Retiree Insurance Benefits For Plan Year

October 1, 2016 to September 30, 2017

 Medical  Medicare Supplement  Life  Dental  Vision

OCPS RETIREES: INSURACE SUMMARY RATE SHEET The following are monthly rates for retirees who are not eligible for Medicare. I. Medical Insurance PLAN A: LOCAL PLUS OAP IN-NETWORK

PLAN B: HEALTH REIMBURSEMENT ACCOUNT (HRA)

PLAN C: OAP IN-NETWORK (PREMIUM)

Retiree

$ 678.82

$ 709.90

$ 709.90

Retiree + Children

$ 720.50

$ 1,158.70

$ 970.92

Retiree + Spouse

$ 887.17

$ 1,349.18

$ 1,144.90

Retiree + Children + Spouse

$ 928.83

$ 1,526.92

$ 1,307.23

Spouse*

$678.82

$709.90

$709.90

Spouse + Children*

$720.50

$1,158.70

$970.92

Children Only*

$250.00

$448.80

$448.80

CIGNA PLANS

*When retiree is enrolled in an FSRBC plan

II. Term Life Insurance *rates subject to change $ 1,000

$ 4.09

$ 5,000 (health questions required)

$ 20.45

$ 10,000 (health questions required)

$ 40.90

III. Group Universal Life (GUL) Please refer to the Group Universal Life section of the OCPS Retiree Handbook. IV. Dental Insurance A: DELTACARE USA MANAGED DENTAL PLAN BASIC

B: DELTACARE USA MANAGED DENTAL PLAN COMPREHENSIVE

C: DELTA DENTAL PPO (PREFERRED PROVIDER ORGANIZATION) PLAN

Retiree Only

$ 8.02

$ 13.12

$ 34.30

Retiree + 1 Dependent

$ 13.25

$ 24.53

$ 58.90

Retiree + 2 or More Dependents

$ 19.58

$ 30.03

$ 84.23

V. Vision Care VISION CARE PLAN Retiree Only

$ 5.27

Retiree + Dependents

$ 14.58

TABLE OF CONTENTS

I.

GENERAL INSURANCE INFORMATION

II.

MEDICAL INSURANCE

A. B. C. D. E. F. G.

A. B. C. D. E.

Enrollment Information …………………………………………………………….2 Plan Overviews ……………………………………………………………………..5 Frequently Called Phone Numbers ……………………………………………….7 Websites for Provider Directories …………………………………………………8 Use and Disclosure of Protected Health Information ……………………………9 Notice of Privacy Practices ………………………………………………………12 Plan Administration ……………………………………………………………….20

Cigna LocalPlus In-Network ……………………………………………………..21 Cigna Health Reimbursement Account (HRA) …………………………………37 Cigna OAP In-Network …………………………………………………………...56 CVS/Caremark Pharmacy Benefit ………………………………………………72 Orlando Behavioral Heathcare …………………………………………………..91 (Mental Health and Chemical Dependency Coverage)

III.

MEDICARE SURROUND PLAN ……………….………………….….....….95

IV.

TERM LIFE INSURANCE ……………….……………………………..…….96

V.

GROUP UNIVERSAL LIFE INSURANCE (GUL) ……………..……..……97

VI.

DENTAL INSURANCE

Coverage Overview …………………………………………………………………..98 A. DeltaCare® USA Basic Managed Care Dental Plan ………………………….103 B. DeltaCare® USA Comprehensive Managed Care Dental Plan ……………...119 C. Delta Dental PPO Dental Plan …………………………………………………134 (Preferred Provider Organization)

D. Orthodontics Discount Program for Retirees …………………………………154 E. Vision Discount Program for Retirees …………………………………………155 VII.

VISION INSURANCE ………………………………………………………..156

VIII.

GLOSSARY …………………………………………………………………..161

I. GENERAL INSURANCE INFORMATION

A. ENROLLMENT INFORMATION B. PLAN OVERVIEWS C. FREQUENTLY CALLED PHONE NUMBERS D. WEBSITES FOR PROVIDER DIRECTORIES E. USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION F. NOTICE OF PRIVACY PRACTICES G. PLAN ADMINISTRATION

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A. ENROLLMENT INFORMATION ELIGIBILITY Benefits are generally limited to: Retirees Individuals who have retired from Orange County Public Schools. Retirees may not be covered as a dependent on another OCPS medical plan. In order to have any coverage, all eligible retirees must complete the enrollment process through Total Administrative Services Corporation (TASC). Dependents The following definition of dependents applies to the medical plan. Dependent children and domestic partner eligibility will vary by type of coverage (i.e. dental, vision, life). Review specific plan details for more information. Retirees must provide documented proof of dependency at the time of enrollment or as requested by TASC. Failure to provide documented proof of dependency will result in termination of the dependent on the last day of the month, following 60 days from the date of notification to the Retiree, by regular U.S. Mail to the Retiree’s last known address as shown by the records of TASC. 1. Spouse (supported by a marriage certificate) 2. The Retiree’s same-sex domestic partner (as supported by the OCPS Domestic Partner Affidavit, proof of residency and financial co-dependence). A domestic partner must meet the following requirements to enroll in a medical plan: a. Same gender as retiree. b. Must be 18 years of age and mentally competent. c. Not related by blood in a manner that would bar marriage under Florida law. d. The domestic partner must be the Retiree’s "sole spousal equivalent" and not married to or partnered with any other spouse, spousal equivalent or domestic partner. e. The retiree and domestic partner must share the same residence and live together in an exclusive, committed relationship and intend to do so indefinitely. f. Must assume joint responsibility for basic living expenses—food, shelter, common necessities of life and welfare. g. Neither partner has had another domestic partner at any time during the twelve (12) months preceding enrollment. (The length of cohabitation is waived for first time domestic partner applicants.) 3. A child of the covered Retiree or the covered Retiree’s spouse through the end of the calendar year in which the child attains the age of 26 (as supported by a birth certificate). The term child includes: a. A natural child. b. A stepchild. c. A legally adopted child. d. A child for whom the covered Retiree or the covered Retiree’s spouse has legal guardianship. e. A child for whom health care coverage is required through a “Qualified Medical Child Support Order” or other court or administrative order. f. A dependent of a currently enrolled dependent (e.g. your grandchild). A newborn child of a covered dependent child is eligible from birth until the end of the month in which the child reaches 18 months of age. Otherwise, grandchildren’s eligibility is contingent upon legal guardianship. 4. A child of the Retiree’s domestic partner through the end of the calendar year in which the child attains the age of 26 (as supported by required domestic partner documentation and child’s birth certificate). A child of a Retiree’s domestic partner includes:

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a. b. c. d.

A natural child. A legally adopted child. A child for whom the covered Retiree’s domestic partner has legal guardianship. A child for whom health care coverage is required through a “Qualified Medical Child Support Order” or other court or administrative order. e. A dependent of a currently enrolled dependent (e.g. your grandchild). A newborn child of a covered dependent child is eligible from birth until the end of the month in which the child reaches 18 months of age. Otherwise, grandchildren’s eligibility is contingent upon legal guardianship. 5. An adult child covered in 3 and 4 above may continue coverage through the end of the calendar year in which the child attains the age of 30 if the adult child meets all of the following conditions: a. Unmarried; and b. No dependent children of their own; and c. Full-time or part-time student or reside in the State of Florida, if not a student; and d. Does not have private insurance coverage and is not eligible for public insurance coverage including coverage under Title XVII of the Social Security Act. The premium is equal to the single adult rate for COBRA continuation coverage. Coverage for an unmarried dependent child who is already enrolled in an OCPS medical plan and is not able to be self-supporting because of mental or physical handicap will not end just because the child has reached a certain age. Coverage will be extended beyond the limiting age for as long as the child is incapacitated and primarily dependent upon the Covered Retiree for support and maintenance. Annual documentation is required. NOTE: When a dependent is no longer eligible for coverage, it is the Retiree’s responsibility to contact the TASC office to verify that the correct amount of premium deduction is taken. Coverage will be effective upon approval and notification from TASC. TERMINATION OF COVERAGE Benefits generally end: 1. The first day of any month for which continuous premium payments are not made 2. When dependents are no longer considered eligible under these plans a. Grandchildren who are covered as a dependent of dependent (other than spouse/domestic partner). b. If the parent becomes ineligible during the grandchild’s 18 months eligibility period, coverage for both the parent and the child will terminate. 3. When these plans are no longer in force. 4. The last day of the month preceding the date the Retiree attains the age of 65, with respect to a Retiree who becomes eligible for Medicare on or after January 1, 2004, and who does not enroll in Medicare Part A and Part B and comply with the applicable verification and written request requirements. 5. When the Retiree fails to provide documented proof of dependency at enrollment or when requested by the TASC: a. Coverage ends the last day of the month following 60 days from the date of notification to the Retiree, by regular U.S. Mail to the Retiree’s last known address as shown by the records of TASC.

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PLAN YEAR October 1 through September 30 of each year for retirees NOT enrolled in Medicare. TERMS OF ENROLLMENT All eligible Retirees and dependents can drop coverage at any time during the plan year but will never be able to enroll in any of the medical plans again. RENEWALS Once enrolled, your coverage automatically will be continued unless you notify the TASC office in writing of your desire to terminate or unless the coverage is no longer offered. MONTHLY PREMIUMS Premiums are due prior to the first of each month for that month’s coverage and are payable to Total Administrative Services Corporation (TASC). IDENTIFICATION CARDS The identification card (ID card) for the medical insurance plan you select will be mailed to your home address. You should present this ID card when you utilize one of the providers/services. You also will receive a separate card for your pharmacy benefit. You should present this card when you have any prescriptions filled at a retail pharmacy. All Cigna members will receive a new card for the 2016-17 plan year. If your ID card is stolen or misplaced, please contact the appropriate carrier or administrator. DISCLAIMER The information contained in this handbook is a summary of the coverages for each plan. If there is a conflict between the information in this handbook and the actual plan documents or policies, the documents or policies will always govern. Complete details about the benefits can be obtained by reviewing current plan descriptions, contracts, certificates, policies and plan documents. OCPS EEO NON-DISCRIMINATION STATEMENT The School Board of Orange County, Florida, does not discriminate in admission or access to, or treatment or employment in its programs and activities, on the basis of race, color, religion, age, sex, national origin, marital status, disability, genetic information, sexual orientation, gender identity or expression, or any other reason prohibited by law. The following individuals at the Ronald Blocker Educational Leadership Center, 445 W. Amelia Street, Orlando, Florida 32801, attend to compliance matters: ADA Coordinator & Equal Employment Opportunity (EEO) Supervisor: Carianne Reggio; Section 504 Coordinator: Latonia Green; Title IX Coordinator: James Larsen. (407.317.3200)

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B. PLAN OVERVIEWS MEDICAL INSURANCE One of the benefits you may purchase as a retiree of OCPS is medical insurance. You may choose one of the options described below. Medical insurance also is available for your spouse/domestic partner and/or your eligible children. Plan A: Cigna Local Plus OAP In-Network When using this plan, you can go to any provider within the network to identify, evaluate and help manage all your healthcare needs. This network is limited to specific providers in central Florida. Plan B: Cigna Health Reimbursement Account With this plan, you have the option to go to any medical person and facility. However, when choosing the providers in the network, your benefit coverage will be at a greater level than when opting to receive services outside the network. Plan C: Cigna OAP In-Network When using this plan, you can go to any provider within the network to identify, evaluate and help manage all your healthcare needs. Medicare Surround Plans Once you or your spouse become(s) eligible for Medicare Parts A and B, benefits are available through the Florida School Retiree Benefits Consortium (FSRBC). You must enroll in Medicare Parts A (Hospital) and B (Physician) and one of the FSRBC plans. If any other family members are currently covered under your medical plan, they can select one of the three previously described medical plans. All family members must enroll in the same plan. TERM LIFE INSURANCE The term life insurance offered by OCPS provides life insurance protection while you are a Retiree. GROUP UNIVERSAL LIFE INSURANCE (Underwritten by Minnesota Life Insurance Company) Portability Participating employees, spouses/domestic partners and dependent children may continue their coverage on a direct-bill basis if the employee terminates employment or retires after the plan effective date or if a spouse or child no longer meets the eligibility requirement. Minimum rates (cost of insurance) may increase in the future. For more information concerning portability, please contact Minnesota Life at 1.866.293.6047. DENTAL INSURANCE Dental insurance is provided to Retirees of OCPS and their dependents. OCPS provides three different options of quality dental care. You may choose from either two managed care plans or a PPO plan. DeltaCare® USA Basic Managed Care Dental Plan (HMO Type) The main focus of this plan is preventive dentistry and is designed for individuals who currently have healthy teeth and gums. You must use a participating general dentist to receive benefits. If you are referred to a participating dental specialist (or if you refer yourself), you will receive a 25 percent reduction from usual and customary fees for services performed. DeltaCare® USA Comprehensive Managed Care Dental Plan (HMO Type) If you select this plan, you will be able to receive regular checkups, cleanings and x-rays at no charge. A benefits and copayment schedule is enclosed that shows the amount you will be responsible to pay. To be eligible for this plan, you will need to select a dentist from the enclosed list. If you are referred to a participating dental specialist, you will pay no more than what is listed in the schedule. Orthodontic care

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also is a covered benefit. There is little paperwork with this plan, and there are no maximum benefit restrictions with the exception of orthodontia and accidental injury to the sound natural teeth. Delta Dental PPO (Preferred Provider Organization) Dental Plan You may select any dentist you wish under this plan. However, if you choose a preferred dentist from the PPO dental plan list, you receive greater coverage and have lower out-of-pocket costs. The enclosed schedule of benefits shows the maximum amount the PPO dentist will be reimbursed for each procedure code. You will be responsible for any applicable deductible and/or coinsurance amounts. With this plan the maximum benefit each year is $1,300. For procedures that are not diagnostic and preventive, there is a $25 calendar year deductible (maximum $75 per family) when using the in-network PPO dentists and a $50 calendar year deductible (maximum $150 per family) when using the out-of-network dentists. Orthodontic Discount Program for Retirees You and your family are eligible to receive discounts on Orthodontics through this plan. There is no monthly premium and it is not necessary to complete any enrollment forms. Upon showing proper proof that you are a Retiree of OCPS, you and any dependent can receive the 25% discount on Orthodontics. The participating orthodontist will ask for proper proof of retirement from OCPS. To receive a list of participating orthodontists, please call 407.660.9034 and leave your name and email address. Vision Discount Program for Retirees You and your family are eligible to receive a courtesy discount on vision care up to 35%. There are no monthly premiums and it is not necessary to complete any enrollment forms. To print an ID card and get a list of participating EyeMed providers, visit www.eyemedvisioncare.com/deltadental or call 1.866.246.9041. When scheduling your appointment, inform the office that you are an EyeMed member with a Delta Dental discount plan. Present your printed ID card at your appointment to receive discounted services. Plan Administration DeltaCare® USA Basic and Comprehensive Managed Care Plans: Private Medical-Care, Inc. 1130 Sanctuary Parkway, Suite 600 Alpharetta, GA 30009 800.422.4234 Delta Dental PPO (Preferred Provider Organization) Plan: Delta Dental Insurance Company Attn: Professional Services Dept. 1130 Sanctuary Parkway, Suite 600 Alpharetta, GA 30009 800.616.3629 VISION INSURANCE Being a retiree of OCPS gives you the opportunity to purchase vision insurance. If you select the Humana Specialty Benefits Vision Plan, you receive prepaid services for routine eye care – vision exam plus glasses (lenses and frames) or contacts – through a nationwide network, including more than 1,000 eye doctors in Florida.

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C. FREQUENTLY CALLED PHONE NUMBERS Cigna (For All Cigna Medical Plans)

1.800.244.6224

CVS/Caremark

1.800.378.9264

Total Administration Services Corporation (TASC)

1.800.422.4661

DeltaCare® USA Managed Dental Plans

1.800.422.4234

Delta Dental PPO (Preferred Provider Organization) Dental Plan

1.800.616.3629

Employee Wellness Program

407.317.3200, Ext. 200 2929

Humana Specialty Benefits Vision Plan

1.800.865.3676

Lincoln Financial Group Disability Plan

1.800.423.2765

Minnesota Life Insurance Group Universal Life

1.800.843.8358

OCPS Insurance Benefits Office

407.317.3245

Orlando Behavioral Healthcare

407.637.8080

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D. WEBSITES (FOR PROVIDER DIRECTORIES) Plan A: Cigna Local Plus OAP In-Network

www.cigna.com Choose Find A Doctor. Click on the For plans offered through work or school… link, enter a search location, then click the down arrow at Select a Plan, choose LocalPlus. In the Looking For box, enter the provider’s name, specialty or type of service. Click Search.

Plan B: Cigna Health Reimbursement Account

www.cigna.com Choose Find A Doctor. Click on the For plans offered through work or school… link, enter a search location, then click the down arrow at Select a Plan, choose Open Access Plus, OA Plus, Choice Fund OA Plus. In the Looking For box, enter the provider’s name, specialty or type of service. Click Search. Please note, when looking for a specialist, the copay is reduced from $60 to $40 when you choose a Cigna Care Designation provider.

Plan C: Cigna OAP In-Network

www.cigna.com Choose Find A Doctor. Click on the For plans offered through work or school… link, enter a search location, then click the down arrow at Select a Plan, choose Open Access Plus, OA Plus, Choice Fund OA Plus. In the Looking For box, enter the provider’s name, specialty or type of service. Click Search.

CVS/Caremark

www.caremark.com

Total Administration Services Corporation (TASC)

www.tasconline.com

DeltaCare® USA Managed Dental Plans

www.deltadentalins.com Under Find a Dentist, select plan network, DeltaCare USA (for the DeltaCare Basic or Comprehensive plans). Select your state, then your city or zip code.

Delta Dental PPO (Preferred Provider Organization)Dental Plan

www.deltadentalins.com Under Find a Dentist, select your plan network, Delta Dental PPO. Select your state, then your city or zip code.

Humana Specialty Benefits Vision Plan

www.humanavisioncare.com Select HumanaVision VCP provider locator. Enter your address or zip code. Click Search.

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E. USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION The Medical Indemnity Plan of the Orange County Public Schools (the “Plan”) will use protected health information (“PHI”) to the extent of and in accordance with the uses and disclosures permitted by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). Specifically, the Plan will use and disclose PHI for purposes related to health care treatment, payment for health care and health care operations. The Notice of Privacy Practices for the Plan is found in Section F. PAYMENT FOR HEALTH CARE Payment includes activities undertaken by the Plan to obtain premiums or determine or fulfill its responsibility for coverage and provision of Plan benefits that relate to an individual to whom health care is provided. These activities include, without limitation, the following: 1.

Determination of eligibility, coverage and cost sharing amounts (for example, cost of a benefit, plan maximums and copayments as determined for an individual’s claim).

2.

Coordination of benefits.

3.

Adjudication of health benefit claims (including appeals and other payment disputes).

4.

Subrogation of health benefit claims.

5.

Establishing employee contributions.

6.

Adjusting amounts due based on enrollee health status and demographic characteristics.

7.

Billing, collection activities and related health care data processing.

8.

Claims management and related health care data processing, including auditing payments, investigating and resolving payment disputes and responding to participant inquiries about payments.

9.

Obtaining payment under a contract for reinsurance (including stop-loss and excess of loss insurance).

10.

Medical necessity reviews or appropriateness of care or justification of charges reviews.

11.

Utilization review, including precertification, preauthorization, concurrent review and retrospective review.

12.

Disclosure to consumer reporting agencies related to the collection of premiums or reimbursement (the following PHI may be disclosed for payment purposes: name, address, date of birth, Social Security number, payment history, account number, name and address of the provider and/or health plan).

13.

Reimbursement to the Plan.

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HEALTH CARE OPERATIONS Health Care Operations include, without limitation, the following activities: 1.

Quality assessment.

2.

Population-based activities relating to improving health or reducing health care costs, protocol development, case management and care coordination, disease management, contacting health care providers and patients with information about treatment alternatives and related functions.

3.

Rating provider and Plan performance, including accreditation, certification, licensing or credentialing activities.

4.

Underwriting, premium rating and other activities relating to the creation, renewal or replacement of a contract of health insurance or health benefits, and ceding, securing or placing a contract for reinsurance of risk relating to health care claims (including stop-loss insurance and excess of loss insurance).

5.

Conducting or arranging for medical review, legal services and auditing functions, including fraud and abuse detection and compliance programs.

6.

Business planning and development, such as conducting cost-management and planningrelated analyses related to managing and operating the Plan, including formulary development and administration, development or improvement of payment methods or coverage policies.

7.

Business management and general administrative activities of the Plan, including, without limitation: a. Management activities relating to the implementation of and compliance with HIPAA’s administrative simplification requirements, or b. Customer service, including the provision of data analyses for policyholders, Plan sponsors or other customers.

8.

Resolution of internal grievances.

9.

Due diligence in connection with the sale or transfer of assets to a potential successor in interest, if the potential successor in interest is a “covered entity” under HIPAA or, following completion of the sale or transfer, will become a covered entity under HIPAA.

