Date Address 1 Address 2 Re: ICUBA Retirement Benefits ... · Toll Free: 1-877-747-4141 | Secure Fax: 1-855-731-5065 ... the ICUBA Retiree Medicare Supplemental Plan. If your spouse

Date

Name

Address 1

Address 2

Re: ICUBA Retirement Benefits

Dear Name:

Congratulations on your upcoming retirement from Nova Southeastern University. We at ICUBA are

pleased to offer you retiree benefits. You have the option of enrolling in the Transamerica/ RetireeRx Care

Medicare Supplement Plan, the ICUBA “Blue Cross Blue Shield” Retiree Medical Plan or COBRA. If you

elect COBRA coverage it will be effective for up to an 18-month period beginning the first day you are no

longer employed at Nova Southeastern University. You will receive a COBRA notification separately.

Please note: if you elect COBRA coverage, you will not be able to elect retiree benefits in the future.

If you plan to enroll in the Transamerica/ RetireeRx Care Medicare Supplement Plan or the ICUBA “Blue

Cross Blue Shield” Retiree Medical Plan; you will need to enroll in Medicare Parts A and B. It is your

responsibility to ensure you are enrolled in Medicare Parts A and B. Medicare will be your primary payer.

Your election forms are enclosed. All applicable forms with your signature should be returned to the

below listed address no later than 30 days from the date of your retirement.

Continuon Services, LLC | 1350 Spring Street, Suite 700 | Atlanta, GA 30309

Toll Free: 1-877-747-4141 | Secure Fax: 1-855-731-5065

You will receive premium payment coupons once your election has been processed. Please note:

Continuation of your insurance benefits will depend on timely, whole (not partial) premium

payment by the due date shown on the coupons. You have a 60-day grace period as a retiree to

make your payment. If the payment is not postmarked within this 60-day grace period, your

coverage will be cancelled. Coverage cancellations are irrevocable.

We understand that the health insurance choice you make is important to you. For this reason, a

dedicated Retiree Benefits Administrator is available to assist you Monday through Thursday 9:00

a.m. to 8:00 p.m. and Friday 9:00 a.m. to 5:30 p.m. EST. You may contact a dedicated Retiree Benefits

Administrator by phone at 1-877-747-4141, by email at: [email protected] or

fax at: 1-855-731-5065.

Sincerely,

Continuon Services, LLC

mailto:[email protected]

ICUBA Retiree Medical Plan

Frequently Asked Questions (FAQs)

How will I know if Continuon has received and processed my Retiree enrollment form?

Once Continuon has received and processed your enrollment form, we will send you retiree payment

coupons. Please note: Coupons will be mailed to all retirees, even those who enrolled in EFT and Recurring

Credit card.

Can I enroll my spouse and/or eligible dependents in the ICUBA Retiree Medical Plan if I

choose not to enroll as a retiree?

No. You must be enrolled in coverage to enroll a spouse or other eligible dependent(s).

If my spouse is not covered at the time of my retirement but he/she later has a qualifying

event would he/she be eligible to enroll in benefits under my ICUBA retiree coverage?

Yes. Your Dependent spouse must submit a request for Special Enrollment in writing and provide

supporting documentation of loss of other coverage to the plan administrator no later than 30

days after the date of a qualifying event (e.g., spouse loss of employer provided coverage).

What health insurance benefits am I eligible to participate in?

Under Age 65

If you retire before attaining age 65, you are eligible to participate in the ICUBA Retiree benefit

plan you were enrolled in at the time of your retirement.

Age 65 or older

If you are age 65 or older you will be offered a choice to remain on the ICUBA Plan or switch to

the ICUBA Retiree Medicare Supplemental Plan.

When will, my benefits go into effect?

If you choose the FL Blue Cross Blue Shield plan your medical and prescription drug coverage benefits will start

on the first day of your retirement. If you choose the ICUBA Supplemental Plan your medical and

prescription drug coverage will start on the first day of the month in which you retire as long as

your election is received within 30 days of your retirement date. If your enrollment is received

after the 30th day of your retirement your prescription drug coverage will start on the 1st day of

the following month.

Is prescription drug coverage available with the above plans?

Yes. Under the ICUBA Retiree plan prescriptions continue to be covered through Catamaran Rx.

The ICUBA Prescription Drug Benefit is Creditable Coverage, which means that you will receive

credit towards Medicare Part D upon your retirement if you choose to enroll in Medicare Part D.

Creditable coverage means the amount the plan expects to pay on average for prescription drugs

for individuals covered under the plan in the applicable year is the same or more than what

standard Medicare prescription drug coverage would be expected to pay on average.

The ICUBA Retiree Medicare Supplemental Plan includes an enhanced Medicare Part D

prescription drug plan. There is no additional cost for prescription coverage.

What if I am 65 or older and my spouse is less than 65?

If you are age 65 or older you will be offered a choice to remain on the ICUBA Plan or switch to

the ICUBA Retiree Medicare Supplemental Plan. If your spouse is under 65 he/she will be offered

the ICUBA Retiree Plan if he/she was enrolled in coverage during the 3-month period immediately

prior to your date of retirement and you were actively at work on the day prior to your retirement.

What if my spouse is 65 or older and I am less than 65?

If your spouse is age 65 or older he/she will be offered a choice to remain on the ICUBA Plan or

switch to the ICUBA Retiree Medicare Supplemental Plan. If you are under 65 you will be offered

the ICUBA Retiree Plan if you were enrolled in coverage during the 3-month period immediately

prior to your date of retirement and you were actively at work on the day prior to your retirement.

What will happen to my ICUBA Retiree coverage when I or my spouse attain age 65 after I

retire?

You and/or your spouse will be offered a choice to remain on the ICUBA Retiree Plan or switch to

the ICUBA Retiree Medicare Supplemental Plan. If you or your spouse have previously enrolled in

the ICUBA Retiree Medicare Supplemental Plan then you or your spouse must enroll in the ICUBA

Retiree Medicare Supplemental Plan upon attaining age 65.

What is the ICUBA Retiree Medicare Supplemental Plan?

ICUBA Retiree Medicare Supplemental Plan is a Medigap (also called “Medicare Supplement

Insurance”) policy and is private health insurance that is designed to supplement Original

Medicare. This means it helps pay some of the health care costs (“gaps”) that Original Medicare

doesn’t cover (like copayments, coinsurance, and deductibles). Medigap policies may also cover

certain things that Medicare doesn’t cover. If you are in Original Medicare and you have a Medigap policy,

Medicare will pay its share of the Medicare-approved amounts for covered health care costs. Then your Medigap

policy pays its share. It is a Medicare Supplement plan that pays the balance of approved Medicare expenses not

covered by Medicare once you meet your calendar year deductible.

I am a retiree over the age of 65, is my ICUBA coverage primary or secondary to my

Medicare coverage?

Both the ICUBA Retiree Plan and the Transamerica Life Medicare Supplement Plan pay secondary

to Medicare. Please note: The plan requires that all retired covered persons eligible for Medicare

enroll in Medicare Parts A and B and pay any associated premiums. The plan will pay benefits

based on the premise that the retired covered person has elected coverage under Medicare Parts

A and B, regardless of whether the retired covered person actually has.

How are claims paid under the ICUBA Retiree Medicare Supplemental Plan?

Example: If the total cost for a covered service is $100, Medicare will pay 80%, or $80. The

remaining balance of $20 is paid in full by Transamerica. Your cost for the service is $0. After

Medicare has paid their portion of the claim, Medicare will automatically send the remaining

portion of the claim to be paid to Transamerica Life.

How are claims paid under the ICUBA Retiree Medical Plan?

Example: If the total cost for a covered service is $100, Medicare will pay 80%, or $80. The ICUBA

Retiree Plan will process the remainder of the claim ($20) based on the plan you are enrolled in.

Under the Blue Option Preferred PPO Plan the appropriate benefit would be applied on the

remaining portion of the covered service ($20). The plan’s coinsurance must be met so 80% of

the $20 would be covered. Your cost will be $4.00.

Refer to the Plan Document or the Plan Summary of Benefits for a list of services and

associated costs.

Address: Continuon Services, LLC | P.O. Box 7127 | Atlanta, GA 30309 Toll Free: 1-877-747-4141 | Secure Fax: 1-855-731-5065

1.877.747.4141

RETIREE

RECURRING BANK DRAFT/ACH AUTHORIZATION

Participant Name: ________________________________________ Last 4 digits of SSN: _____________________ Former Employer: ________________________________________ Phone: ________________________________ I (we) hereby authorize Continuon Services, LLC, hereinafter called COMPANY, to initiate debit entries to my (our) account (choose one): Checking Account Savings Account

PREMIUM & CONVENIENCE FEES

Debit my bank account each month

Premium is due on the 1st day of the month. If you are behind at the time of sign up, your account will be brought current.

Payment Type Convenience Fee = Total Due

Bank None $

My (our) depository financial institution is named below, hereinafter called DEPOSITORY, and to debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law. Depository name: _________________________________________________________________________

Branch: _________________________________________________________________________________

City: ___________________________________________________________________________________

State: ____________________________________ Zip: ________________________________________

Routing Number: _________________________________________________________________________

Account Number: _________________________________________________________________________

** Please attach a voided check to this form**

AUTHORIZATION & AGREEMENT This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it. I understand that RETIREE participant premium is due on the 1st day of the month. A debit entry will be submitted on or after the 1st of each month for my full premium due and any current or past due balance will be billed immediately at the time of sign up to bring my account current. I understand that the premium due may change at each annual open enrollment and that I will be notified in advance of such change. If funds are not available, a fee of $30 or the maximum fee allowed by law will be assessed (this may be in addition to any fees assessed by your financial institution). Continuon Services, LLC reserves the right to demand check, money order, or cashier’s check payment at any time. I authorize Continuon Services, LLC to bill my bank account above for my full monthly Retiree (per my billing coupons) and the service fees described above per the instructions above. I understand that Retiree and administration fees are not refundable.

