2017 St. Lucie Public Schools...4 Enrollment at a Glance 6 COBRA Eligibility Requirements 7 Florida...

St. Lucie Public SchoolsFlexible Benefits Plan Reference Guide

2017 B E N E F I T S

M A D E S I M P L E

COBRA & Retiree Participants

2www.myFBMC.com

If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, a federal law gives you more choices about your prescription drug coverage. Please see page 31 for more details.

2017 St. Lucie Public Schools

Table of Contents3 Plan Highlights

4 Enrollment at a Glance

6 COBRA Eligibility Requirements

7 FloridaBlueHealthBenefitsSummary

10 Group Health Plan Premiums

11 MedicareHealthPlanSummary- PPO Plan 1

17 Medicare Group Rx Option 1

18 MedicareHealthPlanSummary- PPO Plan 2

24 Medicare Group Rx Option 3

25 Dental Plan

27 Vision Plan

28 Group Hospital Indemnity Insurance

29 Group Term Life Insurance

30 Group Cancer Insurance Plan

31 Creditable Coverage Notice

Back BenefitsDirectory

PayFlex – FBMC’s COBRAOutsource ProviderCOBRA benefits communication is being supported by FBMC Benefits Management’s outsource provider,PayFlex Systems USA, Inc. Please note that all PayFlexcorrespondence you receive is approved for distribution by the St.LuciePublicSchoolsandFBMCBenefitsManagement,Inc. ForCOBRAquestionsaboutyourBenefitsOpenEnrollmentand throughout the year, please contact PayFlex at1-855-LUCIE4U(1-855-582-4348).

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Plan Highlights• Thisyearisachangesonlyenrollment.AllCOBRAparticipantsand

retirees of St. Lucie Public Schoolsmay complete an enrollmentformtomakechangestoyourcoverage.Ifyoudonotcompleteanenrollmentform,yourcurrentbenefitswillcontinue.

• SLPSwill continue to offer the BlueOptions Plan 05771 andBlueOptionsPlans05180/05181toCOBRAparticipantsandretirees.

• BlueMedicareGroupPPOPlans1and2areavailabletoallMedicare-eligibleretireesandtheirdependents.

Important Enrollment Information• Ifyouwish tomakechanges toyourexistingcoverage,youmust

completeandmailanenrollmentformbyNovember11,2016.

• COBRA participants:AtOpenEnrollment,aQualifiedBeneficiaryunderCOBRAwillbegiventhesameopportunityassimilarly-situatedactiveparticipantsandbeneficiaries,tochangehisorhergrouphealthplans,todropdependentsortoaddeligibledependentswhoarenotalreadycoveredunderCOBRA.

• FBMCBenefitsManagement, Inc. has contractedwith PayflexSystemsUSA,Inc.toadministerCOBRAservicesasrequiredbylaw.COBRA participants must complete and mail an enrollment form by November11,2016tocontinueCOBRAbenefitstoPayFlexSystemsUSA,Inc.BenefitsBillingDepartmentP.O.Box2239Omaha,NE68103-2239.Formsmaybe faxed to1-402-231-4302oremailedto [email protected] also call PayFlex Systems at1-855-LUCIE4U(1-855-582-4348).

• Retiree Participants:AtOpenEnrollment,aretireemaycontinue,cancel or decrease coverage.A retireemay not add or increasecoverage,oraddorincreasedependentcoverage.

• Retiree Participants: If you currently do not have your premiums deducted from your Florida Retirement System (FRS)monthlybenefitcheck,andwouldliketo,pleasecompletetheenclosedFRSDeductionAuthorizationFormandreturn itwithyourenrollmentform.Yourdeductionswillstartassoonaspossible.Pleasebeawarethat you must make your payments via personal check or money orderuntiltheFRSdeductionsbegin.

• Ifyouaremakingchangestoyourbenefits,youmustcompleteandmailanFBMCRetireeEnrollmentFormbyNovember11,2016to:

FBMCBenefitsManagement,Inc. Retiree and Direct Bill Department P.O.Box10789 Tallahassee,FL32302-2789 • IfyouareMedicare-eligibleandyouelecttoenrollineither

BlueMedicareGroupPPOplan,youmustalsocompleteandmailaFloridaBlueBlueMedicareenrollmentformto:

Florida Blue P.O.Box45296 Jacksonville,FL32232-5296

• Dependents:Ifyouareenrollingincoverageforyourdependents,pleaserecordyourdependents’SocialSecuritynumbersanddatesofbirthonyourenrollmentform.

Enrollment Information

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Important Dates to RememberYourOpenEnrollmentdatesare:

October 24, 2016 through November 11, 2016.

YourPeriodofCoveragedatesare:January 1, 2017 through December 31, 2017.

Medicare Advantage PlansSLPSofferstwoMedicareAdvantagePlansforeligibleretireeswhoareage65orolderandareeligibleforMedicare.IfyouarecurrentlyeligibleforMedicareandwouldliketoenrollineitherplan,pleasecompletethe enclosed application alongwith the FloridaBlueBlueMedicareenrollmentform.TheeffectivedateofyourMedicareAdvantagePlanwillbeJanuary1,2017.

If youwill becomeeligible forMedicareduring the2017PlanYearandwouldliketoparticipateintheMedicareAdvantagePlan,pleasecontactSt.LuciePublicSchoolsRiskManagementOfficetorequestanapplication.TheeffectivedateofyourMedicareAdvantagePlancanbethesamedateyourMedicarebecomeseffective.Forasummaryofthebenefitsthisplanoffers,pleaserefertoPage11.

COBRA Open EnrollmentAtOpenEnrollment,aqualifiedbeneficiaryisgiventhesameopportunityas similarly-situated active participants andbeneficiaries, to changehisorhergrouphealthplans,dropdependentsand/ortoaddeligibledependentswhoarenotalreadyonCOBRA.

Please refer to the information contained on your current BenefitStatementandinthisbookwhenmakingyourCOBRAselectionsforthe2017PlanYear.

You can cover your dependents under every benefit that shows apremiumamountfordependentcoverage(refertotheratesinthisbook)providedyouparticipateinthesamebenefit.Refertopage6formoredetailsonCOBRAandHIPAAexclusions.

Ifyouaremakingchangestoyourbenefits,youmustfullycomplete,signandreturntheenclosedenrollmentformtoPayFlexSystemsUSA,Inc.BenefitsBillingDepartmentP.O.Box2239Omaha,NE68103-2239.YoumayalsocallPayFlexSystemsat1-855-LUCIE4U(1-855-582-4348).Formsmaybe faxed to 1-402-231-4302or emailed to [email protected]. If youdo complete an enrollment form, please assureyouhavenotedallbenefitsyouwanttocontinueinthenewplanyear.LateformswillnotbeacceptedandthebenefitsshownonyourcurrentBenefitStatementwillbeterminatedasofDecember31,2016.Formoreinformation,contactFBMCServiceCenterat1-855-LUCIE4U(1-855-582-4348),Monday-Friday,7a.m.-7p.m.ET.

Retiree Open EnrollmentAtOpenEnrollment,retireesmaynotaddorincreasecoverage,oraddorincreasedependentcoverage.Onceacoverageiscancelled,itmaynotbereinstatedoraddedatalaterdate.

PleaserefertotheinformationcontainedonyourcurrentBenefitStatementandinthisguidewhenmakingselectionsforthe2017PlanYear.

If you are making changes to your benefits, you must complete a 2017 enrollment form. If you are Medicare-eligible and you elect to enroll in either BlueMedicare Group PPO plan, you must also complete and mail a Florida Blue BlueMedicare enrollment form to:Florida Blue P.O. Box 45296 Jacksonville, FL 32232-5296

Pleaseassureyouhavenotedallbenefitsyouwanttocontinueinthenewplanyear.Lateformswillnotbeaccepted.Formoreinformation,contact FBMCServiceCenter at 1-855-LUCIE4U (1-855-582-4348),Monday-Friday,7a.m.-7p.m.ET.

Any changes to your retiree benefits will require your writtenauthorization. Premium changes required because of suchwrittenauthorizationwillbeinitiatedassoonaspossibleafterreceiptofyourwrittenrequest.IfyouarehavingFRSdeductionsforpremiumpayments,anyrequiredrefundswillbecompletedassoonasithasbeenverifiedthatFRShaschangedyourdeduction.

Retirees are encouraged to submit their enrollment form(s) early during Open Enrollment to ensure that deductions are made by FRS in a timely manner.

Any coverage you elect to cancel cannot be reinstated. Please send yourenrollmentform,markingcanceltocancelselectedcoverageduringOpenEnrollment, to:FBMCBenefitsManagement, Inc.,RetireeandDirectBillDepartment,P.O.Box10789,Tallahassee,FL32302-2789.

Insurance Coverage after RetirementUndersection112.0801,FloridaStatutes,yourFRSemployerisrequiredto offer you or your eligible dependents the option of continued participationinanyemployer-sponsoredgroupinsuranceplansinwhichyouwereparticipatingatyourretirementoratyourDROPterminationdate.