THE PLAN WILL USE AND DISCLOSE PHI AS REQUIRED BY LAW AND AS PERMITTED BY AUTHORIZATION OF THE PARTICIPANT OR BENEFICIARY With an authorization, the Plan will disclose PHI to the Disability Insurance Plan or any other benefit plan of Orange County Public Schools that requires PHI as a prerequisite to obtain benefits for purposes related to administration of those plans. ORANGE COUNTY PUBLIC SCHOOLS IS THE PLAN SPONSOR The Plan will disclose PHI to the Plan Sponsor only upon receipt of a certification from the Plan Sponsor that the Plan documents have been amended to incorporate the provisions and conditions outlined below.

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WITH RESPECT TO PHI, THE PLAN SPONSOR AGREES TO CERTAIN CONDITIONS The Plan Sponsor agrees to: 1.

Not use or further disclose PHI other than as permitted or required by the Plan document or as required by HIPAA.

2.

Ensure that any agents, including a subcontractor, to whom the Plan Sponsor provides PHI received from the Plan agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to such PHI.

3.

Not use or disclose PHI for employment-related actions and decisions unless authorized by an individual. Not use or disclose PHI in connection with any other benefit or employee benefit plan of the Plan Sponsor unless authorized by an individual.

4. 5.

If it becomes aware, report to the Plan any PHI use or disclosure that is inconsistent with the uses or disclosures as permitted by HIPAA.

6.

Make PHI available to an individual in accordance with HIPAA’s access requirements.

7.

Make PHI available for amendment and incorporate any amendments to PHI in accordance with HIPAA.

8.

If requested by an individual, make available the information required to provide an accounting of disclosures in accordance with HIPAA.

9.

Make internal practices, books and records relating to the use and disclosure of PHI received from the Plan available to the United States Department of Health and Human Services’ Secretary for the purpose of determining the Plan’s compliance with HIPAA.

10.

If feasible, return or destroy all PHI received from the Plan that the Plan Sponsor still maintains in any form, and retain no copies of such PHI when no longer needed for the purpose for which disclosure was made (or if return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction impracticable).

ADEQUATE SEPARATION BETWEEN THE PLAN AND THE PLAN SPONSOR MUST BE MAINTAINED In accordance with HIPAA, only the following employees or classes of employees of Orange County Public Schools may be given access to PHI: 1. 2.

Sr. Director of Risk Management. Staff designated by the Risk Manager.

LIMITATIONS OF PHI ACCESS AND DISCLOSURE The persons described above may only have access to and use and disclose PHI for Plan administration functions that the Plan Sponsor performs for the Plan. NONCOMPLIANCE ISSUES If the persons described above do not comply with this policy, the Plan Sponsor shall provide a mechanism for resolving issues of noncompliance, including disciplinary sanctions.

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F. HEALTH INSURANCE “REQUIRED DISCLOSURES AND NOTICES” NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THIS NOTICE IS EFFECTIVE OCTOBER 1, 2008. If you have questions about this notice, please contact the Sr. Director, Risk Management at 407.317.3245. WHO WILL FOLLOW THIS NOTICE? This notice describes the medical information practices of the Medical Indemnity Plan of the Orange County Public Schools (the "Plan") and that of any third party that assists in the administration of Plan claims. OUR PLEDGE REGARDING MEDICAL INFORMATION The Plan understands that medical information about you and your health is personal. The Plan is committed to protecting medical information about you. The Plan creates a record of the health care claims reimbursed under the Plan for Plan administration purposes. This notice applies to all of the medical records the Plan maintains. Your personal doctor or health care provider may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor's office or clinic. This notice will tell you about the ways in which the Plan may use and disclose medical information about you. It also describes our obligations and your rights regarding the use and disclosure of medical information. The Plan is required by law to:  make sure that medical information that identifies you is kept private;  give you this notice of our legal duties and privacy practices with respect to medical information about you; and  follow the terms of the notice that is currently in effect. HOW THE PLAN MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe different ways that the Plan uses and discloses medical information. For each category of uses or disclosures the Plan will explain what the Plan means and present some examples. Not every use or disclosure in a category will be listed. All of the ways the Plan is permitted to use and disclose information will fall within one of the categories. For Treatment (as described in applicable regulations) The Plan may use or disclose medical information about you to facilitate medical treatment or services by providers. The Plan may disclose medical information about you to providers including doctors, nurses, technicians, medical students, or other hospital personnel who are involved in taking care of you. For example, the Plan might disclose information about your prior prescriptions to a pharmacist to determine if a pending prescription is contraindicative with prior prescriptions. For Payment (as described in applicable regulations) The Plan may use and disclose medical information about you to determine eligibility for Plan benefits, to facilitate payment for the treatment and services you receive from health care providers, to determine benefit responsibility under the Plan, or to coordinate Plan coverage. For example, the Plan may tell your health care provider about your medical history to determine whether a particular treatment is experimental, investigational, or medically necessary or to determine whether the Plan will cover the treatment. The Plan may also share medical information with a utilization review or precertification service

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provider. Likewise, the Plan may share medical information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments. For Health Care Operations (as described in applicable regulations). The Plan may use and disclose medical information about you for other Plan operations. These uses and disclosures are necessary to run the Plan. For example, the Plan may use medical information in connection with: conducting quality assessment and improvement activities, underwriting, premium rating, and other activities relating to Plan coverage, submitting claims for stop-loss (or excess loss) coverage, conducting or arranging for medical review, legal services, audit services, and fraud and abuse detection programs, business planning and development such as cost management; and business management and general Plan administrative activities. As Required By Law The Plan will disclose medical information about you when required to do so by federal, state or local law. For example, the Plan may disclose medical information when required by a court order in a litigation proceeding such as a malpractice action. To Avert a Serious Threat to Health or Safety The Plan may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. For example, the Plan may disclose medical information about you in a proceeding regarding the licensure of a physician. SPECIAL SITUATIONS Disclosure to Health Plan Sponsor Information may be disclosed to another health plan maintained by the Plan Sponsor for purposes of facilitating claims payments under that plan. In addition, medical information may be disclosed to the Plan Sponsor solely for purposes of administering benefits under the Plan. Organ and Tissue Donation If you are an organ donor, the Plan may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank as necessary to facilitate organ or tissue donation and transplantation. Military and Veterans If you are a member of the armed forces, the Plan may release medical information about you as required by military command authorities. The Plan may also release medical information about foreign military personnel to the appropriate foreign military authority. Workers' Compensation The Plan may release medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness. Public Health Risks The Plan may disclose medical information about you for public health activities. These activities generally include the following:  to prevent or control disease, injury or disability;  to report births and deaths;  to report child abuse or neglect;  to report reactions to medications or problems with products;  to notify people of recalls of products they may be using;  to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;

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

to notify the appropriate government authority if the Plan believes a patient has been the victim of abuse, neglect or domestic violence. The Plan will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities The Plan may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. Lawsuits and Disputes If you are involved in a lawsuit or a dispute, the Plan may disclose medical information about you in response to a court or administrative order. The Plan may also disclose medical information about you in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. Law Enforcement The Plan may release medical information if asked to do so by a law enforcement official:  in response to a court order, subpoena. warrant, summons or similar process;  to identify or locate a suspect, fugitive, material witness, or missing person;  about the victim of a crime if, under certain limited circumstances, the Plan is unable to obtain the person's agreement;  about a death the Plan believes may be the result of criminal conduct;  about criminal conduct at the hospital, and  in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime. Coroners, Medical Examiners and Funeral Directors The Plan may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. The Plan may also release medical information about patients of the hospital to funeral directors as necessary to carry out their duties. National Security and Intelligence Activities The Plan may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. Inmates If you are an inmate of a correctional institution or under the custody of a law enforcement official, the Plan may release medical information about you to the correctional institution or law enforcement official. This release would be necessary: a. for the institution to provide you with health care: b. to protect your health and safety or the health and safety of others, or c. for the safety and security of the correctional institution. YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU You have the following rights regarding medical information the Plan maintains about you: Right to Inspect and Copy You have the right to inspect and copy medical information that may be used to make decisions about your Plan benefits. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Sr. Director, Risk Management at 407.317.3245. If you request a copy of the information, the Plan may charge a fee for the costs of copying, mailing or other supplies associated with your request. I. General Information

14

The Plan may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Right to Amend If you feel that medical information the Plan has about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Plan. To request an amendment, your request must be made in writing and submitted to the Sr. Director, Risk Management. In addition, you must provide a reason that supports your request. The Plan may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, the Plan may deny your request if you ask to amend information that:  is not part of the medical information kept by or for the Plan;  was not created by us, unless the person or entity that created the information is no longer available to make the amendment;  is not part of the information which you would be permitted to inspect and copy; or  is accurate and complete. Right to an Accounting of Disclosures You have the right to request an "accounting of disclosures" where such disclosure was made for any purpose other than treatment, payment, or health care operations. To request this list or accounting of disclosures, you must submit your request in writing to the Sr. Director, Risk Management. Your request must state a time period which may not be longer than six years and may not include dates before April 2003. Your request should indicate in what form you want the list (for example, paper or electronic). The first list you request within a 12 month period will be free. For additional lists, the Plan may charge you for the costs of providing the list. The Plan will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. Right to Request Restrictions You have the right to request a restriction or limitation on the medical information the Plan uses or discloses about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information the Plan discloses about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that the Plan not use or disclose information about a surgery you had. The Plan is not required to agree to your request. To request restrictions, you must make your request in writing to the Sr. Director, Risk Management. In your request, you must tell us: a. what information you want to limit; b. whether you want to limit our use, disclosure or both; and c. to whom you want the limits to apply, for example, disclosures to your spouse. Right to Request Confidential Communications You have the right to request that the Plan communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that the Plan only contact you at work or by mail. To request confidential communications, you must make your request in writing to the Sr. Director, Risk Management. The Plan will not ask you the reason for your request. The Plan will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

I. General Information

15

Right to Receive Notification of any Security Breaches If the Plan has any unsecured protected health information about you, and that unsecured information is accessed, acquired or disclosed by or to an unauthorized person, you have the right to receive notification about such security breach. The Plan will abide by breach notification requirements under the law. A Note About Personal Representatives You may exercise your rights through a personal representative. Your personal representative will be required to produce evidence of his/her authority to act on your behalf before that person will be given access to your PHI or allowed to take any action for you. Proof of such authority may take one of the following forms:  a power of attorney for health care purposes, notarized by a notary public;  a court order of appointment of the person as the conservator or guardian of the individual; or  an individual who is the parent of a minor child. The Plan retains discretion to deny access to your PHI to a personal representative to provide protection to those vulnerable people who depend on others to exercise their rights under these rules and who may be subject to abuse or neglect. This also applies to personal representatives of minors. Right to a Paper Copy of This Notice You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our Web site, http://Insurance.ocps.net. To obtain a paper copy of this notice, contact the Sr. Director, Risk Management at 407.317.3245. Changes to This Notice The Plan reserves the right to change this notice. The Plan reserves the right to make the revised or changed notice effective for medical information the Plan already has about you as well as any information The Plan receives in the future. The Plan will post a copy of the current notice on the OCPS Intranet. The notice will contain on the first page, in the top right-hand corner, the effective date. Complaints If you believe your privacy rights have been violated you may file a complaint with the Plan. To file a complaint with the Plan, contact the Sr. Director, Risk Management at 407.317.3245. All complaints must be submitted in writing. In addition to filing a complaint with the Plan you may file a complaint with the Secretary of the Department of Health and Human Services. Region IV, Office for Civil Rights, U.S. Department of Health and Human Services, Atlanta Federal Center, Suite 3B70, 61 Forsyth Street, SW., Atlanta, GA 30303-8909. Voice Phone 404.562.7886 FAX 404.562.7881 TDD 404.331.2867 For all complaints filed by e-mail send to: [email protected]. You will not be penalized for filing a complaint. Other Uses of Medical Information Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, the Plan will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that the Plan is unable to take back any disclosures the Plan has already made with your permission, and that the Plan is required to retain our records of the care that the Plan provided to you.

I. General Information

16

NOTICE OF SPECIAL ENROLLMENT RIGHTS If you are declining enrollment for your dependents (including your spouse or domestic partner) because of other health insurance or group health plan coverage, you may be able to enroll your dependents in this plan if your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your dependents’ other coverage). However, you must request enrollment within 30 days after your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. To request special enrollment or obtain more information, contact TASC at 1.800.720.4460. NEWBORNS AND MOTHERS HEALTH PROTECTION ACT Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not is excess of 48 hours (or 96 hours). WOMAN’S HEALTH AND CANCER RIGHTS On October 21, 1998, Congress passed a bill called the Women’s Health and Cancer Rights Act. This new law requires group health plans that provide coverage for mastectomy to provide coverage for certain reconstructive services. These services include:  Reconstruction of the breast upon which the mastectomy has been performed,  Surgery/reconstruction of the other breast to produce a symmetrical appearance,  Prostheses, and  Physical complications during all stages of mastectomy, including lymphedemas In addition, the plan may not:  interfere with a woman’s rights under the plan to avoid these requirements, or  offer inducements to the health provider, or assess penalties against the health provider, in an attempt to interfere with the requirements of the law.  However, the plan may apply deductibles and copays consistent with other coverage provided by the plan. If you have questions about the current plan coverage, please contact Cigna. QUALIFIED MEDICAL CHILD SUPPORT ORDER (QMCSO) Eligibility for Coverage under a QMCSO If a Qualified Medical Child Support Order (QMCSO) or Order is issued for your child, that child will be eligible for coverage as required by the QMCSO and you will not be considered a Late Entrant for Dependent Insurance. You must notify your Employer and elect coverage for that child and yourself, if you are not already enrolled, within 31 days of the QMCSO being issued. Qualified Medical Child Support Order Defined A Qualified Medical Child Support Order is a judgment, decree or order (including approval of a settlement agreement) or administrative notice, which is issued pursuant to a state domestic relations law (including a community property law), or to an administrative process, which provides for child support or provides for health benefit coverage to such child and relates to benefits under the group health plan, and satisfies all of the following: 1. the Order recognizes or creates a child’s right to receive group health benefits for which a participant or beneficiary is eligible;

I. General Information

17

2. the Order specifies your name and last known address, and the child’s name and last known address, except that the name and address of an official of a state or political subdivision may be substituted for the child’s mailing address; 3. the Order provides a description of the coverage to be provided, or the manner in which the type of coverage is to be determined; 4. the Order states the period to which it applies; and 5. if the Order is a National Medical Support Notice completed in accordance with the Child Support Performance and Incentive Act of 1998, such Notice meets the requirements above. The QMCSO may not require the health insurance policy to provide coverage for any type or form of benefit or option not otherwise provided under the policy, except that an Order may require a plan to comply with State laws regarding health care coverage. Payment of Benefits Any payment of benefits in reimbursement for Covered Expenses paid by the child, or the child’s custodial parent or legal guardian, shall be made to the child, the child’s custodial parent or legal guardian, or a state official whose name and address have been substituted for the name and address of the child. COVERAGE OF STUDENTS ON MEDICALLY NECESSARY LEAVE OF ABSENCE (MICHELLE’S LAW) If your Dependent child is covered by the medical plan as a student, as defined in the Definition of Dependent, coverage will remain active for that child if the child is on a medically necessary leave of absence from a postsecondary educational institution (such as a college, university or trade school.) Coverage will terminate on the earlier of: a) The date that is one year after the first day of the medically necessary leave of absence; or b) The date on which coverage would otherwise terminate under the terms of the plan. The child must be a Dependent under the terms of the plan and must have been enrolled in the plan on the basis of being a student at a postsecondary educational institution immediately before the first day of the medically necessary leave of absence. The plan must receive written certification from the treating physician that the child is suffering from a serious illness or injury and that the leave of absence (or other change in enrollment) is medically necessary. A “medically necessary leave of absence” is a leave of absence from a postsecondary educational institution, or any other change in enrollment of the child at the institution that: (1) starts while the child is suffering from a serious illness or condition; (2) is medically necessary; and (3) causes the child to lose student status under the terms of the plan. NOTICE OF OPT-OUT STATUS FOR MENTAL HEALTH SERVICES The Health Insurance Portability and Accountability Act (HIPAA) requires that Mental Health benefits be administered in the same manner as both medical and surgical benefits, but allows self-funded nonfederal governmental group plans to opt out of this requirement. The Mental Health benefit currently offered to OCPS members affords all members initial access to counseling at no cost to them. If OCPS opts in and changes the plan to mirror medical and surgical benefits that would mean that copayments/coinsurance would be charged at the same rate as Primary Care Physician and Specialist visits and inpatient hospitalization, which would not be in the best interest of employees/dependents.

I. General Information

18

Since OCPS administers a self-funded non-federal governmental group plan and has the option to opt out of the requirements of the Mental Health Parity Act, OCPS has determined to do so. OCPS will continue to offer mental health benefits to its employees and dependents covered under the healthcare plan in the same manner as it always has. OCPS is required to provide the following notice to its members as notice of opt-out status. NOTICE TO ENROLLEES IN A SELF-FUNDED NON-FEDERAL GOVERNMENTAL GROUP HEALTH PLAN Group health plans sponsored by State and local governmental employers must generally comply with Federal law requirements in title XXVII of the Public Health Service Act. However, these employers are permitted to elect to exempt a plan from the requirements listed below for any part of the plan that is “selffunded” by the employer, rather than provided through a health insurance policy. The Orange County Public Schools Benefits Trust has elected to exempt the Mental Health benefit provided through Orlando Behavioral Health associated with all plans for healthcare provided by Orange County Public Schools Benefits Trust from the following requirement: Protections against having benefits for mental health and substance use disorders be subject to more restrictions than apply to medical and surgical benefits covered by the plans. The exemption from these Federal requirements was initially in effect for 2010-2011 plan year beginning October 1, 2010 and ending September 30, 2011, continued through the 2011-2012, 2012-2013, 20132014, 2014-2015, 2015-2016 plan years and is being renewed for the subsequent 2016-2017 plan year beginning October 1, 2016 and ending September 30, 2017. The election may be renewed for subsequent plan years. Questions about this Notice should be directed to the Sr. Director, Risk Management, Orange County Public Schools, 445 W. Amelia St., Orlando, FL 32801, or by telephone at 407.317.3245. OCPS GRIEVANCE PROCEDURE A grievance is a formal complaint filed by a Covered Person. The OCPS Grievance Procedure follows a confidential method of hearing and resolving grievances involving interpretations of the Plan. Find the OCPS Grievance Procedure at: https://www.ocps.net/fs/risk/insurance/Pages/default.aspx.

I. General Information

19

G. PLAN ADMINISTRATION Name of Plan: The Medical Indemnity Plan of the Orange County Public Schools Employer whose employees and retirees are covered by the Plan (the “Employer”): The School Board of Orange County, Florida Policy Number: 08001 I.R.S. Employer Identification No. of sponsor of the Plan: 59-6000771 Plan number assigned by sponsor of the Plan: 502 Plan Administrator: Orange County Public Schools, Senior Director, Risk Management 445 W. Amelia St. Orlando, FL 32801 407.317.3245 Name and address of agent for service of legal process: Dr. Barbara Jenkins, Superintendent Orange County Public Schools P. O. Box 271, Orlando, FL 32802 (Service of legal process may also be made upon the plan administrator). The general administration of this plan is provided by the third party administrator contracted to handle certain administrative responsibilities and to process claims: Cigna Health Plans Hamilton Village Claim Office P.O. Box 182223 Chattanooga, TN 37422-7223 1.800.244.6224

CVS/Caremark One CVS Drive Woonsocket, RI 027895 1.800.378.9264

Orlando Behavioral Healthcare 260 Lookout Place, Suite 202 Maitland, FL 32765 407.637.8080

All benefits are funded through the School Board of Orange County, Florida, Employee Benefits Trust with the majority of assets held at Wells Fargo of Orlando. Investment instruments may be made through other institutions as appropriate. Name and title for the Trustees of the Trust are as follows: Dr. Barbara Jenkins, Superintendent Orange County Public Schools

Richard Collins, Consultant Orange County Public Schools

Dr. Karen van Caulil, President Florida Health Care Coalition

Dale Kelly, Chief Financial Officer Orange County Public Schools

Meredith Robertson, Consultant University of Central Florida Trustees can be reached at: Orange County Public Schools, P.O. Box 271, Orlando, FL 32802

I. General Information

20

II. MEDICAL INSURANCE

A. PLAN A: CIGNA LOCAL PLUS IN-NETWORK

II. MEDICAL INSURANCE

Plan A: Cigna Local Plus In-Network OVERVIEW Cigna Health Care LocalPlus In-Network is designed to provide the highest quality healthcare while maintaining your freedom to choose from a local selection of personal physicians. You have the option to choose a Primary Care Physician (PCP) who specializes in one of these areas: family practice, internal medicine, general medicine or pediatrics. Your PCP or personal physician can be a source for routine care and for guidance if you need to see a specialist or require hospitalization. If you see a provider who is not in the LocalPlus Network, your plan does not cover those services, except in emergencies. To access an online provider directory for these plans visit www.cigna.com, choose “Find a Doctor,” choose “LocalPlus ONLY.” For detailed instructions in using the provider directory, please see page 8 of the General Insurance Information section of this handbook. Cigna Health Care LocalPlus In-Network provides well-managed services to deliver cost effective, quality care through the physicians’ private offices and facilities. To ensure full and proper medical treatment, and reduce unnecessary procedures, this program emphasizes pre-admission screening, prior authorization for specific services, ambulatory services, home healthcare, and preventive care. Please use the Summary of Benefits and Coverage as a guide to your plan. This schedule does not contain all provisions of your benefit plan.