Name: ________________________________________________________ Phone:___________________ Please Print Date: _____________________________Signature: _____________________________________________ NOTE: ALL WRITTEN DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.

Address: Continuon Services, LLC | P.O. Box 7127 | Atlanta, GA 30309 Toll Free: 1-877-747-4141 | Secure Fax: 1-855-731-5065

1.877.747.4141

RETIREE

RECURRING CREDIT CARD AUTHORIZATION

Participant Name: ________________________________________ Last 4 digits of SSN: _____________________ Former Employer: ________________________________________ Phone: ________________________________

CREDIT CARD BILLING INFORMATION (Please Print)

I (we) hereby authorize Continuon Services, LLC, to initiate charges for RETIREE/Retiree premiums and convenience fees to my (our) credit card described as a: Visa MasterCard Discover American Express Cardholder Name: _____________________________________________________________________________

Card Number: ______________________________________________ CVC Number: ______________________

CVC Number is 3 or 4 digits

Expiration Date: _________/___________ Issuing Bank Name: ________________________________________

Billing Street Address: _________________________________ Email:___________________________________

Billing City: ____________________________________________ Billing State: _________ Billing Zip: __________

PREMIUM & CONVENIENCE FEES

Charge my credit card each month

Premium is due on the 1st day of the month. If you are behind at the time of sign up, your account will be brought current.

Payment Type + Convenience Fee of 3% of Monthly Premium

= Total Due

Visa, MasterCard, Discover & Amex None $

AUTHORIZATION & AGREEMENT

I affirm that the information contained herein is accurate. I agree that this authorization is to remain in full force and effect until I notify Continuon Services, LLC of its termination in such time and in such manner as to afford Continuon Services, LLC a reasonable opportunity to act on it. I understand that inaccurate or incomplete information may delay processing and possibly result in the termination of my RETIREE continuation coverage if such delay occurs after the grace period allowed by the plan. I understand that it is my responsibility to advise Continuon Services, LLC of any change in my credit card billing information (i.e. a change in card number, expiration date, billing address, etc.). I understand that RETIREE participant premium is due on the 1st day of the month. A debit entry will be submitted on or after the 1st of each month for my full premium due and any current or past due balance will be billed immediately at the time of sign-up to bring my account current. I understand that the premium due may change at each annual open enrollment and that I will be notified in advance of such change. If my credit card is declined, I understand that Continuon Services, LLC may withdraw the offer of credit card payment and require payment by check, money order, or guaranteed funds such as a cashier’s check. I authorize Continuon Services, LLC to bill my credit card above for my full monthly Retiree premium (per my billing coupons) and the convenience fees and service fees described above per the instructions above. I understand that Retiree and administration fees are not refundable.

_______________________________________________________ __________________________________ CARDHOLDER SIGNATURE DATE

Effective 4/1/19

Summary of PPO Benefits Benefit Period April 1-March 31

A PPO, or Preferred Provider Organization, offers two levels of benefits. If you receive services from a provider who is in the PPO network, you’ll

receive the highest level of benefits. If you receive services from a provider who is not in the PPO network, you’ll receive the lower level of benefits. In

either case, you coordinate your own care. There is no requirement to select a Primary Care Physician (PCP) to coordinate your care. Below are specific

benefit levels.

ICUBA Preferred PPO Plan

Benefit In-Network Out-of-Network

(Coinsurance and Copays displayed as Employee responsibility) Deductible Per Benefit Period (PBP)

Individual

Family

$2,500

$5,000

$4,000

$10,750

Coinsurance 20% 40%

Out-of-Pocket Maximums PBP

(includes deductible, coinsurance, and

medical copays)

Individual

Family

$4,000

$8,000

$7,500

$15,000

Lifetime Maximum No Maximum

Physician Office Visits (Internal Medicine, General Practice, Family

Practice, Pediatrician, OB/GYN)

20%

(not subject to deductible) 40% after deductible

Blue Distinction Total Care Office Visit (Internal Medicine, Family Practice,

Pediatrician)

0%

(not subject to deductible or copayment) N/A

Teladoc Telemedicine Visit 0% after $5 copay N/A

Maternity Office Visit Benefit

(initial OB visit only)

$20 copay


Specialist Office Visits 20%


Independent Clinical Labs *

(free standing facilities and office visits)

Outpatient Facility (Hospital setting) **

0%

(not subject to deductible)

20% coinsurance

40% after deductible

Preventive Care - Annual Physical and

Gynecological exam

0%

(not subject to deductible) Not Covered

Chlamydia and STD tests 0%


PAP tests 0%


Prostate cancer screenings (PSA) 0%


Mammograms and

Ultrasounds of the Breast

0%


Urinalysis 0%


Venipuncture/Conveyance Fee 0%


General Health Blood Panel, Glucose

Test, Lipid Panel, Cholesterol, and

ALT/AST.

0%


Adult and Pediatric Immunizations 0%


Related Wellness Services (e.g., blood

stool tests, colonoscopies, sigmoidoscopies,

electrocardiograms, echocardiograms, and

bone mineral density tests)

0%


* Quest Diagnostic Labs is the In-Network Lab for BlueCross BlueShield of Florida. ** Outpatient Facility Lab – If you go to your doctor’s office at/in a hospital facility and have lab work done (ex: Moffitt Center)

ICUBA Preferred PPO Plan

Effective 4/1/19


(Coinsurance and Copays displayed as Employee responsibility)

Allergy Injections 0%


Emergency Room Services 0% after $300 copay (waived if admitted)

Medically Necessary Emergency

Transportation 0% after $250 copay

Convenient Care Clinic (Retail) Minute Clinic- CVS/Healthcare Clinic - Walgreens

0% after $10 copay

Urgent Care Center 0% after $30 copay

Hospital Expenses

Inpatient 20% after deductible 40% after deductible

Outpatient 20% after deductible 40% after deductible

Outpatient Surgery Office Setting

(Physician or Specialist)

20%


Outpatient Facility 20% after deductible 40% after deductible

Related professional services 20% after deductible 40% after deductible

Non-Emergent Surgeries with SurgeryPlus Please call 1-855-200-2119 for this separate benefit

Deductible and coinsurance is waived when

utilizing SurgeryPlus services and network Not Covered

Infertility Services (Counseling and testing to

diagnose only) 20% after deductible 40% after deductible

Outpatient Physical Therapy *** 20% (not subject to deductible) 40% after deductible

Limit: 30 visits/ benefit period

Outpatient Speech Therapy *** 20% (not subject to deductible) 40% after deductible

(Restorative services only) Limit: 30 visits/ benefit period

Outpatient Occupational Therapy 20% (not subject to deductible) 40% after deductible


Spinal Manipulation 20% (not subject to deductible) 40% after deductible


Diagnostic Services

(X-Ray and other tests) 20% after deductible 40% after deductible

Outpatient Diagnostic Imaging

(MRI, MRA, CAT Scan, PET Scan) Allowed Charges up to $500 Copay 40% after deductible

Durable Medical Equipment 20% after deductible 40% after deductible

Prosthetic Appliances 20% after deductible 40% after deductible

Hearing Care Services

Hearing aid screening/exam 20% (not subject to deductible)

Hearing aid 20% after in-network deductible

Combined limit: $1,500/ benefit period

Temporomandibular Joint Disorder

(Medical necessity required; excludes

appliances and orthodontic treatment) 20% after deductible 40% after deductible

Inpatient Rehabilitation 20% after deductible 40% after deductible

Limit: 60 days/ benefit period

Skilled Nursing Rehabilitation 20% after deductible 40% after deductible


Home Health Care 20% after deductible 40% after deductible

Private Duty Nursing 20% after deductible 40% after deductible

Hospice

(Inpatient and Outpatient Care) 0%


Mental Health, Substance Abuse Benefits are provided by Aetna Behavioral Health - Available 24 hours at 877-398-5816

Mental Health/Substance Abuse

Inpatient

20% after deductible 40% after deductible

Outpatient 20% (not subject to deductible) 40% after deductible ***Up to 60 visits/benefit period combined with occupational therapy. Note on Out-of-Network Providers: Services rendered by an out-of-network provider may be subject to balance billing by the out-of-network provider for the difference

between the allowed amount and provider billed charges. This is not intended as a contract of benefits. It is designed purely as a reference of the many benefits available

under your program. Please see your Plan Document for detailed information on plan terms and the appeals process.

Effective 4/1/19


A PPO, or Preferred Provider Organization, offers two levels of benefits. If you receive services from a provider who is in the PPO network,

you’ll receive the highest level of benefits. If you receive services from a provider who is not in the PPO network, you’ll receive the lower level

of benefits. In either case, you coordinate your own care. There is no requirement to select a Primary Care Physician (PCP) to coordinate your

care. Below are specific benefit levels.

