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Indian River County BOCC Retiree Medicare Advantage Renewal Evaluation Effective Date: October 1, 2016 GEHRING AGROUP I N S U A A N C S . N O N r N SIA i C O N S U L T A N T S 'Cardiac; P --Physical; S=Speech; Occupational; 158 Plan Structure Florida Blue Medicare Advantage Florida Blue Medicare Advantage Blue Medicare Group PPO 1 RX 1 Blue Medicare Group PPO 2 RX 2 Network Name PPO I Out of Network PPOI Out of Network Lifetime Maximum Unlimited Unlimited Calendar Year Deductible (CYD) Individual No deductiblei $1,000 No deductible l $2,000 Family N/A I N/A N/A I N/A Annual Out -of -Pocket Maximum Individual $1,000 $3,000 $2,000 ' $4,000 Family N/A NjA / Physician Services Primary Care Office Visit $10 / visit j 20% after CYD $35 / visit j 40% after CYD Specialist Office Visit $30 / visit ! 20% after CYD $50 / visit 40% after CYD Chiropractic Services $20 / visit i 20% after CYD $20 / visit I 40% after CYD Preventive Services No Charge i 20% Coinsurance No charge i 40% Coinsurance Lab & Radiology Services Diagnostic Tests & X -Rays $50 / visit i 20% after CYD $100 / visit I 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 ! 40Yo after CYD Laboratory Provider Quest I N/A Quest I N/A Hospital Services Inpatient $150/day to max of I 20% after CYD I $250/day to max of I $1,050/admit ! $1,750/admit 40% after CYD Outpatient $150/visit ! 20% after CYD $250/visit ! 40% after CYD Physician Services at Facility No charge ! 20% after CYD No charge ! 40`Yo after CYD Outpatient Advanced Imaging $150 / visit ! 20% after CYD $150 / visit 40Yo after CYD Emergency Room $75 /visit I $75 / visit $75 / visit I $75 /visit Urgent Care Center $30 / visit ! $30 /visit $50 /visit ! $50 / visit Ambulance $150 / occurrence i $150 / occurrence $150 / occurrence i $150 / occurrence Outpatient Rehabilitation Facility Charge $30 I 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, 0 Durable Medical Equipment $0-20%/item ! 20% after CYD $0-20%/item ! 40% after CYD Prescription Drugs Prescription ONLY Deductible No Deductible Not Covered $75 (Brand Drugs Only) Not Covered $0 to Catastrophic Preferred Generics $10 ($0 through ! Not covered $15 ($8 through j Not covered mail order) i mail order) ; Non -Preferred Generics $10 ($0 through ! Not covered $15 ($8 through Not covered mail order mail order) Preferred Brand $40 ! Not covered $45 ! Not covered Non -Preferred Brand $70 Not covered $85 Not covered Specialty Injectables 25% ! Not covered 25% ! Not covered Mail Order (90 day supply) 2x I Not covered 3x Not covered Catastrophic 2015 >_ $41,70O/2016 >_ $4,850 2016 > _ $4,85012017>= $4,950 Generic Greater of 5% or i ! Not covered Greater of 5% or i j Not covered $2.65 / $2.95 ! $2.95 / $3.30 i Preferred Brand Greater of S% or Not covered Greater of 5% or I 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 I $7.40 / $8.25 I Specialty Injectables Greater of 5% or 1 Not covered Greater of S% or Not covered $6.60 / $7.40 $7.40 / $8.25 Mail Order (90 day supply)2x I Not covered 2x ! Not covered Monthly Premium Current Alternative #t2 Single $319.92 $330.07 Family N/A N/A % Chane N/A 3.2% 'Cardiac; P --Physical; S=Speech; Occupational; 158