II. Medical Insurance: Cigna LocalPlus In-Network

21

The School Board of Orange County, Florida: LocalPlus IN

Coverage Period: 10/01/2016 - 09/30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Individual + Family | Plan Type: LCP This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.myCigna.com or by calling 1-800-Cigna24 Important Questions

What is the overall deductible?

Are there other deductibles for specific services? Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? Is there an overall annual limit on what the plan pays?

Answers For in-network providers $250 person / $500 family Does not apply to in-network preventive care, immunizations, mental health services, substance abuse services, and prescription drugs Co-payments don't count toward the deductible. Deductible amounts met in July, August, September apply to current plan year and following plan year. No. Yes. For in-network medical providers $5,000 person / $10,000 family For in-network prescription drugs - $500 person/ $1,000 family For in-network Mental Health/Substance Abuse $500 person/ $1,000 family Premium, balance-billed charges, and health care this plan doesn't cover. No.

Does this plan use a network of providers?

Yes. For a list of participating providers, see www.myCigna.com or call 1-800-Cigna24

Do I need a referral to see a specialist?

No. You don't need a referral to see a specialist.

Why this Matters: You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over. See the chart starting on page 23 for how much you pay for covered services after you meet the deductible. You don't have to meet deductibles for specific services, but see the chart starting on page 23 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don't count toward the out-ofpocket limit. The chart starting on page 23 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your innetwork doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 23 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan.

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 2016-2017 22

Important Questions

Answers

Are there services this plan doesn't cover?

Yes.

Why this Matters: Some of the services this plan doesn't cover are listed on page 26. See your policy or plan document for additional information about excluded services.

Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount of the service. For example, if the health plan's allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven't met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charge is $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, co-payments and co-insurance amounts. Common Medical Event

If you visit a health care provider's office or clinic

Services You May Need Primary care visit to treat an injury or illness MDLIVE Specialist visit Other practitioner office visit

If you have a test

Preventive care/screening/ immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs)

Your Cost if you use an In-Network Provider Out-of-Network Provider

Limitations & Exceptions

$20 co-pay/visit

Not Covered

-----------none-----------

$10 co-pay/visit $35 co-pay/visit

Not Covered Not Covered

$25 co-pay/visit for chiropractor

Not Covered

-----------none---------------------none----------Coverage for Chiropractic care and Rehabilitation services (includes Cardiac rehab) is limited to 50 days annual max.

No charge

Not Covered

-----------none-----------

No charge

Not Covered

-----------none-----------

$100 co-pay per procedure

Not Covered

-----------none-----------

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 2016-2017 23

Common Medical Event

Services You May Need

Your Cost if you use an In-Network Provider Out-of-Network Provider

Limitations & Exceptions

$7 co-pay: retail 30-day prescription

Generic drugs

Not Covered

Maintenance drugs are not covered at retail beginning with the 4th fill of a 30-day supply. See Insurance Benefits Handbook for full list of Exclusions/Limitations.

Not Covered

Maintenance drugs are not covered at retail beginning with the 4th fill of a 30-day supply. See Insurance Benefits Handbook for full list of Exclusions/Limitations.

Not Covered

See Insurance Benefits Handbook for full list of Exclusions/Limitations.

Not Covered

Maintenance drugs are not covered at retail beginning with the 4th fill of a 30-day supply. See Insurance Benefits Handbook for full list of Exclusions/Limitations.

10% co-insurance

Not Covered

-----------none-----------

10% co-insurance $300 co-pay/visit

Not Covered $300 co-pay/visit

-----------none----------Per visit co-pay is waived if admitted

10% co-insurance

10% co-insurance

-----------none-----------

$35 co-pay/visit

$35 co-pay/visit

Per visit co-pay is waived if admitted

$14 co-pay: CVS/Caremark mail order or CVS Retail 90- day prescription $21 co-pay: retail 90-day prescription 10% co-insurance (min. $30): retail 30-day prescription

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at CVS/Caremark www.caremark.com

Preferred brand drugs

10% co-insurance (min. $60): CVS/Caremark mail order or CVS Retail 90-day prescription 10% co-insurance (min. $90): retail 90-day prescription

Non-preferred brand drugs Not Covered 10% co-insurance (min. $75): retail 30-day prescription

Covered medications more than $1,500 for a 30-day supply

10% co-insurance (min. $150): CVS/Caremark mail order or CVS Retail 90-day prescription 10% co-insurance (min. $225): retail 90-day prescription

If you have outpatient surgery If you need immediate medical attention

Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services Emergency medical transportation Urgent care

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 2016-2017 24

Common Medical Event

Services You May Need

If you have a hospital stay

Facility fee (e.g., hospital room) Physician/surgeon fees

If you have mental health, behavioral health, or substance abuse needs contact Orlando Behavioral Healthcare 407.637.8080

If you are pregnant

If you need help recovering or have other special health needs

If your child needs dental or eye care

Your Cost if you use an In-Network Provider Out-of-Network Provider

Limitations & Exceptions

10% co-insurance

Not Covered

-----------none-----------

10% co-insurance

Not Covered

-----------none-----------

The schedule for behavioral and mental health services is outlined in Section II. E.

Prenatal and postnatal care

$150 co-pay, plus 10% co- insurance

Not Covered

-----------none-----------

Delivery and all inpatient services

10% co-insurance

Not Covered

-----------none-----------

Home health care

No charge

Not Covered

Rehabilitation services

$25 co-pay/visit

Not Covered

Habilitation services

Not Covered

Not Covered

Skilled nursing care

10% co-insurance

Not Covered

Durable medical equipment Hospice services Eye Exam Glasses Dental check-up

No charge 10% co-insurance Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered

Coverage is limited to 100 days innetwork annual max Coverage is limited to annual max of: 50 days for Rehabilitation (including Cardiac rehab) and Chiropractic care services -----------none----------Coverage is limited to 120 days annual max -----------none---------------------none---------------------none---------------------none---------------------none-----------

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 2016-2017 25

Excluded Services & Other Covered Services Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.)  Acupuncture  Bariatric surgery  Habilitation services  Cosmetic surgery  Infertility treatment  Routine eye care (Adult)  Dental care (Adult)  Long-term care  Routine foot care  Dental care (Children)  Non-emergency care when traveling outside the U.S.  Eye care (Children) Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.)  Mental/Behavioral health inpatient and outpatient services  Chiropractic care  Prescription drugs  Weight loss programs  Private Duty Nursing  Hearing Aids  Substance use disorder inpatient and outpatient services

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 2016-2017 26

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 2016-2017 27

Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples?  

    

Costs don't include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren't specific to a particular geographic area or health plan. The patient's condition was not an excluded or pre existing condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.

What does a Coverage Example show?

For each treatment situation, the Coverage Example helps you see how deductibles, co-payments, and co-insurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn't covered or payment is limited.

Does the Coverage Example predict my own care needs?

No. Treatments shown are just examples. The

care you would receive for this condition could be different based on your doctor's advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict my future expenses?

No. Coverage Examples are not cost estimators.

Can I use Coverage Examples to compare plans?

Yes. When you look at the Summary of Benefits

and Coverage for other plans, you'll find the same Coverage Examples. When you compare plans, check the "Patient Pays" box in each example. The smaller that number, the more coverage the plan provides.

Are there other costs I should consider when comparing plans?

Yes. An important cost is the premium you pay.

Generally, the lower your premium, the more you'll pay in out-of-pocket costs, such as co-payments, deductibles, and co-insurance. You also should consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.

You can't use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 2016-2017 28

Plan A: Cigna Local Plus In-Network PRECERTIFICATION/UTILIZATION MANAGEMENT The precertification/utilization management process ensures that you, as the patient, are receiving medical care and treatment that is appropriate, medically necessary and being performed in the best setting. Therefore, if your physician recommends hospitalization, outpatient surgery or defined procedures/services as listed below, for you or your eligible dependent, precertification is required by your physician for in-network services and by you and/or your physician for out of network services by calling 1.800.CIGNA24 (1.800.244.6224) five (5) days prior to services being rendered. You must receive services from an in-network provider in order to receive your highest level of benefit reimbursement. You will receive a letter stating what services and/or treatments have been approved. If your hospitalization is for a maternity stay, no authorization is required for a 48 hour stay for vaginal deliveries or a 96 hour stay for Cesarean section. Longer stay must be authorized by Cigna HealthCare. If admission is due to an emergency, you or a member of your family, and your physician must call Cigna Health Care at 1.800.CIGNA24 (1.800.244.6224) within 48 hours or as soon as possible. All emergency admissions will be reviewed for medical necessity. Concurrent review will be performed during your hospital stay to ensure that continued hospitalization is warranted. You will be visited by a Cigna Health Care nurse to assist with any discharge needs you may have. Precertification is required for ALL in-patient admissions, and the following list of services and procedures whether performed in a hospital, outpatient facility, or doctor’s office:  All elective and urgent/emergent admissions, observation stays, skilled nursing facility, rehab facilities, hospice facilities, and transfers between facilities.  Any covered dental-treatments and procedures including, but not limited to: orthognathic procedures, TMJ procedures, procedures to treat injury to sound natural teeth.  MRA, MRI, CT, and PET Scans  Durable medical equipment  Devices including, but not limited to: cochlear implants, insulin pumps  Home health care and home infusion therapy  Tonsillectomy – in-patient only  Uvulopharyngopalatoplasty – in-patient only  Hysterectomy  Speech therapy, prior to the first visit Please note: List of services is subject to change without notice. When pre-certifying procedures, all claims are subject to retrospective review, if necessary, to confirm that procedures or services are covered and not excluded under the Plan Document.

II. Medical Insurance: Cigna LocalPlus In-Network

29

PENALTIES THE PRECERTIFICATION PROGRAM IS MANDATORY. If services as listed are not pre-certified, up to a $500 penalty will be imposed on the covered person when utilizing an out-of-network physician. Serious Illness If you or a covered family member ever need care beyond a traditional hospital stay, Cigna Health Care Case Management service provides valuable counseling, support and care coordination. An experienced case manager, assigned specifically to your situation, works closely with your doctor to help you sort out your options, contact facilities, arrange care, and access helpful community resources and programs. For more information call Customer Service at the toll-free number on your Cigna Health Care ID card, 1.800.CIGNA24 (1.800.244.6224). The Cigna Health Care Your Health First Program Your Cigna Health Care plan includes the Cigna Health Care Your Health First Program for better health. It offers valuable, confidential support for you and your covered family members with specific medical conditions. The Cigna Health Care Your Health First Program provides educational materials that help you learn more about your health condition, regular reminders of important checkups and tests and helpful information that keeps your doctor advised of the latest care and treatment techniques. The Cigna Health Care Your Health First Program helps you and your doctor follow your condition more closely and treat it more effectively. The following programs are available:  Asthma  Heart Disease  Coronary Artery Disease  Angina  Congestive Heart Failure  Acute Myocardial Infarction  COPD (Emphysema and Chronic Bronchitis)  Diabetes Type 1  Diabetes Type 2  Metabolic Syndrome  Peripheral Arterial Disease  Low Back Pain  Osteoarthritis  Depression  Anxiety  Bipolar Disorder To learn more or to enroll in the program, call 1.855.246.1873. Once you complete the simple enrollment process, you will be provided with:  Access to registered nurses who specialize in your condition.  Information and resources that include assistance with self-care materials and services; and informative topic sheets on a variety of condition related topics.  Reminders of self-care routines, exams and doctor appointments and other important topics.

II. Medical Insurance: Cigna LocalPlus In-Network

30

Cigna Health Care Healthy Babies® (Well Pregnancy Program) The Cigna Health Care Healthy Babies program provides education and support for covered mothers-to-be along with special attention for high-risk pregnancies. The program includes:  Access to a valuable toll-free information line staffed by experienced registered nurses  Educational materials from a recognized source of information on pregnancy and babies -- March of Dimes.  Post-delivery support and services. Once your baby arrives, Cigna Health Care continues to provide access to the services you'll need for the first few days and after. Financial incentives (awarded after baby’s birth) will be awarded to members who participate and meet the requirements of the program outlined at enrollment. If you enroll:  Prenatal Vitamins: Participants will receive their prescription prenatal vitamins free - no copays.  Preconception: Up to 12 months before becoming pregnant - incentive equals $225.  Pregnancy up to the 12th week of pregnancy - incentive equals $175.  From the 13th to the 23rd week of pregnancy - incentive equals $50. For members enrolled in the Well Pregnancy Program, Lamaze classes are “free of charge” at specified locations. Please call Cigna Health Care at the toll-free number on your Cigna Health Care ID card, 1.800.CIGNA24 (1.800.244.6224). Hearing Aid Program This program allows coverage of hearing aids through the Cigna in-network provider, Amplifon/HearPo. This benefit will NOT be covered at an out-of-network provider. Your coverage includes:  Up to two hearing aids in a covered three year period; maximum benefit of $3,000 per hearing aid device through the Cigna in-network provider, Amplifon/HearPo.  Co-insurance and deductibles apply. To access services, call Amplifon/HearPo at 1.888.207.2798. Weight Phases Program This program is designed to assist the individual with a Body Mass Index (BMI) of 33 with one major risk factor or 35 or above without any risk factors. Components of the program include supervised exercise training three times per week; monthly fitness evaluations with an Exercise Specialist; Bod Pod analysis; weekly weigh-ins; nutritional counseling, calorie recommendations, recipes and educational material. Weight Phases participants pay a monthly fee directly to the Orlando Regional Wellness Center. After successful completion of all the program requirements, participants are eligible to receive a percentage reimbursement. To qualify for this program, participants must:  Be more than 14 years old  Have a Body Mass Index (BMI) of 33 with one major risk factor or 35 or above without any risk factors  Obtain a physician’s approval if requested by Orlando Regional Wellness Center Contact the Orlando Regional Wellness Center at 407.237.6351

II. Medical Insurance: Cigna LocalPlus In-Network

31

Smoking Cessation Program – Smoke Free OCPS This program is designed to assist individuals attempting to quit smoking. Components of the program include an eight week problem solving, social supportive educational class, coverage of prescription or over-the-counter (OTC) nicotine replacement and reimbursement for any group therapy costs. After 12 months of successfully quitting smoking, participants are eligible to receive reimbursements with proper documentation. Contact the Employee Wellness Program at 407.317.3200, Ext. 200 2929 to obtain an enrollment packet. The Cigna Health Care 24-Hour Health Information Line No matter where you are in the U.S., you can call the Cigna Health Care 24-Hour Health Information Line, toll-free at 1.800.CIGNA24 (1.800.244.6224).  You can speak to a registered nurse for answers to your health questions, assistance in locating nearby medical facilities, and helpful self-care tips.  You can listen to informative, recorded audio tapes on hundreds of health topics.  This service is available around the clock, 24-hours a day, seven days a week. MDLIVE offered through Cigna Easy and cost effective Telehealth solution that provides on-demand 24/7/365 access to nonurgent health care through a national network of licensed, board certified U.S. – based doctors and pediatricians. You can talk with doctors by phone or online video. MDLIVE’s doctors can diagnose you, prescribe medications when appropriate and send the prescription directly to your pharmacy. When to use it? MDLIVE is available 24 hours a day, seven days a week, 365 days a year to conveniently help you find treatment for minor, non-emergency conditions. You can use it anytime, from anywhere. All you need is a phone or computer with webcam. Use MDLIVE to talk to a doctor about: › Acne › Allergies › Asthma › Bronchitis › Cold & Flu › Diarrhea › Ear Aches › Fever › Head Ache › Infections › Insect Bites › Joint Aches › Nausea › Pink Eye › Rashes › Respiratory Infections › Sinus Infections › Skin Infections › Sore Throat › Urinary Tract Infections Child medical conditions - Cold & Flu - Constipation - Ear Aches - Nausea - Pink Eye  

For Copay plans – Pay $10 copay For Deductible plans – Pay $38 until Deductible is met, then pay $10 copay

To access MDLIVE:   

Telephone: Call 1.888.726.3171 and speak to a coordinator to find a doctor who meets your needs – talk to the doctor. Website: Go to www.mdlive.com/ocps. Find a doctor who meets your needs. Video chat with the doctor. Mobile App: Download MDLIVE App for an easier and more convenient way to visit with the doctor.

This service and the MDLIVE website are provided exclusively by MDLIVE and not by Cigna. MDLIVE doctors are independent practitioners solely responsible for the treatment provided to their patients. They are not agents of Cigna. MDLive operates in the U.S. subject to state regulation and may not be available in certain states. Medicare Primary Beneficiaries are not eligible for coverage of MDLIVE services.

II. Medical Insurance: Cigna LocalPlus In-Network

32

Cigna Healthy Rewards Program Healthy Rewards is a discount program offered to Cigna members. Healthy Rewards offers discounts for acupuncture, laser vision correction, hearing aids, cosmetic dentistry, smoking cessation, fitness club memberships, herbal supplements and a variety of other services and programs. There are no claims to file. The discount applies the minute service is paid for. Members use their Cigna medical plan ID card for identification. Discounts apply only with Healthy Rewards participating providers. Members can find a list of providers and services by calling 1.800.870.3470 or by visiting www.cigna.com/healthyrewards or www.mycigna.com. Healthy Rewards discounts can’t be applied to any copayments or coinsurance for services already covered by your medical plan. Customer Service  The toll-free number is 1.800.CIGNA24 (1.800.244.6224). Please have your Cigna Health Care ID card ready when you call.  Cigna's Customer Service is available 24 hours a day, 7 days a week.  Se habla Espanol— and more than 140 other languages. Cigna provides bi-lingual representatives in Spanish-speaking areas; for other non-English speaking members, Cigna also offers a Language Line service that can translate virtually any language. Cigna Health Care ID Card Carry it with you at all times and present it whenever you access medical care. This will help ensure that your claim is handled properly.

II. Medical Insurance: Cigna LocalPlus In-Network

33

EXCLUSIONS/LIMITATIONS Expenses for the following are excluded and/or limited: MEDICAL PLAN 1. Any treatment for cosmetic purposes or for cosmetic surgery, except that the plan will pay for cosmetic treatment or surgery: a. Due solely to an accidental bodily injury which occurred while the covered person was under this plan; or b. Due solely to a birth defect of a covered person’s eligible dependent child. 2. Any service for the treatment of injury or illness considered not medically necessary and/or appropriate as determined by the medical director or his designee. 3. Collection or donation of blood products, except for autologous donation in anticipation of scheduled services where in the opinion of the Medical Director the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery. Blood administration for the purpose of general improvement of health. 4. Surgery to reverse surgical sterilization procedures. 5. Services and supplies related to sexual dysfunctions or inadequacies, or for sex change operations. 6. Fertility studies, sterility studies, procedures to restore or enhance fertility, artificial insemination, or invitro fertilizations. 7. Care or services of any kind performed by or under the direct supervision of a dentist, except that the plan will pay for dental treatment necessary to repair injuries to sound, natural teeth caused by a non-occupational accident occurring while the covered person is covered and which are performed within six months of the accident. The contributing cause of the accident must be something other than teeth grinding, chewing, or biting. 8. Treatment on or to the teeth, the nerves or roots of the teeth, gingival tissue of alveolar processes; however, benefits will be payable for the charges incurred for the treatment required because of accidental bodily injury to natural teeth sustained while covered (this exception shall not in any event be deemed to include expenses for treatment for the repair or replacement of a denture). 9. Non-surgical treatment involving bones and joints of the jaw and facial region. All orthognathic procedures and other craniomandibular disorder treatments not medically necessary. 10. Diagnosis or treatment of weak or flat feet, fallen or high arches, for instability or imbalance metatarsalgia not caused by disease (except for bone surgery), bunions (except for capsular or bone surgery), corns or calluses, or toenails (except for complete or partial removal of nail root); unless needed in treatment of a metabolic or peripheral vascular disease. 11. Routine hearing examinations, routine physical examinations, premarital examinations, preemployment physicals, preschool examinations, or annual boosters except as indicated in the summary of benefits. 12. Hearing aids or examination for prescriptions or fitting of hearing aids, except as indicated in the summary of benefits.

