Florida School Retiree Benefits Consortium Benefits Plan ...humanresources.brevardschools.org/Shared Documents... · Plan 3. See page 11 for a description of this plan. If an election

Florida School Retiree Benefits Consortium

Benefits PlanReference

Guide2015

Plan Year 01/01/2015 - 12/31/2015

2 | FLORIDA SCHOOL RETIREE BENEFITS CONSORTIUM REFERENCE GUIDE

FSRBC | Table of ConTenTs

INTRODUCTION LETTER ............................................................................................3

IMPORTANT INFORMATION ......................................................................................4

YOUR ENROLLMENT AT A GLANCE ............................................................................5

ELIGIBILITY REQUIREMENTS .......................................................................................6

MEDICARE PLANS .......................................................................................................7

MEDICARE SUPPLEMENT PLANS ................................................................................9

MEDICARE ADVANTAGE PLANS ................................................................................10

MEDICARE ADVANTAGE ENROLLMENT OPTIONS BY DISTRICT ............................... 12

HOW TO ENROLL .....................................................................................................14

COMPLIANCE AND LEGAL ........................................................................................ 15

CONTACT INFORMATION ......................................................................................... 16

Table of Contents

Your Open Enrollment Period is: 10/27/14 - 11/21/14

Retiree Fair Dates:

Brevard Public Schools10/29/2014 1:00 p.m. to 4:00 p.m. 11/4/2014 9:00 a.m. to 12:00 p.m.Brevard Schools District Board Room2700 Judge Fran Jamieson WayViera, FL 32940

Duval County Public Schools11/6/2014 8:00 a.m. to 12:00 p.m. The Schultz Center4019 Boulevard Center Dr.Jacksonville, FL 32207

Escambia County School District11/12/2014 9:00 a.m. - 1:00 p.m11/13/20149:00 a.m. - 1:00 p.mNew World Landing600 South Palafox St. Pensacola, FL 32502

To: Medicare Eligible Retireefrom: FBMC Benefits Management Company, Inc.CC: Florida School Retiree Benefits Consortium (FSRBC)Date: October 10, 2014

Re: Enrollment Package Information

Welcome to your 2015 Plan Year Retiree open enrollment!

On behalf of your School District, the floRIDa sCHool ReTIRee benefITs ConsoRTIUM’s (fsRbC) goal is to provide Medicare eligible members with access to high-quality, medical, dental, vision, identity theft, and IT technical support benefit plans that are tailored especially for retirees.

Together with FSRBC and your School District, your retiree benefits are now managed through fbMC benefITs ManaGeMenT CoMPanY, InC. (fbMC) – your new benefits plan administrator. Look to FBMC for quality support services to help meet your enrollment needs.

Please read this information carefully, as your current medical and certain other plans will no longer be available after December 31, 2014. This Enrollment Package provides all the resources you need to make new selections for the 2015 plan year. To make the best decisions for 2015, follow this easy process:• ReaD – Carefully read the information in the packet and other information sent to you by Medicare

providers to learn about the options available to you.• leaRn – Call the Medicare providers directly to learn more about the different plans available to you,

including AARP® Medicare Supplement Insurance Plans, Medicare Advantage Plans, and Medicare Part D Prescription Drug Plans. Contact information is included throughout this guide and on the back cover.

• Do – Make sure you have coverage in 2015 by enrolling in the plans that best fit your needs. To avoid losing coverage, you must make an election for the 2015 plan year. Enrollment information is provided in this guide to make your enrollment process smooth and easy.

Your Enrollment Package includes this Reference Guide with medical plan highlights, including new options from Cigna, Health First, and UnitedHealthcare® Insurance Company (UHC). Your Enrollment Package also includes: • Inserts describing valuable non-medical benefits: dental, vision, identity theft, and IT technical support • A 2015 Plan Year Retiree Non-Medical Enrollment Form • A Florida Retirement System (FRS) Insurance Payroll Deduction Authorization Form • A Direct Debit (ACH) Form • A return envelope for submission of your form(s)

Please note: If you are Medicare eligible and have not enrolled already, please enroll in Medicare by contacting your local Social Security office today.

