BlueSelect, affordable health plan options with comprehensive benefits for individuals and small employers. BlueSelect is unique and affordable! The BlueSelect network uses a community-focused network without reducing benefits. The network covers all medical specialties and is largely concentrated in the area where members live, work, and play. BlueSelect provides comprehensive coverage priced up to less. Members should check to see if the doctor or hospital where they plan to visit is part of the BlueSelect network. Participating Hospitals Pinellas County Bayfront Medical Center IASIS Palms of Pasadena All Children s Hospital Note: The physician network includes all specialties Hillsborough County Tampa General IASIS Memorial Hospital of Tampa IASIS AMI Town & Country We will continue to add community-based network providers throughout the year. Check the OPD for the most current list. Members must use an exclusive provider for certain ancillary services (see back for complete list). If members choose to seek care outside of the network, their cost share will be higher. Business Segment Targets: Individuals under 65, Small Group Only available in select markets Working uninsured and those who may become uninsured within the next 18 months. These consumers may be insured customers that feel they have reached an unacceptable price/ value proposition Introductory Market New Developments New Programs 1/1/2009 Effective date Tampa area (Pinellas and Hillsborough Counties) Expansion mid 2009 to N. Broward, Polk, Charlotte, Pasco and Hernando Counties targeting a 7/1/09 effective date. Additional expansion markets to be pursued throughout 2009 Prior authorization for Advanced Imaging Services Prior Authorization for certain drugs covered under medical benefits Prior Authorization for certain self-administered drugs covered under pharmacy benefits A new prior authorization program for Durable Medical Equipment and Medical Supplies effective 7/1/09 Note: this is for informational purposes only to use as a quick reference tool April 2009
Important Guidelines Remain In Network Use only Exclusive Providers* for Ancillary Services ER visits and all related services Maternity, mammograms, colonoscopies, and well-child care visits, including checkups and immunizations All diabetic equipment and supplies Office visits, inpatient and outpatient services Clinical lab tests Behavioral health care and substance dependency services Durable medical equipment and medical supplies Home health care services * BlueSelect is a Preferred Provider/Exclusive Provider Network made up of independent hospitals, physicians, and ancillary providers. Services subject to an Exclusive Provider Provision are only covered when they are rendered by the Exclusive Provider for such services. BlueSelect Pharmacy Benefit Design:! In-network pharmacy plan designs consist of a 2-tier plan structure (generic or brand). Rx! Utilization Management Programs The BlueSelect product will incorporate several Utilization Management programs. The list of medications attached to these programs is distinct and can be found in the BlueSelect Medication Guide. Prior Authorization Require that specific clinical criteria be met before the drugs will be covered. Responsible Quantity Program allows a maximum quantity per time period. Responsible Steps Requires that members try another designated or prerequisite drug first before a drug listed in the Responsible Steps program will be covered. Certain services and supplies are covered only if you use the exclusive providers within the BlueSelect network If generic drugs are available, but a brand drug is requested, the member is responsible for the cost difference between generic and brand (DAW1 & DAW2). BlueSelect uses a closed formulary: all generics are covered as tier 1 unless specifically excluded and coverage for brand drugs (covered as tier 2) is limited to brand drugs listed on the formulary. A formulary exception process is available in cases where special circumstances dictate the use of non-formulary drugs (process is outlined in the BlueSelect Medication Guide). The higher out-of-network cost share will apply when Specialty Medications are provided by a pharmacy