Asaretiree,yourpremiumcostforhealthandhospitalizationinsurancecoverage may not exceed the total employee and employer premium costapplicable toactiveemployees.Youmay loseyoureligibility toparticipateifyouchoosenottocontinueparticipatinginyouremployer’sgroupplanatretirement,initiallychoosetocontinuebutsubsequentlystopparticipating,deferyourretirementtoafuturedate,orotherwisedo notmeet your employer’s group plan requirements. Before youterminateemployment,contactyourFRSemployeraboutcontinuingyouremployer-sponsoredgroupinsurancecoverage.Thedivisionhasno authority over or responsibility for employer group health and hospitalizationplans.

Enrollment at a Glance

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IncomeTaxesonYourRetirementBenefitEachyearattheendofJanuary,thedivisionprovidesyouanIRSForm1099-R.Yourannualtaxableincomeisshowninthetaxableamountbox(Box2a).Youshouldusethisformwhenyoufileyourincometaxreturn.

Dependent Eligibility for Group Health andDentalPlan:Anindividualwhomeetstheeligibilitycriteriaspecifiedbelowisaneligibledependentandiseligibletoapplyforcoverageunderthisreferenceguide:1.Thecoveredemployee’sspouseunderalegally-validexistingmarriage;2.Thecoveredemployee’snatural,newborn,adopted,foster,orstep

child(ren) (or a child forwhom the covereddependent has beencourt-appointedaslegalguardianorlegalcustodian)who:a) hasnotreachedtheendofthecalendaryearinwhichheorshe

becomes 26

b) has reached the endof the calendar year inwhichheor shebecomes26,buthasnotreachedtheendofthecalendaryearinwhichheorshebecomes30andwho:i.isunmarriedanddoesnothaveadependent;ii.isaFloridaresidentorafull-timeorpart-timestudent;iii.isnotenrolledinanyotherhealthcoveragepolicyorplan;andiv.isnotentitledtobenefitsunderTitleXVIIIoftheSocialSecurityActunlessthechildisahandicappeddependentchild.

c) in the case of a handicappeddependent child, such child iseligible to continue coverage beyond the limiting age of 30 as a covereddependentifthedependentchildis:i.otherwiseeligibleforcoverageundertheGroupMasterPolicy;ii. incapableofself-sustainingemploymentbyreasonofmentalorphysicalhandicap;and

iii.chieflydependentuponthecovereddependentforsupportand maintenance provided that the symptoms or causes of thechild’shandicapexistedpriortothechild’s30thbirthday.This eligibility shall terminate on the last day of the month in whichthedependentchildnolongermeetstherequirementsforextendedeligibilityasahandicappedchild.

or3.Thenewbornchildofacovereddependentchildwhohasnotreachedtheendofthecalendaryearinwhichheorshebecomes26.Coverageforsuchnewbornchildwillautomaticallyterminate18monthsafterthebirthofthenewbornchild.

Note: Ifacovereddependentchildwhohas reached theendof thecalendaryearinwhichheorshebecomes26obtainsadependentoftheirown(e.g.,throughbirthoradoption),suchnewbornchildwillnotbeeligibleforthiscoverage.Itisyoursoleresponsibilityasthecovereddependent to establish that a child meets the applicable requirements foreligibility.Eligibilitywillterminateonthelastdayofthemonthinwhichthechildnolongermeetstheeligibilitycriteriarequiredtobeaneligibledependent.

Dependent Eligibility For Other PlansRefer to the benefit description pages in this reference guide for informationoneachbenefit.Youmaycoveryoureligibledependentsunder every benefit that shows a premium amount for dependentcoverage (refer to the rate charts that appear with each benefitdescription)providedyouparticipateinthesamebenefit.Aneligibledependentis:yourlegalspouse;anunmarrieddependentchildofeitheryouoryourlegalspouse(includingastepchild,alegallyadoptedchild,a child placed and approved for adoption in your home or a child for whomyouhavebeenappointedlegalguardian),providedtheyresideinyourhouseholdandprimarilydependonyouforsupport.

Untilthefollowingconditionsarereached,eligibledependentswillbecoveredfrombirth,adoptionortimeofguardianship:• Group Cancer Insurance and Hospital Indemnity Insurance – coverage

willceaseattheendofthecalendaryearinwhichthechildreachesage25ifthechildlivesinyourhomeanddependsonyouforsupport,orattendsschoolfullorparttime.

• Vision-coveragewillceaseattheendofthecalendaryearinwhichthechildreachesage19(or25ifthechildlivesinyourhomeanddependsonyouforsupportorattendsschoolfullorparttime).

• Unmarried insured children who are physically or mentallyhandicappedandfullyincapableofself-care,willbecovereduntildisablementbecomesotherthantotal.Proofofdisabilitymustbesubmitted to your insurance provider following the child’s 19thbirthday.

Please refer to the specific dependent eligibility information on theindividualbenefitinformationpagesofthisreferenceguide.

Enrollment at a Glance

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What is continuation coverage?Federallawrequiresthatmostgrouphealthplans,giveemployeesandtheir families the opportunity to continue their health care coverage whenthereisa“qualifyingevent”thatwouldresultinalossofcoverageunder anemployer’s plan. Formore information,please contact theFBMCServiceCenterat1-855-LUCIE4U(1-855-582-4348),Monday-Friday,7a.m.-7p.m.ET.

COBRA CoverageAQualifiedBeneficiary's(QB)periodofcoverageisJanuary1,2017,throughDecember31,2017,unlessaQB'sscheduledCOBRAexpirationdateissooner.QBswhohaveelectedtocontinueeligiblegrouphealthplansunderCOBRAwillbegiventhesameopportunitytochangetheircoverage options or add or drop eligible dependents at Open Enrollment assimilarlysituatedactiveemployeesandbeneficiaries.

AQB'sMedicalExpenseFSAcoveragewillnotbecontinuedbeyondthePlanYearinwhichthequalifyingCOBRAeventoccurs.

HIPAA'sspecialenrollmentrightsmayapplytothosewhohaveelectedCOBRA.HIPAA,afederallaw,givesapersonalreadyonCOBRAcertainrightstoadddependentsifsuchpersonacquiresanewdependent,orifan eligible dependent declines coverage because of alternative coverage andlaterlosessuchcoverageduetocertainqualifyingreasons.SpousesordependentswhoareaddedunderthislawdonotbecomeQualifiedBeneficiaries—andtheircoveragewillendatthesametimecoverageendsforthepersonwhoelectedCOBRAandlateraddedthem.

Ifthere’salossofcoverageforagrouphealthplan,duetooneofthetriggeringeventsbelow,thenCOBRArightsmayhavebeencreated:

ForCoveredEmployeesupon:• termination of employment (other than for grossmisconduct),

includingretirement,or• a reduction in hours of employment

ForSpousesorDependentChild(ren)upon:•a covered employee’s terminationof employment (other than for

grossmisconduct),includingretirement•acoveredemployee’sreductioninhoursofemployment•acoveredemployee’sdeath•adivorceorlegalseparation(ifrecognizedbystatelaw)ofaspouse

from a covered employee• acoveredemployee’sentitlementtoMedicare,or• achild’slossofdependentstatus

Method of PaymentACOBRAParticipant’sinitialpaymentincludingallbackpremiumsisduewithin45daysofCOBRAcontinuationelection.Subsequentmonthlypremiumpaymentsaredueonthefirstofeverymonth.COBRAlawallowsfora30-daygraceperiodaftertheduedateformonthlypayments.If a full premium payment is not received from a COBRA Participant by 30daysaftertheduedate,COBRAcoveragewillbecanceledretroactivetothefirstdayofthemonthforwhichthefullpremiumpaymentisdue.AcancellationnoticewillbesenttotheCOBRAParticipantifhisorherfullpremiumpaymentisnotreceived.

COBRA Eligibility Requirements

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Florida Blue Health Benefits Summary

Summary of Health Benefits for St. Lucie Public Schools 01-01-17 thru 12-31-17COST SHARINGMaximums shown are Per Benefit Period (BPM) unless noted

BlueOptionsHSA-Compatible 05180

(Single Cov erage)“Network Blue”


(Family Cov erage) “Network Blue”

BlueOptions 05771

“Network Blue”Only Av ailable

To Employees HiredPrior to 1/1/14

Deductible (DED) (Per Person/Family Agg)In-Network $1,500 / Not Applicable $3,000 / $3,000 $1,500 / $4,500Out-of-Network $3,000 / Not Applicable $6,000 / $6,000 $4,500 / $13,500

Coinsurance (Member Responsibility)In-Network 10% 10% 20%Out-of-Network 40% of Allowed Amount +

Subject to Balance Bill ing Charges

40% of Allowed Amount + Subject to Balance Bill ing

Charges

50% of Allowed Amount + Subject to Balance Bill ing

ChargesOut of Pocket Maximum (Per Person/Family Agg)

Includes DED, Coins, & Copays



In-Network $3,000 / Not Applicable $6,000 /$6,000 $4,500 / $9,000Out-of-Network $6,000 / Not Applicable $12,000 / $12,000 $9,000 / $18,000

Lifetime Maximum No Maximum No Maximum No Maximum

PROFESSIONAL PROVIDER SERVICESAllergy Injections

In-Network Primary/Family Care Physician DED + 10% DED + 10% $10In-Network Specialist DED + 10% DED + 10% $10Out-of-Network DED + 40% DED + 40% DED + 50%

