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Indian River County BOCC Retiree Medicare Advantage Renewal Evaluation Effective Date: October 1, 2016 GEHRING AGROUP INS U AANC I A AOA I AS, L CON S UCIA NTS 'Cardiac; P --Physical; S=Speech; O -Occupational; 157 Plan Structure Florida Blue Medicare Advantage Florida Blue Medicare Advantage Blue Medicare Group PPO 1 RX 1 Blue Medicare Group PPO 2 RX 1 Network Name PPO i I Out of Network PPO ! Out of Network Lifetime Maximum Unlimited Unlimited Calendar Year Deductible (CYD) Individual No deductible $1,000 No deductible 1 $2,000 Family N/A N/A N/A N/A Annual Out -of -Pocket Maximum Individual $1,000 $3,000 $2,000$4,000 i Family N/A N/A Physician Services Primary Care Office Visit $10 / visit i 20% after CYD $35 / visit i 40% after CYD Specialist Office Visit $30 / visit i 20% after CYD $50 / visit i 40% after CYD Chiropractic Services $20 / visit i 20% after CYD $20 / visit 40% after CYD Preventive Services No Charge i 20% Coinsurance No charge i 40% Coinsurance Lab & Radiology Services Diagnostic Tests & X -Rays $50 / visit 20% after CYD $100 /visit � 40% after CYD Office Advanced Imaging $125 / visit 20% after CYD $175 / visit 40% after CYD Lab Services No charge ! 20% after CYD No charge ! 40% after CYD Laboratory Provider Quest ! N/A Quest ! N/A Hospital Services Inpatient P $150/day to max of i 20% after CYD $250/day to max of 40% after CYD $1,050/admit $1,750/admit i Outpatient $150/visit ! 20% after CYD $250/visit 40% after CYD Physician Services at Facility No charge 20% after CYD No charge ! 40% after CYD Outpatient Advanced Imaging $150 / visit ! 20% after CYD $150 / visit ! 40% after CYD Emergency Room $75 / visit l i $75 /visit $75 /visit j $75 /visit Urgent Care Center $30 / visit $30 /visit i! $50 /visit $50 /visit Ambulance $150 / occurrence j $150 / occurrence $150 / occurrence i $150 / occurrence Outpatient Rehabilitatlon Facility Charge $30 20% after CYD $40 40% 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, O Durable Medical Equipment $0-20%/item ! 20% after CYD $0-20%/item ! 40% after CYD Prescription Drugs Prescription ONLY Deductible No Deductible Not Covered No Deductible ! Not Covered $0 to Catastrophic Preferred Generics $10 ($0 through I E Not covered $10 ($0 through 1 i Not covered mail order) mail order) Non -Preferred Generics $10 ($0 through g ! Not covered ! $10 ($0 through ' Not covered mail order) mail order) Preferred Brand $40 ! Not covered $40 ! Not covered Non -Preferred Brand $70 j Not covered $70 i Not covered Specialty Injectables 25% Not covered 25% ! Not covered Mail Order (90 day supply)2x Not covered 2x i Not covered Catastrophic 2015 >= $4,70012016 >= $4,850 2016 > _ $4,850/2017>= $4,950 Generic Greater of 5% or Not covered Greater of 5% or Not covered $2.65 / $2.95 $2.95 / $3.30 Preferred Brand Greater of 5% or ! Not covered Greater of 5% or i Not covered $6.60 / $7.40 $7.40 / $8.25 l Non -Preferred Brand Greater of 5% or i E Not covered Greater of 5% or ! ! Not covered $6.60 / $7.40 i $7.40 / $8.25 Specialty Injectables Greater of 5% or ! Not covered Greater of 5% or i Not covered $6.60 / $7.40 i $7.40 / $8.25 i Mail Order (90 day supply) 2x E Not covered 2x Not covered Monthly Premium Current Alternative #1 Single $319.92 $365.54 Family N/A N/A %Chane N/A 14.3% 'Cardiac; P --Physical; S=Speech; O -Occupational; 157