It is important to your School District that you have access to quality benefits during your retirement. In the event you do not take action and actively select your 2015 benefits during this enrollment period, you will be auto-enrolled into a default plan as described in the Important Information Section on Page 4.

Our FBMC Service Center Agents will gladly assist you with your questions. Contact us at 1-855-44fsRbC (1-855-443-7722), Monday – Friday, 7 a.m. – 7 p.m. ET. or visit www.myFSRBC.org.

Thank you.


FSRBC | IMPoRTanT InfoRMaTIon

Important Information

Please read below for information about steps you must complete in order to continue your benefits for the 2015 plan year.

Your School District, through the FSRBC, is making a selection of Medicare and non-medical plan offerings available to you for the 2015 plan year, because your current plans are ending. In many cases, the same plan options will be available to you, but they will no longer be administered directly by your School District. Please note: If your current Medicare, dental or vision plan is mapped to a new FSRBC version, you will need to make payment arrangements for your coverage to remain in effect for 2015. To ensure you have the Medicare and non-medical plans in 2015 that best suit your needs, please take an active role and make or confirm your selections during this Open Enrollment season.1. For Medicare eligible retirees age 65 and older,

the current health plans offered through your School District are ending. This also applies to your Medicare eligible spouse who is age 65 or older. Many of the plan choices available to you for the 2015 plan year closely mirror your 2014 plan options. You should - Select one of the new plan offerings by November 21, 2014. If you do not, you may be auto enrolled in UnitedHealthcare Plan 3. See page 11 for a description of this plan. If an election is not made by November 21, 2014 you may not receive your ID cards by January 1, 2015.

2. Your non-Medicare eligible spouse and eligible dependents will remain on the School District health plan until they become eligible for Medicare at age 65 or older. At that time, your spouse will have available to him or her the same plans that are available to you. You should –Respond to the Open Enrollment information sent by your School District.

3. You have three choices for paying the premiums for the plans you select. You should - Choose the payment option that works best for you. Information on each of the options is available in this guide on page 6. a. Recommended. Have your premiums deducted automatically from your FRS retirement benefit.b. Pay your premiums electronically directly from your personal bank account.c. Pay your premiums directly by check or money order. If you choose this option, coupons will be provided to you.

4. If you are enrolled in an individual Medicare plan directly with a provider, you may remain in that plan and maintain the current billing process. However, there are financial benefits to enrolling in a Medicare plan through this FSRBC program because your premiums can be deducted from your FRS retirement benefit, which is a tax benefit to you. You should – Confirm your benefits with your Medicare plan provider. No other action is needed on your part, unless you choose to enroll in a Medicare plan through the FSRBC program or in any of the non-medical benefits available to you through the FSRBC.

5. Your current dental and vision plans available through your School District will also be ending as of December 31, 2014. (Escambia retirees may keep their current dental coverage.) Dental, vision, identity theft, and IT technical support plans, specifically designed with retirees in mind, are now available to you and your dependents through the FSRBC. You should - Read the inserts in this package for details on these plans and enroll in your selections. See page 14 for enrollment instructions. An enrollment form and return envelope are also included for your convenience.

FLORIDA SCHOOL RETIREE BENEFIT CONSORTIUM REFERENCE GUIDE | 5

YoUR enRollMenT aT a GlanCe | 2015

WelcomeWelcome to your floRIDa sCHool ReTIRee benefITs ConsoRTIUM (fsRbC) 2015 Plan Open Enrollment. fbMC benefITs ManaGeMenT, InC. (fbMC) supports FSRBC by managing this program for you. We look forward to assisting you with your enrollment questions for your 2015 plan year benefits!

This Reference Guide and the supporting enrollment packet will highlight information about the benefits available to you and your dependents. It explains eligibility requirements, information about the coverage options available to you and your dependents, and provides instructions on how to enroll and important contact information. Separately, you will find inserts describing the non-medical benefits available to you and your dependents: dental, vision, identity theft, and IT technical support plans.

What’s New?• Medicare eligible retirees age 65 and over must

make new Medicare elections for the 2015 plan year to avoid losing coverage. An overview of the available plans is included in this Reference Guide.