E-Office Visit Serv icesIn-Network Primary/Family Care Physician DED + 10% DED + 10% $10In-Network Specialist DED + 10% DED + 10% $10Out-of-Network DED + 40% DED + 40% DED + 50%

Office Serv icesIn-Network Primary/Family Care Physician DED + 10% DED + 10% $30In-Network Specialist DED + 10% DED + 10% $55Out-of-Network DED + 40% DED + 40% DED + 50%

Prov ider Services at Hospital and ERIn-Network Primary/Family Care Physician DED + 10% DED + 10% DED + 20%In-Network Specialist DED + 10% DED + 10% DED + 20%Out-of-Network In-Ntwk DED + 10% In-Ntwk DED + 10% In-Ntwk DED + 20%

Prov ider Services at Other LocationsIn-Network Primary/Family Care Physician DED + 10% DED + 10% $30In-Network Specialist DED + 10% DED + 10% $55Out-of-Network DED + 40% DED + 40% DED + 50%

Radiology, Pathology and Anesthesiology Prov ider Services at Ambulatory Surgical Center

In-Network Specialist DED + 10% DED + 10% ASC: $55Hospital: DED + 20%

Out-of-Network In-Ntwk DED + 10% In-Ntwk DED + 10% ASC: $55Hospital: In-Ntwk DED +

20%

PREVENTIVE CAREAdult Wellness Office Serv ices

In-Network Primary/Family Care Physician $0 $0 $0In-Network Specialist $0 $0 $0Out-of-Network 40% (No DED) 40% (No DED) 50% (No DED)

Colonoscopies (Routine-1 ev ery 10 years) Age 50+ then Frequency Schedule Applies

Age 50+ then Frequency Schedule Applies

Age 50+ then Frequency Schedule Applies

In-Network $0 $0 $0Out-of-Network $0 $0 $0

Mammograms (Routine)In-Network $0 $0 $0Out-of-Network $0 $0 $0

Well Child Office Visits (No BPM)In-Network Primary/Family Care Physician $0 $0 $0

In-Network Specialist $0 $0 $0Out-of-Network 40% (No DED) 40% (No DED) 50% (No DED)

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COST SHARINGMaximums shown are Per Benefit Period (BPM) unless noted


(Single Cov erage)


(Family Cov erage)

BlueOptions 05771

(Only Av ailableTo Employees Hired

Prior to 1/1/14)

EMERGENCY / URGENT / CONVENIENT CARE

Ambulance Maximum (per day) No Maximum No Maximum No MaximumIn-Network DED + 10% DED + 10% DED + 20%Out-of-Network In-Ntwk DED + 10% In-Ntwk DED + 10% In-Ntwk DED + 20%

Conv enient Care Centers (CCC)In-Network DED + 10% DED + 10% $30Out-of-Network DED + 40% DED + 40% DED + 50%

Emergency Room Facility Serv ices(also see Professional Provider Services)In-Network DED + 10% DED + 10% $250Out-of-Network In-Ntwk DED + 10% In-Ntwk DED + 10% $250

Urgent Care Centers (UCC)In-Network DED + 10% DED + 10% $60Out-of-Network OON DED + 10% OON DED + 10% OON DED + $60

FACILITY SERVICES – HOSPITAL / SURGICAL / ICL / IDTF

Unless otherwise noted, physician services are in addition to facility services. See Professional Provider Services.

Ambulatory Surgical CenterIn-Network DED + 10% DED + 10% $200Out-of-Network DED + 40% DED + 40% DED + 50%

Independent Clinical LabIn-Network (Quest Diagnostics) DED DED $0Out-of-Network DED + 40% DED + 40% DED + 50%

Independent Diagnostic Testing Facility -Xrays and AIS (Includes Physician Serv ices)

In-Network - Advanced Imaging Services (AIS)

DED + 10% DED + 10% $250

In-Network - Other Diagnostic Services DED + 10% DED + 10% $50Out-of-Network DED + 40% DED + 40% DED + 50%

Inpatient Hospital (per admit)In-Network Option 1 - DED + 10%

Option 2 - DED + 10%Option 1 - DED + 10% Option 2 - DED + 10%

Option 1 - DED + 20%Option 2 - DED + 20%

Out-of-Network DED + 40% DED + 40% $500 PAD + DED + 50%Inpatient Rehab Maximum (PBP) 30 Days 30 Days 30 Days Outpatient Hospital (per v isit)

In-Network Option 1 - DED + 10% Option 2 - DED + 10%

Option 1 - DED + 10% Option 2 - DED + 10%


Out-of-Network DED + 40% DED + 40% DED + 50%Therapy at Outpatient Hospital

In-Network

Out-of-Network ER SVIES AD


DED + 40%


DED + 40%

Option 1 - $55Option 2 - $80

DED + 50%

OTHER SPECIAL SERVICES AND LOCATIONSAdv anced Imaging Services in Physician's Office

In-Network Primary/Family Care Physician DED + 10% DED + 10% $250In-Network Specialist DED + 10% DED + 10% $250Out-of-Network DED + 40% DED + 40% DED + 50%

Birthing CenterIn-Network DED + 10% DED + 10% DED + 20%Out-of-Network DED + 40% DED + 40% DED + 50%

Durable Medical Equipment, Prosthetics, Orthotics BPM

No Maximum No Maximum No Maximum

In-Network (Carecentrix) DED + 10% DED + 10% DED + 20%Out-of-Network DED + 40% DED + 40% DED + 50%

Home Health Care BPM 20 Visits 20 Visits 20 Visits In-Network (Carecentrix) DED + 10% DED + 10% DED + 20%Out-of-Network DED + 40% DED + 40% DED + 50%

Hospice LTM No Maximum No Maximum No MaximumIn-Network DED + 10% DED + 10% DED + 20%Out-of-Network DED + 40% DED + 40% DED + 50%

Skilled Nursing Facility BPMIn-Network

60 DaysDED + 10%

60 DaysDED + 10%

60 DaysDED + 20%

Out-of-Network DED + 40% DED + 40% DED + 50%

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COST SHARINGMaximums shown are Per Benefit Period (BPM) unless noted


(Single Cov erage)


(Family Cov erage)

BlueOptions 05771

(Only Av ailableTo Employees Hired

Prior to 1/1/14)

MENTAL HEALTH AND SUBSTANCE ABUSEInpatient Hospitalization-Facility

In-Network

Out-of-Network

Option 1- DED + 10%Option 2 - DED + 10%

DED + 40%

Option 1- DED + 10%Option 2 - DED + 10%

DED + 40%

Option 1- $0Option 2 - $050% (No DED)

Outpatient Hospitalization- Facility (per v isit)In-Network

Out-of-Network


DED + 40%


DED + 40%

Option 1 - $0Option 2 - $050% (No DED)

Prov ider Services at Hospital and ERIn-Network Family Physician or SpecialistOut-of-Network Provider

DED + 10%In-Ntwk DED + 10%


$0$0

Physician Office VisitIn-Network Family Physician or SpecialistOut-of Network Provider

DED + 10%DED + 40%

DED + 10%DED + 40%

$050% (No DED)

Emergency Room Facility Serv ices(per v isit)

In-NetworkOut-of-Network



$0$0

Prov ider Services at Locations other than Hospital and ER

In-Network Family PhysicianIn-Network SpecialistOut-of-Network Provider

DED + 10%DED + 10%DED + 40%

DED + 10%DED + 10%DED + 40%

$0$0

50% (No DED)

PRESCRIPTION DRUGS

Deductible$1500

In-Network Plan Deductible Applies

$3000In-Network Plan

Deductible Applies$0

In-Network (Mandatory Generic Program)Retail (30 days)

Generic/Preferred Brand/Non-Preferred $10 / $30 / $50 $10 / $30 / $50 $10 / $30 / $50

Mail Order/Retail (90 days)Generic/Preferred Brand/Non-Preferred $20 / $60 / $100 $20 / $60 / $100 $20 / $60 / $100

CONDITION Rx PROGRAM FOR HSA PLANS ONLY To access the cov ered medications,click here: Condition Care Rx Drug List

Deductible$1500

In-Network Plan Deductible Applies

$3000In-Network Plan

Deductible AppliesIn-Network (Mandatory Generic Program)Retail (30 days)

Generic/Preferred Brand/Non-PreferredGeneric/Preferred Brand/Non-Preferred

$10 $30 $50Generic/Preferred Brand/Non-Preferred

$10 $30 $50

Mail Order/Retail (90 days)Generic/Preferred Brand/Non-Preferred $20 $60 $100 $20 $60 $100

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.

The information contained in this proposal includes benefit changes required as a result of the Patient Protection And Affordable Care Act (PPACA), otherwise known as Health Care Reform (HCR). Please note that

plan benefits are subject to change and may be revised based on guidance and regulations issued by the Secretary of Health and Human Services (HHS) or other applicable federal agency. In addition, the rates

quoted within this proposal are based on the plan benefits at the time the proposal is issued and may change before the plan effective date if additional plan changes become necessary.

Additionally, Interim rules released by the Federal Government February 2, 2010 require BCBSF to test all benefit plans to ensure compliance with the Mental Health Parity and Addiction Equity Act (MHPAE). Benefits

and rates reflected in the proposal are subject to change based on the outcomes of the test.

