Out-of-Network Provider CYD + 40% Coins CYD + 40% Coins Not Covered 50% Coins (No CYD) Emergency Room Facility Services (per visit; waived if admitted) In-Network CYD + 20% Coins CYD + 20% Coins $0 $0 Out-of-Network In-Network CYD + 20% Coins In-Network CYD + 20% Coins $0 $0 Other Provider Services Provider Services at Hospital and ER In-Network CYD + 20% Coins CYD + 20% Coins $0 $50 Out-of-Network In-Network CYD + 20% Coins In-Network CYD + 20% Coins $0 $50 Radiology, Pathology, Anesthesiology Provider Services at an Ambulatory Surgical Center In-Network CYD + 20% Coins CYD + 20% Coins $0 $45 Out-of-Network In-Network CYD + 20% Coins In-Network CYD + 20% Coins Not Covered $45 Provider Services at Locations other than Office, Hospital and Emergency Room In-Network Family Physician/PCP CYD + 20% Coins CYD + 20% Coins $10 $20 In-Network Specialist CYD + 20% Coins CYD + 20% Coins $10 $45 Home Health Care (CYM) 20 Visits 20 Visits 60 Visits 20 Visits In-Network CYD + 20% Coins CYD + 20% Coins $0 CYD Outpatient Therapy and Spinal Manipulations (CYM) Refer to location of service for payment details 35 visits 35 visits 30 visits 35 visits Skilled Nursing Facility (CYM) 60 days 60 days 45 Days 60 days In-Network CYD + 20% Coins CYD + 20% Coins $10 CYD Hospice In-Network CYD + 20% Coins CYD + 20% Coins $0 CYD 11

5 2016 Bi-Monthly Payroll Deductions Plan (Individual) Plan (Family) Plan 55 Plan Employee Only $15.00 N/A $57.27 $ Employee / Spouse N/A $30.00 $ $ Employee / Child(ren) N/A $22.50 $ $ Family N/A $50.00 $ $ This is not an insurance contract or Benefit Booklet. The above Benefit Summary is only a partial description of the many benefits and services covered by Blue Cross and Blue Shield of Florida, Inc., an independent licensee of the Blue Cross and Blue Shield Association. For a complete description of benefits and exclusions, please see Blue Cross and Blue Shield of Florida s Benefit Booklet and Schedule of Benefits; their terms prevail. *Reminder When choosing family coverage on plan 05193, the deductible and out-of-pocket maximum is not per person. It can be met by one person or a combination of any family members covered on the plan. Calendar Year Deductible (CYD) The amount a member must pay before insurance covers the cost. Your deductible is a Calendar Year Deductible, therefore it resets January 1 st. Coinsurance (Coins) Coinsurance refers to money that an individual is required to pay for services, after a deductible has been paid. Coinsurance is often specified by a percentage. Calendar Year Maximum (CYM) The maximum number of visits insurance will pay for a covered benefit throughout the Calendar Year. For Blue Cross Blue Shield of Florida Customer Service please call or visit 12

6 Dental Options Administered by Standard Suwannee River Water Management District Plan Design Summary Dental Plan Benefit In Network Out of Network Type 1 100% 100% Type 2 90% 80% Type 3 60% 50% Deductible $50/Calendar Year $50/Calendar Year Waived Type 1 Waived Type 1 3 Family Maximum 3 Family Maximum Maximum (per person) $1,000/Calendar Year $1,000/Calendar Year PPO PPO Plus Allowance Type 1 Discounted Fee 90th U&C Type 2 Discounted Fee 90th U&C Type 3 Discounted Fee 90th U&C Waiting Period None None LASIK Assist SM None None Annual Open Enrollment None None Orthodontia Summary Allowance All Plan Designs: In Network, discounted fee. Out of Network, U&C. Plan Benefit 50% Coverage for Adults No Lifetime Maximum (per person) $1,000 Waiting Period None Dental Benefits are provided by the District at no cost to the Employee. Please select the appropriate Coverage Level [Employee Only, Employee + Spouse, Employee + Child(ren) or Family] when making your selections on-line]. 17

