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Indian River County BOCC Retiree Medicare Advantage Renewal Evaluation Effective Date: October 1, 2016 GEHRING AGROUP INS U A ANC C A AOA[ AS, . CONSULTANTS 'C=Cardiac; P --Physical; S=Speech; Occupational; 156 Plan Structure Florida Blue Medicare Advantage Florida Blue Medicare Advantage Blue Medicare Group PPO 1 RX 1 Blue Medicare Group PPO 1 RX 1 Network Name PPO Out of Network PPO Out of Network Lifetime Maximum Unlimited Unlimited Calendar Year Deductible (CYD) Individual No deductible 1 $1,000 No deductible 1 $1,000 Family N/A I N/A N/A IN/A Annual Out -of -Pocket Maximum Individual $1,000 1 $3,000 $1,000 $3,000 Family N/A N/A Physician Services Primary Care Office Visit $30 / visit i 20% after CYD $10 / visit 20% after CYD Specialist Office Visit $30 / visit ! 20% after CYD $30 / visit i 20% after CYD Chiropractic Services $20 / visit i 20% after CYD $20 / visit i 20% after CYD Preventive Services No Charge i 20% Coinsurance No charge 20% Coinsurance Lab & Radiology Services Diagnostic Tests & X -Rays $50 / visit i 20% after CYD $50 / visit i 20% after CYD Office Advanced Imaging $125 / visit ! 20% after CYD $125 / visit 20% after CYD Lab Services No charge ! 20% after CYD No charge 20% after CYD Laboratory Provider Quest I N/A Quest ! N/A Hospital Services Inpatient p $150/day to max of i 20%after CYD $150/day to max of 20% after CYD $1,050/admit $1,050/admit i Outpatient $150/visit ! 20% after CYD $150/visit ! 20% after CYD Physician Services at Facility No charge ! 20% after CYD No charge 20% after CYD Outpatient Advanced Imaging $150 / visit ! 20% after CYD! $150 /visit 20% after CYD Emergency Room $75 / visit I $75 / visit $75 /visit $75 visit Urgent Care Center $30 visit i $30 visit $30 /visit $30 /visit Ambulance $150 / occurrence $150 /occurrence $150 / occurrence $150 / occurrence Outpatient Rehabilitation Facility Charge $30 20% after CYD $30 ! 20% after CYD Annual Maximum Visits $1,940 Max - P,S / $1,940 Max - 0 $1,940 Max - P,S / $1,940 Max - 0 Services Include" C, P, S, 0 C, P, S, 0 Durable Medical Equipment $0-20%/item ! 20% after CYD $0-20%/item ! 20% after CYD Prescription Drugs Prescription ONLY Deductible No Deductible Not Covered No Deductible Not Covered $0 to Catastrophic Preferred Generics $30 ($0 through ! I Not covered $10 ($0 through ! Not covered mail order) mail order) Non -Preferred Generics $10 ($0 through j I Not covered $10 ($0 through ! Not covered mail order) mail order) E Preferred Brand $40 ! Not covered $40 I Not covered Non -Preferred Brand $70 Not covered $70 Not covered Specialty Injectables 25% i Not covered 25% Not covered Mail Order (90 day supply) 2x Not covered 2x Not covered Catastrophic 2015 >= $4,70012016 >= $4,850 2016 > _ $4,85012017 >= $4,950 Generic Greater of 5% or i ! Not covered Greater of 5% or j Not covered $2.65 / $2.95 i $2.95 / $3.30 i Preferred Brand Greater of 5% or I Not covered Greater of 5% or ! Not covered $6.60 / $7.40 $7.40 / $8.25 Non -Preferred Brand Greater of 5% or ! i Not covered Greater of 5% or Not covered $6.60 / $7.40 $7.40 / $8.25 I Specialty Injectables Greater of 5% or ! ! Not covered Greater of 5% or ! Not covered $6.60 / $7.40 i $7.40 / $8.25 Mail Order (90 day supply) 2x Not covered 2x ! Not covered Monthly Premium Current Renewal Single $319.92 $402.01 Family N/A N/A % Chane N/A 25.7% 'C=Cardiac; P --Physical; S=Speech; Occupational; 156