**WAIVED** XX

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Group Health Plan Premiums

2017 COBRA Participant and Retiree Monthly ContributionsBlue Options - Plan 05180 (Single)/05181 (Family) Retiree COBRA

Participant Only $535.20 $545.90

SpouseOnly(RetireeisenrolledinBlueMedPlan) $663.88

Participant & 1 Dependent $1,199.08 $1,223.06

Participant & Family $1,523.56 $1,554.03

Blue Options - Plan 05771 Retiree COBRA

Participant Only $571.32 $582.75

SpouseOnly(RetireeisenrolledinBlueMedPlan) $708.68

Participant & 1 Dependent $1,280.00 $1,305.60

Participant & Family $1,627.52 $1,660.07

BlueMedicare Group PPO Plan 1 Premiums for Medicare Eligible Retirees and Medicare-Eligible Dependents (age 65 and older)

Retiree

Retiree Only $320.93

Retiree&Spouse $641.86

BlueMedicare Group PPO Plan 2 Premiums for Medicare Eligible Retirees and Medicare-Eligible Dependents (age 65 and older)

Retiree

Retiree Only $196.90

Retiree&Spouse $393.80

Florida Blue

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Florida BlueMedicare Health Plan Summary - PPO Plan 1

Y0011_31874 0916 EGWP C: 09/2016 1

St. Lucie Public Schools District #24936 2017 BlueMedicare Group PPO (Employer PPO) Health Benefits

Benefits BlueMedicare Group PPO Plan 1

Premium (per member, per month) $320.93 for PPO1Rx1

Annual Deductible (DED) $0 In-Network / $1,000 Out-of-Network

Out-of Pocket Maximum (based on plan year)

$1,000 In-Network / $3,000 Out-of-NetworkIn-Network out-of-pocket maximum accumulates toward Out-of-Network out-of-pocket maximum

Physician Office

Primary Care (per visit) In-Network $10 CopaymentOut-of-Network DED & 20% Coinsurance

Specialist Care (per visit) In-Network $30 CopaymentOut-of-Network DED & 20% Coinsurance

e-Visit In-Network $5 CopaymentOut-of-Network DED & 20% Coinsurance

Convenient Care Center In-Network / Out-of-Network $30 Copayment

Podiatry Services (per visit)(routine foot care up to 6 visits per year)

In-Network $30 CopaymentOut-of-Network DED & 20% Coinsurance

Chiropractic Services (per visit)For each Medicare-covered visit (manualmanipulation of the spine to correct subluxation)


Outpatient Mental Health Care (per visit)For individual or group therapy(including partial hospitalization)


Outpatient Substance Abuse Care (per visit) In-Network $35 CopaymentOut-of-Network DED & 20% Coinsurance

Part B Drugs (including chemotherapy) In-Network 20% CoinsuranceOut-of-Network DED & 20% Coinsurance

Allergy Injections In-Network $5 CopaymentOut-of-Network DED & 20% Coinsurance

12www.myFBMC.com

Medicare Health Plan Summary - PPO Plan 1Florida Blue

Y0011_31874 0916 EGWP C: 09/2016 2


Other Services

Outpatient Surgery In-Network $150 Copayment for each outpatient

hospital facility visit $100 Copayment for each visit to an

ambulatory surgical centerOut-of-Network DED & 20% Coinsurance

In-Network / Out-of-Network $0 Copayment for physician services

Diagnostic Tests, X-RaysOffice

IDTF

Lab ServicesIndependent Clinical LabOutpatient HospitalAll Locations

Advanced Imaging (MRI, MRA, CT Scan, PET Scan and Nuclear Medicine):

Office

IDTF

Outpatient Hospital

In-Network PCP $10 Copayment Specialist $30 Copayment

Out-of-Network DED & 20% Coinsurance


In-Network $0 CopaymentIn-Network $15 CopaymentOut-of-Network DED & 20% Coinsurance




13 www.myFBMC.com


Y0011_31874 0916 EGWP C: 09/2016 3


Outpatient Hospital Services (per visit):Occupational Therapy, Physical Therapy, Speech & Language Therapy, Cardiac and Pulmonary Rehab (including intensive cardiac rehab)

Radiation Therapy

Dialysis

Lab Only

All Other Diagnostic Tests, X-Rays,Advanced Imaging, etc.

In-Network $30 CopaymentOut-of-Network DED & 20% Coinsurance$1,960 Physical and Speech Therapy Annual Benefit Maximum$1,960 Occupational Therapy Annual Benefit Maximum


In-Network / Out-of-Network 20% Coinsurance



Urgently Needed Care(This is not emergency care, and in most cases is out-of-the-service area.)

In-Network / Out-of-Network $30 Copayment

Emergency Services In-Network / Out-of-Network $75 CopaymentWorldwide Coverage

Dental, Hearing and Vision (Medicare-Covered)


Home Health In-Network / Out-of-Network $0 Copayment

Ambulance In-Network / Out-of-Network $150 Copayment for Medicare-covered ambulance services

14www.myFBMC.com


Y0011_31874 0916 EGWP C: 09/2016 4


Outpatient Medical Services and Supplies

Durable Medical Equipment/Diabetic SuppliesDiabetic Supplies (glucose meters, test strips and lancets)Note: needles, syringes and insulin for self-injection are covered under your Part D benefit

Equipment: Plan-Approved Electric Customized Wheelchairs, Electric Scooters

All Other Medicare-Covered Durable Medical Equipment


In-Network 20% CoinsuranceOut-of-Network DED & 20% Coinsurance


Prosthetic Devices In-Network $0 Copayment for Medicare-covered itemsOut-of-Network DED & 20% Coinsurance

Outpatient RehabilitationOccupational Therapy, Physical Therapy, Speech & Language Therapy, Cardiac and Pulmonary Rehab (including intensivecardiac rehab)

Office or Freestanding Facility Services

Outpatient Hospital Services

Dialysis

$1,960 Physical and Speech Therapy Annual Benefit Maximum$1,960 Occupational Therapy Annual Benefit MaximumIn-Network $30 Copayment for each visitOut-of-Network DED & 20% Coinsurance

In-Network $30 Copayment for each visitOut-of-Network DED & 20% Coinsurance

In-Network/Out-of-Network 20% Coinsurance

Inpatient Care

Inpatient Hospital Care(including substance abuse treatment)

In-Network $150 Copayment each day for day(s) 1-7

for a Medicare-covered stay in a network hospital

After the 7th day, the plan pays 100% of covered expenses per stay


15 www.myFBMC.com


Y0011_31874 0916 EGWP C: 09/2016 5


Inpatient Mental Health Care In-Network $200 Copayment each day for day(s) 1-7

for a Medicare-covered stay in a network hospital

$0 Copayment for day(s) 8-90 for aMedicare-covered stay in a network hospital

190-day lifetime limit in a psychiatric hospital


Skilled Nursing Facility(in a Medicare-certified skilled nursing facility)

In-Network $0 Copayment each day for days 1-20 per

benefit period $75 Copayment each day for days 21-100

per benefit period There is a limit of 100 days for each benefit

period 3-day prior hospital stay is not required


Hospice Member must receive care from a Medicare-certified hospice

Preventive Services

Annual Screening Mammograms(for women with Medicare, age 40 and older)

In-Network $0 Copayment for Medicare-covered screening mammogramsOut-of-Network 20% Coinsurance

Pap Smears and Pelvic Exams(for women with Medicare)

In-Network $0 Copayment per Pap smear $0 Copayment per pelvic exam

Out-of-Network 20% Coinsurance

Bone Mass Measurement(for people with Medicare who are at risk)

In-Network $0 Copayment for each Medicare-covered bone mass measurementOut-of-Network 20% Coinsurance

Colorectal Screening Exams(for people with Medicare age 50 and older)

In-Network $0 Copayment for Medicare-covered colorectal screening examsOut-of-Network 20% Coinsurance

Prostate Cancer Screening Exams(for men with Medicare age 50 and older)

In-Network $0 Copayment for Medicare-covered prostate cancer screening examsOut-of-Network 20% Coinsurance

16www.myFBMC.com


Y0011_31874 0916 EGWP C: 09/2016 6


Vaccines (Medicare-covered) In-Network $0 Copayment for influenza vaccine $0 Copayment for pneumococcal vaccine $0 Copayment for hepatitis B vaccine


Health & Wellness Benefit

Fitness Free membership through SilverSneakers

BlueMedicare Group PPO out-of-pocket maximum includes all covered health services member cost share rendered in/out of network on a calendar year basis. Supplemental services and Part D costs are not applied to out-of-pocket maximum.

Medicare Part B - the premium provided under this plan excludes the Medicare Part B premium payments. (Members must continue to pay the Medicare Part B premium unless paid by Medicaid or another third party.)

Florida Blue is a PPO Plan with a Medicare contract. Enrollment in Florida Blue depends on contract renewal.