• Medicare eligible retirees age 65 and over and their dependents are now eligible to enroll in any of the new dental, vision, identity theft protection, and IT technology support benefits plans. Additional information on these plans is provided in this package.

• Medicare eligible retirees age 65 and over and Medicare eligible dependents age 65 and over are offered an array of Medicare plans regardless of previous cancellation of Medicare plans. An overview of the available plans is included in this Reference Guide.

• All those under age 65, whether the retiree or dependent, will remain with the School District group health plan until turning age 65 and enrolling in Medicare Parts A and B.

• Please keep this reference guide for use during the plan year. It is also available on the FSRBC Learning Center at www.myFSRBC.org.

Your Enrollment at a Glance

Retiree Open EnrollmentMedical PlansYou can easily enroll in your selected Medicare Plan by telephone or by completing and submitting provider-specific enrollment forms. Be sure to review the chart on page 7 to see the options available to you based on where you live.• Health first Medicare advantage Plans - You will

automatically receive a Medicare Advantage kit at your home address if you reside in their area of coverage.

• Cigna leon Medical Center Health Plans - Leon Cares (HMO) Medicare Advantage Plan - You will automatically receive a Medicare Advantage kit at your home address if you reside in their area of coverage. Please note that Cigna uses paper enrollment only.

• UnitedHealthcare Plans - You will automatically receive an AARP Medicare Supplement kit at your home address. If you are interested in the UHC Medicare Advantage or Part D Prescription Drug Plans, please contact UHC at 1-877-776-1466, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week.

Non-Medical PlansDetailed information about the non-medical plans available to you is included in this package. Please complete the Non-Medical Enrollment Form in this package in its entirety to enroll in these benefits and return it to FBMC. Please call FBMC at 1-855-44fsRbC (1-855-443-7722) with any questions about non-medical benefits, Monday - Friday, 7 a.m. - 7 p.m. ET.

IMPoRTanT noTe: Please enRoll eaRlY To ensURe YoU ReCeIVe YoUR MeDICal Plan ID CaRDs anD To esTablIsH YoUR PaYMenT MeTHoD.


FSRBC | elIGIbIlITY ReqUIReMenTs

Any Medicare eligible retiree age 65 or over who is a retiree of a School District participating in the FSRBC is eligible for benefits coverage. For Medicare benefits, you and/or your dependent must be Medicare eligible and participate in Medicare Parts A & B.

Retiree’s spouse – a person to whom you are legally married.

Retiree’s Child(ren) – biological child, legally adopted child, stepchild, child for whom you have legal guardianship, or foster child (if eligible under your School District’s Plan) and currently enrolled in a sponsored plan.

Method of PaymentfRs DeductionRecommended option. Your premium payments can be submitted through deductions from your FRS retirement benefit. FBMC requires a completed and signed FRS Insurance Payroll Deduction Authorization Form (included in this package) if this payment method is selected. Until FRS deductions begin, payment by personal check or money order is required. FRS deductions are taken one month prior to the month of coverage.

Please note: Partial payments cannot be deducted - your monthly retirement benefit must be sufficient to cover your premium deductions. Otherwise, you will need to select another payment option.

aCH PaymentYou have the option of setting up electronic payments through your personal bank. If you choose this method of payment, be sure you notify your bank each time premium costs change to be sure your coverage continues. FBMC requires a completed and signed Direct Debit (ACH) Form, which is included in this package. All premiums must be paid by the due date.

Personal Check or Money order PaymentPremium payments can be submitted by personal check or money order directly to FBMC. If you choose this payment method, you will receive payment coupons for remittance of your premiums. All premiums must be paid by the due date.

Making Changes to Your Coverage Be sure to carefully consider your benefits elections. Coverage you select will remain in effect for the 2015 plan year. Coverage that is cancelled during the plan year cannot be reinstated until the next annual open enrollment period.

If you experience certain life changes during your coverage as a retiree, you may be able to increase or decrease your coverage levels based on the type of event.

If you are having premium payments deducted from your FRS retirement benefit or from your personal bank account (ACH) and are owed a refund, your refund will be completed as soon as verification is received that your deduction has changed. Refunds are processed one time each month and mailed no later than the 15th of the following month.