ICUBA Premier Copay Plan



Individual

Family

$2,500

$5,000

$4,000

$10,750

Coinsurance 20% 40%


(includes deductible, coinsurance, and

medical copays)

Individual

Family

$4,000

$8,000

$7,500

$15,000




0% after $25 copay


Blue Distinction Total Care Office Visit (Internal Medicine, Family Practice,

Pediatrician)

0%




(initial OB visit only) 0% after $25 copay


Specialist Office Visits 0% after $50 copay





0%


20% coinsurance



Gynecological exam

0%




PAP tests 0%




Mammograms and


0%


Urinalysis 0%






ALT/AST.

0%




Related Wellness Services (e.g., blood stool

tests, colonoscopies, sigmoidoscopies,

electrocardiograms, echocardiograms, and bone

mineral density tests)

0%


* Quest Diagnostic Labs is the In-Network Lab for BlueCross BlueShield of Florida.

** Outpatient Facility Lab – If you go to your doctor’s office at/in a hospital facility and have lab work done (ex: Moffitt Center)

ICUBA Premier Copay Plan

Effective 4/1/19



Allergy Injections 0%






0% after $10 copay


Hospital Expenses




Physician

Specialist

0% after $25 copay

0% after $50 copay 40% after deductible




Deductible and coinsurance is waived when

utilizing SurgeryPlus services and network Not Covered



Outpatient Physical Therapy *** 0% after $30 copay 40% after deductible


Outpatient Speech Therapy *** 0% after $30 copay 40% after deductible (Restorative services only) Limit: 30 visits/ benefit period

Outpatient Occupational Therapy 0% after $30 copay 40% after deductible


Spinal Manipulation 0% after $30 copay 40% after deductible


Diagnostic Services


Outpatient Diagnostic Imaging (MRI, MRA, CAT Scan, PET Scan)

Allowed Charges up to $500 Copay 40% after deductible

Durable Medical Equipment 20% after deductible 40% after deductible

Prosthetic Appliances 20% after deductible 40% after deductible


Hearing aid 20% after in-network deductible


Temporomandibular Joint Disorder (Medical necessity required; excludes appliances and

orthodontic treatment) 20% after deductible 40% after deductible







Hospice

(Inpatient and Outpatient Care) 0%




Inpatient


Outpatient 0% after $25 copay 40% after deductible *** Up to 60 visits/benefit period combined with occupational therapy. Note on Out-of-Network Providers: Services rendered by an out-of-network provider may be subject to balance billing by the out-of-network provider for the difference

between the allowed amount and provider billed charges. This is not intended as a contract of benefits. It is designed purely as a reference of the many benefits available


Effective 4/1/19


A PPO, or Preferred Provider Organization, offers two levels of benefits. If you receive services from a provider who is in the PPO network, you’ll

receive the highest level of benefits. If you receive services from a provider who is not in the PPO network, you’ll receive the lower level of benefits.

In either case, you coordinate your own care. There is no requirement to select a Primary Care Physician (PCP) to coordinate your care. Below are

specific benefit levels.

ICUBA $4,000/$8,000 Deductible PPO Plan



Individual

Family

$4,000

$8,000

$8,000

$16,000

Coinsurance 30% 50%


(includes deductible, coinsurance, and medical

copays)

Individual

Family

$5,350

$10,700

$10,700

$21,400




0% after $35 copay


Blue Distinction Total Care Office Visit (Internal Medicine, Family Practice, Pediatrician)

$0 copay




(initial OB visit only)

0% after $35 copay


Specialist Office Visits 0% after $70 copay





0%


30% coinsurance



Gynecological exam

0%




PAP tests 0%




Mammograms and


0%


Urinalysis 0%






ALT/AST.

0%




Related Wellness Services (e.g., blood stool

tests, colonoscopies, sigmoidoscopies,

electrocardiograms, echocardiograms, and

bone mineral density tests)

0%


* Quest Diagnostic Labs is the In-Network Lab for BlueCross BlueShield of Florida.

** Outpatient Facility Lab – If you go to your doctor’s office at/in a hospital facility and have lab work done (ex: Moffitt Center)

ICUBA $4,000/$8,000 Deductible PPO Plan

Effective 4/1/19



Allergy Injections 0% (not subject to deductible) 50% after deductible





0% after $10 copay


Hospital Expenses




Physician

Specialist

0% after $35 Copay

0% after $70 Copay





Deductible and coinsurance is waived when utilizing

SurgeryPlus services and network Not Covered



Outpatient Physical Therapy *** 0% after $40 copay (not subject to deductible) 50% after deductible


Outpatient Speech Therapy *** 0% after $40 copay (not subject to deductible) 50% after deductible

(Restorative services only) Limit: 30 visits/ benefit period

Outpatient Occupational Therapy 0% after $40 copay (not subject to deductible) 50% after deductible


Spinal Manipulation 0% after $40 copay (not subject to deductible) 50% after deductible


Diagnostic Services


Outpatient Diagnostic Imaging

(MRI, MRA, CAT Scan, PET Scan) Allowed Charges up to $500 Copay 50% after deductible

Durable Medical Equipment (DME) $2,000 Deductible of the $4,000 Individual

Deductible must be satisfied before

30% coinsurance applies


Prosthetic Appliances 50% after deductible


Hearing aid 30% after in-network DME deductible


Temporomandibular Joint Disorder

(Medical necessity required; excludes

appliances and orthodontic treatment) 30% after deductible 50% after deductible







Hospice

(Inpatient and Outpatient Care) 0% (not subject to deductible) 50% after deductible



Inpatient


Outpatient 0% after $35 copay 50% after deductible ***Up to 60 visits/benefit period combined with occupational therapy.

Note on Out-of-Network Providers: Services rendered by an out-of-network provider may be subject to balance billing by the out-of-network provider for the difference between the allowed amount and provider billed charges. This is not intended as a contract of benefits. It is designed purely as a reference of the many benefits available


Preferred PPO Plan Aetna Behavioral Health and Substance Abuse

Aetna Open Choice PPO Network

EAP, Mental Health, Substance Abuse Benefits and Applied Behavioral Analysis (ABA) are provided by Aetna Behavioral Health Available 24 hours at 877-398-5816

Deductibles and Out of Pocket Maximum Amounts are COMBINED with BCBS Medical In Network Out of Network Employee Assistance Program (EAP) Up to 6 short-term professional counseling sessions per episode per year. Talk with a licensed clinician regarding stress, relationship issues, grief, etc.

$0 No coverage

Inpatient* 20% after deductible 40% after deductible Mental Health Hospital Admission* 20% after deductible 40% after deductible Substance Abuse Hospital Admission* 20% after deductible 40% after deductible Residential* Residential Services focus on evaluating and stabilizing the patient. They help the patient learn effective ways to cope with the symptoms and impact of the patient’s illness.


Inpatient Detoxification* Inpatient detoxification provides 24 hour treatment in a residential or hospital setting for patients who are abusing alcohol or other physically addictive drugs. Patients typically stay in detoxification only as long as their withdrawal symptoms require 24 hour medical and nursing services.


Outpatient 20% (not subject to deductible) 40% after deductible Professional Counseling Sessions Talk with a licensed clinician regarding anxiety, attention deficit hyperactivity disorder (ADHD), depression, mood disorders, oppositional defiance disorder (ODD), schizophrenia, trauma, etc.

20% (not subject to deductible)


Psychiatric Medication Evaluation 20% (not subject to deductible) 40% after deductible Applied Behavioral Analysis Therapy* Behavioral health services related to Autism Spectrum Disorder (ASD) diagnosis

20% (not subject to deductible) 40% after deductible

Partial Hospitalization (PHP)* These programs are longer and more intensive than an IOP, usually 4-6 hours per day, 5-7 days per week. Services include physician and nursing services, as well as group, individual, family or multi-family group psychotherapy, psycho-educational services, and other services. These programs are often used in lieu of an inpatient stay, or as a transition from an inpatient stay.


Outpatient Detoxification* Monitor withdrawal from alcohol or another substance of abuse and may administer medications that assist with detoxification and recovery from addiction.


Intensive Outpatient Sessions (IOP)* These planned and structured programs are usually 2-3 hours/day (or evening), and 3-7 days per week. They may include group, individual, family or multi-family group psychotherapy, psycho-educational services, and other services.


AbleTo Meet with a therapist and coach via web-based videoconferencing, or over the telephone for a 8 week program for select conditions including breast and prostate cancer recovery, heart problems, diabetes, depression, digestive health, pain management, respiratory problems, substance abuse, anxiety, postpartum depression, caregiver status (child, elder, Autism, etc.), grief/loss, and military transition.

$0 No coverage

*Services require prior-authorization

Premier Copay Plan Aetna Behavioral Health and Substance Abuse




$0 No coverage





Outpatient $25 copayment (not subject to deductible) 40% after deductible Professional Counseling Sessions Talk with a licensed clinician regarding anxiety, attention deficit hyperactivity disorder (ADHD), depression, mood disorders, oppositional defiance disorder (ODD), schizophrenia, trauma, etc.

$25 copayment (not subject to deductible)


Psychiatric Medication Evaluation $25 copayment (not subject to deductible) 40% after deductible Applied Behavioral Analysis Therapy* Behavioral health services related to Autism Spectrum Disorder (ASD) diagnosis

$25 copayment (not subject to deductible) 40% after deductible








$0 No coverage


$4,000/$8,000 Deductible PPO Plan Aetna Behavioral Health and Substance Abuse




$0 No coverage





Outpatient $35 copayment (not subject to deductible) 50% after deductible Professional Counseling Sessions Talk with a licensed clinician regarding anxiety, attention deficit hyperactivity disorder (ADHD), depression, mood disorders, oppositional defiance disorder (ODD), schizophrenia, trauma, etc.