17 www.myFBMC.com

Florida BlueMedicare Group Rx Option 1

St. Lucie Public Schools District #249362017 BlueMedicare Group Rx (Employer PDP)

Benefits BlueMedicare Group Rx Option 1

Premium Included in PPO1Rx1

Annual Deductible $0

Retail 31-day Supply

Tier 1 - Preferred Generics $10 Copayment

Tier 2 - Generics $10 Copayment

Tier 3 - Preferred Brand $40 Copayment

Tier 4 - Non-Preferred Brand $70 Copayment

Tier 5 - Specialty Drugs 25% Coinsurance

Mail Order 90-day Supply with PRIME Mail Order





Tier 5 - Specialty Drugs 25% Coinsurance (31-day supply only)

Gap 31-day Supply






Catastrophic$3.30 Copayment for generic drugs$8.25 Copayment for brand drugs

Florida Blue is an Rx (PDP) Plan with a Medicare contract. Enrollment in Florida Blue depends oncontract renewal.

Prescription drug copays do not accumulate towards the health plan annual out-of-pocket maximum.

Part D Creditable Coverage – The enrolling member may incur late enrollment penalties as definedand set by CMS in accordance with Part D guidelines if prior creditable coverage cannot be proven.

Y0011_31876 0916 EGWP C: 09/2016

18www.myFBMC.com

Medical Health Plan Summary - PPO Plan 2Florida Blue

Y0011_31875 0916 EGWP C: 09/2016 1

St. Lucie Public Schools District #24936 2017 BlueMedicare Group PPO (Employer PPO) Health Benefits


Premium (per member, per month) $196.90 for PPO2Rx3

Annual Deductible (DED) $0 In-Network / $2,000 Out-of-Network

Out-of Pocket Maximum (based on plan year)

$2,000 In-Network / $4,000 Out-of-NetworkIn-Network out-of-pocket maximum accumulates toward Out-of-Network out-of-pocket maximum

Physician Office

Primary Care (per visit) In-Network $35 CopaymentOut-of-Network DED & 40% Coinsurance

Specialist Care (per visit) In-Network $50 CopaymentOut-of-Network DED & 40% Coinsurance

e-Visit In-Network $5 CopaymentOut-of-Network DED & 40% Coinsurance

Convenient Care Center In-Network / Out-of-Network $50 Copayment

Podiatry Services (per visit)(routine foot care up to 6 visits per year)


Chiropractic Services (per visit)For each Medicare-covered visit (manualmanipulation of the spine to correct subluxation)


Outpatient Mental Health Care (per visit)For individual or group therapy(including partial hospitalization)


Outpatient Substance Abuse Care (per visit) In-Network $40 CopaymentOut-of-Network DED & 40% Coinsurance

Part B drugs (including chemotherapy) In-Network 20% coinsuranceOut-of-Network DED & 40% Coinsurance

Allergy Injections In-Network $10 CopaymentOut-of-Network DED & 40% Coinsurance

19 www.myFBMC.com

Florida BlueMedical Health Plan Summary - PPO Plan 2

Y0011_31875 0916 EGWP C: 09/2016 2


Other Services

Outpatient Surgery In-Network $250 Copayment for each outpatient hospital

facility visit $175 Copayment for each visit to an

ambulatory surgical centerOut-of-Network DED & 40% Coinsurance

In-Network / Out-of-Network $0 Copayment for physician services

Diagnostic Tests, X-RaysOffice

IDTF

Lab ServicesIndependent Clinical LabOutpatient HospitalAll Locations

Advanced Imaging (MRI, MRA, CT Scan, PET Scan and Nuclear Medicine):

Office

IDTF

Outpatient Hospital



In-Network $0 CopaymentIn-Network $30 CopaymentOut-of-Network DED & 40% Coinsurance




20www.myFBMC.com


Y0011_31875 0916 EGWP C: 09/2016 3


Outpatient Hospital Services (per visit):Occupational Therapy, Physical Therapy, Speech & Language Therapy, Cardiac Rehab (including intensive cardiac rehab)

Pulmonary Rehab

Radiation Therapy

Dialysis

Lab Only

All Other Diagnostic Tests, X-Rays, Advanced Imaging, etc.

In-Network $40 CopaymentOut-of-Network DED & 40% Coinsurance$1,960 Physical and Speech Therapy Annual Benefit Maximum$1,960 Occupational Therapy Annual Benefit Maximum



In-Network / Out-of-Network 20% Coinsurance



Urgently Needed Care(This is not emergency care, and in most cases is out-of-the-service area.)

In-Network / Out-of-Network $50 Copayment

Emergency Services In-Network / Out-of-Network $75 CopaymentWorldwide Coverage

Dental, Hearing and Vision (Medicare-Covered)


Home Health In-Network / Out-of-Network $0 Copayment

Ambulance In-Network / Out-of-Network $150 Copayment for Medicare-covered ambulance services

21 www.myFBMC.com


Y0011_31875 0916 EGWP C: 09/2016 4


Outpatient Medical Services and Supplies

Durable Medical Equipment/Diabetic SuppliesDiabetic Supplies (glucose meters, test strips and lancets)Note: needles, syringes and insulin for self-injection are covered under your Part D benefit

Equipment: Plan-Approved Electric Customized Wheelchairs, Electric Scooters

All Other Medicare-Covered Durable Medical Equipment


In-Network 20% CoinsuranceOut-of-Network DED & 40% Coinsurance


Prosthetic Devices In-Network $0 Copayment for Medicare-covered itemsOut-of-Network DED & 40% Coinsurance

Outpatient RehabilitationOccupational Therapy, Physical Therapy, Speech & Language Therapy, Cardiac Rehab (including intensive cardiac rehab)

Office or Freestanding Facility Services

Outpatient Hospital Services

Pulmonary Rehab

Dialysis

$1,960 Physical and Speech Therapy Annual Benefit Maximum$1,960 Occupational Therapy Annual Benefit MaximumIn-Network $40 Copayment for each visitOut-of-Network DED & 40% Coinsurance



In-Network/Out-of-Network 20% Coinsurance

Inpatient Care

Inpatient Hospital Care(including substance abuse treatment)

In-Network $250 Copayment each day for day(s) 1-7 for

a Medicare-covered stay in a network hospital

After the 7th day, the plan pays 100% of covered expenses per stay


22www.myFBMC.com


Y0011_31875 0916 EGWP C: 09/2016 5


Inpatient Mental Health Care In-Network $250 Copayment each day for day(s) 1-7 for

a Medicare-covered stay in a network hospital

$0 Copayment for day(s) 8-90 for aMedicare-covered stay in a network hospital

190-day lifetime limit in a psychiatric hospitalOut-of-Network DED & 40% Coinsurance

Skilled Nursing Facility(in a Medicare-certified skilled nursing facility)

In-Network $0 Copayment each day for days 1-20 per

benefit period $100 Copayment each day for days 21-100

per benefit period There is a limit of 100 days for each benefit

period 3-day prior hospital stay is not required


Hospice Member must receive care from a Medicare-certified hospice

Preventive Services

Annual Screening Mammograms(for women with Medicare, age 40 and older)

In-Network $0 Copayment for Medicare-covered screening mammogramsOut-of-Network 40% Coinsurance

Pap Smears and Pelvic Exams(for women with Medicare)

In-Network $0 Copayment per Pap smear $0 Copayment per pelvic exam


Bone Mass Measurement(for people with Medicare who are at risk)

In-Network $0 Copayment for each Medicare-covered bone mass measurementOut-of-Network 40% Coinsurance

Colorectal Screening Exams(for people with Medicare age 50 and older)

In-Network $0 Copayment for Medicare-coveredcolorectal screening examsOut-of-Network 40% Coinsurance

Prostate Cancer Screening Exams(for men with Medicare age 50 and older)

In-Network $0 Copayment for Medicare-covered prostate cancer screening examsOut-of-Network 40% Coinsurance

23 www.myFBMC.com


Y0011_31875 0916 EGWP C: 09/2016 6


Vaccines (Medicare-covered) In-Network $0 Copayment for influenza vaccine $0 Copayment for pneumococcal vaccine $0 Copayment for hepatitis B vaccine


Supplemental Benefit

Fitness Free membership through SilverSneakers

BlueMedicare Group PPO out-of-pocket maximum includes all covered health services member cost share rendered in/out of network on a calendar year basis. Supplemental services and Part D costs are not applied to out-of-pocket maximum.

Medicare Part B - the premium provided under this plan excludes the Medicare Part B premium payments. (Members must continue to pay the Medicare Part B premium unless paid by Medicaid or another third party.)

Florida Blue is a PPO Plan with a Medicare contract. Enrollment in Florida Blue depends on contract renewal.

24www.myFBMC.com

Medicare Group Rx Option 3Florida Blue

Y0011_31878 0916 EGWP C: 09/2016

St. Lucie Public Schools District #24936 2017 BlueMedicare Group Rx (Employer PDP)

Florida Blue is an Rx (PDP) Plan with a Medicare contract. Enrollment in Florida Blue depends on contract renewal.

Prescription drug copays do not accumulate towards the health plan calendar year out-of-pocket maximum.

After your total Plan Year drug costs reach $3,700 you enter the Coverage Gap. During the Coverage Gap, coverage for generic drugs remains the same as during the Initial Coverage Period. For brand drugs, you will pay 40% on the negotiated manufacturer’s plan cost for the drugs.

Part D Creditable Coverage – The enrolling member may incur late enrollment penalties as defined and set by CMS in accordance with Part D guidelines if prior creditable coverage cannot be proven.