7 Dental Options Administered by Standard The following is a sample list of dental procedures payable under the plan. Plan Design Summary In Network 100/90/60 $50/Calendar Year Waived Type 1 3 Family Maximum $1,000 Plan 1 Out of Network 100/80/50 $50/Calendar Year Waived Type 1 3 Family Maximum $1,000 Type 1 Procedure (Frequency) Type 2 Procedure (Frequency) Type 3 Procedure (Frequency) Routine Exam Bitewing X-rays Full Mouth/Panoramic X-rays (1 in 3 years) Periapical X-rays Cleaning Fluoride for Children 13 and under (1 per benefit period) Sealants (age 13 and under) Space Maintainers Restorative Amalgams Restorative Composites (anterior and posterior teeth) Endodontics (nonsurgical) Endodontics (surgical) Periodontics (nonsurgical) Periodontics (surgical) Simple Extractions Anesthesia Onlays Crowns (1 in 5 years per tooth) Crown Repair Denture Repair Implants Prosthodontics (fixed bridge; removable complete/partial dentures) (1 in 5 years) Complex Extractions Routine Exam Bitewing X-rays Full Mouth/Panoramic X-rays (1 in 3 years) Periapical X-rays Cleaning Fluoride for Children 13 and under (1 per benefit period) Sealants (age 13 and under) Space Maintainers Restorative Amalgams Restorative Composites (anterior and posterior teeth) Endodontics (nonsurgical) Endodontics (surgical) Periodontics (nonsurgical) Periodontics (surgical) Simple Extractions Anesthesia Onlays Crowns (1 in 5 years per tooth) Crown Repair Denture Repair Implants Prosthodontics (fixed bridge; removable complete/partial dentures) (1 in 5 years) Complex Extractions Current Dental Terminology American Dental Association 18

8 HumanaVision Vision Care Plan SUWANNEE RIVER WATER MANAGEMENT See a participating provider Exam with dilation $10 copay Lenses $15 copay $15 copay $15 copay Additional plan discounts See a nonparticipating provider Frames $50wholesale allowance Contact lenses $150 allowance $150 allowance Frequency (based on date of service) 24 months 24 months 1 If a member prefers contact lenses, the plan provides an allowance for contacts in lieu of all other benefits (including frames) (Vision Care Plan only). 2 The contact lens allowance applies to professional services (evaluation and fitting fee) and materials. Members receive a 15 percent discount on in-network professional services. The discount for professional services is available for 12 months after the covered eye exam. 3 Contact lens allowance must be used at one time; no amount will be carried forward. Vision Benefits are provided by the District at no cost to the Employee. Please select the appropriate Coverage Level [Employee Only, Employee + Spouse, Employee + Child(ren) or Family] when making your selections on-line]. HumanaVision Lasik discount We have contracted with many well-known facilities and eye doctors to offer Lasik procedures at substantially reduced fees. You can take advantage of these low fees when procedures are done by network providers. The network locations listed below offer the following prices (per eye): TLC (designated locations only) LasikPlus QualSight LASIK *with IntraLase TM Conventional / Traditional $695 3 * LasikPlus free enhancements for 1 year $895 QualSight free enhancements for 1 year Custom $895 $1,295 $1,895* $1,395* LasikPlus free enhancements for life $1,295 with QualSight Lifetime Assurance Plan $1,895* LasikPlus free enhancements for life $1,320 $1,995* with QualSight Lifetime Assurance Plan You can also use independent Lasik provider network doctors to receive a 10% discount from usual and customary prices and pay no more than $1,800 per eye for Conventional Lasik and $2,300 per eye for Custom Lasik. 19