Psychiatric Medication Evaluation $35 copayment (not subject to deductible) 50% after deductible Applied Behavioral Analysis Therapy* Behavioral health services related to Autism Spectrum Disorder (ASD) diagnosis









$0 No coverage


ATTENTION ICUBA MEMBERS

© 2018 Optum, Inc. and its affiliated companies.

ICUBA April 1, 2019 – March 31, 2020 Prescription Medication Plan

The following is a brief overview of your pharmacy benefit‡. To help keep your costs

low, ICUBA pays a portion of the cost, and you pay the rest.

30-Day Supply Nationwide Pharmacy Network You have access to more than 62,000 chain and independent

pharmacies including: Costco, CVS, Publix Super Markets Inc.,

Walgreens, Target, The Medicine Shoppe, Walmart, Winn-Dixie

Stores, Inc. 90-Day Supply Convenient Mail Service Pharmacy Home Delivery is an easy way to receive up to a 90-day supply

of your maintenance medication delivered by mail to your door.

Standard shipping is free. Orders are shipped in confidential,

tamper-evident packaging from Home Delivery pharmacies. Call

toll-free at (800) 763-0044.

90-Day at Retail Program This program allows you to obtain a 90-day supply of your

maintenance medication at more than 45,000 participating

community pharmacies.

Out-of-Pocket Maximum In-network Rx copays will be applied toward an individual

maximum out-of-pocket of $2,000 and $4,000 for family. Once

you reach your out-of-pocket maximum, your prescriptions will

be paid at 100% by the plan and no cost to you ($0 copay).

Diabetic Supplies The following prescribed diabetic supplies are covered at 100%,

$0 copay: meters, lancets, lancing devices, test strips, control

solution, insulin needles and syringes.

Rx with Over-the-Counter (OTC) alternatives The Rx with OTC strategy excludes certain prescription products when therapeutically acceptable over-the-counter (OTC) alternatives are available.

Over-The-Counter and Generic Preventive Medications With a prescription from your physician, the following OTC and

generic preventive medications are covered as part of your

pharmacy benefit with $0 copay: Aspirin for adults, prenatal vitamins

or folic acid for women planning or capable of pregnancy, iron

supplementation, oral fluoride supplementation for children,

vaccines, Vitamin D for adults, bowel preparation agents for

colorectal cancer screening, and select statins for prevention of

cardiovascular disease (CVD).

Tobacco Cessation Tobacco cessation medications are covered with $0 copay when

you participate in coaching or counseling options though local Area

Health Education Centers, BCBS telephonic coaching or Resources

for Living counseling. (See flyer for more information!)

Specialty Medications Certain medications used for treating complex health conditions

(e.g. Hepatitis, HIV/AIDS, Oncology, etc.) must be obtained through

Briova Specialty Pharmacy. Call Briova toll-free at (855) 4BRIOVA.

Optum Rx Web Portal Find answers by visiting the OptumRx Portal thorough the single

sign-on section at ICUBAbenefits.org with features designed so you

can find your lowest copay, manage your Home Delivery

prescriptions, keep track of your health history and more!

Health Care Advisor If you have a question about your pharmacy benefit, call the Health

Care Advisor team toll-free at (855) 811-2213, 24 hours a day, 7

days a week.

Pharmacist Advocate Program If you have a question about your pharmacy benefit and would like

to speak with a Pharmacist at ICUBAcares, call (877) 286-3967.

‡ Prior authorization may be required to ensure safe and effective use of select prescription drugs. Your physician may be asked to provide additional information to determine medical necessity.

* Unless medically necessary, members will be required to pay the difference in cost between a brand and generic drug if the brand is requested when a generic equivalent is available.

** The PML is a list of medications preferred by your plan that can help you maximize your pharmacy benefit by minimizing your prescription costs. You can view the PML online by visiting optumrx.com

*** Specialty medications are limited to a 30 Day Supply. Copay Assistance Cards are acceptable to preferred specialty products

Copayments Prescription-Fill Methods*

Tier

Retail: Up to a

30-day supply

90-Day at Retail Program

Up to a 90-day supply

Mail: Up to a

90-day supply

Preferred generics at the Nova Southeastern University (NSU) pharmacy $0 $0 N/A

Preferred generics at other network pharmacies $5 $10 $10

Non-Preferred generics $10 $20 $20

Preferred brands: brand-name medications on the Preferred Medication List (PML)** $40 $80 $80

Non-preferred brands: brand-name medications not on the Preferred Medication List $75 $150 $150

Preferred specialty at Briova Specialty Pharmacy $75*** N/A N/A

Non-preferred specialty at Briova Specialty Pharmacy $75*** N/A N/A

SurgeryPlus is a supplemental benefit at NO ADDITIONAL COST that offers higher-quality, a great experience and lower costs for non-emergent surgical procedures.

SurgeryPlus has Located the Nation’s Top-Quality SurgeonsSurgeryPlus has already located and rigorously screened the area’s top-quality surgeons for the best possible care. Our highly qualified surgeons chose to be part of the SurgeryPlus network for a number of reasons, including quick and easy claims payments, no denials, direct referrals of surgery-ready patients and the opportunity to participate in an elite network setting them apart from other under-performing surgeons.

Board CertificationSpecialty Training RequirementsProcedure Volume RequirementsState Sanctions CheckMedical Malpractice Claims ReviewCriminal Background ChecksCMS Quality Requirements (Hospital Only)Monthly Network Monitoring

Optional MandatoryOptional Mandatory

Other Network

You Can Save Money SurgeryPlus will waive your coinsurance and deductible, eliminating all out-of-pocket costs, including consultation, surgical procedure and post-procedure appointments up to 90 days.

Care Advocates Manage the Entire ProcessA dedicated Care Advocate will manage the entire procedure process for you, including locating a surgeon, scheduling appointments, transferring medical records and arranging all logistics. You’ll work with the same Care Advocate throughout the entire process so they’ll know all the details of your case and ensure your top-satisfaction. The Care Advocate will provide you with at least three top quality surgeons for your covered procedure. In the event that the surgeon you select requires you to travel, SurgeryPlus will provide you and a companion with a travel allowance.

Hundreds of Procedures are Covered Hundreds of procedures are covered. Below is a list of the main categories; however, call SurgeryPlus to inquire about a specific procedure and a Care Advocate will assist you with your needs and questions.

You Do Not Need to Enroll in SurgeryPlus If you are covered under ICUBA’s medical plan, you have been automatically enrolled in this extra benefit at no additional cost. If you are planning a procedure, call SurgeryPlus as you could save thousands of dollars.

To learn more about SurgeryPlus, call (855) 200-2119

• Spine• Cardiac• General Surgery• Genitourinary

• Orthopedic• Ear, Nose & Throat• Pain Management• Bariatric

SurgeryPlus covers hundreds of planned surgeries including, but

not limited to:

Not all covered procedures are listed. If you don’t see a

procedure listed, speak to a Care Advocate at (855) 200-2119

GenitourinaryHysterectomyBladder Repair

General SurgeryGallbladder RemovalHernia RepairThyroidectomy

SpineFusionsDisk Repair/Replacement LaminectomyLaminotomy

OrthopedicKnee ReplacementHip ReplacementShoulder ReplacementAnkle/Wrist/Elbow ReplacementArthroscopyRotator Cuff RepairTendon RepairCarpal TunnelBunionectomy

Ear, Nose & Throat SeptoplastySinuplastyEustachian Tubes

CardiacCardiac Valve SurgeryCardiac Defibrillator Implant

Pain ManagementCervical Epidural Lumbar Epidural SteroidStellate Ganglion Block

GIEndoscopy

BariatricGastric BypassLaparoscopic Sleeve Gastrectomy

Contact customer support center at

1‐800‐979‐4760Hours of Operation: Monday thru Friday 8 a.m.‐ 6 p.m. EST

Humana Dental DHMO CS250 MembersHow to Select Your Primary Care Dentist (PCD) 2018

Effective Date of Your Change –Any changes done prior to the 15th of the month will be effective on the first day of the next month. (i.e. a change on July 12 will be effective August 1)

Any changes made after the 15th of the month will become effective for the first day of the second following month. (i.e. a change on July 16 will be effective September 1)

How to Select Your PCD at the Time of Enrollment (First‐Time Only) Log on to the ICUBA Benefits Portal websiteat http://icubabenefits.org For the dental enrollment, select the DHMO HumanaDentalPrepaid radio button On the Dental – Primary Care Provider screen, enter the six digit Dentist ID number

In the drop down box, select if you are a new or established patient

If You Have Previously Enrolled in the DHMO and your enrollment window is closed, you MUST Contact Humana Directly to Select or to

Change Your Primary Care Dentist.

How to Search for a PCD Visit www.humanadental.com Click on Find a Dentist Select the DHMO radio button and enter your zip code Select HD DHMO/Prepaid CS250 Network Set your search criteria Search for a dentist Select a dentist and locate the Dentist ID number Select Show Info radio button to verify that the provider

is accepting new patients

GCA0AWGHH 4/13

The HumanaDental DHMO plans focus on maintaining oral health, prevention and cost-containment. A member may see a primary care dentist as often as necessary. There are no yearly maximums, no deductibles to meet and no waiting periods. CS plans copayments are applicable at either a participating general dentist or a participating specialist.

Member costs listed here are for services provided by your chosen participating primary care dentist (PCD) only. As your dental professional, your PCD may decide that you need to see an contracted dental specialist. No referral is necessary to see a network specialist.