Benefits BlueMedicare Group Rx Option 3

Premium Included in PPO2Rx3

Annual Deductible $75 for Brand Drugs Only

Retail 31-day Supply Tier 1 - Preferred Generics $10 Copayment





Mail Order 90-day Supply with PRIME Mail Order Tier 1 - Preferred Generics $10 Copayment




Tier 5 - Specialty Drugs 33% Coinsurance (31-day supply only)

Gap 31-day Supply Tier 1 - Preferred Generics $10 Copayment


Tier 3 - Preferred Brand 45% Coinsurance

Tier 4 - Non-Preferred Brand 45% Coinsurance

Tier 5 - Specialty Drugs 58% Coinsurance (Generic) / 45% Coinsurance (Brand)

Catastrophic Greater of $3.30 Copayment or 5% Coinsurance for generic drugsGreater of $8.25 Copayment or 5% Coinsurance for brand drugs

25 www.myFBMC.com

Dental PlanDental PPO for both COBRA and Retiree Participants

2017 Dental Benefits for St. Lucie Public Schools - Retirees and COBRA

BlueDental Choice Low

BlueDental Choice High

Financial Features In-Network Out-of-Network In-Network Out-of-NetworkDeductible (Basic & Major Services Only)Per Person Per Plan YearPer Family Per Plan YearIn-Network deductible credits apply to Out-of-Network deductible and Out-of-Network deductible credits apply to In-Network deductible.

$50$150

$50$150

$50$150

$50$150

Coinsurance *

PREVENTIVE **

BASIC **

MAJOR **

We Pay

100 %

80%

50%

You Pay

0%

20%

50%

We Pay

100%

80%

50%

You Pay

0%

20%

50%

We Pay

100%

90%

60%

You Pay

0%

10%

40%

We Pay

90%

80%

50%

You Pay

10%

20%

50%

Service HighlightsOral Evaluations (Exams)Bitewing X-rayProphylaxis/Periodontal Cleanings (4) – Adult/ChildFluoride Treatment (No age limit)Office VisitsX-rays – Intraoral/Complete Series/PanoramicSealants

Preventive Preventive

Amalgam Restorations (Silver Fillings)Resin-Based Restorations (Anterior and Posterior)Extractions Surgical ExtractionsRoot Canal TherapyPeriodontal Treatment

Basic Basic

Crowns Osseous SurgeryComplete DenturesPartial DenturesFixed Partial Dentures (Bridges)Surgical Placement of Implant BodyImplant Supported Porcelain Fused to Metal Crown

Major Major

Orthodontia Services (children to age 19)Orthodontia Lifetime MaximumBlueDental PaysBenefit Waiting Period

$50050%

NONE

$1,00050%

NONEWaiting Period: (Major Services) NONE NONE

Calendar Year Maximum Per Person $1,000 $1,500

Procedures Performed By Specialist Covered Covered

Dental Rollover Yes Yes

TYPE OF COVERAGE MONTHLY PREMIUMRETIREE COBRA RETIREE COBRA

Employee $29.52 $30.11 $35.98 $36.70Employee Plus 1 $62.02 $63.26 $75.70 $77.21Employee Plus 2 or more $106.83 $108.97 $133.45 $136.12

The information provided above is a summary of benefits for the group Choice certificate. It is intended to highlight key points of the Dental Plan and is provided to the employee as an aid in deciding whether to enroll in the Plan. This summary should in no way be construed as a part of the contract. Possession of this summary in no way implies coverage nor does it guarantee benefits under the plan.

* Percentage of fee schedule ** Some limitations may apply *** Percentage of fee schedule + balance of any charges; non-par dentists may charge fees in excess of our Fee Schedule and may bill you the difference.

26www.myFBMC.com

Dental PlanDental PPO for both COBRA and Retiree Participants

ThefollowingexampleshowshowyourMaximumRolloveramountisdetermined.

If your annual benefit maximum is:

AND your total claims paid for the benefit

period do not exceed:

THEN we will rollover Accumulated totals will be capped at:

$1,000-$1,249 $500 $350 $1,000

$1,250-$1,499 $600 $450 $1,250

$1,500-$1,999 $700 $500 $1,250

$2,000-$2,499 $800 $600 $1,500

To see a list of the dentists in our network, visitwww.floridabluedental.com.Don’t see your dentist in our network? Send an e-mail [email protected](904)866-4846.

Questions?Needmoreinformation?OurCustomerServicerepresentativescanhelp.Justcall(888)223-4892from8a.m.to8p.m.MondaythroughFriday.

*Networksarecomprisedofindependentcontracteddentists.

**Certaindentistshavevoluntarilyagreedtooffera20%discountofftheirusualchargefornon-coveredcosmeticororthodonticservices.ThesedentistsareidentifiedbyanaffiliationtoeithertheCosmeticDentalDiscountProgramorOrthodonticDiscountProgram.Becausethesedentistsareneithercontractuallynorlegallyboundtoofferthesediscounts,werecommendthatyoucontacttheprovidertoinquireaboutthecontinuedavailabilityofanydiscountpriortoschedulinganappointment.

BlueDental ChoiceDid you know that dental health can have an influence on thedevelopmentofconditionssuchasdiabetes,coronaryarterydiseaseand low-birth-weight,prematurebabies?Anundeniable relationshipexistsbetweenahealthymouthandoverallgoodhealth.Thatmeansitis more important than ever for you to receive regular preventive dental carethatwillhelpyoumaintainnotonlyyourgoodoralhealth,butyourgoodhealthingeneral.

BlueDental ChoiceSM is a flexible PPOplan designed to encourageregular cleanings and preventive services that lead to good oral health andbetteroverallhealth.

OurdentalPPOnetworkconsistsofanetworkofqualitydentistswhohaveagreedtoprovideservicesbasedonanegotiatedfee.WhenyouuseaparticipatingdentistintheBlueDentalChoicenetwork*foryourplan,you’llreceivemaximumplanbenefitsandbeprotectedagainstbalance billing (the difference between theBlueDentalChoice feescheduleandthedentist’snormalcharges).Youalsohavetheoptionofvisitinganon-participatingdentistalthoughbalancebillingmayoccur.

AsaBlueDentalChoicememberyoucanlookforwardto:• No referrals or authorizations to see a general dentist or specialist•AccesstooneofthelargestdentalnetworksinFlorida•Accesstoavastnationalnetwork

MaximumRollover-MaximumRolloverisaBlueDentalChoicebenefitthatrewardsyoujustforvisitingthedentist.Eachyearwhenyouvisitthedentistanduselessthantheyearlyclaimpaymentthreshold,you’llreceive Rollover dollars to help cover future unexpected visits or higher out-of-pocketcostsforcomplexprocedures.

It’sthateasy.MaximumRolloverisappliedautomaticallyaslongas:•Youreceiveatleastonecoveredserviceduringyourplanyear•Youareanactivememberofyourplanonthelastdayoftheplanyear•Youdon’texceedtheclaimpaymentthresholdinyourplanyear

BenefitsOrthodontic Discount Program** – When you choose an orthodontist inourorthodonticprovidernetwork,you’llreceive20percentoffyourtotalcasefee.Thisdiscountisonlyavailabletoyouwhenorthodonticcoverageisnotpartofyourplan.

CosmeticDentalDiscountProgram**–Youcanexperiencesignificantsavings on cosmetic dentistry procedures by visiting a dentistwhoparticipatesinourcosmeticdentistrynetwork.AsaBlueDentalChoicemember,you’llreceivea20-percentsavingsonthefollowingprocedures:• Cosmetic Contouring•LaminateVeneer(porcelainorcomposite)•Whitening(inofficeorat-homesystem)

27 www.myFBMC.com

Therearetwovisioncareoptionsavailable,theIn-NetworkOptionandtheOut-of-NetworkOption.• In-NetworkOption:Youchooseadoctorfromthepanelproviderlist.

Servicesareprovidedatpredeterminedrates.• Out-of-NetworkOption:Youcanchooseanyeyedoctor.Youare

reimbursedapercentageofyourcosts.

Plan Features• No deductible • Examination—Onceevery12months• Lenses—Onceevery12months,ifnecessary• Frames—Onceevery12months,ifnecessary• ContactLenses—Onceevery12months(inplaceofexam,lenses

andframes)•RefractiveCare—VisionCarePlan(VCP)offerstheLASIKprocedure

for planmemberswho are nearsightedor have astigmatism andwear glasses or contacts.Youmay also use independent Lasikprovider-network doctors to receive a ten percent discount fromusualandcustomarypricesandpaynomorethan$1,800pereyeforconventionalLasikand$2,300pereyeforcustomLasik,duetoSB632.

To utilize the RefractiveCare program,members first contactVCPto request a LASIK ID card and a list of network eye doctors forinitialscreeningtodetermineif thepatient isacandidate forLASIK.If the patient qualifies, the doctor can alsomake arrangements fortheprocedurewithoneof theLASIKcenters thatparticipates in thisprogram.PlanmemberscanalsogodirectlytooneoftheparticipatingRefractiveCareophthalmologists.