9 How does the wholesale frame allowance work? Benefits include a wholesale frame allowance. If the wholesale cost exceeds the frame allowance, members pay twice the wholesale difference. They never pay full retail. Retail price * Wholesale price Wholesale allowance Member pays Savings $125 $50 $50 $0 $125 $ $75 $50 $50 ($75-$50=$25x2=$50) $ * Retail costs may differ and are based on 2½ times the wholesale cost. Actual savings may vary. Vision health impacts overall health Routine eye exams can lead to early detection of vision problems and other diseases such as diabetes, hypertension, multiple sclerosis, high blood pressure, osteoporosis, and rheumatoid arthritis. 1 Use your HumanaVision benefits HumanaVision options have you covered and make eye care affordable. You have access to one of the largest vision networks in the United States, with more than 35,000 participating optometrist, ophthalmologists, and national retail locations, including LensCrafters, Pearle Vision, Sears Optical, Target Optical, and JCPenney Optical. In addition you ll enjoy: The same benefits at all participating providers, no matter where they re located Wholesale pricing on frames, avoiding high retail markups Simple access to plan information, provider search, Customer Care and other automated services at HumanaVisionCare.com How it Works 1. After signing up for your vision plan, you will receive an ID card in the mail 2. Prior to scheduling your appointment, select a network provider through the Customer Care Center, automated information line, or HumanaVisionCare.com 3. Schedule an appointment, providing your name, the patient s name and employer 4. Sign your provider s form after your exam, you ll pay any copayments and/or costs of any upgrades at this time Know what your plan covers Attached is a summary of HumanaVision benefits that are described in detail in your certificate. You can find your certificate on HumanaVisionCare.com or call Here s what you can expect: Quality routine eye health care from independent eye care professionals and national retail locations. Services and materials provided on a prepaid basis, and the plan pays in-network providers directly, you also have the freedom to use out-of-network providers if you prefer Life without claim forms! With HumanaVision, you pay your eye care professional directly for copayments and any extra cosmetic options selected at the time of service Select a vision provider from our network simply by visiting HumanaVisionCare.com, if you prefer, call us at Know what your plan doesn t cover Some items and services not included in HumanaVision are: Orthoptics or vision training, subnormal vision aids or Plano (non-prescription) lenses Replacement of lost or broken lenses, except at the regularly-scheduled plan intervals Medical or surgical treatment of eyes Care provided through or required by any government agency or program, including Workers Compensation or a similar law JCPenney Optical 1 Thompson Media Inc. This is not a complete disclosure of plan qualifications and limitations. Check with your local Humana or HumanaDental sales office to verify product availability. 20

10 Supplemental Life Insurance Administered by Standard A Peace of Mind... Group Term Life Insurance All full-time active employees of Suwannee River Water Management District are provided with an employer paid Group Term Life Insurance policy of $50,000. This policy also includes Accidental Death & Dismemberment (AD&D) Benefit equal to the amount of your Life Insurance Benefit. Benefits will be payable to the designated beneficiary according to the terms of the Group Policy after a Proof of Loss Claim has been submitted. You will be required to enter your beneficiary information in HRconnection. Voluntary Life Insurance 21

11 Disability Benefits Administered by Standard All full-time active employees are eligible for the Employer Paid Long Term Disability Plan. Benefits under the Suwannee River Water Mangement District plan include: Benefits The long-term disability plan provides up to $7,000 a month, or 60% of your basic monthly earnings, whichever is less. This plan pays a minimum of $100/month and coordinates with other plans, including Social Security, to ensure 60% of your income. Benefit Waiting Period (amount of time you must be out of work before your benefits begin) - 60 days (or at the end of accumulated sick leave, whichever is greater. Benefit Duration - 24 months covering your current occupation. You will continue to be considered disabled if, after 24 months, you are unable to perform the material duties of any occupatoin for which you are (or may reasonably become) qualified by education, training or experience. In this case your benefit would continue to the age of 65. If you become disabled after age 65, benefits are available on a decreasing scale. LTD Benefits are provided by the District at no cost to the Employee. You will only be required to confirm coverage in HRconnection and you will have the option to review the benefit description and carrier contact information. 22