Specialists services: Should you need a specialist, (i.e., endodontist, oral surgeon, periodontist, pediatric dentist), you may be referred by your participating general dentist, or you may refer yourself to any participating specialist. For CS plans, copayment amounts are applicable when treatment is performed by participating specialists.

Summary of servicesAppointments Member paysD9310 Consultation (diagnostic service provided by

dentist other than practitionerproviding treatment) . . . . . . . . . . . . . . . . . . . . . . . . . $ 20 .00

D9430 Office visit (normal hours) . . . . . . . . . . . . . . . . . . . . $ 5 .00D9440 Office visit (after regularly scheduled hours) . . . $ 35 .00D9999 Emergency visit during regularly scheduled

hours, by report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 20 .00D9999 Broken appointments (without 24 hr . notice,

per 15 min) —maximum $40 per brokenappointment . No charge will be made dueto emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 10 .00

Diagnostic Member paysD0120 Periodic oral examination . . . . . . . . . . . . . . . . . . . . . no chargeD0140 Limited/comprehensive/detailed and

extensive oral eval . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0150 Limited/comprehensive/detailed and

extensive oral eval . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0160 Limited/comprehensive/detailed and

extensive oral eval . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0180 Comprehensive periodontal evaluation . . . . . . . . $ 15 .00D0210 X-ray intraoral—complete series

including bitewings . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0220 X-ray intraoral—periapical, first radiographic

image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0230 X-ray intraoral—periapical, each additional

radiographic image . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0270 X-ray bitewing—single radiographic image . . . no chargeD0272 X-ray bitewings—two radiographic images . . . no chargeD0274 Bitewings—four radiographic images . . . . . . . . . no chargeD0330 Panoramic radiographic image . . . . . . . . . . . . . . . no chargeD0460 Pulp vitality tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0470 Diagnostic casts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargePreventive Member paysD1110 Prophylaxis—adult, routine

(once every 6 months) . . . . . . . . . . . . . . . . . . . . . . . . no chargeD1120 Prophylaxis—child, routine

(once every 6 months) . . . . . . . . . . . . . . . . . . . . . . . . no chargeD1110 Prophylaxis—adult/child, (additional) . . . . . . . . . $ 25 .00D1120 Prophylaxis—adult/child, (additional) . . . . . . . . . $ 25 .00D1206 Topical application of fluoride varnish (for child

<16) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge

D1208 Topical application of fluoride (not includingprophylaxis)—child (up to 16 years of age) . . . . no charge

D1330 Oral hygiene instruction . . . . . . . . . . . . . . . . . . . . . . no chargeD1351 Sealant-per tooth . . . . . . . . . . . . . . . . . . . . . . . . . .$ 15 .00D1510 Space maintainer—fixed, unilateral . . . . . . . . .$ 55 .00+labD1515 Space maintainer—fixed, bilateral . . . . . . . . . .$ 55 .00+labD1520 Space maintainer—removable, unilateral . . .$ 95 .00+labD1525 Space maintainer—removable, bilateral . . . .$ 95 .00+lab D1550 Recementation of space maintainer . . . . . . . .$ 15 .00Restorative Member paysD2140 Amalgam—one surface, primary

or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 20 .00D2150 Amalgam—two surfaces, primary

or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 25 .00D2160 Amalgam—three surfaces, primary

or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 30 .00D2161 Amalgam—four or more surfaces, primary

or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 40 .00D2940 Sedative filling . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 20 .00D2999 Sedative base (under fillings), by report . . . . . .no chargeResin restorative Member paysD2330 Resin based composite—one surface, anterior . .$ 40 .00D2331 Resin based composite—two

surfaces, anterior . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 45 .00D2332 Resin based composite—three

surfaces, anterior . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 55 .00D2391 Resin based composite—one

surface, posterior . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 70 .00D2392 Resin based composite—two

surfaces, posterior . . . . . . . . . . . . . . . . . . . . . . . . . .$ 90 .00D2393 Resin based composite—three

surfaces, posterior . . . . . . . . . . . . . . . . . . . . . . . . . .$ 110 .00D2394 Resin based composite—four or more

surfaces, posterior . . . . . . . . . . . . . . . . . . . . . . . . . .$ 130 .00D2510 Inlay—metallic, one surface . . . . . . . . . . . . . . . .$ 115 .00D2520 Inlay—metallic, two surfaces . . . . . . . . . . . . . . .$ 125 .00D2530 Inlay—metallic, three or more surfaces . . . . .$ 150 .00Crown and bridge Member paysD2740 Crown—porcelain/ceramic substrate . . . . . . .$ 310 .00+labD2750* Crown—porcelain fused to high noble metal . .$ 310 .00D2751 Crown—porcelain fused to predominantly

base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 310 .00

HumanaDental DHMO 250 CS Plan

GCA0AWGHH 4/13

D2752* Crown—porcelain fused to noble metal . . . . . . $ 310 .00D2790* Crown—full cast high noble metal . . . . . . . . . . . $ 310 .00D2791 Crown—full cast predominantly base metal . $ 310 .00D2792* Crown—full cast noble metal . . . . . . . . . . . . . . . . $ 310 .00D2910 Recement inlay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 20 .00D2920 Recement crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 20 .00D2929 Crown—prefabricated porcelain/ceramic crown

- primary tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 90 .00D2930 Prefabricated stainless steel crown—

primary tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 90 .00D2950 Core buildup, including any pins . . . . . . . . . . . . . $ 50 .00D2951 Pin retention—per tooth, in addition

to restoration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 20 .00D2952 Cast post and core in addition to crown . . . . . . $ 100 .00+labD2953 Each additional cast post—same tooth . . . . . . $ 100 .00+labD2954 Prefabricated post and core in addition to crown . $ 100 .00D2962 Labial veneer (porcelain laminate)—laboratory . . . . . . . . . . . . . . . . . . . . . . $ 310 .00+labProsthodontics (fixed) Member paysD6210* Pontic—cast high noble metal . . . . . . . . . . . . . . . $310 .00D6211 Pontic—cast predominantly base metal . . . . . $ 310 .00D6212* Pontic—cast noble metal . . . . . . . . . . . . . . . . . . . $ 310 .00D6240* Pontic—porcelain fused to high noble metal . $ 310 .00D6241 Pontic—porcelain fused to predominantly

base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 310 .00D6242* Pontic—porcelain fused to noble metal . . . . . . $ 310 .00 D6750* Crown—porcelain fused to high noble metal . $ 310 .00D6751 Crown—porcelain fused to predominantly

base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 310 .00D6752* Crown—porcelain fused to noble metal . . . . . . $ 310 .00D6790* Crown—full cast high noble metal . . . . . . . . . . . $ 310 .00D6791 Crown—full cast predominantly base metal . $ 310 .00D6792* Crown—full cast noble metal . . . . . . . . . . . . . . . . $ 310 .00D6930 Recement fixed partial denture (per unit) . . . . . $ 15 .00Endodontics Member paysD3220 Therapeutic pulpotomy . . . . . . . . . . . . . . . . . . . . . $ 40 .00D3221 Pulpal debridement, primary and

permanent teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 110 .00D3310 Root canal therapy—anterior

(excluding final restoration) . . . . . . . . . . . . . . . . . . $ 150 .00D3320 Root canal therapy—bicuspid

(excluding final restoration) . . . . . . . . . . . . . . . . . . $ 250 .00D3330 Root canal therapy—molar

(excluding final restoration) . . . . . . . . . . . . . . . . . . $ 300 .00D3410 Apicoectomy/periradicular surgery—anterior . . $ 150 .00Periodontics (gum treatment) Member paysD4210 Gingivectomy/gingivoplasty per quadrant . . . $ 150 .00D4211 Gingivectomy/gingivoplasty per tooth . . . . . . . . $ 45 .00D4260 Osseous surgery, per quadrant . . . . . . . . . . . . . . . $ 375 .00D4261 Osseous surgery—1 to 3 teeth, per quadrant . $ 375 .00D4277 Free soft tissue graft procedure (including donor

site surgery) - first tooth . . . . . . . . . . . . . . . . . . . . . $250 .00D4278 Free soft tissue graft procedure (including donor

site surgery), ea add’l . . . . . . . . . . . . . . . . . . . . . . . . $ 188 .00D4341 Periodontal scaling and root planing,

per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 55 .00D4342 Periodontal scaling and root planing

1 to 3 teeth per quadrant . . . . . . . . . . . . . . . . . . . . $ 55 .00D4355 Full mouth debridement to enable

comprehensive evaluation and diagnosis . . . . $ 50 .00

D4381 Localized delivery of chemotherapeuticagents (per tooth) . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50 .00