Exclusions•Orthoptics or vision training, subnormal vision aids, aniseikonic

lensesorplan(non-prescription)lenses• Medical or surgical treatment of the eyes•Twopairsofglassesinlieuofbifocals•Brokenorlostframesorlensreplacement,exceptatspecifiedtimes•Workers’ Compensation-provided services andmaterials; any

employer-required exam; other group plan-provided services ormaterials and

•Servicesormaterialsnotobtainedintheprescribedprocedure

Forvisioncarequestions,pleasecontactVisionCarePlanMemberServicesonlineatwww.compbenefits.comorcall1-800-865-3676,Mon-Fri,8a.m.-5p.m.ET.

YourMonthlyVisionCareRatesCoverage Retiree COBRA

Participantonly $6.00 $6.12Participant&Family $16.94 $17.28

In-NetworkOptionandOut-of-NetworkOption Copayment/Credit Schedule IN-NETWORK OUT-OF-NETWORK EYE DOCTOR EYE DOCTOR* (uptoplan maximums)Vision Examination Covered in full $35 reimbursementMaterials SingleVisionLenses Coveredinfull $25reimbursement Bifocal Lenses Covered in full $40 reimbursement Trifocal Lenses Covered in full $60 reimbursement Lenticular Lenses Covered in full $100 reimbursement Frames $30retailallowance $30reimbursementContact Lenses Medically Necessary Covered in full $210 reimbursement Elective $85allowance $85reimbursement (inlieuofexam, (inlieuofexam, framesandlenses) framesandlenses)

*Please note:Amountsshownabovearemaximums.

Plan ProviderHumana/CompBenefitsunderwritestheVisionplan.CallVisionCarePlanat 1-800-865-3676toobtainyourclaimformspriortogoingtotheeyedoctor. For questions regarding your visionbenefit, callVisionCare,visit theVisionCare website atwww.compbenefits.com or call FBMCServiceCenterat1-855-LUCIE4U(1-855-582-4348).

Vision PlanVision Plan for both COBRA and Retiree Participants

28www.myFBMC.com

GroupHospitalIndemnityInsuranceprovidesdailybenefitsifyouoryour covered dependents are hospitalized for a covered sickness or injury.

The19levelsofdailycoverageare: $10 $15 $20 $25 $30 $35 $40 $45 $50 $55 $60 $65 $70 $75 $80 $85 $90 $95 $100

Plan Features•Benefitsstartonthefirstdayofhospitalization.•Benefits continue up to 365 days or until you are discharged,

whicheveroccursfirstforeachinjuryorsickness.•Youmay continue this benefit if you retire from School Board

employmentbysubmittinganEmployeeChangeInStatusFormtoFBMCBenefitsManagement,Inc.,withinthe60-dayperiodprecedingyourretirement.

•Your coveragewill continue as long as theGroupMaster Policyremainsineffect,youpayyourpremiumsandyouremaineligibleforcoverageundertheplan.

What’sNotCovered•Suicideattemptsorintentionallyself-inflictedinjuries• Injuriesorsicknessresultingfromdeclaredorundeclaredwarorany

act thereof,orsustainedwhileservingin thearmedforcesofanycountry

•TreatmentforinjuriesorsicknessescoveredbyWorkers’Compensation• Treatment for the prevention or cure of narcotic addiction or

alcoholism • Injuriessustainedinthecommissionofafelonyorwhileinjail

HowtoFileaClaim1.ContacttheFBMCServiceCentertoobtainanIn-HospitalIndemnity

BenefitClaimFormtobegintheprocess,oryoumaycontactFidelitySecurityLifeInsuranceCompany(FSL)directlytoobtainaformandfileaclaim.

2. PleasecompletetheStatementofInsuredsectionoftheClaimFormandattachcopiesof itemizedhospitalbillings, to includedate(s),placeofserviceanddiagnosis.

3. SubmittheClaimForm,alongwiththedocumentstoFBMCBenefitsManagement,Inc.

4. FBMCwillforwardalldocumentstoFSLforfinalprocessing.

Plan ProviderFidelitySecurityLifeInsuranceCompanyunderwritesthisplan.FidelitySecurityLifeInsuranceCompanyhasbeenrated“A-”,Excellent,basedonananalysisoffinancialpositionandoperatingperformancebyA.M.BestCompany,anindependentanalystoftheinsuranceindustry.

PolicyForm#M-00116

PolicyNo.HP-5

For Retiree Participants OnlyGroup Hospital Indemnity Insurance

YourGroupHospitalIndemnityInsuranceRates24 PAY PERIODS - DAILY BENEFIT AMOUNT

Coverage $10 $15 $20 $25 $30 $35 $40 $45 $50

RetireeOnly $1.60 $2.40 $3.20 $4.00 $4.80 $5.60 $6.40 $7.20 $8.00

Retiree&Family $3.60 $5.40 $7.20 $9.00 $10.80 $12.60 $14.40 $16.20 $18.00

Coverage $55 $60 $65 $70 $75 $80 $85 $90 $95 $100

RetireeOnly $8.80 $9.60 $10.40 $11.20 $12.00 $12.80 $13.60 $14.40 $15.20 $16.00

Retiree&Family $19.80 $21.60 $23.40 $25.20 $27.00 $28.80 $30.60 $32.40 $34.20 $36.00

29 www.myFBMC.com

Ifyou’relikemostpeople,youwanttomakesurethatyourlovedonesareadequatelyprovidedforifsomethinghappenstoyou.

There are a number of levels of Group TermLifeInsurance: $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000

Youmaycontinuethelifeinsurancelevelyouhadinforceatthetimeofyourretirement.DuringOpenEnrollment,youmaydecreaseorcancelyourretireelifeinsurance.Youmaynotincreaseyourlevelofcoverage.

Premium Waiver Youcanapplyforapremiumwaiverifyouhavebeentotallydisabledfornineconsecutivemonthswhileinsured.CallFBMCServiceCenterat1-855-LUCIE4U(1-855-582-4348)forawaiverofpremiumapplication.

Coverage Level At Ages 65 and 70Yourbenefitsdecreaseby35percentatage65.Allbenefitamountsinexcessof$3,000willreduceto$3,000atage70.

HowtoFileaClaim:1. ThelistedbeneficiarymustnotifyFBMCServiceCenteroftheclaim

tobegintheprocess.2. Thelistedbeneficiarymustprovidethefollowing

• The date of death • Caller’snameandrelationshiptoinsured • Thename,addressandphonenumberofthecaller

3. The following forms and proofswill be required for submission,including: • Acompletedclaimformbybeneficiary(ifmorethanone, eachbeneficiarymustcompleteaform) • Certifiedcopyofdeathcertificate • Ifanaccidentaldeath,anautopsyreportandthepolice accidentorinvestigationreportwillberequired.

4. Ifaclaimprocess isstartedthroughFBMCBenefitsManagement,letterswillbesenttothebeneficiaryrequestingalltheformsneededtoprocesstheclaim.FBMCwillforwardtheclaimtoFSLforfinalprocessing.

Plan ProviderFidelitySecurityLifeInsuranceCompany(FSL)underwritesthisplan.FidelitySecurityLifeInsuranceCompanyhasbeenrated“A-”(Excellent),basedonananalysisoffinancialpositionandoperatingperformancebyA.M.BestCompany,anindependentanalystoftheinsuranceindustry.Forthelatestrating,visit www.ambest.com.

PolicyForm#ML-00072

PolicyNo.TL-30

YourMonthlyGroupTermLifeInsuranceRates Based on Your Age as of 1/1/2017

Retirees under 65 under 30 30-34 35-39 40-44$10,000 $3.10 $3.10 $3.10 $3.10$15,000 $3.65 $3.75 $3.95 $4.60$20,000 $4.00 $4.40 $4.80 $6.10$25,000 $4.75 $5.05 $5.65 $7.60$30,000 $5.30 $5.70 $6.50 $9.10$35,000 $5.85 $6.35 $7.35 $10.60$40,000 $6.40 $7.00 $8.20 $12.10$45,000 $6.95 $7.65 $9.05 $13.60$50,000 $7.50 $8.30 $9.90 $15.10

45-49 50-54 55-59 60-64$10,000 $3.10 $3.10 $3.10 $3.10$15,000 $5.50 $6.95 $8.85 $11.45$20,000 $7.90 $10.80 $14.60 $19.80$25,000 $10.30 $14.65 $20.35 $28.15$30,000 $12.70 $18.50 $26.10 $36.50$35,000 $15.10 $22.35 $31.85 $44.85$40,000 $17.50 $26.20 $37.60 $53.20$45,000 $19.90 $30.05 $43.35 $61.55$50,000 $22.30 $33.90 $49.10 $69.90

Retiree age 65 and over, but under 70 65-69 $6,500 $2.02 $9,750 $3.02 $13,000 $10.48 $16,250 $18.48 $19,500 $26.47 $22,750 $34.47 $26,000 $42.46 $29,750 $50.46 $32,500 $58.45

Retiree age 70 and over 70 + $3,000 $0.93

For Retiree Participants OnlyGroup Term Life Insurance

30www.myFBMC.com

FidelitySecurityLifewillnolongeroffertheGroupCancerPolicy,effective1/1/2018.Forthe2017PlanYear,yourexistingpolicycanbe changed from “employee and family”to“employeeonly”oryourpolicycanbecancelled.

Withimprovedmedicaltechnologies,yourchancesofsurvivingcancerare better today than ever before.This plan helps cover the cost ofprocedures and treatments for you and your covered dependents and paysbenefitsinadditiontoanyothermedicalcoverageyouhave.