II. Medical Insurance: Cigna LocalPlus In-Network

34

13. Routine eye examination, eye glasses, contact lenses or their fitting (unless for initial replacement of the lens of the eye after cataract surgery), eye exercises, visual therapy, fusion therapy, visual aids or orthoptics, any related examination and eye refraction, or radial keratatomy. 14. For experimental, investigational or unproven services which are medical, surgical, psychiatric, substance abuse or other healthcare technologies, supplies, treatments, procedures, drug therapies, or devices that are determined to be: a. Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not recognized for the treatment of the particular indication in one of the standard reference compendia (The United States Pharmacopeia Drug Information, the American Medical Association Drug Evaluations, or the American Hospital Formulary Service Drug Information) or in medical literature. Medical literature means scientific studies published in a peer-reviewed national professional journal; or b. The subject of review or approval by an Institutional Review Board for the proposed use; or c. The subject of an ongoing clinical trial that meets the definition of a phase I, II, or III Clinical Trial as set forth in the FDA regulations, regardless of whether the trial is subject to FDA oversight; or d. Not demonstrated, through existing peer-reviewed literature, to be safe and effective for treating or diagnosing the condition or illness for which its use is proposed. 15. Any organ or tissue transplant, except as otherwise listed in the Plan Document. 16. Education, training, and bed and board while confined to an institution which is primarily a school or other institution for training; a place of rest, a place for the aged, or for custodial care or for testing or training due to mental, nervous, or emotional conditions. 17. Education (excluding diabetes education), training, or counseling of any type no matter what the diagnosis. The mental health benefit covers counseling. 18. Health Services and associated expenses for bariatric procedures/surgeries intended primarily for the treatment of morbid obesity or weight loss, including but not limited to gastric bypasses, gastric balloons, stomach stapling, jejunal bypasses, wiring of the jaw and health services of a similar nature. 19. Weight control counseling or services primarily for weight loss or control. Necessary treatment for eating disorders, as defined by DSM-III-R codes, is covered under the mental health benefit approved by Orlando Behavioral Healthcare. Coverage for weight control is provided in network only and follows the guidelines set forth in the Health Care Reform Act at http://www.healthcare.gov/law/about/provisions/services/lists.html. 20. Vitamins, minerals, or food supplements, whether or not prescribed by a qualified practitioner. Exception: Legend vitamins and minerals when adequate nutrition cannot be sustained with over-the-counter vitamins and minerals. Clinically necessary I.V. hyperalimentation or when adequate nutrition cannot be sustained through usual pathway. 21. Any personal items while hospital confined. 22. Hospitalization primarily for x-ray, laboratory, diagnostic study, physical therapy, hydrotherapy, medical observation, convalescent or rest care, or any other medical examination or tests not clinically necessary.

II. Medical Insurance: Cigna LocalPlus In-Network

35

23. Services, supplies, or tests not generally accepted in health care practices as needed in the diagnosis or treatment of the patient, even if ordered by a doctor. 24. Medical supplies such as adhesive tape, antiseptics, or other common first aid supplies. 25. Services provided by a person who usually lives in the same household as the covered person, or who is a member of his/her immediate family or the family of his/her spouse. 26. Those services incurred prior to the date coverage is in force or after coverage ends, except if the person is totally disabled on the date this medical plan ends. 27. Those services which a covered person would not be legally obligated to pay if health insurance coverage did not exist. 28. Illness for which the covered person is entitled to benefits under any worker’s compensation law or act, or accidental bodily injury arising out of or in the course of the covered person’s employment or services rendered by any governmental program (i.e., V.A. hospital) unless there is a legal obligation to pay for coverage. 29. Illness resulting from war, whether declared or undeclared. 30. Illness or injury to which a contribution cause was the commission of, or attempted commission of, an act of aggression or a felony, or participating in a riot by the covered person. 31. Any charges in excess of approved charges as determined by Cigna. 32. Claims not submitted within 12 months from the date of service. 33. All charges during a hospitalization deemed medically unnecessary or inappropriate by the medical director or his designee. 34. Penalties for failure to comply with any and all applicable precertification requirements. 35. Claims for services to improve a covered person’s general physical condition, for private membership clubs and clinics, and for any other organization charging membership fees. 36. Charges for the first $10,000 of bodily injury to a person while riding a motorcycle without a helmet. 37. Any tests not requiring a physician’s order and purchased over-the-counter. 38. Assistance in the activities of daily living, including but not limited to eating, bathing, dressing or other Custodial Services or self-care activities, homemaker services and services primarily for rest, domiciliary or convalescent care. 39. Cost of biologicals that are immunizations or medications for the purpose of travel, or to protect against occupational hazards and risks.

II. Medical Insurance: Cigna LocalPlus In-Network

36

II. MEDICAL INSURANCE

B.

PLAN B: CIGNA HEALTH REIMBURSEMENT ACCOUNT (HRA)

II. MEDICAL INSURANCE

Plan B: Cigna Health Reimbursement Account (HRA) OVERVIEW Cigna Health Care Open Access Plus (HRA) is designed to provide the highest quality healthcare while maintaining your freedom to choose from a wide selection of personal physicians. You have the option to choose a Primary Care Physician (PCP) who specializes in one of these areas: family practice, internal medicine, general medicine or pediatrics. Your PCP or personal physician can be a source for routine care and for guidance if you need to see a specialist or require hospitalization. To access an online provider directory for these plans visit www.cigna.com, choose “ Find a Doctor,” choose “Open Access Plus, OA Plus, Choice Fund OA Plus.” For detailed instructions in using the provider directory, please see page 8 of the General Insurance Information section of this handbook. With these plans, you have the option to go to any medical person and facility. However, when choosing the providers in the Open Access Plus network, your benefit coverage will be a greater level than opting to receive services outside the Open Access Plus network. Also, with out of network health care professionals and facilities, you may be responsible for any amount over the maximum reimbursable charge. Cigna Health Care Open Access Plus (HRA) provides well-managed services to deliver cost effective, quality care through the physicians’ private offices and facilities. To ensure full and proper medical treatment, and reduce unnecessary procedures, this program emphasizes pre-admission screening, prior authorization for specific services, ambulatory services, home healthcare, and preventive care. Cigna Care Designation (CCD) is designed to help promote quality care and to help retirees and their families select the Health Care Professional (HCP) that's best for them. Utilizing Cigna claim information, HCPs are assigned the CCD designation when they meet Cigna's criteria for certain quality, and cost-efficiency measures. CCD is available in certain geographic locations. This Cigna Care Network (CCN) Plan provides a higher level of In-Network benefits (coinsurance and/or copayment) when services are received from CCD HCPs in the following designated specialties: 19 Specialist Types: Allergy/Immunology Cardiology Cardio-Thoracic Surgery Colon and Rectal Surgery Dermatology Ear/Nose/Throat

Endocrinology Gastroenterology General Surgery Hematology/Oncology Nephrology Neurology Neurosurgery

OB/GYN Ophthalmology Orthopedics/Surgery Pulmonology Rheumatology Urology

The In-Network benefits described in the companion summary show both CCN and Non-CCN copayment and coinsurance levels as applicable. * Note that the CCN levels apply to professional charges and do not apply to facility charges. CCN level:  CCN Designated HCPs performing in one of the above specialties. Non-CCN level:  Non-CCN Designated HCPs performing any service  Non-Reviewed Specialist HCPs performing any service outside of the specialties identified above. II. Medical Insurance: Cigna Health Reimbursement Account (HRA)

37

CCN Tiering applies to Office visits and Inpatient and Outpatient Professional (Surgical) charges, except for Radiologists, Pathologists and Anesthesiologists. Your former employer has established a health reimbursement account that you can use to pay for eligible out-of-pocket expenses during the Plan Year. Employer Contribution

Retiree Only - One contribution of $750 Dependents do not receive a contribution from OCPS.

Please use the Summary of Benefits and Coverage as a guide to your plan. This schedule does not contain all provisions of your benefit plan.

II. Medical Insurance: Cigna Health Reimbursement Account (HRA)

38

The School Board of Orange County, Florida: Choice Fund Open Access Plus HRA

Coverage Period: 10/01/2016 - 09/30/2017

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Individual + Family | Plan Type: OAP This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.cigna.com/sp/ or by calling 1-800-Cigna24 Important Questions

What is the overall deductible?

Are there other deductibles for specific services?

Is there an out-of-pocket limit on my expenses?

What is not included in the out-of-pocket limit?

Answers For in-network providers $1,500 person / $ 3,000 family For out-of-network providers $3,000 person / $6,000 family Does not apply to in-network preventive care, immunizations, in-network office visits, mental health services, substance abuse services, and prescription drugs Co-payments don't count toward the deductible. Amount OCPS contributes to the retiree’s account One contribution of $750. Dependents do not receive a contribution. Deductible met July, August, and September applies to current plan year and following plan year. Yes, $100 deductible per procedure for out-of-network imaging (CT/PET scans, MRIs) There are no other specific deductibles. Yes. For in-network medical providers $3,000 person / $6,000 family / For out-of-network medical providers $6,000 person / $12,000 family For in-network prescription drugs $500 person/ $1,000 family For in-network Mental Health/Substance Abuse $500person / $1,000 family Premium, balance-billed charges, penalties for no preauthorization, and health care this plan doesn't cover.

Why this Matters:

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over. See the chart starting on page 41 for how much you pay for covered services after you meet the deductible.

You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don't count toward the out-ofpocket limit.

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 2016-2017 39

Important Questions Is there an overall annual limit on what the plan pays?

Answers

Does this plan use a network of providers?

Yes. For a list of participating providers, see www.myCigna.com or call 1-800-Cigna24

Do I need a referral to see a specialist?

No. You don't need a referral to see a specialist.

You can see the specialist you choose without permission from this plan.

Are there services this plan doesn't cover?

Yes.

Some of the services this plan doesn't cover are listed on page 44. See your policy or plan document for additional information about excluded services.

No.

Why this Matters: The chart starting on page 41 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your innetwork doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 41 for how this plan pays different kinds of providers.

Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount of the service. For example, if the health plans allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven't met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed , you may have to pay the difference. For example, if an out-of-network hospital charge is $1,500 for an overnight stay and the allowed is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, co-payments and co-insurance amounts.

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 2016-2017 40

Common Medical Event

Services You May Need Primary care visit to treat an injury or illness MDLIVE

If you visit a health care provider's office or clinic

Specialist visit

$25 co-pay/visit

30% co-insurance

-----------none-----------

$10 co-pay/visit

Not Covered

-----------none-----------

30% co-insurance

Contact your employer for Cigna Care Network specialties information

CCN Specialist: $40 co- pay/visit Non-CCN Specialist: $60 co- pay/visit

Other practitioner office visit

$25 co-pay/visit for chiropractor

30% co-insurance

Coverage for Chiropractic care and Rehabilitation services (includes Cardiac rehab) is limited to 50 days annual max.

Preventive care/screening/ immunization

No charge

30% co-insurance

-----------none-----------

Diagnostic test (x-ray, blood work) If you have a test

Your Cost if you use an Limitations & Exceptions In-Network Provider Out-of-Network Provider

Imaging (CT/PET scans, MRIs)

PCP: $25 co-pay/visit CCN Specialist: $40 co-pay/visit Non-CCN Specialist $60 co-pay/visit 30% co-insurance All Other: 10% co-insurance $100 co-pay per procedure, plus 10% $100 deductible per co-insurance procedure, plus 30% coinsurance

$500 penalty for no precertification. $500 penalty for no precertification.

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 2016-2017 41

Common Medical Event

Services You May Need

Generic drugs

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at CVS/Caremark www.caremark.com

Preferred brand drugs

Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services

If you need immediate medical attention

$30 co-pay: retail 30-day prescription $60 co-pay: CVS/Caremark mail order or CVS Retail 90- day prescription $90 co-pay: retail 90-day prescription

Emergency medical transportation Urgent care

Limitations & Exceptions Maintenance drugs are not covered at retail beginning with the 4th fill of a 30-day supply. See Insurance Benefits Handbook for full list of Exclusions/Limitations.

Co-insurance or co-payment plus the difference in cost between out-of-network and network cost to the plan

Maintenance drugs are not covered at retail beginning with the 4th fill of a 30-day supply. See Insurance Benefits Handbook for full list of Exclusions/Limitations.

Not Covered

See Insurance Benefits Handbook for full list of Exclusions/Limitations.

$75 co-pay: retail 30-day prescription $150 co-pay: CVS/Caremark mail order or CVS Retail 90- day prescription $225 co-pay: retail 90-day prescription

Co-insurance or co-payment plus the difference in cost between out-of-network and network cost to the plan

Maintenance drugs are not covered at retail beginning with the 4th fill of a 30-day supply. See Insurance Benefits Handbook for full list of Exclusions/Limitations.

10% co-insurance

30% co-insurance

$500 penalty for no precertification.

10% co-insurance $300 co-pay/visit, plus 10% coinsurance

30% co-insurance $300 co-pay/visit, plus 10% co- insurance

$500 penalty for no precertification.

10% co-insurance

10% co-insurance

-----------none-----------

$75 co-pay/visit

$75 co-pay/visit

Per visit co-pay is waived if admitted.

Non-preferred brand drugs Not Covered

Covered medications more than $1,500 for a 30-day supply

If you have outpatient surgery

Your Cost if you use an In-Network Provider Out-of-Network Provider $7 co-pay: retail 30-day prescription $14 co-pay: CVS/Caremark mail Co-insurance or co-payment order or CVS Retail 90-day plus the difference in cost prescription between out-of-network and $21 co-pay: retail 90-day network cost to the plan prescription

Per visit co-pay is waived if admitted.

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 2016-2017 42

Common Medical Event

Services You May Need

If you have a hospital stay

Facility fee (e.g., hospital room) Physician/surgeon fees

If you have mental health, behavioral health, or substance abuse needs contact Orlando Behavioral Healthcare 407.637.8080

If you are pregnant

If you need help recovering or have other special health needs

Your Cost if you use an In-Network Provider Out-of-Network Provider

Limitations & Exceptions

10% co-insurance

30% co-insurance

$500 penalty for no precertification.

10% co-insurance

30% co-insurance

$500 penalty for no precertification.

The schedule of benefits for behavioral and mental health services is outlined in Section II. E.

Prenatal and postnatal care Delivery and all inpatient services

10% co-insurance

30% co-insurance

-----------none-----------

10% co-insurance

30% co-insurance

$500 penalty for no precertification.

Home health care

10% co-insurance

30% co-insurance

Rehabilitation services

$25 co-pay/visit

30% co-insurance

Habilitation services

Not Covered

Not Covered

Skilled nursing care

10% co-insurance

30% co-insurance

Durable medical equipment Hospice services

10% co-insurance 10% co-insurance

30% co-insurance 30% co-insurance

$500 penalty for no precertification. Coverage is limited to 100 days annual max. Maximums crossaccumulate. $500 penalty for failure to precertify speech therapy services. Coverage is limited to annual max of: 50 days for Rehabilitation including Cardiac rehab and Chiropractic care services -----------none----------$500 penalty for no precertification. Coverage is limited to 120 days annual max $500 penalty for no precertification. $500 penalty for no precertification.

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 2016-2017 43

Common Medical Event

Services You May Need

If your child needs dental or eye care

Eye Exam Glasses Dental check-up

Your Cost if you use an In-Network Provider Out-of-Network Provider Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Limitations & Exceptions -----------none---------------------none---------------------none-----------

Excluded Services & Other Covered Services Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.)  Acupuncture  Eye care (Children)  Non-emergency care when  Bariatric surgery  Habilitation services traveling outside the U.S.  Cosmetic surgery  Routine eye care (Adult)  Infertility treatment  Dental care (Adult)  Routine foot care  Long-term care  Dental care (Children) Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.)  Substance use disorder  Mental/Behavioral health inpatient and outpatient services  Chiropractic care inpatient and outpatient  Prescription drugs services  Hearing Aids  Private-duty nursing  Weight loss programs

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 2016-2017 44

Coverage Examples About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

This is not a cost estimator. Don't use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Please consider any contributions you may receive in an HRA, HSA or FSA. Note: These numbers assume enrollment in individual-only coverage.

Having a baby (normal delivery)  Amount owed to providers: $7,540  Plan pays: $5,370  Patient pays: $2,170 Sample care costs: Hospital charges (mother) Routine Obstetric Care Hospital charges (baby) Anesthesia Laboratory tests Prescriptions Radiology Vaccines, other preventive Patient pays: Deductible

Managing type 2 diabetes

$2,700 $2,100 $900 $900 $500 $200 $200 $40 $7,540

$1,500

(routine maintenance of a well-controlled condition)  Amount owed to providers: $5,400  Plan pays: $4,290  Patient pays: $1,110 Sample care costs: Prescriptions $2,900 Medical equipment and supplies $1,300 Office visits & procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductible Co-pays

Co-pays $70 Co-insurance Co-insurance $570 Limits or exclusions Limits or exclusions $30 Total Total $2,170 Note: These numbers assume the patient has given notice of her pregnancy to the plan. If you are pregnant and have not given notice of your pregnancy, your costs may be higher. For more information, please contact the OCPS Employee Wellness Program at 407.317.3200, Ext. 200 2929.

$140 $690 $0 $280 $1,110

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 2016-2017 45

Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples?  

    

Costs don't include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren't specific to a particular geographic area or health plan. The patient's condition was not an excluded or pre existing condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.

What does a Coverage Example show?

For each treatment situation, the Coverage Example helps you see how deductibles, co-payments, and co-insurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn't covered or payment is limited.

Does the Coverage Example predict my own care needs?

No. Treatments shown are just examples. The

care you would receive for this condition could be different based on your doctor's advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict my future expenses?

No. Coverage Examples are not cost estimators.

Can I use Coverage Examples to compare plans?

Yes. When you look at the Summary of Benefits

and Coverage for other plans, you'll find the same Coverage Examples. When you compare plans, check the "Patient Pays" box in each example. The smaller that number, the more coverage the plan provides.

Are there other costs I should consider when comparing plans?

Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you'll pay in out-of-pocket costs, such as co-payments, deductibles, and co-insurance. You also should consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.

You can't use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 2016-2017 46

Regarding In-Network Services:  All services must be provided by one of the preferred providers on the Cigna Open Access Plus Provider Directory. 

Once the plan year out-of-pocket maximum is reached, the plan pays 100% of eligible charges for the remainder of the plan year.



All inpatient hospital admissions require Pre-Certification and concurrent review will be performed during the hospital stay. Failure to obtain Pre-Certification and/or concurrent review may result in non-compliance penalties and/or reduction of benefits. Call the toll-free number on your Cigna Health Care ID Card.

Regarding Out-of-Network Services: 

Your out-of-pocket costs will be higher than with a preferred provider. Your out-of-network coverage pays a smaller share of the cost of your care than your in-network benefits. Some services may not be covered.



You are responsible for the filing of claims. Save your claim information from the physician or facility along with the receipt of payment. For each claim filed, you will receive an Explanation of Benefits (EOB) that helps you keep track of your out-of-pocket payments, your deductible and the payments made by your plan.



Services are covered only up to "reasonable and customary" amounts. These are determined by comparing what the physicians in the area charge for specific services. These are the maximum amounts your plan pays for out- of-network care. Any charges above these maximums are your responsibility. Services provided outside of the service area are only covered at 70% of what that same service would cost in the plan service area and are excluded from your out-of-pocket maximum. Any charges in excess will be the responsibility of the member in addition to the 30% co-insurance.



Once the plan year out-of-pocket maximum is reached, the plan pays 100% of eligible charges for the remainder of the plan year.



All inpatient hospital admissions require Pre-Certification and concurrent review. Failure to obtain Pre-Certification and/or concurrent review may result in non-compliance penalties and/or reduction of benefits. Call the toll-free number on your Cigna Health Care ID Card.

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Cigna Open Access Plus Health Reimbursement Account (HRA) PRECERTIFICATION/UTILIZATION MANAGEMENT

The precertification/utilization management process ensures that you, as the patient, are receiving medical care and treatment that is appropriate, medically necessary and being performed in the best setting. Therefore, if your physician recommends hospitalization, outpatient surgery or defined procedures/services as listed below, for you or your eligible dependent, precertification is required by your physician for in-network services and by you and/or your physician for out of network services by calling 1.800.CIGNA24 (1.800.244.6224) five (5) days prior to services being rendered. You must receive services from an in-network provider in order to receive your highest level of benefit reimbursement. You will receive a letter stating what services and/or treatments have been approved. If your hospitalization is for a maternity stay, no authorization is required for a 48 hour stay for vaginal deliveries or a 96 hour stay for Cesarean section. Longer stay must be authorized by Cigna HealthCare. If admission is due to an emergency, you or a member of your family, and your physician must call Cigna Health Care at 1.800.CIGNA24 (1.800.244.6224) within 48 hours or as soon as possible. All emergency admissions will be reviewed for medical necessity. Concurrent review will be performed during your hospital stay to ensure that continued hospitalization is warranted. You will be visited by a Cigna Health Care nurse to assist with any discharge needs you may have. Precertification is required for ALL in-patient admissions, and the following list of services and procedures whether performed in a hospital, outpatient facility, or doctor’s office:  All elective and urgent/emergent admissions, observation stays, skilled nursing facility, rehab facilities, hospice facilities, and transfers between facilities. 

Any covered dental-treatments and procedures including, but not limited to: orthognathic procedures, TMJ procedures, procedures to treat injury to sound natural teeth.