If your coverage change results in an increase in premium to be deducted from your FRS retirement benefit or personal bank account (ACH), you may need to pay the difference by check or money order until your deductions are flowing correctly.

Please send enrollment forms, correspondence and premium payments to:

fbMC benefits Management/Direct billP.o. box 10789Tallahassee, florida 32302-2789or fax: 1-850-514-5803

Eligibility Requirements


MeDICaRe Plans | 2015

IMPoRTanT: Your current Medicare Plan will no longer be available after December 31, 2014 and you will need to make a Medicare Plan selection for the 2015 plan year. There are a variety of options available to you, depending on your county of residence, and you can enroll in one of the following Medicare Plan Options, including: AARP Medicare Supplement Plans in addition to Original Medicare, Medicare Part D Prescription Drug Plans, and Medicare Advantage Plans. Please note that you will automatically receive an AARP Medicare Supplement kit at your home address, and for those living in the Cigna or Health First coverage areas, you will receive Medicare Advantage kits from those providers. Be sure to contact the appropriate provider for plan details, and remember that plan design and/or rates vary by county of residence. The following charts are intended to provide a summary of plan availability and benefits.

The plan options available to you are based upon where you live in Florida or in another state. See the charts below to learn more about the coverage options available to you for the 2015 plan year.

Plan OptionsMedicare supplement Plans Medicare Supplement Plans, sold by private companies, can help pay some of the health care costs that “Original Medicare” doesn’t cover, like copayments, coinsurance and deductibles. Original Medicare is fee-for-service coverage under which the government pays your health care providers directly for your benefits. Plans A, F and N are endorsed by the FSRBC; see your packet for options to continue other plans. These plans are available statewide and also out of state.

Medicare Part D Prescription Drug PlansMedicare Part D Prescription Drug Plans (sometimes called “PDPs”) add drug coverage to Original Medicare and some other types of Medicare plans. These plans are available statewide and also out of state. A brief summary of the Comprehensive Pharmacy Plan and Premier Pharmacy Plan can be found on page 9.

Medicare Plans

aaRP Medicare supplement Plans

Plan AUnitedHealthcare

1-877-776-1466 Packet will be mailed to youPlan FPlan N

Medicare Part D Perscription Drug Plan

Comprehensive Pharmacy Plan UnitedHealthcare1-877-776-1466

Call UHC for additional information or to request a complete packet.

Premier Pharmacy Plan


FSRBC | MeDICaRe sUPPleMenT, aDVanTaGe anD PResCRIPTIon DRUG Plans

Medicare Plans

Medicare Advantage PlansA Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. If you’re enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.

These plans are available in specific areas. See the chart beginning on page 12 for any Medicare Advantage Plans available in your county of residence. A high-level summary of the benefits available under these plans can be found on page 10.

Medicare advantage Plans – County specific

Zero Premium HMO Plan Cigna Leon Cares1-866-393-5366

Packet will be mailed to you if you live in the service area, as shown beginning on Page 12.

HMO Zero Premium PlanHealth First

1-800-716-7737

Packet will be mailed to you if you live in the service area, as shown beginning on Page 12.

Group Plus A HMOGroup HMO POSZero Premium PPO Plan

UnitedHealthcare1-877-776-1466

Call UHC for additional information or to request a complete packet.Comprehensive Option 3 National PPO

Low Premium National PPO


MeDICaRe sUPPleMenT, aDVanTaGe anD PResCRIPTIon DRUG Plans | 2015

supplement benefits Plan a Plan f Plan n

Part A Coinsurance and Hospital Costs √ √ √

Medicare Part B Coinsurance or Copayment √ √

Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that don’t result in an inpatient admission.

Blood (First 3 Pints) √ √ √Part A Hospice Care Coinsurance or Copayment √ √ √Skilled Nursing Facility Care Coinsurance √ √Medicare Part A Deductible ($1,216) √ √Medicare Part B Annual Deductible ($147) √Medicare Part B Excess Charges (15%) √Foreign Travel Emergency (To Limits*)*Care needed immediately because of an injury or an illness of sudden and unexpected onset. Benefit covers 80% and beneficiaries are responsible for 20%.