PlanFeatures:*•Benefitsarepaiddirectlytoyou• Pays regardless of other insurance • $100 per day during the first 90 cumulative days that you are

hospitalizedforcancer.After91cumulativedays,hospitalexpensesare fully covered up to $5,000 permonth, in lieu of all otherbenefits

•Upto$1,500forradiationtreatment,chemotherapyandX-rays,(doesnotincludediagnosticprocedures)

•Upto$120foranesthesiologistservices($40forskincancer)•Upto$1,000forsurgery(persurgeryschedule)•Upto$1,200forbloodandplasma(nomaximumforleukemia)•Upto$30perdayforaprivatedutynurse($750maximum)and•Up to $50 per ambulance service per confinement ($500

maximum).• CancerScreeningBenefitfortheinsured/insuredspousethatpays50

percentupto$50accordingtothebaselineschedule(shownbelow)perbenefitperiodforascreeningbylow-dosemammography** for thepresenceofoccultbreastcancer.Adiagnosisofcancerisnotnecessaryforthisbenefittobepayable. MammographyBaselineSchedule 1baseline-age35to40 1everytwoyears-age40to50 1everyyear-age50+

* Note:Allbenefitsaremaximumsperillnessperiod.Anillnessperiodbeginswhenexpensesarefirstincurred.Followingaperiodofatleast45daysduringwhichnoeligibleexpenseisincurred,anyeligibleexpensesincurredthereafterwillbeginanewillnessperiod.Allbenefitsreduceby50percentatage65.

** low-dosemammographymeansX-ray examinations of the breast using equipment dedicatedspecificallyformammography.

YourMonthlyCancerProtectionRates Coverage Retiree COBRA Participant $6.90 $7.04 Participant&Family $10.86 $11.08

EligibilityIfyou,yourspouseoryourunmarrieddependentchildrenunderage25(mustbedependentuponyouforsupportandlivinginyourhouseholdorafull-timestudent)havereceivednomedicaltreatmentforanytypeofcancerwithin10yearsofyourplan’seffectivedate,youareeligiblefortheCancerProtectionplan.YourcoveragewillcontinueforaslongastheGroupMasterPolicyremainsineffect,youpayyourpremiums,andyouremaineligibleforcoverageundertheplan.

What’sNotCovered• Cancer that materializes before you have been insured for 30

continuous dayswill not be covered until after 12months ofcoverage

• Illnessesorinjuriesotherthancancerand• Treatment received from a VA or other government hospital unless

youarelegallyrequiredtopayintheabsenceofinsurance.

HowtoFileaClaim:1. ContacttheFBMCServiceCentertoobtaina“StatementofCancer

Claim”formtobegintheprocess;or,youmaycontactFidelitySecurityLifeInsuranceCompanydirectlytoobtainaformandfileaclaim.

2. Pleasecompletethe“StatementofCancerClaim”formandforwardtothephysicianandrequestthattheAttendingPhysicianStatementbecompleted.

3. AftertheAttendingPhysicianStatementiscompleted,submititandthecompletedclaimformalongwithacopyofthepathologist’sreportandanybillsforcoveredexpensestoFidelitySecurityLifeInsuranceCompany.

4. Ifaclaimprocess isstartedthroughFBMCBenefitsManagement,letterswillbesent to the insuredrequestingall the formsneededtoprocesstheclaim.FBMCwillforwardtheclaimtoFSLforfinalprocessing.

Plan ProviderFidelitySecurityLifeInsuranceCompanyunderwritesthisplan.FidelitySecurityLifeInsuranceCompanyhasbeenrated“A-”(Excellent),basedonananalysisoffinancialpositionandoperatingperformancebyA.M.BestCompany,anindependentanalystoftheinsuranceindustry.Forthelatestrating,visitwww.ambest.com.

PolicyForm#M-7000-FL

PolicyNo.CA-54

For both COBRA and Retiree Participants (For information purposes only)Group Cancer Insurance Plan

31 www.myFBMC.com

Creditable Coverage Notice

Important Notice from St. Lucie Public Schools About Your Prescription Drug Coverage and Medicare

Please note that this notice only pertains to you if:

You are Medicare eligible (over age 65 or considered disabled by the Social Security Administration) and currently covered or eligible for coverage under the health plan sponsored by St. Lucie Public Schools for retired employees, or You have a dependent spouse/domestic partner or child who is covered by Medicare or Medicaid and who is currently covered or eligible for coverage under the health plan sponsored by St. Lucie Public Schools for employees and retired employees.

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with St. Lucie Public Schools and about your options under Medicareʼs prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

There are two important things you need to know about your current coverage and Medicareʼs prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. St. Lucie Public Schools has determined that the prescription drug coverage offered by the St. Lucie Public Schools Prescription Drug Plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

32www.myFBMC.com

Creditable Coverage Notice

When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? While you have Creditable Coverage, you can decline coverage under Medicare Part D and if you decide to enroll in Medicare Part D in the future, you will not be assessed a late payment charge by the Center for Medicare and Medicaid Services (CMS). This letter serves as your “Notice of Creditable Coverage.” If you are covered under the St. Lucie Public Schools Prescription Drug Plan, you have Creditable Coverage.

• Enrollment for Medicare Part D for the 2017 calendar year begins October 15, 2016 and runs through December 7, 2016. If you elect the St. Lucie Public Schools Prescription Drug Plan for 2017, you will have Creditable Coverage and you can choose to delay enrollment in Medicare Part D without paying a Medicare Part D late enrollment penalty. As long as you maintain Creditable Coverage, you will not be assessed a late enrollment penalty if you choose to enroll in Medicare Part D at a later date. Individuals can enroll in a Medicare prescription drug plan when they first become eligible for Medicare. If you leave employment during the year, you may be eligible for a Special Enrollment Period to sign up for a Medicare prescription drug plan.

• If you enroll or your dependent enrolls in Medicare Part D for the 2017 calendar year, you or your dependent cannot maintain coverage in the St. Lucie Public Schools Prescription Drug Plan. If you or one of your dependents enrolls in Medicare Part D, you must disenroll them from the St. Lucie Public Schools Prescription Drug Plan. To disenroll yourself or your dependent from prescription coverage, please call Risk Management. You will be able to re-enroll in the St. Lucie Public Schools Prescription Drug Plan in the future during each annual open enrollment.

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with St. Lucie Public Schools and don t̓ join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

33 www.myFBMC.com

Creditable Coverage NoticeIf you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage... Contact the Risk Management Department for further information. NOTE: Youʼll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through St. Lucie Public Schools changes. You also may request a copy of this notice at any time.

For More Information About Your Options Under Medicare Prescription Drug Coverage... More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You l̓l get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage: • Visit www.medicare.gov • Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486- 2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325- 0778).

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Date: 09/15/16 Name of Entity/Sender: St. Lucie Public Schools Contact--Position/Office: Risk Management Address: 4204 Okeechobee Road, Fort Pierce, FL 34947 Phone Number: (772) 429-5520

34www.myFBMC.com

Notes

St. Lucie Public Schools RiskManagementDept.1-772-429-5521

Florida BlueCustomerService-CommercialPlansRetirees/COBRAMon-Fri,8a.m.-6p.m.ET1-800-352-2583www.floridablue.com

Florida BlueBlueMedicare Group PPO Plans 1 & 2CustomerServiceMon-Fri,8a.m.-9p.m.ET1-800-926-6565www.bluemedicarefl.com

Florida Combined Life DentalCustomerService1-888-223-4892Mon–Fri,8a.m.–5p.m.www.floridabluedental.com

VisionCare Plan (VCP),AHumana/CompBenefitsCompany(Vision)MemberServicesMon-Fri,8a.m.-5p.m.ET1-800-865-3676

Fidelity Security Life Insurance Company(GroupHospitalIndemnityInsurance,GroupTermLifeandGroupCancerInsurance)FBMCServiceCenterMon-Fri,7a.m.-7p.m.ET1-855-LUCIE4U(1-855-582-4348)

FBMC/SLPSB_CR/1016

Benefits Directory

© FBMC 2016

Information contained herein does not constitute an insurance certificateorpolicy.Certificateswillbeprovidedtoparticipantsfollowingthestartoftheplanyear,ifapplicable.

Contract Administrator FBMCBenefitsManagement,Inc.P.O.Box1878•Tallahassee,Florida32302-1878ServiceCenter1-855-LUCIE4U(1-855-582-4348)

PayFlex Systems USA, Inc.(COBRAServices)BenefitsBillingDepartmentP.O.Box2239Omaha,NE68103-22391-855-LUCIE4U(1-855-582-4348)Fax:402-231-4302E-mail:[email protected]

FBMC Benefits Management, Inc.Retiree and Direct Bill DepartmentP.O.Box10789Tallahassee,FL32302-2789ServiceCenter1-855-LUCIE4U(1-855-582-4348)DirectBillFax:1-866-836-9943

Health Equity1-866-346-5800www.healthequity.com

Transamerica(ExistingUniversalLifeandLong-termCarepolicies)UniversalLife1-800-322-0426Long-termCare1-800-227-3740

Trustmark(ExistingAccident,CriticalIllness,LifeEventsandUniversalLifepolicies)1-800-918-8877www.trustmarksolutions.com

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