MRA, MRI, CT, and PET Scans



Durable medical equipment



Devices including, but not limited to: cochlear implants, insulin pumps



Home health care and home infusion therapy



Tonsillectomy – in-patient only



Uvulopharyngopalatoplasty – in-patient only



Hysterectomy



Speech therapy, prior to the first visit

Please note: List of services is subject to change without notice. When pre-certifying procedures, all claims are subject to retrospective review, if necessary, to confirm that procedures or services are covered and not excluded under the Plan Document.

II. Medical Insurance: Cigna Health Reimbursement Account (HRA)

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PENALTIES THE PRECERTIFICATION PROGRAM IS MANDATORY. If services as listed are not pre-certified, up to a $500 penalty will be imposed on the covered person when utilizing an out-of-network physician. Serious Illness If you or a covered family member ever need care beyond a traditional hospital stay, Cigna Health Care Case Management service provides valuable counseling, support and care coordination. An experienced case manager, assigned specifically to your situation, works closely with your doctor to help you sort out your options, contact facilities, arrange care, and access helpful community resources and programs. For more information call Customer Service at the toll-free number on your Cigna Health Care ID card, 1.800.CIGNA24 (1.800.244.6224). The Cigna Health Care Your Health First Program Your Cigna Health Care plan includes the Cigna Health Care Your Health First Program for better health. It offers valuable, confidential support for you and your covered family members with specific medical conditions. The Cigna Health Care Your Health First Program provides educational materials that help you learn more about your health condition, regular reminders of important checkups and tests and helpful information that keeps your doctor advised of the latest care and treatment techniques. The Cigna Health Care Your Health First Program helps you and your doctor follow your condition more closely and treat it more effectively. The following programs are available: 

Asthma



Heart Disease



Coronary Artery Disease



Angina



Congestive Heart Failure



Acute Myocardial Infarction



COPD (Emphysema and Chronic Bronchitis)



Diabetes Type 1



Diabetes Type 2



Metabolic Syndrome



Peripheral Arterial Disease



Low Back Pain



Osteoarthritis



Depression



Anxiety



Bipolar Disorder

To learn more or to enroll in the program, call 1.855.246.1873.

II. Medical Insurance: Cigna Health Reimbursement Account (HRA)

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Once you complete the simple enrollment process, you will be provided with:  Access to registered nurses who specialize in your condition. 

Information and resources that include assistance with self-care materials and services; and informative topic sheets on a variety of condition related topics.



Reminders of self-care routines, exams and doctor appointments and other important topics.

Cigna Health Care Healthy Babies® (Well Pregnancy Program) The Cigna Health Care Healthy Babies program provides education and support for covered mothers-to-be along with special attention for high-risk pregnancies. The program includes:  Access to a valuable toll-free information line staffed by experienced registered nurses 

Educational materials from a recognized source of information on pregnancy and babies -March of Dimes®



Post-delivery support and services. Once your baby arrives, Cigna Health Care continues to provide access to the services you'll need for the first few days and after.

Financial incentives (awarded after baby’s birth) will be awarded to members who participate and meet the requirements of the program outlined at enrollment. If you enroll:  Prenatal Vitamins: Participants will receive their prescription prenatal vitamins free - no copays. 

Preconception: Up to 12 months before becoming pregnant - incentive equals $225.



Pregnancy up to the 12th of pregnancy - incentive equals $175.



From the 13th the 23rd week of pregnancy - incentive equals $50.

For members enrolled in the Well Pregnancy Program, Lamaze classes are “free of charge” at specified locations. Please call Cigna Health Care at the toll-free number on your Cigna Health Care ID card, 1.800.CIGNA24 (1.800.244.6224). Hearing Aid Program This program allows coverage of hearing aids through the Cigna in-network provider, Amplifon/HearPo. This benefit will NOT be covered at an out-of-network provider. Your coverage includes:  Up to two hearing aids in a covered three year period; maximum benefit of $3,000 per hearing aid device through the Cigna in-network provider, Amplifon/HearPo. 

Co-insurance and deductibles apply.

To access services, call Amplifon/HearPo at 1.888.207.2798.

II. Medical Insurance: Cigna Health Reimbursement Account (HRA)

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Weight Phases Program This program is designed to assist the individual with a Body Mass Index (BMI) of 33 with one major risk factor or 35 or above without any risk factors. Components of the program include supervised exercise training three times per week; monthly fitness evaluations with an Exercise Specialist; Bod Pod analysis; weekly weigh-ins; nutritional counseling, calorie recommendations, recipes and educational material. Weight Phases participants pay a monthly fee directly to the Orlando Regional Wellness Center. After successful completion of all the program requirements, participants are eligible to receive a percentage reimbursement. To qualify for this program, participants must:  Be more than 14 years old 

Have a Body Mass Index (BMI) of 33 with one major risk factor or 35 or above without any risk factors



Obtain a physician’s approval if requested by Orlando Regional Wellness Center

Contact the Orlando Regional Wellness Center at 407.237.6351. Smoking Cessation Program – Smoke Free OCPS This program is designed to assist individuals attempting to quit smoking. Components of the program include an eight week problem solving, social supportive educational class, coverage of prescription or over-the-counter (OTC) nicotine replacement and reimbursement for any group therapy costs. After 12 months of successfully quitting smoking, participants are eligible to receive reimbursements with proper documentation. Contact the Employee Wellness Program at 407.317.3200, Ext. 2002929 to obtain an enrollment packet. The Cigna Health Care 24-Hour Health Information Line No matter where you are in the U.S., you can call the Cigna Health Care 24-Hour Health Information Line, toll-free at 1.800.CIGNA24 (1.800.244.6224).  You can speak to a registered nurse for answers to your health questions, assistance in locating nearby medical facilities, and helpful self-care tips. 

You can listen to informative, recorded audio tapes on hundreds of health topics.



This service is available around the clock, 24-hours a day, seven days a week.

MDLIVE offered through Cigna Easy and cost effective Telehealth solution that provides on-demand 24/7/365 access to nonurgent health care through a national network of licensed, board certified U.S. – based doctors and pediatricians. You can talk with doctors by phone or online video. MDLIVE’s doctors can diagnose you, prescribe medications when appropriate and send the prescription directly to your pharmacy. When to use it? MDLIVE is available 24 hours a day, seven days a week, 365 days a year to conveniently help you find treatment for minor, non-emergency conditions. You can use it anytime, from anywhere. All you need is a phone or computer with webcam. Use MDLIVE to talk to a doctor about: › Acne › Allergies › Asthma › Bronchitis › Cold & Flu › Diarrhea › Ear Aches › Fever › Head Ache › Infections › Insect Bites › Joint Aches › Nausea › Pink Eye › Rashes › Respiratory Infections › Sinus Infections › Skin Infections › Sore Throat › Urinary Tract Infections Child medical conditions - Cold & Flu - Constipation - Ear Aches - Nausea - Pink Eye For Copay plans – Pay $10 copay For Deductible plans – Pay $38 until Deductible is met, then pay $10 copay

II. Medical Insurance: Cigna Health Reimbursement Account (HRA)

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To access MDLIVE:  Telephone: Call 1.888.726.3171 and speak to a coordinator to find a doctor who meets your needs – talk to the doctor.  Website: Go to www.mdlive.com/ocps. Find a doctor who meets your needs. Video chat with the doctor.  Mobile App: Download MDLIVE App for an easier and more convenient way to visit with the doctor. This service and the MDLIVE website are provided exclusively by MDLIVE and not by Cigna. MDLIVE doctors are independent practitioners solely responsible for the treatment provided to their patients. They are not agents of Cigna. MDLive operates in the U.S. subject to state regulation and may not be available in certain states. Medicare Primary Beneficiaries are not eligible for coverage of MDLIVE services. Cigna Healthy Rewards Program Healthy Rewards is a discount program offered to Cigna members. Healthy Rewards offers discounts for acupuncture, laser vision correction, hearing aids, cosmetic dentistry, smoking cessation, fitness club memberships, herbal supplements and a variety of other services and programs. There are no claims to file. The discount applies the minute service is paid for. Members use their Cigna medical plan ID card for identification. Discounts apply only with Healthy Rewards participating providers. Members can find a list of providers and services by calling 1.800.870.3470 or by visiting www.cigna.com/healthyrewards or www.mycigna.com. Healthy Rewards discounts cannot be applied to any copayments or coinsurance for services already covered by your medical plan. Customer Service Cigna Customer Service:  The toll-free number is 1.800.CIGNA24 (1.800.244.6224). Please have your Cigna Health Care ID card ready when you call. 

Cigna's Customer Service is available 24 hours a day, 7 days a week.



Se habla Espanol - and more than 140 other languages. Cigna provides bi-lingual representatives in Spanish-speaking areas; for other non-English speaking members, Cigna also offers a Language Line service that can translate virtually any language.

Cigna Health Care ID Card Carry it with you at all times and present it whenever you access medical care. This will help ensure that your claim is handled properly.

II. Medical Insurance: Cigna Health Reimbursement Account (HRA)

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EXCLUSIONS/LIMITATIONS Expenses for the following are excluded and/or limited: MEDICAL PLAN 1. Any treatment for cosmetic purposes or for cosmetic surgery, except that the plan will pay for cosmetic treatment or surgery: a. Due solely to an accidental bodily injury which occurred while the covered person was under this plan; or b. Due solely to a birth defect of a covered person’s eligible dependent child. 2.

Any service for the treatment of injury or illness considered not medically necessary and/or appropriate as determined by the medical director or his designee.

3.

Collection or donation of blood products, except for autologous donation in anticipation of scheduled services where in the opinion of the Medical Director the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery. Blood administration for the purpose of general improvement of health.

4.

Surgery to reverse surgical sterilization procedures.

5.

Services and supplies related to sexual dysfunctions or inadequacies, or for sex change operations.

6.

Fertility studies, sterility studies, procedures to restore or enhance fertility, artificial insemination, or invitro fertilizations.

7.

Care or services of any kind performed by or under the direct supervision of a dentist, except that the plan will pay for dental treatment necessary to repair injuries to sound, natural teeth caused by a non- occupational accident occurring while the covered person is covered and which are performed within six months of the accident. The contributing cause of the accident must be something other than teeth grinding, chewing, or biting.

8.

Treatment on or to the teeth, the nerves or roots of the teeth, gingival tissue of alveolar processes; however, benefits will be payable for the charges incurred for the treatment required because of accidental bodily injury to natural teeth sustained while covered (this exception shall not in any event be deemed to include expenses for treatment for the repair or replacement of a denture).

9.

Non-surgical treatment involving bones and joints of the jaw and facial region. All orthognathic procedures and other craniomandibular disorder treatments not medically necessary.

10.

Diagnosis or treatment of weak or flat feet, fallen or high arches, for instability or imbalance metatarsalgia not caused by disease (except for bone surgery), bunions (except for capsular or bone surgery), corns or calluses, or toenails (except for complete or partial removal of nail root); unless needed in treatment of a metabolic or peripheral vascular disease.

11.

Routine hearing examinations, routine physical examinations, premarital examinations, pre-employment physicals, preschool examinations, or annual boosters except as indicated in the summary of benefits.

12.

Hearing aids or examination for prescriptions or fitting of hearing aids, except as indicated in the summary of benefits.

13.

Routine eye examination, eye glasses, contact lenses or their fitting (unless for initial replacement of the lens of the eye after cataract surgery), eye exercises, visual therapy, fusion therapy, visual aids or orthoptics, any related examination and eye refraction, or radial keratatomy.

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14.

For experimental, investigational or unproven services which are medical, surgical, psychiatric, substance abuse or other healthcare technologies, supplies, treatments, procedures, drug therapies, or devices that are determined to be: a. Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not recognized for the treatment of the particular indication in one of the standard reference compendia (The United States Pharmacopeia Drug Information, the American Medical Association Drug Evaluations, or the American Hospital Formulary Service Drug Information) or in medical literature. Medical literature means scientific studies published in a peerreviewed national professional journal; or b. The subject of review or approval by an Institutional Review Board for the proposed use; or c. The subject of an ongoing clinical trial that meets the definition of a phase I, II, or III Clinical Trial as set forth in the FDA regulations, regardless of whether the trial is subject to FDA oversight; or d. Not demonstrated, through existing peer-reviewed literature, to be safe and effective for treating or diagnosing the condition or illness for which its use is proposed

15.

Any organ or tissue transplant, except as otherwise listed in the Plan Document.

16.

Education, training, and bed and board while confined to an institution which is primarily a school or other institution for training; a place of rest, a place for the aged, or for custodial care or for testing or training due to mental, nervous, or emotional conditions.

17.

Education (excluding diabetes education), training, or counseling of any type no matter what the diagnosis. The mental health benefit covers counseling.

18.

Health Services and associated expenses for bariatric procedures/surgeries intended primarily for the treatment of morbid obesity or weight loss, including but not limited to gastric bypasses, gastric balloons, stomach stapling, jejunal bypasses, wiring of the jaw and health services of a similar nature.

19.

Weight control counseling or services primarily for weight loss or control. Necessary treatment for eating disorders, as defined by DSM-III-R codes, is covered under the mental health benefit approved by Orlando Behavioral Healthcare. Coverage for weight control is provided in network only and follows the guidelines set forth in the Health Care Reform Act at http://www.healthcare.gov/law/about/provisions/services/lists.html.

20.

Vitamins, minerals, or food supplements, whether or not prescribed by a qualified practitioner. a. Exception: Legend vitamins and minerals when adequate nutrition cannot be sustained with over- the-counter vitamins and minerals. Clinically necessary I.V. hyperalimentation or when adequate nutrition cannot be sustained through usual pathway.

21.

Any personal items while hospital confined.

22.

Hospitalization primarily for x-ray, laboratory, diagnostic study, physical therapy, hydrotherapy, medical observation, convalescent or rest care, or any other medical examination or tests not clinically necessary.

23.

Services, supplies, or tests not generally accepted in health care practices as needed in the diagnosis or treatment of the patient, even if ordered by a doctor.

24.

Medical supplies such as adhesive tape, antiseptics, or other common first aid supplies.

25.

Services provided by a person who usually lives in the same household as the covered person, or who is a member of his/her immediate family or the family of his/her spouse.

26.

Those services incurred prior to the date coverage is in force or after coverage ends, except if the person is totally disabled on the date this medical plan ends.

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27.

Those services which a covered person would not be legally obligated to pay if health insurance coverage did not exist.

28.

Illness for which the covered person is entitled to benefits under any worker’s compensation law or act, or accidental bodily injury arising out of or in the course of the covered person’s employment or services rendered by any governmental program (i.e., V.A. hospital) unless there is a legal obligation to pay for coverage.

29.

Illness resulting from war, whether declared or undeclared.

30.

Illness or injury to which a contribution cause was the commission of, or attempted commission of, an act of aggression or a felony, or participating in a riot by the covered person.

31.

Any charges in excess of approved charges as determined by Cigna.

32.

Claims not submitted within 12 months from the date of service.

33.

All charges during a hospitalization deemed medically unnecessary or inappropriate by the medical director or his designee.

34.

Penalties for failure to comply with any and all applicable precertification requirements.

35.

Claims for services to improve a covered person’s general physical condition, for private membership clubs and clinics, and for any other organization charging membership fees.

36.

Charges for the first $10,000 of bodily injury to a person while riding a motorcycle without a helmet.

37.

Any tests not requiring a physician’s order and purchased over-the-counter.

38.

Assistance in the activities of daily living, including but not limited to eating, bathing, dressing or other Custodial Services or self-care activities, homemaker services and services primarily for rest, domiciliary or convalescent care.

39.

Cost of biologicals that are immunizations or medications for the purpose of travel, or to protect against occupational hazards and risks.

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II. MEDICAL INSURANCE

C.

PLAN C: CIGNA OAP IN-NETWORK

II. MEDICAL INSURANCE

Plan C: Cigna OAP In-Network OVERVIEW The Cigna Health Care OAP In-Network plan is designed to provide high quality healthcare to you and your family. You have the option to choose a “Primary Care Physician” (PCP) who specializes in one of four areas: family practice, internal medicine, general medicine or pediatrics. Your PCP or personal physician can be a source for routine care and for guidance if you need to see a specialist or require hospitalization. With the Cigna Health Care OAP In-Network plan no referrals are needed to see a participating specialist. If you see a provider who is not in the Cigna Open Access Plus network, your plan does not cover those services, except in emergencies. Each family member can choose his or her own PCP. To access an online provider directory for the Cigna OAP In-Network plan visit www.cigna.com, choose “Find A Doctor,” choose “Open Access Plus, OA Plus, Choice Fund OA Plus.” For detailed instructions in using the provider directory, please see page 8 of the General Insurance Information section of this handbook. Cigna Health Care Network provides cost-effective, high quality healthcare services through participating physician offices and facilities. To ensure full and proper medical treatment, this program emphasizes pre-admission screening, prior authorization for specific services, ambulatory services, home healthcare, and preventive care. Please use the Summary of Benefits and Coverage as a guide to your plan. This schedule does not contain all provisions of your benefit plan.

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The School Board of Orange County, Florida: Open Access Plus IN

Coverage Period: 10/01/2016 - 09/30/2017

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Individual + Family | Plan Type: OAP This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.cigna.com/sp/ or by calling 1-800-Cigna24 Important Questions What is the overall deductible? Are there other deductibles for specific services? Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? Is there an overall annual limit on what the plan pays?

Answers $0 No. Yes. For in-network providers $3,500 person / $7,000 family For in-network prescription drugs - $500 person/ $1,000 family For in-network Mental Health/Substance Abuse$500 person/ $1,000 family Premium, balance-billed charges, and health care this plan doesn't cover. No.

Why this Matters: See the chart starting on page 59 for your costs for services this plan covers. You don't have to meet deductibles for specific services, but see the chart starting on page 59 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don't count toward the out-ofpocket limit. The chart starting on page 59 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your innetwork doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 59 for how this plan pays different kinds of providers.

Does this plan use a network of providers?

Yes. For a list of participating providers, see www.myCigna.com or call 1-800-Cigna24

Do I need a referral to see a specialist?

No. You don't need a referral to see a specialist.

You can see the specialist you choose without permission from this plan.

Yes.

Some of the services this plan doesn't cover are listed on page 61. See your policy or plan document for additional information about excluded services.

Are there services this plan doesn't cover?

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 2016-2017 57

Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount of the service. For example, if the health plan's allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven't met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charge is $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, co-payments and co-insurance amounts. Common Medical Event

Your Cost if you use an In-Network Provider Out-of-Network Provider

Limitations & Exceptions

$20 co-pay/visit

Not Covered

-----------none-----------

$10 co-pay/visit

Not Covered

-----------none-----------

Specialist visit

$40 co-pay/visit

Not Covered

Other practitioner office visit

$25 co-pay/visit for chiropractor

Not Covered

-----------none----------Coverage for chiropractic care and rehabilitation services (includes cardiac rehab) is limited to 50 days annual max.

Preventive care/screening/ immunization

No charge

Not Covered

-----------none-----------

Diagnostic test (x-ray, blood work)

No charge (physician's office/independent lab)20% coinsurance(inpatient or outpatient services)

Not Covered

-----------none-----------

Imaging (CT/PET scans, MRIs)

$100 co-pay per procedure

Not Covered

-----------none-----------

Services You May Need Primary care visit to treat an injury or illness MDLIVE

If you visit a health care provider's office or clinic

If you have a test

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 2016-2017 58

Common Medical Event

Services You May Need

Generic drugs

Your Cost if you use an In-Network Provider Out-of-Network Provider $7 co-pay: retail 30-day prescription $14 co-pay: CVS/Caremark mail order or CVS Retail 90-day prescription Not Covered $21 co-pay: retail 90-day prescription

Limitations & Exceptions Maintenance drugs are not covered at retail beginning with the 4th fill of a 30-day supply. See Insurance Benefits Handbook for full list of Exclusions/Limitations.

$30 co-pay: retail 30-day prescription If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.myCigna.com

Preferred brand drugs

$60 co-pay: CVS/Caremark mail order or CVS Retail 90- day prescription Not Covered $90 co-pay: retail 90-day prescription Not Covered

See Insurance Benefits Handbook for full list of Exclusions/Limitations.

Not Covered

Maintenance drugs are not covered at retail beginning with the 4th fill of a 30-day supply. See Insurance Benefits Handbook for full list of Exclusions/Limitations.

20% co-insurance

Not Covered

-----------none-----------

20% co-insurance $300 co-pay/visit

Not Covered $300 co-pay/visit

-----------none----------Per visit co-pay is waived if admitted

20% co-insurance

20% co-insurance

-----------none-----------

$35 co-pay/visit

$35 co-pay/visit

Per visit co-pay is waived if admitted

Non-preferred brand drugs Not Covered $75 co-pay: retail 30-day prescription Covered medications more than $1,500 for a 30-day supply

Maintenance drugs are not covered at retail beginning with the 4th fill of a 30-day supply. See Insurance Benefits Handbook for full list of Exclusions/Limitations.