D4910 Periodontal maintenance . . . . . . . . . . . . . . . . . . . . $ 55 .00Prosthodontics Member paysD5110 Complete denture—maxillary . . . . . . . . . . . . . . . $ 325 .00+labD5120 Complete denture—mandibular . . . . . . . . . . . . . $ 325 .00+labD5130 Immediate denture—maxillary . . . . . . . . . . . . . $ 325 .00+labD5140 Immediate denture—mandibular . . . . . . . . . . . $ 325 .00+labD5211 Maxillary partial denture—resin base . . . . . . . . $ 325 .00+labD5212 Mandibular partial denture—resin base . . . . . . $ 325 .00+labD5213 Maxillary partial denture—cast metal

framework, resin denture bases . . . . . . . . . . . . . . $ 325 .00+labD5214 Mandibular partial denture—cast metal

framework, resin denture bases . . . . . . . . . . . . . . $ 325 .00+labD5410 Adjust complete denture—maxillary . . . . . . . . $ 20 .00D5411 Adjust complete denture—mandibular . . . . . . $ 20 .00D5421 Adjust partial denture—maxillary . . . . . . . . . . . $ 20 .00D5422 Adjust partial denture—mandibular . . . . . . . . . $ 20 .00Repairs to prosthetics Member paysD5510 Repair broken complete denture base . . . . . . . . $ 20 .00+labD5520 Replace missing or broken teeth—complete

denture (each tooth) . . . . . . . . . . . . . . . . . . . . . . . . $ 20 .00+labD5610 Repair resin denture base . . . . . . . . . . . . . . . . . . . . $ 20 .00+labD5630 Repair or replace broken clasp . . . . . . . . . . . . . . . $ 20 .00+labD5640 Replace broken teeth—per tooth . . . . . . . . . . . . $ 20 .00+labD5650 Add tooth to existing partial denture . . . . . . . . . $ 35 .00+labD5730 Reline complete maxillary denture (chairside) . . $ 55 .00D5731 Reline complete mandibular

denture (chairside) . . . . . . . . . . . . . . . . . . . . . . . . . . $ 55 .00D5740 Reline maxillary partial denture (chairside) . . . $ 55 .00D5741 Reline mandibular partial denture (chairside) . . $ 55 .00D5750 Reline complete maxillary denture (laboratory) . . $ 40 .00+labD5751 Reline complete mandibular

denture (laboratory) . . . . . . . . . . . . . . . . . . . . . . . . $ 40 .00+labD5760 Reline maxillary partial denture (laboratory) . . $ 40 .00+labD5761 Reline mandibular partial denture (laboratory) . . $ 40 .00+labD5850 Tissue conditioning—maxillary . . . . . . . . . . . . . . $ 35 .00D5851 Tissue conditioning—mandibular . . . . . . . . . . . . $ 35 .00Extractions/oral and maxillofacial surgery Member paysD7111 Coronal remnants, deciduous tooth . . . . . . . . . . $ 25 .00D7140 Extraction, erupted tooth or exposed tooth . . $ 25 .00D7210 Surgical removal of erupted tooth . . . . . . . . . . . . $ 45 .00D7220 Removal of impacted tooth—soft tissue . . . . . $ 60 .00D7230 Removal of impacted tooth—partially bony . . $ 80 .00D7240 Removal of impacted tooth—completely bony . . $ 100 .00 D7250 Surgical removal of residual tooth roots . . . . . . $ 45 .00 D7310 Alveoloplasty in conjunction with

extractions—per quadrant . . . . . . . . . . . . . . . . . . . $ 45 .00D7311 Alveoplasty in conjunction with extractions—

one to three teeth or tooth spaces,per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 45 .00

D7320 Alveoloplasty not in conjunction with extractions—per quadrant . . . . . . . . . . . . . . . . . . . $ 80 .00

D7321 Alveoplasty not in conjunction withextractions—one to three teeth or toothspaces, per quadrant . . . . . . . . . . . . . . . . . . . . . . . . $ 80 .00

D7510 Incision and drainage of abscess—intraoral . . $ 30 .00Anesthesia Member paysD9215 Local anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD9230 Analgesia (nitrous oxide), per 15 minutes . . . . $ 20 .00

GCA0AWGHH 4/13

Insured or administered by Humana Insurance Company, The Dental Concern, Inc., CompBenefits Dental, Inc., CompBenefits of Alabama, Inc., CompBenefits of Georgia, Inc., or CompBenefits Insurance Company.

* The above copayments do not include the additional cost of precious (high noble) and semi-precious (noble) metal.The additional cost of precious metal shall not exceed $125 per unit and $75 per unit for semi-precious metal.

Note:• Notallparticipatingdentistsperformalllistedprocedures,includingamalgams.Pleaseconsultyourdentistpriorto

treatment for availabilty of services.• Unlistedproceduresareavailableatcertainparticipatingdentistsusualfeeless25%.VisitHumanaDental.comtofind

a participating dentist who offers the discount on non-covered services.• Whencrownand/orbridgeworkexceedssixunitsinthesametreatmentplan,thepatientmaybechargedanadditional

$50 per unit.• Ifyoubreakyourappointmentwithyourdentistwithout24-houradvancenotice,youwillbesubjecttoyourdentist’s

broken appointment fee.• Additionalexclusionsandlimitationsarelistedalongwithfullplaninformationinyourcertificateofbenefits.

Adjunctive general services Member paysD9450 Case presentation, detailed and extensive

treatment planning . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD9951 Occlusal adjustment—limited . . . . . . . . . . . . . . . $ 30 .00D9952 Occlusal adjustment—complete . . . . . . . . . . . . $ 175 .00Orthodontics Member paysD8070 Comprehensive orthodontic treatment of the

transitional/adolescent dentition; Children upto 19 years of age; Up to 24 months of routineorthodontic treatment for Class I andClass II cases

Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 35 .00

Records/treatment planning . . . . . . . . . . . . . . . . . . $ 250 .00Orthodontic treatment . . . . . . . . . . . . . . . . . . . . . . . $ 1,800 .00

D8080 Comprehensive orthodontic treatment of thetransitional/adolescent dentition; Children upto 19 years of age; Up to 24 months of routineorthodontic treatment for Class I andClass II cases



D8090 Comprehensive orthodontic treatment of theadult dentition; Adult 19 years of age and overUp to 24 months of routine orthodontictreatment for Class I and Class II cases



D8680 Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 450 .00

Humana.com

ICUBAFLORIDA

HumanaDental PPO 09 (High Option)

SGB0077A

1-800-233-4013 • Humana.com

If you use IN-NETWORK provider

If you use OUT-OF-NETWORK provider

Plan-year deductible(excludes orthodontia services)

Individual$50

Family$150

Individual$50

Family$150

Annual maximum (excludes orthodontia services)

$2,000After you reach the annual maximum amount, you willreceive 30 percent coinsurance on preventive, basic, andmajor services for the rest of the plan year. (Implants andorthodontia excluded.)

Preventive services• Oral examinations• X-rays• Cleanings (four per plan year)• Topical fluoride treatment

(through age 14, one per plan year)

• Periodontal cleanings (two per plan year)• Sealants (through age 14)

100% no deductible 80% no deductibleof maximum allowed fee

Basic services• Space maintainers (through age 14)• Emergency care for pain relief• Basic oral surgery services - basic

extractions of erupted tooth or root• Fillings (amalgam or composite)• Appliances for children (through age 14)• Prefabricated stainless steel crowns

80% after deductible 50% after deductibleof maximum allowed fee

• Composite fillings for molars• Periodontics• Endodontics (root canal)Major services• Crowns• Inlays and onlays• Bridgework• Dentures• Denture relines and rebases

50% after deductible 30% after deductibleof maximum allowed fee

• Denture repair and adjustments• Complex surgical extractions - surgical

removal of erupted tooth, impactedtooth, and tooth roots

.

Orthodontia Adult/child orthodontia - Plan pays 50 percent (nodeductible) of the covered orthodontia services, up to:$2,000 lifetime orthodontia maximum.

Non-participating dentists can bill you for charges above the amount covered by your HumanaDentalplan. To ensure you do not receive additional charges, visit a participating PPO Network dentist.

Extended Annual Maximum

Not every dental visit is routine.

Someday you could go into your dentist’s office for a routine cleaning and checkup, but you find out there’s a problem. When major dental work is needed, many of us don’t expect or plan for it, but putting it off might not be an option and may cause problems to worsen.

As an example, Kevin, a 40-year-old employee, goes to the dentist regularly. But rather unexpectedly, his dentist tells him there’s an issue. He’ll need a root canal and a crown, which are likely to cost more than his annual maximum benefit. With Extended Annual Maximum, Kevin has the benefits he needs when he needs them.

HumanaDental’s

Extended Annual

Maximum plans give

you a valuable

benefit and dental

coverage when it’s

needed.

As a part of HumanaDental’s PPO High Plan, Extended Annual Maximum takes over after a plan’s annual maximum benefit is reached. It gives employees 30 percent coinsurance on preventive, basic and major services, and it makes those unexpected and costly dental procedures – such as root canals and crowns – easier to afford. There is no cap on dollars that may be paid, which means you can take advantage of the benefit whenever it’s needed within the plan year.

Kevin has the high option PPO with a $50 deductible and has met his $2,000 annual maximum. Now he needs a root canal and a crown. Kevin submits a claim for $875 for the root canal and Extended Annual Maximum picks up 30 percent of the cost, or $262.50. When Kevin later needs a crown, Extended Annual Maximum also pays 30 percent of that cost, $240.

Dental Service Cost Humana Pays

A root canalA crown

$875$800

$262.50 $240

Example is for illustration only. Actual savings may vary. Implants and orthodontia excluded.

ICUBAFLORIDA

HumanaDental Preventive Plus 09 (Low Option)

SGB0077A

1-800-233-4013 • Humana.com

Plan-year deductible(excludes orthodontia services)

Individual$50

Family$150

Annual maximum (excludes orthodontia services)

$1,000

Preventive services• Oral examinations• X-rays• Cleanings• Topical fluoride treatment

(through age 14, one per plan year)• Sealants (through age 14)

100% no deductible

Basic services• Emergency care for pain relief• Basic oral surgery services - basic

extractions of erupted tooth or root• Fillings (amalgams, composite for

anterior teeth)


.