other than BCBSF s preferred specialty pharmacies (CareMark, Accredo, CuraScript). How to obtain medications from these providers is outlined in the BlueSelect Medication Guide. Out-of-network pharmacy purchases are subject to higher member cost-share (brand deductible and/or coinsurance). Maximum 30-day supply at retail; extended supply network is not available. A 90-day supply is available through Prime Therapeutics LLC, mail order pharmacy. With the exception of the generic only Rx plans. Self-administered medications are not covered under the BlueSelect medical benefit; coverage for self-administered medications is available through the pharmacy benefit. BlueSelect distinguishes between Retail Pharmacies and Specialty Pharmacies:»» Retail pharmacies are for non-specialty medications»» Specialty pharmacies are for those medications deemed as specialty medications and are listed as a specialty drug in the BlueSelect Medication Guide
Family Physician Specialist e-office Visit Office Visit / e-office Visit Family Physician Specialist Provider 13260 $1,500 / $4,500 $3,000 / $6,000 13261 / $15,000 $10,000 / $20,000 30% Exclusive Provider Organization Services (EPO) - These services and supplies are covered ONLY if you see the Exclusive providers within the BlueSelect network. (Includes DED, coin, copays; excludes Rx) Brand Deductible Retail & Specialty - Generic / Brand Retail & Specialty - Generic / Brand,000 $4,000 / $8,000 $12,000 / $24,000 Coins / Brand Ded + Coins,000 $22,500 / $45,000 Coins / Brand Ded + Coins 13800 $1,500 / N/A $4,500 / N/A $1,500 Copayment $1,000,000 $10,000 / $10,000 $30,000 / $30,000 Coins / No Coverage 13803 $2,000 / N/A $6,000 / N/A $3,000 Copayment $1,000,000 $25,000 / $25,000 $75,000 / $75,000 Page 1 of 3 Coins / No Coverage
Family Physician Specialist e-office Visit Office Visit / e-office Visit Family Physician Specialist Provider 13262 $500 / $1,500 $20 Copayment $600 Copayment 13462 $500 / $1,500 $15 Copayment $600 Copayment $250 Copayment $15 Copayment Exclusive Provider Organization Services (EPO) - These services and supplies are covered ONLY if you see the Exclusive providers within the BlueSelect network. (Includes DED, coin, copays; excludes Rx) Brand Deductible Retail & Specialty - Generic / Brand Retail & Specialty - Generic / Brand,000 $2,500 / $100 $10 / Brand Deductible + $60 Coins / Brand Ded + Coins,000 $2,500 / Coins / Brand Ded + Coins 13464 $2,000 / $6,000 $4,000 / $12,000,000 $4,000 / $8,000 $12,000 / $24,000 Coins / Brand Ded + Coins 13465 $750 / $2,250 $60 Copayment $900 Copayment,000 $3,500 / $7,000 $10,500 / $21,000 Page of 3 Coins / Brand Ded + Coins
Family Physician Specialist e-office Visit Office Visit / e-office Visit Family Physician Specialist Provider 14202 Limited Benefit $1,000 / $2,000 $3,000 / $6,000 30% $40 Copayment $750 Copayment $150 Copayment Exclusive Provider Organization Services (EPO) - These services and supplies are covered ONLY if you see the Exclusive providers within the BlueSelect network. Annual Benefit Maximum / Pharmacy Deductible Retail & Specialty - Generic / Brand Retail & Specialty - Generic / Brand $25,000 Unlimited Not Applicable $100 Coins / No Coverage This plan has a six (6) physician office visits per person, per benefit period maximum. e-office Visits do not count towards your office visit maximum. Note: Visits considered as Adult Wellness*, Well Child, Mental Health*, *, Maternity Services and Outpatient Therapy* & Spinal Manipulation* are not subject to the six physician office visit maximum. (*These benefits have separate benefit maximums.) Annual Benefit Maximum Applies per person, per benefit period. All services that would be applied to the Lifetime Maximum in a benefit period for other BlueSelect plans would also be applied to the Annual Benefit Maximum. Once the Annual Benefit Maximum has been met for a member, no services will be covered for the remainder of that benefit period (except pharmacy). Page 3 of 3 This is only a partial description of the many benefits and services covered by Blue Cross and Blue Shield of Florida. This does not constitute a contract. For a complete description of benefits and exclusions, please see the BlueSelect Group Master Policy.