$150 co-pay: CVS/Caremark mail order or CVS Retail 90- day prescription $225 co-pay: retail 90-day prescription

If you have outpatient surgery If you need immediate medical attention

Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services Emergency medical transportation Urgent care

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 2016-2017 59

Common Medical Event

Services You May Need

If you have a hospital stay

Facility fee (e.g., hospital room) Physician/surgeon fees

If you have mental health, behavioral health, or substance abuse needs contact Orlando Behavioral Healthcare 407.637.8080

If you are pregnant

If you need help recovering or have other special health needs

Your Cost if you use an In-Network Provider Out-of-Network Provider

Limitations & Exceptions

20% co-insurance

Not Covered

-----------none-----------

20% co-insurance

Not Covered

-----------none-----------

The schedule of benefits for behavioral and mental health services is outlined in Section II. E.

Prenatal and postnatal care

$150 co-pay, plus 20% coinsurance

Not Covered

-----------none-----------

Delivery and all inpatient services

20% co-insurance

Not Covered

-----------none-----------

Home health care

No charge

Not Covered

Rehabilitation services

$25 co-pay/visit

Not Covered

Habilitation services

Not Covered

Not Covered

Skilled nursing care

20% co-insurance

Not Covered

Durable medical equipment

No charge 20% co-insurance/inpatient services and No charge/outpatient services

Not Covered

Coverage is limited to 100 days innetwork annual max Coverage is limited to annual max of: 50 days for Rehabilitation (including Cardiac rehab) and Chiropractic care services -----------none----------Coverage is limited to 120 days annual max -----------none-----------

Not Covered

-----------none-----------

Hospice services

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 2016-2017 60

Common Medical Event

Services You May Need

If your child needs dental or eye care

Eye Exam Glasses Dental check-up

Your Cost if you use an In-Network Provider Out-of-Network Provider Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Limitations & Exceptions -----------none---------------------none---------------------none-----------

Excluded Services & Other Covered Services Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.)  Acupuncture  Bariatric surgery  Habilitation services  Cosmetic surgery  Infertility treatment  Routine eye care (Adult)  Dental care (Adult)  Long-term care  Routine foot care  Dental care (Children)  Non-emergency care when traveling outside the U.S.  Eye care (Children) Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.)  Hearing aids  Mental/Behavioral health inpatient and outpatient services  Chiropractic care  Prescription drugs  Private-duty nursing  Substance use disorder inpatient and outpatient services  Weight loss programs

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 2016-2017 61

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 2016-2017 62

Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples?  

    

Costs don't include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren't specific to a particular geographic area or health plan. The patient's condition was not an excluded or pre existing condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.

What does a Coverage Example show?

For each treatment situation, the Coverage Example helps you see how deductibles, co-payments, and co-insurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn't covered or payment is limited.

Does the Coverage Example predict my own care needs?

No. Treatments shown are just examples. The

care you would receive for this condition could be different based on your doctor's advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict my future expenses?

No. Coverage Examples are not cost estimators.

Can I use Coverage Examples to compare plans?

Yes. When you look at the Summary of Benefits

and Coverage for other plans, you'll find the same Coverage Examples. When you compare plans, check the "Patient Pays" box in each example. The smaller that number, the more coverage the plan provides.

Are there other costs I should consider when comparing plans?

Yes. An important cost is the premium you pay.

Generally, the lower your premium, the more you'll pay in out-of-pocket costs, such as co-payments, deductibles, and co-insurance. You also should consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.

You can't use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 2016-2017 63

Cigna NETWORK

PRECERTIFICATION/UTILIZATION MANAGEMENT The precertification/utilization management process ensures that you, as the patient, are receiving medical care and treatment that is appropriate, medically necessary and being performed in the best setting. Your Primary Care Physician is the key to obtaining the highest level of benefits under your health plan. The Primary Care Physicians have been carefully selected to provide and manage all of the medical care needs for you and your family. Therefore, if your physician recommends hospitalization, out-patient surgery or defined procedures/services as listed below for you or your eligible dependent, precertification is required. Please contact your physician to ensure your elective hospitalization or procedure has been pre-certified five (5) days prior to services being rendered. Your care must be provided by participating providers in order to receive benefits unless a non- participating provider has been pre-authorized to provide services by Cigna Health Care. If your Primary Care Physician feels you require the services of a specialist, he or she can coordinate your health care needs to a participating Cigna Health Care physician. Referrals are required; you pay the appropriate copayment amount for an office visit. If your hospitalization is for a maternity stay, no authorization is required for a 48 hour stay for vaginal deliveries or a 96 hour stay for Cesarean section. Longer stay must be authorized by Cigna Health Care. If admission is due to an emergency, you or a member of your family, and your physician must call Cigna Health Care at 1.800.244.6224 (1.800.CIGNA24) within 48 hours/next working day following the admission. All emergency admissions will be reviewed for medical necessity. Concurrent review will be performed during your hospital stay to ensure that continued hospitalization is warranted. You may be visited by a Cigna Health Care nurse to assist with any discharge needs you may have. In non-life threatening situations that occur inside or outside the Cigna Health Care service area, please call your Primary Care Physician before you seek emergency care services. Your Primary Care Physician can then direct you for appropriate care. Chronic or less severe problems should be handled during routine office hours. Any unauthorized medical expenses incurred for nonemergency services may result in no benefits. Primary Care Physicians are required to provide coverage 24 hours a day, including weekends and holidays. In life-threatening situations, such as severe chest pain, unconsciousness, uncontrolled bleeding, severe shortness of breath, convulsions or multiple injuries, go directly to the nearest emergency facility. If admission to the hospital is required, have the emergency department or a family member contact your Primary Care Physician and Cigna Health Care. Always contact your Primary Care Physician within 24 hours of an emergency visit. If you are outside of the Cigna Health Care service area and require emergency care, go to the nearest medical facility for treatment. Please call your Primary Care Physician and Cigna Health Care within 24 hours of receiving such care. Non-emergency medical care incurred out of the service area, or lack of notification, will result in no benefits. Please refer to your schedule of benefits for coinsurance, copayment or other requirements of your benefit plan. All follow-up care, such as suture removal, x-ray, lab work, or revisits, should be coordinated by your Primary Care Physician.

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Precertification is required for ALL in-patient admissions, and the following list of services and procedures whether performed in a hospital, outpatient facility, or doctor’s office:  All elective and urgent/emergent admissions, observation stays, skilled nursing facility, rehab facilities, hospice facilities, and transfers between facilities. 

Any covered dental-treatments and procedures including, but not limited to: orthognathic procedures, TMJ procedures, procedures to treat injury to sound natural teeth.



MRA, MRI, CT, and PET Scans



Durable medical equipment



Devices including, but not limited to: cochlear implants, insulin pumps



Home health care and home infusion therapy



Tonsillectomy – In-patient only



Uvulopharyngopalatoplasty – In-patient only



Hysterectomy



Speech therapy, prior to the first visit

Please note: List of services is subject to change without notice. When pre-certifying procedures, all claims are subject to retrospective review, if necessary, to confirm that procedures or services are covered and not excluded under the Plan Document. Serious Illness If you or a covered family member ever need care beyond a traditional hospital stay, Cigna Health Care Case Management service provides valuable counseling, support and care coordination. An experienced case manager, assigned specifically to your situation, works closely with your doctor to help you sort out your options, contact facilities, arrange care, and access helpful community resources and programs. For more information call Customer Service at the toll-free number on your Cigna Health Care ID card, 1.800.CIGNA24 (1.800.244.6224). The Cigna Health Care Your Health First Program Your Cigna Health Care plan includes the Cigna Health Care Your Health First Program for better health. It offers valuable, confidential support for you and your covered family members with specific medical conditions. The Cigna Health Care Your Health First Program provides educational materials that help you learn more about your health condition, regular reminders of important checkups and tests and helpful information that keeps your doctor advised of the latest care and treatment techniques. The Cigna Health Care Your Health First Program helps you and your doctor follow your condition more closely and treat it more effectively. The following programs are available:  Heart Disease  Asthma  Coronary Artery Disease  Metabolic Syndrome  Angina  Peripheral Arterial Disease  Congestive Heart Failure  Low Back Pain  Acute Myocardial Infarction  Osteoarthritis  COPD (Emphysema and Chronic Bronchitis)  Depression  Diabetes Type 1  Anxiety  Diabetes Type 2  Bipolar Disorder To learn more or to enroll in the program, call 1.855.246.1873. II. Medical Insurance: Cigna OAP In-Network

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Once you complete the simple enrollment process, you will be provided with:  Access to registered nurses who specialize in your condition 

Information and resources that include assistance with self-care materials and services; and informative topic sheets on a variety of condition related topics.



Reminders of self-care routines, exams and doctor appointments and other important topics.

Cigna Health Care Healthy Babies® (Well Pregnancy Program) The Cigna Health Care Healthy Babies program provides education and support for covered mothers-to-be along with special attention for high-risk pregnancies. The program includes:  Access to a valuable toll-free information line staffed by experienced registered nurses 

Educational materials from a recognized source of information on pregnancy and babies -March of Dimes®



Post-delivery support and services. Once your baby arrives, Cigna Health Care continues to provide access to the services you'll need for the first few days and after.

Financial incentives (awarded after baby’s birth) will be awarded to members who participate and meet the requirements of the program outlined at enrollment. If you enroll:  Prenatal Vitamins: Participants will receive their prescription prenatal vitamins free - no copays. 

Preconception: Up to 12 months before becoming pregnant – incentive equals $225.



Pregnancy up to the 12th week of pregnancy – incentive equals $175.



From the 13th the 23rd week of pregnancy – incentive equals $50.

For members enrolled in the Well Pregnancy Program, Lamaze classes are “free of charge” at specified locations. Please call Cigna Health Care at the toll-free number on your Cigna Health Care ID card, 1.800.CIGNA24 (1.800.244.6224). Hearing Aid Program This program allows coverage of hearing aids through the Cigna in-network provider, Amplifon/HearPo. This benefit will NOT be covered at an out-of-network provider. Your coverage includes:  Up to two hearing aids in a covered three year period; maximum benefit of $3,000 per hearing aid device through the Cigna in-network provider, Amplifon/HearPo. 

Co-insurance and deductibles apply.

To access services, call Amplifon/HearPo at 1.888.207.2798. Weight Phases Program This program is designed to assist the individual with a Body Mass Index (BMI) of 33 with one major risk factor or 35 or above without any risk factors. Components of the program include Bod Pod analysis; supervised exercise training three times per week; monthly fitness evaluations with an Exercise Specialist; weekly weigh-ins; nutritional counseling, calorie recommendations, recipes and educational material. Weight Phases participants pay a monthly fee directly to the Orlando Regional Wellness Center. After successful completion of all the program requirements, participants are eligible to receive a percentage reimbursement.

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To qualify for this program, participants must:  Be more than 14 years old 

Have a Body Mass Index (BMI) of 33 with one major risk factor or 35 or above without any risk factors



Obtain a physician’s approval if requested by Orlando Regional Wellness Center

Contact the Orlando Regional Wellness Center at 407.237.6351 Smoking Cessation Program – Smoke Free OCPS This program is designed to assist individuals attempting to quit smoking. Components of the program include an eight week problem solving, social supportive educational class, coverage of prescription or over-the-counter (OTC) nicotine replacement and reimbursement for any gr oup therapy costs. After 12 months of successfully quitting smoking, participants are eligible to receive reimbursements with proper documentation. Contact the Employee Wellness Program at 407.317.3200, Ext. 2002929, to obtain an enrollment packet. The Cigna Health Care 24-Hour Health Information Line No matter where you are in the U.S., you can call the Cigna Health Care 24-Hour Health Information Line, toll-free at 1.800.CIGNA24 (1.800.244.6224).  You can speak to a registered nurse for answers to your health questions, assistance in locating nearby medical facilities, and helpful self-care tips. 

You can listen to informative, recorded audio tapes on hundreds of health topics.



This service is available around the clock, 24-hours a day, seven days a week.

MDLIVE offered through Cigna Easy and cost effective Telehealth solution that provides on-demand 24/7/365 access to nonurgent health care through a national network of licensed, board certified U.S. – based doctors and pediatricians. You can talk with doctors by phone or online video. MDLIVE’s doctors can diagnose you, prescribe medications when appropriate and send the prescription directly to your pharmacy. When to use it? MDLIVE is available 24 hours a day, seven days a week, 365 days a year to conveniently help you find treatment for minor, non-emergency conditions. You can use it anytime, from anywhere. All you need is a phone or computer with webcam. Use MDLIVE to talk to a doctor about: › Acne › Allergies › Asthma › Bronchitis › Cold & Flu › Diarrhea › Ear Aches › Fever › Head Ache › Infections › Insect Bites › Joint Aches › Nausea › Pink Eye › Rashes › Respiratory Infections › Sinus Infections › Skin Infections › Sore Throat › Urinary Tract Infections Child medical conditions - Cold & Flu - Constipation - Ear Aches - Nausea - Pink Eye For Copay plans – Pay $10 copay For Deductible plans – Pay $38 until Deductible is met, then pay $10 copay To access MDLIVE:  Telephone: Call 1.888.726.3171 and speak to a coordinator to find a doctor who meets your needs – talk to the doctor.  Website: Go to www.mdlive.com/ocps. Find a doctor who meets your needs. Video chat with the doctor.  Mobile App: Download MDLIVE App for an easier and more convenient way to visit with the doctor. This service and the MDLIVE website are provided exclusively by MDLIVE and not by Cigna. II. Medical Insurance: Cigna OAP In-Network

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MDLIVE doctors are independent practitioners solely responsible for the treatment provided to their patients. They are not agents of Cigna. MDLive operates in the U.S. subject to state regulation and may not be available in certain states. Medicare Primary Beneficiaries are not eligible for coverage of MDLIVE services. Cigna Healthy Rewards Program Healthy Rewards is a discount program offered to Cigna members. Healthy Rewards offers discounts for acupuncture, laser vision correction, hearing aids, cosmetic dentistry, smoking cessation, fitness club memberships, herbal supplements and a variety of other services and programs. There are no claims to file. The discount applies the minute service is paid for. Members use their Cigna medical plan ID card for identification. Discounts apply only with Healthy Rewards participating providers. Members can find a list of providers and services by calling 1.800.870.3470 or by visiting www.cigna.com/healthyrewards or www.mycigna.com. Healthy Rewards discounts can’t be applied to any copayments or coinsurance for services already covered by your medical plan. Customer Service Cigna Customer Service:  The toll-free number is 1.800.CIGNA24 (1.800.244.6224). Please have your Cigna Health Care ID card ready when you call. 

Cigna's Customer Service is available 24 hours a day, 7 days a week.



Se habla Espanol - and more than 140 other languages. Cigna provides bi-lingual representatives in Spanish-speaking areas; for other non-English speaking members, Cigna also offers a Language Line service that can translate virtually any language.

Cigna Health Care ID Card Carry it with you at all times and present it whenever you access medical care. This will help ensure that your claim is handled properly. EXCLUSIONS/LIMITATIONS Expenses for the following are excluded and/or limited: MEDICAL PLAN 1. Any treatment for cosmetic purposes or for cosmetic surgery, except that the plan will pay for cosmetic treatment or surgery: a. Due solely to an accidental bodily injury which occurred while the covered person was under this plan; or b. Due solely to a birth defect of a covered person’s eligible dependent child. 2. Any service for the treatment of injury or illness considered not medically necessary and/or appropriate as determined by the medical director or his designee. 3. Collection or donation of blood products, except for autologous donation in anticipation of scheduled services where in the opinion of the Medical Director the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery. Blood administration for the purpose of general improvement of health. 4. Surgery to reverse surgical sterilization procedures. II. Medical Insurance: Cigna OAP In-Network

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5. Services and supplies related to sexual dysfunctions or inadequacies, or for sex change operations. 6. Fertility studies, sterility studies, procedures to restore or enhance fertility, artificial insemination, or invitro fertilizations. 7. Care or services of any kind performed by or under the direct supervision of a dentist, except that the plan will pay for dental treatment necessary to repair injuries to sound, natural teeth caused by a non-occupational accident occurring while the covered person is covered and which are performed within six months of the accident. The contributing cause of the accident must be something other than teeth grinding, chewing, or biting. 8. Treatment on or to the teeth, the nerves or roots of the teeth, gingival tissue of alveolar processes; however, benefits will be payable for the charges incurred for the treatment required because of accidental bodily injury to natural teeth sustained while covered (this exception shall not in any event be deemed to include expenses for treatment for the repair or replacement of a denture). 9. Non-surgical treatment involving bones and joints of the jaw and facial region. All orthognathic procedures and other craniomandibular disorder treatments not medically necessary. 10. Diagnosis or treatment of weak or flat feet, fallen or high arches, for instability or imbalance metatarsalgia not caused by disease (except for bone surgery), bunions (except for capsular or bone surgery), corns or calluses, or toenails (except for complete or partial removal of nail root); unless needed in treatment of a metabolic or peripheral vascular disease. 11. Routine hearing examinations, routine physical examinations, premarital examinations, preemployment physicals, preschool examinations, or annual boosters except as indicated in the summary of benefits. 12. Hearing aids or examination for prescriptions or fitting of hearing aids, except as indicated in the summary of benefits. 13. Routine eye examination, eye glasses, contact lenses or their fitting (unless for initial replacement of the lens of the eye after cataract surgery), eye exercises, visual therapy, fusion therapy, visual aids or orthoptics, any related examination and eye refraction, or radial keratotomy. 14. For experimental, investigational or unproven services which are medical, surgical, psychiatric, substance abuse or other healthcare technologies, supplies, treatments, procedures, drug therapies, or devices that are determined to be: a. Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not recognized for the treatment of the particular indication in one of the standard reference compendia (The United States Pharmacopeia Drug Information, the American Medical Association Drug Evaluations, or the American Hospital Formulary Service Drug Information) or in medical literature. Medical literature means scientific studies published in a peerreviewed national professional journal; or b. The subject of review or approval by an Institutional Review Board for the proposed use; or

II. Medical Insurance: Cigna OAP In-Network

69

c. The subject of an ongoing clinical trial that meets the definition of a phase I, II, or III Clinical Trial as set forth in the FDA regulations, regardless of whether the trial is subject to FDA oversight; or d. Not demonstrated, through existing peer-reviewed literature, to be safe and effective for treating or diagnosing the condition or illness for which its use is proposed. 15. Any organ or tissue transplant, except as otherwise listed in the Plan Document. 16. Education, training, and bed and board while confined to an institution which is primarily a school or other institution for training; a place of rest, a place for the aged, or for custodial care or for testing or training due to mental, nervous, or emotional conditions. 17. Education (excluding diabetes education), training, or counseling of any type no matter what the diagnosis. The mental health benefit covers counseling. 18. Health Services and associated expenses for bariatric procedures/surgeries intended primarily for the treatment of morbid obesity or weight loss, including but not limited to gastric bypasses, gastric balloons, stomach stapling, jejunal bypasses, wiring of the jaw and health services of a similar nature. 19. Weight control counseling or services primarily for weight loss or control. Necessary treatment for eating disorders as defined by DSM-III-R codes, is covered under the mental health benefit approved by Orlando Behavioral Healthcare. Coverage for weight control is provided and follows the guidelines set forth in the Health Care Reform Act at http://www.healthcare.gov/law/about/provisions/services/lists.html. 20. Vitamins, minerals, or food supplements, whether or not prescribed by a qualified practitioner. a. Exception: Legend vitamins and minerals when adequate nutrition cannot be sustained with over-the-counter vitamins and minerals. Clinically necessary I.V. hyperalimentation or when adequate nutrition cannot be sustained through usual pathway. 21. Any personal items while hospital confined. 22. Hospitalization primarily for x-ray, laboratory, diagnostic study, physical therapy, hydrotherapy, medical observation, convalescent or rest care, or any other medical examination or tests not clinically necessary. 23. Services, supplies, or tests not generally accepted in health care practices as needed in the diagnosis or treatment of the patient, even if ordered by a doctor. 24. Medical supplies such as adhesive tape, antiseptics, or other common first aid supplies. 25. Services provided by a person who usually lives in the same household as the covered person, or who is a member of his/her immediate family or the family of his/her spouse. 26. Those services incurred prior to the date coverage is in force or after coverage ends, except if the person is totally disabled on the date this medical plan ends. 27. Those services which a covered person would not be legally obligated to pay if health insurance coverage did not exist.

II. Medical Insurance: Cigna OAP In-Network

70

28. Illness for which the covered person is entitled to benefits under any worker’s compensation law or act, or accidental bodily injury arising out of or in the course of the covered person’s employment or services rendered by any governmental program (i.e., V.A. hospital) unless there is a legal obligation to pay for coverage. 29. Illness resulting from war, whether declared or undeclared. 30. Illness or injury to which a contribution cause was the commission of, or attempted commission of, an act of aggression or a felony, or participating in a riot by the covered person. 31. Any charges in excess of approved charges as determined by Cigna. 32. Claims not submitted within 12 months from the date of service. 33. All charges during a hospitalization deemed medically unnecessary or inappropriate by the medical director or his designee. 34. Penalties for failure to comply with any and all applicable precertification requirements. 35. Claims for services to improve a covered person’s general physical condition, for private membership clubs and clinics, and for any other organization charging membership fees. 36. Charges for the first $10,000 of bodily injury to a person while riding a motorcycle without a helmet. 37. Any tests not requiring a physician’s order and purchased over-the-counter. 38. Assistance in the activities of daily living, including but not limited to eating, bathing, dressing or other Custodial Services or self-care activities, homemaker services and services primarily for rest, domiciliary or convalescent care. 39. Cost of biologicals that are immunizations or medications for the purpose of travel, or to protect against occupational hazards and risks.