Discount Services

Basic services• Space maintainers (through age 14)• Appliances for children• Prefabricated stainless steel crownsMajor services• Crowns• Inlays and onlays• Bridgework• Dentures• Denture relines and rebases• Denture repair and adjustments• Complex surgical extractions - surgical

removal of erupted tooth, impactedtooth, and tooth roots

• Periodontics (gum therapy)• Endodontics (root canals)Orthodontia services• Adult and child orthodontia

These services are not covered under this plan. Members may receive a discount on non-covered services and may contact their participating provider to determine if any discounts are available on non-covered services.

Non-participating dentists can bill you for charges above the amount covered by your HumanaDentalplan. To ensure you do not receive additional charges, visit a participating PPO Network dentist. If amember sees an out-of-network dentist, the coinsurance level will apply to the maximum allowable fee.

Feel good about choosing a HumanaDental plan

Make regular dental visits a priorityRegular cleanings can help manage problemsthroughout the body such as heart disease,diabetes, and stroke.* Your HumanaDental PPOplan focuses on prevention and early diagnosis,providing four exams and cleanings every planyear: two regular and two periodontal.* www.perio.org

Go to MyDentalIQ.comTake a health risk assessment that immediatelyrates your dental health knowledge. You’ll receivea personalized action plan with health tips. Youcan print a copy of your scorecard to discuss withyour dentist at your next visit.

Tips to ensure a healthy mouth• Use a soft-bristled toothbrush• Choose toothpaste with fluoride• Brush for at least two minutes twice a day• Floss daily• Watch for signs of periodontal disease such as

red, swollen, or tender gums• Visit a dentist regularly for exams and cleanings

Did you know that 74 percent of adult Americans believean unattractive smile could hurt a person’s chances forcareer success?* HumanaDental helps you feel good aboutyour dental health so you can smile confidently.* American Academy of Cosmetic Dentistry

Use your HumanaDental benefits

Find a dentistWith HumanaDental’ s PPO plan, you can see anydentist. You save an average of 28 percent whenyou visit a dentist in HumanaDental’ s PPONetwork. To find a dentist in HumanaDental’ s PPONetwork, log on to Humana.com or call1-800-233-4013.

Know what your plan coversThe other side of this page provides a summary ofHumanaDental benefits. Your plan certificatedescribes in detail your HumanaDental benefits.You can find it on MyHumana, your personal pageat Humana.com or call 1-800-233-4013.

See your dentistYour HumanaDental identification card contains allthe information your dentist needs to submit yourclaims. Be sure to share it with the office staffwhen you arrive for your appointment. If youdon’t have your card, you can print proof ofcoverage at Humana.com.

Learn what your plan paidAfter HumanaDental processes your dental claim,you will receive an explanation of benefits orclaims receipt. It provides detailed information oncovered dental services, amounts paid, plus anyamount you may owe your dentist. You can alsocheck the status of your claim on MyHumana at Humana.com or by calling 1-800-233-4013.

Questions? Simply call 1-800-233-4013 to speak with a friendly,

knowledgeable Customer Care specialist, or visit Humana.com.

Plan summary created on: 6/20/12 08:38

Insured or administered by HumanaDental Insurance Company

This is not a complete disclosure of plan qualifications and limitations. Your broker will provide youwith specific limitations and exclusions as contained in the Regulatory and Technical Information Guide.Please review this information before applying for coverage. The amount of benefits provided dependsupon the plan selected. Premiums will vary according to the selection made.

Policy Number: FL-70090-HD 3/08 et.al.

HumanaDental Preventive Plus 09

Additional discounts

Take a sneak peek before enrolling

SUMMARY OF BENEFITS

BLM2015

Premium progressives and premium anti-reflective designations are subject to annual review by EyeMed’s Medical Director and are subject to change based on marketconditions. Fixed pricing is reflective of brands at the listed product level . All providers are not required to carry all brands at all levels.

_____________________________ _________________________________________ _________________

ICUBA Base Plan

Vision Care In-Network Out-of-NetworkServices Member Cost Reimbursement

ExamWith Dilation as Necessary $5 Co-pay Up to $35

Retinal Imaging Up to $39 N/A

Frames $0 Co-pay; $100 allowance; 20% off balance over $100 Up to $50

Standard Plastic LensesSingle Vision $15 Co-pay Up to $20Bifocal $15 Co-pay Up to $40Trifocal $15 Co-pay Up to $60Standard Progressive Lens $65 Co-pay Up to $45Premium Progressive Lens $85 Co-pay - $110 Co-payTier 1 $85 Co-pay Up to $45Tier 2 $95 Co-pay Up to $45Tier 3 $110 Co-pay Up to $45Tier 4 $65 Co-pay, 80% of charge less $120 Allowance Up to $45

Lenticular $15 Co-pay Up to $60

Lens Options (paid by the member and added to the base price of the lens)UV Treatment $15 N/ATint (Solid and Gradient) $15 N/AStandard Plastic Scratch Coating $15 N/AStandard Polycarbonate $40 N/AStandard Polycarbonate - Kids under 19 $0 Up to $20Standard Anti-Reflective Coating $45 N/APremium Anti-Reflective Coating $57 - $68 N/ATier 1 $57 N/ATier 2 $68 N/ATier 3 80% of charge N/A

Photochromic/Transitions $75 N/APolarized 20% off retail price N/AOther Add-Ons and Services 20% off retail price N/A

Contact Lens Fit and Follow-Up (Contact lens fit and two follow up visits are available once a comprehensive eye exam has been completed)

Standard Contact Lens Fit & Follow-Up Up to $40 N/APremium Contact Lens Fit & Follow-Up 10% off retail N/A

Contact LensesConventional $0 Co-pay; $100 allowance; 15% off balance over $100 Up to $80Disposable $0 Co-pay; $100 allowance; plus balance over $100 Up to $80Medically Necessary $0 Co-pay, Paid-in-Full Up to $210

Laser Vision CorrectionLasik or PRK from U.S. Laser Network 15% off the retail price or 5% off the promotional price N/A

Hearing CareHearing Health Care from 40% off hearing exams and a low price guarantee N/AAmplifon Hearing Network on discounted hearing aids

FrequencyExamination Once every 12 monthsLenses or Contact Lenses Once every 12 monthsFrame Once every 24 months

40%Complete pairof prescriptioneyeglasses

20%Non-prescriptionsunglasses

20%Remaining balancebeyond plan coverage

These discounts are forin-network providers only

OFF

OFF

OFF

• You’re on the INSIGHTNetwork

• For a complete list ofin-network providersnear you, useour Enhanced ProviderLocator onwww.eyemed.com orcall 1-866-804-0982.

• For Lasik providers, call1-877-5LASER6.

AH2015

Premium progressives and premium anti-reflective designations are subject to annual review by EyeMed’s Medical Director and are subject to change based on marketconditions. Fixed pricing is reflective of brands at the listed product level . All providers are not required to carry all brands at all levels. Benefits are not provided from services ormaterials arising from: 1) Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; 2) Medical and/or surgical treatment of the eye,eyes or supporting structures; 3) Any eye or Vision Examination, or any corrective eyewear required by a Policyholder as a condition of employment; Safety eyewear; 4) Services providedas a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof; 5) Plano (non-pre-scription) lenses; 6) Non-prescription sunglasses; 7) Two pair of glasses in lieu of bifocals; 8) Services or materials provided by any other group benefit plan providing vision care 9) Ser-vices rendered after the date an Insured Person ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services ren-dered to the Insured Person are within 31 days from the date of such order. 10) Lost or broken lenses, frames, glasses, or contact lenses will not be replaced except in the next Benefit Fre-quency when Vision Materials would next become available. Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Standard/PremiumProgressive lens not covered-fund as a Bifocal lens. Standard Progressive lens covered-fund Premium Progressive as a Standard. Underwritten by Fidelity Security Life Insurance Com-pany of Kansas City, Missouri, except in New York. The Certificate of Insurance is on file with your employer. Benefit allowance provides no remaining balance for future use within thesame benefit year. Fees charged for a non-insured benefit must be paid in full to the Provider. Such fees or materials are not covered.

What’s in it for me? Options. It’s simple really. We’re dedicated to helping you see clearly — and that’s why we’ve built a network that gives you lots of choices and flexibility. You can choose from thousands of independent and retail providers to find the one that best fits your needs and schedule. No matter which one you choose, our plan is designed to be easy-to-use and help you access the care you need. Welcome to EyeMed.

Download the EyeMed Members AppIt’s the easy way to view your ID card, see benefit details and find a provider near you.

And now it’s time for the breakdown . . .

Benefits SnapshotExam with dilation as necessary (Once every 12 months)

Frames (Once every 24 months)

Or

Single Vision Lenses (Once every 12 months)

Contacts (Once every 12 months)

With EyeMedOut-of-NetworkReimbursement

$5 Co-pay Up to $35

$0 Co-pay; $100 allowance; 20% off balance over $100 Up to $50

$15 Co-pay Up to $20

$0 Co-pay; $100 allowance; plus balance over $100 Up to $80

Here’s an example of what you might pay for a pair of glasses with us vs. what you’d pay without visioncoverage. So, let’s say you get an eye exam and choose a frame that costs $163 with single vision lensesthat have UV and scratch protection. Now let’s see the difference...

75%SAVINGSwith us*

With EyeMed Without Insurance**

Exam $5 Co-pay Exam $106

Frame $163 Frame $163

-$100 allowance

$63

-$12.60 (20% discount off balance)

$50.40

Lens $15 Co-pay Lens $78$15 UV treatment add-on $23 UV treatment add-on

+$15 Scratch coating add-on +$25 Scratch coating add-on

$45 $126

Total $100.40 Total $395

*This is a snapshot of your benefits. Actual savings will depend on provider, frame and lens selections. **Based on industry averages.