√ √

Medicare Supplement Plans

AARP Medicare Supplement Plan Benefits

Rx benefit Comprehensive Premier

Drug CoverageDrug List 100% + Bonus 100% + BonusInitial Coverage PeriodDeductible $0 $0Generic $2 to $10 $2 to $7Brand Preferred/Non-Preferred $45/$75 $30/$60Specialty 33% $75GapGeneric Preferred $2 to $10 $2 to $7Brand Preferred/Non-Preferred 55% Discount $30/$60Specialty 55% Discount $75CatastrophicGeneric $2.55 or 5% $2.55 or 5%Brand $6.35 or 5% $6.35 or 5%Monthly Premium $84.18 $155.31

UnitedHealthcare MedicareRx Plan



benefit HMo Zero Premium Plan

Group Plus a HMo

Group HMo Pos

Medical HMo HMo In-network out-of-networkAnnual Deductible $0 $0 $0 $0Annual Out-of-Pocket $6,650 $2,000 $3,000 $6,000Hospital Admit $260/Day to 7 Days $250 $150/Day to 5 Days 20%Office Visit $10/$35 $10/$20 $10/$15 20%Emergency Care $65 $50 $50 $50Outpatient Surgery $300 $125 $150 20%RxGeneric $0 to $10 $2 to $10 $2 to $10 N/ABrand $45/$95 $25/$45 $45/$90 N/ASpecialty 33% $90 33% N/ACoverage Gap Applies No Gap Applies AppliesIf you would like more information about the Health First Plans or have questions, please call Health First Member Services, at 1-800-716-7737, from 8:00 a.m. to 8:00 p.m., seven days a week.

benefit Zero Premium Comprehensive Plan 3Medical In-network out-of-network In-network out-of-networkAnnual Deductible $0 $0 $0Annual Out-of-Pocket $4,500 $10,000

combined$2,500

Hospital Admit $275/Day to 6 Days

40% $175 $175

Office Visit $10/$40 $35/$60 $5/$15 $5/$15Emergency Care $65 $65 $65 $65Outpatient Surgery 20% 40% $15 $15RxGeneric $7 N/A $5 N/ABrand $40/$90 N/A $30/$60 N/ASpecialty $90 N/A $80 N/ACoverage Gap Applies N/A No Gap N/AIf you would like more information about the UnitedHealthcare Group Medicare Advantage plan or to receive a complete pre-enrollment plan guide, call UnitedHealthcare at 1-877-776-1466, TTY 711, 8 a.m. – 8 p.m. local time, seven days a week.

Medicare Advantage Plans

Health First Medicare AdvantageBrevard County (See chart for available Medicare Advantage Plans by county of residence.)

UnitedHealthcare Medicare AdvantageBrevard County & Duval County(See chart for available Medicare Advantage Plans by county of residence.)



benefit low Premium Comprehensive Plan 3Medical In-network out-of-network In-network out-of-networkAnnual Deductible $400 Med & $320 Rx $0Annual Out-of-Pocket $6,700 $2,500Hospital Admit $230/Day to

7 Days$230/Day to

7 Days$175 $175

Office Visit $25/$50 $25/$50 $5/$15 $5/$15Emergency Care $65 $65 $65 $65Outpatient Surgery 20% 20% $15 $15RxGeneric 25% $5 N/ABrand 25% $30/$60 N/ASpecialty 25% $80 N/ACoverage Gap Applies No Gap N/AIf you would like more information about the UnitedHealthcare Group Medicare Advantage plan or to receive a complete pre-enrollment plan guide, call UnitedHealthcare at 1 877-776-1466, TTY 711, 8 a.m. – 8 p.m. local time, seven days a week.

UnitedHealthcare Medicare AdvantageEscambia County & Miami-Dade County (See chart for available Medicare Advantage Plans by county of residence.)

benefit Zero PremiumMedical HMoAnnual Deductible $0Annual Out-of-Pocket $3,400Hospital Admit $0Office Visit $0Emergency Care $0Outpatient Surgery $0RxGeneric $0Brand $0Specialty 33%Coverage Gap AppliesIf you would like more information about the Leon Medical Centers Health Plans or have questions, please call Leon Medical Centers Health Plans Member Services, at 305-229-7543 or toll-free 1-866-266-8917 or, for TTY users, 711, from 8:00 a.m. to 8:00 p.m., seven days a week.