II. Medical Insurance: Cigna OAP In-Network

71

II. MEDICAL INSURANCE

D.

CVS / CAREMARK PHARMACY BENEFIT

(Your Pharmacy Benefits for All Medical Plans)

CVS/Caremark Pharmacy Benefits Your Pharmacy Plan CVS/Caremark provides benefits for covered drugs, which are prescribed by your physician and obtained from a participating pharmacy. Purchasing Non-Maintenance Medications If your prescription for a non-maintenance drug is for up to 30days you may visit any participating retail pharmacy. Unlike maintenance medications there is no limit to the number of times you may fill your prescription at the retail pharmacy. Purchasing Maintenance Medications If you or a covered family member receives a prescription for a maintenance medication (any long-term medications you are taking for 90 days or more such as cholesterol, blood pressure, diabetes, as well as oral contraceptives), you can obtain the first 30-day fill and up to two 30-day refills at any participating retail pharmacy. Thereafter, you must purchase your maintenance medication through either the CVS/ Caremark pharmacy or the 90-day retail program at participating retail pharmacies. Otherwise each subsequent fill of a 30-day supply will be 100% of the CVS/Caremark discounted cost of the medication. CVS/Caremark Mail Service or CVS Retail Stores (Maintenance Drugs) CVS/Caremark Mail Service or CVS Retail Stores provide a 90day supply for twice the monthly copayment. Retail 90 (Maintenance Drugs) Copayments at Retail 90 are three times the 30-day copayment. To use Retail 90 simply bring your 90-day prescription for a maintenance medication to a selected participating pharmacy. The Benefits of CVS/Caremark Mail Service SAVE TIME AND MONEY  Receive a 90-day supply  Enjoy convenient delivery to your home (or specified address)  Take advantage of toll-free Customer Care and Pharmacist Consultation  Experience easy refill ordering by phone, internet or by mail How to Order By Mail Ask your doctor to write a prescription for a 90-day supply of your medication. For your first prescription order, complete a CVS/Caremark Mail Service form and mail it along with your copayment and doctor’s prescription. New prescriptions may not be phoned in by your doctor. You may order refills by phone or on the internet. For your convenience, Visa, MasterCard, American Express, Discover and personal checks are accepted. (Payment is required at the time you place your order.) You can register on-line at www.caremark.com or by calling (800)378-9264 . Out-of-Area Services If you are traveling outside the Central Florida area and need a prescription filled, call CVS/Caremark Customer Care at (800)378-9264.

II. Medical Insurance: CVS / Caremark Pharmacy Benefit

Your Identification Card You will find your copayment/coinsurance amounts in your OCPS Insurance Handbook. Remember to show your new CVS/Caremark ID card to your pharmacist each time you have a prescription filled. Copayment/Coinsurance For each prescription you have filled, you will pay an out-ofpocket amount, called a copayment if you are enrolled in either Plan B: Cigna Health Reimbursement Account or Plan C: Cigna OAP In-Network Plan, or coinsurance if you are enrolled in Plan A: Cigna Local Plus OAP In-Network Plan. For your copayment/coinsurance amount and details about your pharmacy benefits, refer to the Schedule of Benefits in your Medical Plan pages of this handbook. Generic Drugs  Generic equivalents of prescription drugs will be dispensed if an equivalent is available.  It is important to note that if you or your physician request a brand-name drug when a generic is available, you will be responsible for 100% of the cost of the medication. Why Generic Drugs Cost Less Generic drugs have the same active ingredients in the same quantity as their brand name equivalents and they meet the same FDA standards for safety and effectiveness. The difference is that the brand name drug makers can "copy" the formula. Their development costs are relatively low and there are no advertising costs, so the generic drug maker can charge less, which saves you money. Questions? If you need more information about your pharmacy benefits or formulary information, call CVS/Caremark at (800)3789264. The formulary is available at www.caremark.com Prior Authorization Program Certain prescriptions require “clinical prior authorization” or approval before they will be covered. Please contact CVS/Caremark clinical services at (800)378-9264 to request approval. Please have available the name of the medication, physician’s name, phone (and fax number, if available), your member ID number and your pharmacy group number (from your ID card). If you have a medication that falls under the Drug Quantity Management program and you would like to request a prior authorization, you may do so by calling the number above. Specialty Pharmacy Program Certain medications used for treating complex health conditions must be obtained through the Specialty Pharmacy program. The following conditions may require drugs that fall under Specialty Pharmacy which include, but are not limited to: Growth Hormone Deficiency, Multiple Sclerosis, HIV and Viral Hepatitis. Prescriptions for these drugs may be filled only through CVS/Caremark’s specialty pharmacy. Please call (800)237-2767 to enroll in this program. For additional information regarding CVS/Caremark’s specialty pharmacy, you can also visit www.CVSCaremarkSpecialtyRx.com.

72

CVS/Caremark PARTICIPATING PHARMACIES

The following pharmacies are available at all locations in Orange, Seminole, Osceola, Brevard, Polk, Lake and Volusia Counties: Albertsons, Costco, CVS, FamilyMeds Pharmacy, K-Mart, Publix, Sam's Club, Target, The Medicine Shoppe, Walmart and Winn –Dixie Stores. Please call CVS/Caremark at (800)378-9264 if you are traveling; to locate the pharmacy closest to your home, or visit www.caremark.com and click on Locate a Pharmacy.

BREVARD COUNTY MIKE'S PHARMACY

8400 ASTRONAUT BLVD

WALMART PHARMACY PORT ST JOHN DISCOUNT PHARMACY SAM'S CLUB PHARMACY CVS PHARMACY CVS PHARMACY PUBLIX PHARMACY PUBLIX PHARMACY PORT ST JOHN DISCOUNT PHARMACY EMPIRE SPECIALTY PHARMACY LLC FIVE POINTS PHCY & WELLNESS WEST COCOA PHCY & COMPOUNDING CVS PHARMACY WINN-DIXIE PHARMACY PUBLIX PHARMACY COCOA BEACH DISCOUNT PHARMACY CVS PHARMACY

2800 CLEARLAKE RD

CAPE CANAVERAL COCOA

6801 1 US HWY 1 NORTH

PUBLIX PHARMACY

270 E EAU GALLIE BLVD

WALMART PHARMACY

1001 E EAU GALLIE BLVD

WINN-DIXIE PHARMACY

961 E EAU GALLIE BLVD

EAU GALLIE DISCOUNT PHARMACY

1070 E EAU GALLIE BLVD UNIT B

BROWNING'S PHCY & HLTHCR INC CVS PHARMACY WALMART PHARMACY WALMART PHARMACY HEALTH FIRST FAMILY PHARMACY OMNI HEALTHCARE INC APOLLO CIRCLES OF CARE INC SUNTREE MEDICAL CVS PHARMACY WALMART PHARMACY MELBOURNE DISCOUNT PHARMACY WALMART PHARMACY INFUSION PARTNERS MELBOURNE LLC THE MEDICINE SHOPPE PUBLIX PHARMACY PUBLIX PHARMACY AMEX PHARMACY PUBLIX PHARMACY SUNTREE PHARMACY

FL

32920

3217837883

FL

32922

3216312823

COCOA

FL

32927

3216370911

450 TOWNSEND RD 1185 FAY BLVD 2324 STATE ROAD 524 7325 N US HIGHWAY 1 2301 STATE ROAD 524 STE 150

COCOA COCOA COCOA COCOA COCOA

FL FL FL FL FL

32926 32927 32926 32927 32926

3216396211 3216394650 3216369335 3216358464 3216366784

6250 US HWY 1 NORTH

COCOA

FL

32927

3216370911

1034 CLEARLAKE RD

COCOA

FL

32922

3215495005

1108 LAKE DR

COCOA

FL

32922

3218063951

2711 CLEARLAKE RD #C-10

COCOA

FL

32922

3213056909

4292 N ATLANTIC AVE 100 CANAVERAL PLAZA BLVD 2067 N ATLANTIC AVE

COCOA BEACH COCOA BEACH COCOA BEACH

FL FL FL

32931 32931 32931

3217840503 4078682287 3217847466

291 W COCOA BEACH CSWY

COCOA BEACH

FL

32931

3217992030

100 N MIRAMAR AVE

FL

32903

3217245634

FL

32937

3217732977

FL

32937

3217730663

FL

32937

4077736326

FL

32937

3217772220

141 E HIBISCUS BLVD 1800 N WICKHAM RD 3950 N WICKHAM RD 3550 S BABCOCK ST

INDIALANTIC INDIAN HARBOUR BEACH INDIAN HARBOUR BEACH INDIAN HARBOUR BEACH INDIAN HARBOUR BEACH MELBOURNE MELBOURNE MELBOURNE MELBOURNE

FL FL FL FL

32901 32935 32935 32901

3217236520 3212592333 3212544170 3217238830

1350 HICKORY ST

MELBOURNE

FL

32901

3214347355

1344 S APOLLO BLVD STE 303 2020 COMMERCE DR 7640 N WICKHAM RD STE 116 5590 N WICKHAM RD 845 PALM BAY RD NE

MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE

FL FL FL FL FL

32901 32904 32940 32940 32904

3217272990 3219526020 3212593400 3217510090 3219841612

401 N WICKHAM RD STE W

MELBOURNE

FL

32935

3217517885

1000 N WICKHAM RD

MELBOURNE

FL

32935

3212426037

3040 VENTURE LANE STE 103

MELBOURNE

FL

32934

3217246004

2176 SARNO RD 3200 LAKE WASHINGTON RD 1411 S BABCOCK ST 1515 ELIZABETH ST STE J 4100 N WICKHAM RD 7025 N WICKHAM RD STE 113B

MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE

FL FL FL FL FL FL

32935 32934 32901 32901 32935 32940

3212422440 3212420592 3217279822 3218720723 3212426166 3212533535

II. Medical Insurance: CVS / Caremark Pharmacy Benefit

73

WALMART PHARMACY PUBLIX PHARMACY CVS PHARMACY CVS PHARMACY CVS PHARMACY SAM'S CLUB PHARMACY PUBLIX PHARMACY LORDONI DISCOUNT PHARMACY THRIFTY DISCOUNT PHARMACY WICKHAM PHARMACY

8500 N WICKHAM RD 7777 N WICKHAM RD 7975 N WICKHAM RD 3050 N WICKHAM RD 15 E NEW HAVEN AVE 4255 W NEW HAVEN AVE 2261 W NEW HAVEN AVE 6300 N WICKHAM RD 32 W NEW HAVEN AVE 1060 N WICKHAM RD

SAVERS DRUG MART

200 OCEAN AVE

PUBLIX PHARMACY

3830 S HIGHWAY A1A

SAVERS LONG TERM CARE

200 OCEAN AVE SUITE A

TARGET PHARMACY

2750 W NEW HAVEN AVE

HOBBS PHARMACY

133 N BANANA RIVER DR

HOBBS NURSING HOME PHARMACY

135 N BANANA RIVER DR

CVS PHARMACY

11 E MERRITT ISLAND CSWY

WALMART PHARMACY

1500 E MERRITT ISLAND CSWY

PUBLIX PHARMACY

1850 N COURTENAY PKWY

TARGET PHARMACY

250 CROCKETT BLVD

PUBLIX PHARMACY

125 E MERRITT ISLAND CSWY

CVS PHARMACY

1345 N COURTENAY PKWY

MERRITT ISLAND DISCOUNT PHARMACY

35 N COURTENAY PKWY

THE PHARMACY

110 S COURTENAY PKWY

WINN-DIXIE PHARMACY MIMS PHARMACY WINN-DIXIE PHARMACY WALMART PHARMACY TOTAL HEALTH PHARMACY

4 CARE MED CENTER FAMILY PRACTICE PALM BAY URGENT CARE

7960 US HIGHWAY 1 2448 US HIGHWAY 1 5270 BABCOCK ST NE STE 120 1040 MALABAR RD SE 6100 MINTON RD STE 103C 1555 PORT MALABAR BLVD STE 101 1599 PALM BAY RD NE 4711 BABCOCK ST NE STE 1 1270 MALABAR RD SE 1150 MALABAR RD SE 1101 MALABAR RD NE 190 MALABAR RD SW 3450 BAYSIDE LAKES BLVD SE 399 EMERSON DR NW 930-1 MALABAR RD SE 1555 PT MALABAR BLVD NE #102B 590 MALABAR RD SE STES 6 AND 7 1155 MALABAR RD STE 10

FAMILY DRUG MART

7135 N COCOA BLVD

WINN-DIXIE PHARMACY

6257 N COCOA BLVD

CVS PHARMACY HEMATOLOGY ONCOLOGY/CNT BREVARD CVS PHARMACY

ACQUAVIVAS PHARMACY CVS PHARMACY KMART PHARMACY RX CARE PHARMACY PUBLIX PHARMACY CVS PHARMACY WINN-DIXIE PHARMACY PUBLIX PHARMACY CVS PHARMACY MALABAR DISCOUNT PHARMACY ACQUAVIVA'S LTC PHARMACY

MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE BEACH MELBOURNE BEACH MELBOURNE BEACH MELBOURNE VILLAGE MERRITT ISLAND MERRITT ISLAND MERRITT ISLAND MERRITT ISLAND MERRITT ISLAND MERRITT ISLAND MERRITT ISLAND MERRITT ISLAND MERRITT ISLAND MERRITT ISLAND MICCO MIMS PALM BAY PALM BAY PALM BAY

FL FL FL FL FL FL FL FL FL FL

32940 32940 32940 32935 32901 32904 32904 32940 32901 32935

3212426778 3212531303 3217517534 3217517524 3214093941 3217680438 3216760173 3216103114 3216765999 3212416433

FL

32951

3217255492

FL

32951

3217253711

FL

32951

3217255492

FL

32904

3217229262

FL

32952

3214520010

FL

32952

3214525058

FL

32952

3214532540

FL

32952

3214524340

FL

32953

3219636393

FL

32953

3214521691

FL

32952

3214522321

FL

32953

3214498641

FL

32953

4074886851

FL

32952

3212088999

FL FL FL FL FL

32976 32754 32905 32907 32907

5616631135 3215674919 3217287041 3217232101 3213080303

PALM BAY

FL

32905

3217257188

PALM BAY PALM BAY PALM BAY PALM BAY PALM BAY PALM BAY PALM BAY PALM BAY PALM BAY

FL FL FL FL FL FL FL FL FL

32905 32905 32907 32907 32907 32907 32909 32907 32907

3217259961 3217258580 3219520656 3217273781 3219845477 4079842575 3217253757 3217335103 3217750911

PALM BAY

FL

32905

3217681400

PALM BAY

FL

32907

8666254280

FL

32907

8666254280

FL

32927

3216310300

FL

32927

3216338150

1696 FISKE BLVD

PALM BAY PORT SAINT JOHN PORT SAINT JOHN ROCKLEDGE

FL

32955

3216312939

107 LONGWOOD AVE

ROCKLEDGE

FL

32955

3216362111

1820 US HIGHWAY 1

ROCKLEDGE

FL

32955

3216393240

II. Medical Insurance: CVS / Caremark Pharmacy Benefit

74

CIRCLES OF CARE INC PUBLIX PHARMACY CITY DISCOUNT PHARMACY ROCKLEDGE DISCOUNT PHARMACY

1770 CEDAR ST 3820 MURRELL RD 1260 US HIGHWAY 1

ROCKLEDGE ROCKLEDGE ROCKLEDGE

FL FL FL

32955 32955 32955

3218901590 3216369820 3218063972

3650 MURRELL RD STE 120

ROCKLEDGE

FL

32955

3219171204

PUBLIX PHARMACY

5380 STADIUM PARKWAY STE 100

ROCKLEDGE

FL

32955

3214331789

CVS PHARMACY

1596 HIGHWAY A1A

FL

32937

3217737611

PUBLIX PHARMACY

1024 HIGHWAY A1A STE 120

FL

32937

3217737035

CVS PHARMACY TARGET PHARMACY EAST COAST PHARMACY

1820 CHENEY HWY 3055 COLUMBIA BLVD 504 GARDEN ST 695 N WASHINGTON AVE UNIT 101 3175 CHENEY HWY 5 GARDEN ST 4401 S HOPKINS AVE STE 102 1535 N SINGLETON AVE 3275 GARDEN ST

FL FL FL

32780 32780 32796

3213835420 3213601087 3217470206

TITUSVILLE

FL

32796

3217470600

TITUSVILLE TITUSVILLE TITUSVILLE TITUSVILLE TITUSVILLE

FL FL FL FL FL

32780 32796 32780 32796 32796

3212685020 3213830311 3216076802 4072642055 3212671233

2175 CHENEY HWY STE B

TITUSVILLE

FL

32780

3212680911

2507 GARDEN ST

TITUSVILLE

FL

32796

3212697772

490 N WASHINGTON AVE

TITUSVILLE

FL

32796

3212684200

8456 N WICKHAM RD 2900 VETERANS WAY

VIERA VIERA WEST MELBOURNE WEST MELBOURNE WEST MELBOURNE

FL FL

32940 32940

3217521870 3216373788

FL

32904

3218217341

FL

32904

3217220995

FL

32904

3219140823

CENTURY PHARMACY WALMART PHARMACY CVS PHARMACY HOPKINS PHARMACY WINN-DIXIE PHARMACY PUBLIX PHARMACY TITUSVILLE DISCOUNT PHARMACY ITANI FAMILY PHARMACY SPACE COAST MED ASSOCIATES LLP TARGET PHARMACY VIERA VA CBOC PHARMACY

SATELLITE BEACH SATELLITE BEACH TITUSVILLE TITUSVILLE TITUSVILLE

TARGET PHARMACY

4305 NORFOLK PWKY STE 102

PUBLIX PHARMACY

145 PALM BAY RD NE STE 117

BLUE SKY DISCOUNT PHARMACY

115 HICKORY ST STE 101

PUBLIX PHARMACY CVS PHARMACY PUBLIX PHARMACY WALMART PHARMACY CVS PHARMACY WALMART PHARMACY

13900 COUNTY ROAD 455 1800 E HIGHWAY 50 250 CITRUS TOWER BLVD 600 US HIGHWAY 27 1640 US HIGHWAY 27 1450 JOHNS LAKE RD 12302 ROPER BLVD STE 106107 1002 E HIGHWAY 50 648 E HIGHWAY 50 17445 US HIGHWAY 192 STE 11 4351 S HIGHWAY 27 4405 S HIGHWAY 27 2660 E HIGHWAY 50 1670 E HIGHWAY 50 STE A 265 W STATE RD 50 16744 CAGAN CROSSING BLVD 207A 2430 US HWY 27 1500 OAKLEY SEAVER DR STE 3

CLERMONT CLERMONT CLERMONT CLERMONT CLERMONT CLERMONT

FL FL FL FL FL FL

34711 34711 34711 34714 34714 34711

4078771565 3522437030 3522416676 3525362730 3522430135 3522436270

CLERMONT

FL

34711

3522436340

CLERMONT CLERMONT CLERMONT CLERMONT CLERMONT CLERMONT CLERMONT CLERMONT

FL FL FL FL FL FL FL FL

34711 34711 34714 34711 34711 34711 34711 34711

3523946828 3522429061 3522430785 3523942915 3522433367 3523947626 3524325930 3523945535

CLERMONT

FL

34714

4077784800

CLERMONT

FL

34714

3522438843

CLERMONT

FL

34711

3529895850

290 CITRUS TOWER BLVD #106

CLERMONT

FL

34711

3529895890

16201 HWY 50 E STE 301 2 E MAGNOLIA AVE 710 N BAY ST 2 E MAGNOLIA AVE STE 201 24450 SR 44 1950 N STATE ROAD 19 1995 N HIGHWAY 19

CLERMONT EUSTIS EUSTIS EUSTIS EUSTIS EUSTIS EUSTIS

FL FL FL FL FL FL FL

34711 32726 32726 32726 32776 32726 32726

4076144602 3523574341 3523575485 3523574341 3523572576 3523575885 3525891330

MEDICAP PHARMACY KMART PHARMACY WINN-DIXIE PHARMACY PUBLIX PHARMACY PUBLIX PHARMACY CVS PHARMACY TARGET PHARMACY SOUTH LAKE PHARMACY MEDICAL INTERVENTIONS NV PHARMACY PUBLIX PHARMACY KEY HEALTH PHARMACY CLERMONT COMMUNITY PHARMACY TRISTAR PHARMACY LLC BAY PHARMACY LAKE PHARMACY BAY INSTITUTIONAL CVS PHARMACY PUBLIX PHARMACY CVS PHARMACY

LAKE COUNTY

II. Medical Insurance: CVS / Caremark Pharmacy Benefit

75

WINN-DIXIE PHARMACY PUBLIX PHARMACY MOUNTDORA PHARMACY PAIN MANAGEMENT INSTITUTE LLC GROVELAND PHARMACY PUBLIX PHARMACY SO LAKE FAMILY HLTH CTR PHCY TARGET PHARMACY SAM'S CLUB PHARMACY WINN-DIXIE PHARMACY CVS PHARMACY RX CARE PHARMACY CVS PHARMACY BURRY'S PHARMACY LEESBURG COMMUNITY PHARM PUBLIX PHARMACY LRMC INSTITUTIONAL PHARMACY WALMART PHARMACY THE PHARMACIST TARGET PHARMACY WINN-DIXIE PHARMACY PUBLIX PHARMACY PUBLIX PHARMACY ADONAI PHARMACY EXPRESS PHARMACY GENOA HEALTHCARE MCHILLS PHARMACY STARX PHARMACY LEESBURG FAMILY HEALTH CENTER CVS PHARMACY CVS PHARMACY TARGET PHARMACY WALMART PHARMACY PUBLIX PHARMACY CVS PHARMACY WATERMAN VILLAGE PHARMACY VINTAGE PHARMACY LLC CVS PHARMACY WINN-DIXIE PHARMACY TAVARES PHARMACY PUBLIX PHARMACY UMATILLA DRUG STORE APOPKA FAMILY HEALTH CTR PHARMACY WALMART PHARMACY CVS PHARMACY WINN-DIXIE PHARMACY PUBLIX PHARMACY CVS PHARMACY APOPKA DISCOUNT DRUGS ARBOR PHARMACY, LLC THE PHARMACY STORE GINGER PHARMACY PUBLIX PHARMACY ADV DERMATOLOGY AND COSMTC SURGERY HOME CARE SOLUTIONS,INC PUBLIX PHARMACY PUBLIX PHARMACY WALMART PHARMACY

1955 NORTH STREET RD #19 2840 DAVID WALKER DR 17435 US HIGHWAY 441 SUITE 102

EUSTIS EUSTIS

FL FL

32726 32726

3525892646 3523579168

EUSTIS

FL

32726

3523571406

2785 S BAY ST STE A

EUSTIS

FL

32726

3109434180

111 N LAKE AVE 7975 STATE ROAD 50 1296 W BROAD ST 716 N US HIGHWAY 441 755 N HWY 27/441 944 BICHARA BLVD 860 AVENIDA CENTRAL 725 US HWY 466 1235 N 14TH ST 500 WEBSTER ST 2500 CITRUS BLVD 717 N 14TH ST 600 E DIXIE AVE 2501 CITRUS BLVD 33124 COUNTY ROAD 473 10401 COUNTY ROAD 44 27405 US HIGHWAY 27 STE 119 10601 US HIGHWAY 441 STE D 27615 US HIGHWAY 27 620 S LAKE ST STE 4 1450 E NORTH BLVD 215 N THIRD STREET 4120 CORLEY ISLAND RD #800 511 MEDICAL PLAZA DR.