Additional discounts

Take a sneak peek before enrolling

SUMMARY OF BENEFITS

BLM2015

Premium progressives and premium anti-reflective designations are subject to annual review by EyeMed’s Medical Director and are subject to change based on marketconditions. Fixed pricing is reflective of brands at the listed product level . All providers are not required to carry all brands at all levels.

_____________________________ _________________________________________ _________________

ICUBA Buy Up Plan

Vision Care In-Network Out-of-NetworkServices Member Cost Reimbursement

ExamWith Dilation as Necessary $5 Co-pay Up to $35

Retinal Imaging Up to $39 N/A

Frames $0 Co-pay; $130 allowance; 20% off balance over $130 Up to $65

Standard Plastic LensesSingle Vision $15 Co-pay Up to $20Bifocal $15 Co-pay Up to $40Trifocal $15 Co-pay Up to $60Standard Progressive Lens $65 Co-pay Up to $45Premium Progressive Lens $85 Co-pay - $110 Co-payTier 1 $85 Co-pay Up to $45Tier 2 $95 Co-pay Up to $45Tier 3 $110 Co-pay Up to $45Tier 4 $65 Co-pay, 80% of charge less $120 Allowance Up to $45

Lenticular $15 Co-pay Up to $60

Lens Options (paid by the member and added to the base price of the lens)UV Treatment $15 N/ATint (Solid and Gradient) $15 N/AStandard Plastic Scratch Coating $15 N/AStandard Polycarbonate $40 N/AStandard Polycarbonate - Kids under 19 $0 Up to $20Standard Anti-Reflective Coating $45 N/APremium Anti-Reflective Coating $57 - $68 N/ATier 1 $57 N/ATier 2 $68 N/ATier 3 80% of charge N/A

Photochromic/Transitions $75 N/APolarized 20% off retail price N/AOther Add-Ons and Services 20% off retail price N/A

Contact Lens Fit and Follow-Up (Contact lens fit and two follow up visits are available once a comprehensive eye exam has been completed)

Standard Contact Lens Fit & Follow-Up Up to $40 N/APremium Contact Lens Fit & Follow-Up 10% off retail N/A

Contact LensesConventional $0 Co-pay; $130 allowance; 15% off balance over $130 Up to $104Disposable $0 Co-pay; $130 allowance; plus balance over $130 Up to $104Medically Necessary $0 Co-pay, Paid-in-Full Up to $210

Laser Vision CorrectionLasik or PRK from U.S. Laser Network 15% off the retail price or 5% off the promotional price N/A

Hearing CareHearing Health Care from 40% off hearing exams and a low price guarantee N/AAmplifon Hearing Network on discounted hearing aids

FrequencyExamination Once every 12 monthsLenses or Contact Lenses Once every 12 monthsFrame Once every 12 months

40%Complete pairof prescriptioneyeglasses

20%Non-prescriptionsunglasses

20%Remaining balancebeyond plan coverage

These discounts are forin-network providers only

OFF

OFF

OFF

• You’re on the INSIGHTNetwork

• For a complete list ofin-network providersnear you, useour Enhanced ProviderLocator onwww.eyemed.com orcall 1-866-804-0982.

• For Lasik providers, call1-877-5LASER6.

AH2015

Premium progressives and premium anti-reflective designations are subject to annual review by EyeMed’s Medical Director and are subject to change based on marketconditions. Fixed pricing is reflective of brands at the listed product level . All providers are not required to carry all brands at all levels. Benefits are not provided from services ormaterials arising from: 1) Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; 2) Medical and/or surgical treatment of the eye,eyes or supporting structures; 3) Any eye or Vision Examination, or any corrective eyewear required by a Policyholder as a condition of employment; Safety eyewear; 4) Services providedas a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof; 5) Plano (non-pre-scription) lenses; 6) Non-prescription sunglasses; 7) Two pair of glasses in lieu of bifocals; 8) Services or materials provided by any other group benefit plan providing vision care 9) Ser-vices rendered after the date an Insured Person ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services ren-dered to the Insured Person are within 31 days from the date of such order. 10) Lost or broken lenses, frames, glasses, or contact lenses will not be replaced except in the next Benefit Fre-quency when Vision Materials would next become available. Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Standard/PremiumProgressive lens not covered-fund as a Bifocal lens. Standard Progressive lens covered-fund Premium Progressive as a Standard. Underwritten by Fidelity Security Life Insurance Com-pany of Kansas City, Missouri, except in New York. The Certificate of Insurance is on file with your employer. Benefit allowance provides no remaining balance for future use within thesame benefit year. Fees charged for a non-insured benefit must be paid in full to the Provider. Such fees or materials are not covered.

What’s in it for me? Options. It’s simple really. We’re dedicated to helping you see clearly — and that’s why we’ve built a network that gives you lots of choices and flexibility. You can choose from thousands of independent and retail providers to find the one that best fits your needs and schedule. No matter which one you choose, our plan is designed to be easy-to-use and help you access the care you need. Welcome to EyeMed.

Download the EyeMed Members AppIt’s the easy way to view your ID card, see benefit details and find a provider near you.

And now it’s time for the breakdown . . .

Benefits SnapshotExam with dilation as necessary (Once every 12 months)

Frames (Once every 12 months)

Or

Single Vision Lenses (Once every 12 months)

Contacts (Once every 12 months)

With EyeMedOut-of-NetworkReimbursement

$5 Co-pay Up to $35

$0 Co-pay; $130 allowance; 20% off balance over $130 Up to $65

$15 Co-pay Up to $20

$0 Co-pay; $130 allowance; plus balance over $130 Up to $104

Here’s an example of what you might pay for a pair of glasses with us vs. what you’d pay without visioncoverage. So, let’s say you get an eye exam and choose a frame that costs $163 with single vision lensesthat have UV and scratch protection. Now let’s see the difference...

81%SAVINGSwith us*

With EyeMed Without Insurance**

Exam $5 Co-pay Exam $106

Frame $163 Frame $163

-$130 allowance

$33

-$6.60 (20% discount off balance)

$26.40

Lens $15 Co-pay Lens $78$15 UV treatment add-on $23 UV treatment add-on

+$15 Scratch coating add-on +$25 Scratch coating add-on

$45 $126

Total $76.40 Total $395

*This is a snapshot of your benefits. Actual savings will depend on provider, frame and lens selections. **Based on industry averages.

ICUBA RETIREE ELECTION FORM

PLEASE RETURN ELECTION FORM BY 03/15/2019 TO THE MAILING ADDRESS OR FAX LISTED BELOW:

Mailing Address: Continuon Services, LLC Fax Number:11.855-731.5065

Attn: Retiree Department Toll Free: 1.877.747.4141

P.O. Box 7127

Atlanta, GA 30357-7127 Email: [email protected]

PERSONAL INFORMATION

Retiree Name

Street

City State Zip Code

Gender Social Security Number xxx-xx-

Date of Birth Phone Number

E-mail Address

Cell Phone Number

Medicare ID# (from Medicare ID Card)

Spouse Name

Gender Social Security Number xxx-xx-

Date of Birth Phone Number

Medicare ID# (from Medicare ID Card)

SELECT YOUR ENROLLMENT OPTIONS BELOW

Florida Blue Medical Coverage

Plan: Preferred Blue Options Premier Copay $4000/$8000K PPO

Level: Retiree Only Retiree + Spouse Retiree + Child(ren)

Retiree + Family Waive Coverage

Humana Dental Coverage

Plan: DHMO CS250 Plan Preventative Plus 09 (Low Option) Dental PPO 09 (High Option)

Level: Retiree Only Retiree + 1 Family Waive Coverage

EyeMed Coverage Plan: Select Plus 100 Base Plan Select Plus 100 Buy-Up Plan

Level: Retiree Retiree + Family Waive Coverage

AUTHORIZATION

HEREBY REQUEST ENROLLMENT IN THE HEALTH BENEFITS CONTINUATION PLAN FOR MYSELF AND ELIGIBLE QUALIFIED DEPENDENTS LISTED ON THIS FORM AND AGREE TO PAY THE PREMIUM AS REQUIRED. I UNDERSTAND THAT CONTINUATION COVERAGE WILL

TERMINATE UNDER SEVERAL CIRCUMSTANCES, INCLUDING: A) ANY REQUIRED PREMIUM IS NOT PAID IN FULL ON TIME, B) THE DATE I OR A CONTINUED DEPENDENT BECOME COVERED UNDER ANOTHER GROUP HEALTH/DENTAL PLAN, C) THE DATE I OR A CONTINUED DEPENDENT BECOME ENTITLED TO MEDICARE PART A, PART B, OR BOTH, D) THE DATE THE EMPLOYER CEASES TO PROVIDE ANY

GROUP HEALTH PLAN FOR ITS EMPLOYEES, E) OR ON THE DATE ON WHICH THE GROUP HEALTH/DENTAL PLAN ENDS. TO PREVENT TERMINATION OF

YOUR PARTICIPATION IN THE PLAN, PAYMENT MUST BE SUBMITTED AND POSTMARKED ON OR BEFORE THE FIRST OF THE MONTH.

Retiree Sign Here: Date:

Documents

Date Address 1 Address 2 Re: ICUBA Retirement Benefits ... · Toll Free: 1-877-747-4141 | Secure Fax: 1-855-731-5065 ... the ICUBA Retiree Medicare Supplemental Plan. If your spouse