Cigna Leon Medical Center Health Plans - Leon Cares (HMO)Miami-Dade County(See chart for available Medicare Advantage Plan by county of residence.)

Medicare Advantage Plans



The table below details the Medicare Advantage Plans available by county. Plan options may vary by county and state. If you would like to enroll in one of the Medicare Advantage Plans or receive more information, please contact the appropriate provider. Contact information is available on page 8 of this guide.

County/ Metro Area Zero / Low Premium Plan Health FirstPlan 1

Health FirstPlan 2

UHCPlan 3

Alachua $301

Baker $301

Bay $301

Bradford $301

Brevard Health First / UHC $154.00 $195.00 $301

Broward $328

Calhoun $301

Charlotte $301

Citrus UHC $301

Clay UHC - $45 $312

Collier UHC $301

Columbia $301

De Soto $312

Dixie UHC $301

Duval UHC $312

Escambia UHC-$25 $232

Flagler UHC $232

Franklin $232

Gadsden $328

Gilchrist $312

Glades $301

Gulf $312

Hamilton $312

Hardee $312

Hendry $328

Hernando UHC $312

Highlands $312

Hillsborough UHC $301

Holmes $301

Indian River UHC / Health First $154.00 $195.00 $312

Jackson $312

Jefferson $328

Lafayette $312

Medicare Advantage Plan Enrollment Options By County of Residence



Medicare Advantage Plan Enrollment Options By County of Residence

County/ Metro Area Zero / Low Premium Plan Health FirstPlan 1

Health FirstPlan 2

UHCPlan 3

Lake UHC $312

Lee UHC $301

Leon $328

Levy $301

Liberty $312

Madison UHC $312

Manatee UHC $301

Marion UHC $312

Martin UHC $328

Miami-Dade UHC-$45 / Cigna $328

Monroe $328

Nassau $301

Okaloosa $301

Okeechobee $312

Orange UHC $301

Osceola UHC $232

Palm Beach $328

Pasco UHC $312

Pinellas UHC $301

Polk UHC- $55 $301

Putnam $301

Santa Rosa $312

Sarasota UHC $301

Seminole UHC $301

St. Johns UHC $312

St. Lucie $312

Sumter UHC $312

Suwannee UHC $312

Taylor $232

Union $312

Volusia $232

Wakulla $312

Walton $301

Washington $312

The table below details the Medicare Advantage Plans available by county. Plan options may vary by county and state. If you would like to enroll in one of the Medicare Advantage Plans or recieve more information, please contact the appropriate provider. Contact information is available on page 8 of this guide.


FSRBC | HoW To enRoll

How to Enroll

Information on this page tells you how to enroll in your Medicare and non-medical benefit choices for 2015.

Medicare benefitsOnce you choose your Medicare Plan, you have two ways to enroll. You can complete your Medicare Plan enrollment by:

1. Calling the Medicare provider directly by telephone, or

2. Completing and submitting a provider-specific enrollment form.

enrolling in the Cigna Medicare PlanIf you live in the Cigna service area, you will receive a packet with information about their Medicare Advantage Plan. If you wish to enroll in the Cigna Plan, complete the form you received in your Cigna packet and return the signed form to Cigna at the following address. You can also call Cigna at the number below if you have questions about their plan.leon Medical Center Health Plans - leon Cares (HMo)P.o. box 66-9440Miami, fl 33166 or call 1-866-393-5366, TTY 711, 8 a.m. - 8 p.m., 7 days a week.

enrolling in a Health first Medicare PlanIf you live in the Health First service area, you will receive a packet with information about their Medicare Advantage Plans. If you wish to enroll in a Health First Plan, complete the form you receive in your Health First packet and return the signed form to Health First at the following address. You can also call Health First at the number below if you have questions about their plan.Health first Medicare Plan6450 Us Hwy. 1Rockledge, fl 32955 or call 1-800-716-7737

enrolling in a UnitedHealthcare (UHC) Medicare PlanThe easiest method to enroll in any of the UHC plans is to call UHC directly at 1-877-776-1466, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. The UHC call center staff will record your enrollment in any of the UHC Medicare options available.

UHC will mail an AARP Medicare Plan enrollment kit describing the AARP Medicare Supplement Plans

available to you. If you wish to enroll in a UHC Plan using the application, complete the application you receive in your AARP Medicare Plan Enrollment kit and return the signed form to UHC at the following address: UnitedHealthcare enrollment DivisionP.o. box 105331atlanta, Ga 30348-5337

If you wish to enroll in a UHC Part D Prescription Drug Plan or Medicare Advantage Plan, call UHC at 1-877-776-1466. You may enroll by phone or request a plan guide. You can complete the application in the packet and return the signed application to UHC at the following address:UnitedHealthcare enrollment DepartmentP.o. box 29675Hot springs, aR 71903 or fax to: 501-262-7070

Medical benefits for non-Medicare eligible DependentsYour dependent(s) not yet eligible for Medicare may retain their health coverage through the School District group medical plan. Your non-Medicare eligible dependent(s) will enroll for their medical plan for 2015 by responding to the Open Enrollment information sent by your School District.

fbMC non-Medical benefitsNon-medical benefits plans have been selected specifically with retirees and their dependents in mind. The inserts included in this Enrollment Package provide information about the valuable benefits, including dental, vision, identity theft, and IT technical support. In most cases, these dental and vision products will replace the dental and vision products previously available to you through your School District’s group plans.

steps to Complete fbMC non-Medical enrollment form:Complete Section 1 (Your personal information).

Place a “√” in the box next to the plan in which you would like to enroll. Be sure to specify the coverage level (ex: Retiree and Spouse). By entering the amount of your selections in the Premium column, you will be able to calculate your total monthly premium.

Be sure to list all dependents who should be covered under your plan. Sign and date form.


CoMPlIanCe anD leGal | 2015

FBMC Statement

This statement applies to products administered by FBMC Benefits Management, Inc. FBMC takes your privacy very seriously. As a provider of products and services that involve compiling personal-and sometimes, sensitive-information, protecting the confidentiality of that information has been, and will continue to be, a top priority of FBMC. This Privacy Statement explains how FBMC handles and protects the personal information we collect. Please note that the information we collect and the extent to which we use it will vary depending on the product or service involved. In many cases, we may not collect all of the types of information noted below. Note this Privacy Statement is not meant to be a Privacy Notice as defined by the Health Insurance Portability and Accountability Act (HIPAA), as amended.

FBMC’s privacy statement is as follows:

I. We collect only the customer information necessary to consistently deliver responsive services.FBMC collects information that helps serve your needs, provide high standards of customer service, and fulfill legal and regulatory requirements. The sources and types of information collected generally vary depending on the products or services you request and may include:Information provided on enrollment and related forms - for example, name, age, address, Social Security number, e-mail address, annual income, health history, marital status, and spousal and beneficiary information. Responses from you and others such as information relating to your employment and insurance coverage. Information about your relationships with us, such as products and services purchased, transaction history, claims history, and premiums. Information from hospitals, doctors, laboratories and other companies about your health condition, used to process claims and prevent fraud.

II. Under federal law you have certain rights with respect to your protected health information.You have rights to see and copy the information, receive an accounting of certain disclosures of the information and, under certain circumstances, amend the information. You also have the right to file a complaint with your Employer or with the Secretary of the U.S. Department of Health and Human Services if you believe your privacy rights have been violated.

III. We maintain safeguards to ensure information security. We are committed to preventing unauthorized access to personal information. We maintain physical, electronic, and procedural safeguards for protecting personal information. We restrict access to personal information to those employees, insurance companies, and service providers who need to know that information to provide products or services to you.

IV. We limit how, and with whom, we share customer information.We do not sell lists of our customers, and under no circumstances do we share personal health information for marketing purposes. With the following exceptions, we will not disclose your personal information without your written authorization. We may share your personal information with insurance companies with whom you are applying for coverage, or to whom you are submitting a claim. We will share personal information of VISTA 401(k) participants with the plan’s recordkeeper. We also may disclose personal information as permitted or required by law or regulation. For example, we may disclose information to comply with an inquiry by a government agency or regulator, in response to a subpoena, or to prevent fraud. If you no longer have a customer relationship with us, we will still treat your information under our Privacy Policy, the words “you” and “customer” are used to mean any individual who obtains or has obtained an insurance, financial product or service from FBMC that is to be used primarily for personal or family purposes.

Notice of Administrator’s Capacity

This notice advises insured persons of the identity and relationship among the contract administrator, the policyholder and the insurer:1. Contract administrator. FBMC Benefits Management (FBMC) has been authorized by your employer to provide administrative services for your employer’s insurance plans offered within your benefit program. In some instances, FBMC may also be authorized by one or more of the insurance companies underwriting the benefits to provide certain services, including, but not limited to: marketing; billing and collection of premiums; and processing insurance claims payments. FBMC is not the policyholder or the insurer.2. Policyholder. This is the entity to whom the insurance policy has been issued; the employer is the policy holder for group insurance products and the employee is the policyholder for individual products. The policyholder is identified on either the face page or schedule page of the policy or certificate.3. Insurer. The insurance companies noted herein have been selected by your employer, and are liable for the funds to pay your insurance claims.If FBMC is authorized to process claims for the insurance company, we will do so promptly. In the event there are delays in claims processing, you will have no greater rights to interest or other remedies against FBMC than would otherwise be afforded to you by law. FBMC is not an insurance company.

Compliance and Legal

FSRBC | ConTaCT InfoRMaTIon

FBMC/FSRBC/1014

© FBMC 2014

Information contained herein does not constitute an insur-ance certificate or policy. Certificates will be provided to participants following the start of the plan year, if applicable.

Contract Administrator FBMC Benefits Management, Inc.

P.O. Box 1878 • Tallahassee, Florida 32302-1878Service Center 1-855-44FSRBC (1-855-443-7722)

www.myFBMC.com

Cigna - leon Medical Center Health Plans - leon Cares (HMo)Customer service 1-866-393-5366, TTY 7117 days a week, 8 a.m. - 8 p.m.P.o. box 66-9440Miami, fl 33166

Davis Vision – Please see the insert for benefit informationClient Code# 3651Customer service 1-800-999-5431Mon - Fri, 8 a.m. - 11 p.m. ET. Sat - 9 a.m. - 4 p.m.Sun - 12 p.m. - 4 p.m.www.davisvision.com

fbMC benefits Management, Inc./Direct bill(Contract administrator) service Center1-855-44fsRbC (1-855-443-7722)Mon - Fri, 7 a.m. - 7 p.m. ET.P.O. Box 10789Tallahassee, FL 32302www.fbmc.com

florida Retirement system (fRs)bureau of Retirement Calculations1-888-738-2252enrollment section1-877-377-3675www.myfrs.com

Health first Medicare PlanCustomer service 1-800-716-77377 days a week, 8 a.m. - 8 p.m.6450 US Hwy. 1Rockledge, FL 32955www.myhfhp.org

Humana Dental– Please see the insert for benefit informationCustomer service 1-800-233-4013Mon - Fri, 8 a.m. - 6 p.m.www.humanadental.com

IDCommander (Identity Theft) – Please see the insert for benefit informationMembership services 1-855-592-7941Mon - Fri 9 a.m. - 6 p.m. ET.

ITPlease – Please see the insert for benefit information(Technology support)Membership services 1-888-384-7935Mon – Fri 9 a.m. – 6 p.m. ET.

UnitedHealthcareCustomer service (for all plans)1-877-776-1466, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week

enrollment materials for UHC Medicare supplement Plan should be returned to:UnitedHealthcare enrollment DivisionP.O. Box 105331Atlanta, GA 30348-5337

enrollment materials for UHC Part D Prescription Plan or Medicare advantage Plan should be returned to:UnitedHealthcare enrollment DepartmentP.O. Box 29675Hot Springs, AR 71903 or fax to: 501-262-7070

Contact Information