GROVELAND GROVELAND GROVELAND LADY LAKE LADY LAKE LADY LAKE LADY LAKE LADY LAKE LEESBURG LEESBURG LEESBURG LEESBURG LEESBURG LEESBURG LEESBURG LEESBURG LEESBURG LEESBURG LEESBURG LEESBURG LEESBURG LEESBURG LEESBURG LEESBURG

FL FL FL FL FL FL FL FL FL FL FL FL FL FL FL FL FL FL FL FL FL FL FL FL

34736 34736 34736 32159 32159 32159 32159 32159 34748 34748 34748 34748 34748 34748 34788 34788 34748 34788 34748 34748 34748 34748 34748 34748

3524291353 3524292969 3524356696 3522058943 3527515989 3527536115 3527501118 3526332105 3527877800 3527873787 3523474064 3527870664 3523153679 3523264044 3527428080 3523600209 3523154199 3523656817 3527872122 3524604030 3524600542 3527020079 3523941333 3523239555

225 N 1ST ST

LEESBURG

FL

34748

3524356699

814 N HIGHWAY 27 17021 US HIGHWAY 441 17450 US HIGHWAY 441 17030 US HIGHWAY 441 18955 US HIGHWAY 441 18915 US HIGHWAY 441 130 WATERMAN AVE 1194 CAMP AVE 550 W BURLEIGH BLVD 450 E BURLEIGH BLVD 524 S DUNCAN DR 1120 BICHARA BLVD 901 N CENTRAL AVE

MINNEOLA MOUNT DORA MOUNT DORA MOUNT DORA MOUNT DORA MOUNT DORA MOUNT DORA MT DORA TAVARES TAVARES TAVARES THE VILLAGES UMATILLA

FL FL FL FL FL FL FL FL FL FL FL FL FL

34715 32757 32757 32757 32757 32757 32757 32757 32778 32778 32778 32159 32784

3522421251 3523576904 3523850747 3527350011 3523831272 3527350768 3523855455 3527292334 3523431502 3523436436 3525086449 3527502424 3526691166

225 E 7TH ST

APOPKA

FL

32703

4078866201

1700 S ORANGE BLOSSOM TRL 65 E MAIN ST 1565 US 441 N 1545 ROCK SPRINGS RD 2311 E SEMORAN BLVD 63 W MAIN ST 1112 ROCK SPRINGS RD 101 S PARK AVE 739 S ORANGE BLOSSOM TRL 242 N ORLANDO AVE

APOPKA APOPKA APOPKA APOPKA APOPKA APOPKA APOPKA APOPKA APOPKA MAITLAND

FL FL FL FL FL FL FL FL FL FL

32703 32703 32703 32712 32703 32703 32712 32703 32703 32751

4078897707 4078898686 4078806493 4078807755 4078802792 4078144844 4078143977 4077035951 4078143868 4075990210

260 LOOKOUT PL STE 103

MAITLAND

FL

32751

4078752080

630 N WYMORE RD STE 370 6551 N ORANGE BLOSSOM TRL #155 301 WEST ROAD 2685 W WEST #

MAITLAND

FL

32751

8882609820

MT DORA

FL

32757

3523832352

OCOEE OCOEE

FL FL

34761 34761

4076561254 4078776910

ORANGE COUNTY

II. Medical Insurance: CVS / Caremark Pharmacy Benefit

76

CVS PHARMACY WINN-DIXIE PHARMACY PUBLIX PHARMACY ATRIUM PHARMACY SAM'S CLUB PHARMACY PUBLIX PHARMACY 1ST COMMUNITY PHARMACY OCOEE DISCOUNT PHARMACY CVS PHARMACY CHILDREN AND FAMILY HEALTH SYS TARGET PHARMACY CVS PHARMACY CVS PHARMACY PUBLIX PHARMACY PUBLIX PHARMACY PUBLIX PHARMACY PUBLIX PHARMACY ORLANDO PHARMACY INC CVS PHARMACY CVS PHARMACY CVS PHARMACY CVS PHARMACY CVS PHARMACY PUBLIX PHARMACY DAVITA RX LLC CITY VIEW PHARMACY AETNA SPECIALTY PHARMACY LLC WALMART PHARMACY RX MEDS PHARMACY INC CVS PHARMACY ACS PHARMACY CVS PHARMACY ICON PHARMACY WALMART PHARMACY AHF PHARMACY ORLANDO CVS PHARMACY WALMART PHARMACY ORANGE COUNTY HEALTH DEPT CVS PHARMACY CVS PHARMACY CVS PHARMACY JR PHARMACY SAM'S CLUB PHARMACY PUBLIX PHARMACY CENTRAL FL FAMILY HLTH CENTER ORLANDO HEALTH SCRIPTS SON CHAU MD PA WALMART PHARMACY SOUTHSIDE FAMILY HEALTH CENTER DPHSCRIPTS WALMART PHARMACY WESTMINSTER SENIOR CARE PHCY MEDICINE SHOPPE PHARMACY

1612 E SILVER STAR RD 1531 E SILVER STAR RD 2600 MAGUIRE RD 10000 W COLONIAL DR STE 181 SWC HWY 50 & APOPKAVINELAND 1720 E SILVER STAR RD 2775 OLD WINTER GARDEN RD 10173 W COLONIAL DR 13454 S ORANGE BLOSSOM TRL

OCOEE OCOEE OCOEE OCOEE

FL FL FL FL

34761 34761 34761 34761

4072947124 4072996960 4076568537 4072961912

OCOEE

FL

34761

4075323134

OCOEE OCOEE OCOEE

FL FL FL

34761 34761 34761

4075222774 4076560641 4076747953

ORLANDO

FL

32837

4072403191

4448 EDGEWATER DR

ORLANDO

FL

32804

4075133010

325 N ALAFAYA TRL 13960 LANDSTAR BLVD 8025 LEE VISTA BLVD 4870 S APOPKA VINELAND RD 1501 MEETING PL 13850 LANDSTAR BLVD 6485 S CHICKASAW TRL 2909 N ORANGE AVE 3212 CURRY FORD RD 5899 S ORANGE BLOSSOM TRL 2201 EDGEWATER DR 1201 E COLONIAL DR 6217 SILVER STAR RD 3400 AVALON PARK EAST BLVD 2616 COMMERCE PARK DR STE 500 595 W CHURCH ST STE H

ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO

FL FL FL FL FL FL FL FL FL FL FL FL FL

32828 32824 32829 32819 32814 32824 32829 32804 32806 32839 32804 32803 32808

4074828194 4074386850 4072756366 4079098085 4078977373 4078566075 4072778788 4078981331 4078980534 4078558426 4074258623 4078941521 4072980303

ORLANDO

FL

32828

4072771216

ORLANDO

FL

32819

4072645100

ORLANDO

FL

32805

3212069426

503 SUNPORT LN

ORLANDO

FL

32809

8667822779

201 S CHICKASAW TRL 2751 N HIAWASSEE RD 7001 OLD WINTER GARDEN RD 6251 CHANCELLOR DR 13300 E COLONIAL DR 300 E CHURCH ST 600 SOUTH ALAFAVA TRAIL 1021 N MILLS AVE 4801 NEW BROAD ST 433 AVALON PARK SOUTH BLVD 832 W CENTRAL BLVD 5190 S CONWAY RD 5886 CONROY RD 10952 E COLONIAL DR 2160 WHISPER LAKES BLVD 5559 CLARCONA OCOEE RD 409 S CHICKASAW TRL

ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO

FL FL FL FL FL FL FL FL FL

32825 32818 32835 32809 32826 32801 32826 32803 32814

4073809724 4077706077 4072532917 8779856337 4072435277 4076498050 4073800546 4077700507 4078945263

ORLANDO

FL

32828

4072071958

ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO

FL FL FL FL FL FL FL

32805 32812 32835 32817 32837 32810 32825

4078362615 4078512140 4072998020 4072778781 4074475612 4072947176 4072771754

5730 LAKE UNDERHILL RD

ORLANDO

FL

32807

4079564320

ORLANDO

FL

32806

3218412818

ORLANDO

FL

32807

4072739410

ORLANDO

FL

32819

4073512191

6101 LAKE ELLENOR DR # 100

ORLANDO

FL

32809

4079564665

9400 TURKEY LAKE RD 7818 W COLONIAL DR 7703 KINGSPOINTE PKWY STE 500 1724 S ORANGE AVE

ORLANDO ORLANDO

FL FL

32819 32818

3218427230 4075225107

ORLANDO

FL

32819

8772449270

ORLANDO

FL

32806

4072465588

1400 S ORANGE AVE STE MP138 1287 N SEMORAN BLVD STE 200 8990 TURKEY LAKE RD

II. Medical Insurance: CVS / Caremark Pharmacy Benefit

77

UNIVERSITY CENTRAL FL KNIGHT AIDE SANDLAKE PHARMACY CVS PHARMACY WALMART PHARMACY THE MINIER WATERFORD LAKES LLC ONE SOURCE PHARMACY FAMILY PHYSICIANS RX TARGET PHARMACY PUBLIX PHARMACY PUBLIX PHARMACY UNIVERSITY OF CENTRAL FLORIDA PHARM CVS PHARMACY CVS PHARMACY HARRISON'S PHARMACY FLORIDA HOSPITAL RXPRESS PHARMACY OLYMPIA PHARMACY NPR FAMILY PHARMACY LIFE WORTH LIVING FOUNDATION MILLENNIUM PHARMACY ORLANDO VAMC PHARMACY FLORIDA HOSPITAL COMMUNTY PHCY HUNTERS CREEK URGENT CARE CTR CVS PHARMACY CVS PHARMACY WALMART PHARMACY WALMART PHARMACY WALMART PHARMACY PHARMACY EXPRESS & MED SUPPLY RX CARE PHARMACY METRO PHARMACY FREEDOM PHARMACY PUBLIX PHARMACY WALMART PHARMACY PUBLIX PHARMACY PUBLIX PHARMACY WALMART PHARMACY WINN-DIXIE PHARMACY CVS PHARMACY PUBLIX PHARMACY CVS PHARMACY C & C COMMUNITY PHARMACY PUBLIX PHARMACY PUBLIX PHARMACY CYSTIC FIBROSIS PHCY INC WINN-DIXIE PHARMACY PRINCETON PLAZA PHARMACY PUBLIX PHARMACY CVS PHARMACY WINN-DIXIE PHARMACY CVS PHARMACY WINN-DIXIE PHARMACY CVS PHARMACY PUBLIX PHARMACY PUBLIX PHARMACY

4000 CNTRL FL BLVD BLG 137 #K 7300 SAND LAKE COMMONS BL #225 13000 TANJA KING BLVD 5991 NEW GOLDENROD RD 12301 LAKE UNDERHILL RD # 118 6404 OLD WINTER GARDEN RD 2285 S SEMORAN BLVD 120 W GRANT ST 400 E CENTRAL BLVD 10250 CURRY FORD RD 4000 CTL FL BLVD BLD 127 RM108 7300 CURRY FORD RD 9306 NARCOOSSEE RD 3333 CURRY FORD RD

ORLANDO

FL

32816

4078820600

ORLANDO

FL

32819

4073518002

ORLANDO ORLANDO

FL FL

32828 32822

4072737618 4073828880

ORLANDO

FL

32828

4072498870

ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO

FL FL FL FL FL

32835 32822 32806 32801 32825

8774908987 4073813085 4076081581 4078727207 4072076112

ORLANDO

FL

32816

4078236337

ORLANDO ORLANDO ORLANDO

FL FL FL

32822 32827 32806

4072826090 4074386898 4078942373

ORLANDO

FL

32803

4073031962

ORLANDO

FL

32835

3213190310

ORLANDO ORLANDO

FL FL

32818 32835

4077045937 4075225683

ORLANDO

FL

32822

8664667779

ORLANDO

FL

32803

4076291599

2501 N ORANGE AVE STE 122

ORLANDO

FL

32804

4073032559

3010 HUNTERS CREEK BLVD

ORLANDO

FL

32837

4072400129

ORLANDO

FL

32821

4072384726

ORLANDO ORLANDO ORLANDO ORLANDO

FL FL FL FL

32821 32808 32817 32819

4073550929 4074454047 4072818905 4073545474

10209 E COLONIAL DR STE 180

ORLANDO

FL

32817

4072730021

5660 CURRY FORD RD 318 W COLONIAL DR 3901 E COLONIAL DR 7640 W SAND LAKE RD 3838 S SEMORAN BLVD 4048 S SEMORAN BLVD 11955 E COLONIAL DR 2500 S KIRKMAN RD 3201 W COLONIAL DR 12339 S ORANGE BLOSSOM TRL 2435 S HIAWASSEE RD 7599 W SAND LAKE RD 927 S GOLDWYN AVE STE 111 3972 TOWN CENTER BLVD 2873 S ORANGE AVE 3901 E COLONIAL DR 4686 E MICHIGAN ST 1800 MERCY DR STE 100 2300 S CHICKASAW TRL 2351 S HIAWASSEE RD 2722 N PINE HILLS RD 5300 S JOHN YOUNG PKWY 1401 S HIAWASSEE RD 9975 LAKE UNDERHILL RD 1921 S ALAFAYA TRL 10115 UNIVERSITY BLVD

ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO

FL FL FL FL FL FL FL FL FL

32822 32801 32803 32819 32822 32822 32826 32811 32808

4072490246 4076684368 8883074427 4072263360 4072774168 4072774848 4073803148 4072979785 4075788151

ORLANDO

FL

32837

4072402474

ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO

FL FL FL FL FL FL FL FL FL FL FL FL FL FL FL FL

32835 32819 32805 32837 32806 32803 32812 32808 32825 32835 32808 32839 32835 32825 32828 32817

4072940448 4073521177 4072956201 4078504361 4078720393 4078984427 4072771912 4078225015 4072779124 4072944009 4072959200 4073702522 4072952333 4072077944 4072776608 4076731749

601 E ROLLINS ST FL 1 6700 CONROY WNDRMR RD STE140 7238 W COLONIAL DR 6488 CURRIN DR # 100 6509 HAZELTINE NATIONAL DR #4 5201 RAYMOND ST

6790 CENTRAL FLORIDA PARKWAY 10701 INTERNATIONAL DRIVE 3101 W PRINCETON ST 11250 E COLONIAL DR 8101 S JOHN YOUNG PKWY

II. Medical Insurance: CVS / Caremark Pharmacy Benefit

78

CVS PHARMACY PUBLIX PHARMACY SAM'S CLUB PHARMACY SAM'S CLUB PHARMACY WINN-DIXIE PHARMACY PUBLIX PHARMACY CVS PHARMACY WINN-DIXIE PHARMACY ACCREDO HEALTH GROUP INC CVS PHARMACY WINN-DIXIE PHARMACY COSTCO PHARMACY PUBLIX PHARMACY TARGET PHARMACY LINCARE INC CVS PHARMACY PINE HILLS FAMILY HEALTH CENTER CVS PHARMACY CARE PLUS CVS/PHARMACY TARGET PHARMACY CVS PHARMACY WINN-DIXIE PHARMACY CVS PHARMACY CENTRAL FLORIDA FAMILY HLTH CTR INC PUBLIX PHARMACY TARGET PHARMACY CVS PHARMACY CVS PHARMACY CVS PHARMACY WALMART PHARMACY AMBIENT HEALTHCARE TARGET PHARMACY PUBLIX PHARMACY PUBLIX PHARMACY PHD PHARMACY PUBLIX PHARMACY ROSEMONT DISCOUNT PHARMACY PUBLIX PHARMACY FIRST CHOICE PHCY & COMPOUNDING CTR MD FAMILY PHARMACY COMPLETE HEALTH & WELLNESS SHARED PHARMACY SERVICES FLORIDA HOSPITAL RXPRESS PHARMACY RX PLUS PHARMACY DR PHILLIPS SPECIALTY PHARMACY METRO RX SCRIPTS PHARMACY LAKE NONA PHARMACY LEGACY PHARMACY KEY HEALTH PHARMACY WALMART PHARMACY SCRIPTS PHARMACY

4974 N ALAFAYA TRL 2015 EDGEWATER DR 7701 E COLONIAL DR 9498 S ORANGE BLOSSOM TRL 5732 N HIAWASSEE RD 12195 S ORANGE BLOSSOM TRL 7451 E COLONIAL DR 13200 E COLONIAL DR 6272 LEE VISTA BLVD STE 100 8981 CONROY WINDERMERE RD 7053 S ORANGE BLOSSOM TRL 2101 WATERBRIDGE BLVD 1400 E COLONIAL DR 718 MAGUIRE BLVD 379 W MICHIGAN ST STE 204 7996 CONROY WINDERMERE RD

ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO

FL FL FL FL FL

32826 32804 32807 32837 32810

4073825583 4078720282 4072821148 4078593920 4075239435

ORLANDO

FL

32837

4078164233

ORLANDO ORLANDO ORLANDO

FL FL FL

32807 32826 32822

4072811876 4073805625 4078524903

ORLANDO

FL

32835

4078768555

ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO

FL FL FL FL FL

32809 32837 32803 32803 32806

4072405694 4073931002 4078987740 4078960401 4074257114

ORLANDO

FL

32835

4072917170

1800 MERCY DR STE 200

ORLANDO

FL

32808

4076145375

7665 W COLONIAL DR 2600 N ORANGE AVE 2155 TOWN CENTER BLVD 12280 LAKE UNDERHILL RD 11957 S APOPKA VINELAND RD 2702 S ORANGE AVE

ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO

FL FL FL FL FL FL

32818 32804 32837 32825 32836 32806

4072991104 4078968917 4078520834 4072733284 4072913387 4072545074

5449 S SEMORAN BLVD STE 14

ORLANDO

FL

32822

4073670928

4501 HOFFNER AVE 880 SAND LAKE RD 4315 CURRY FORD RD 6354 N ORANGE BLOSSOM TRL 3502 EDGEWATER DR 9600 PARKSOUTH CT STE 120 12689 CHALLENGER PKWY STE 100 4750 MILLENIA PLAZA WAY 5350 CENTRAL FLORIDA PKWY 10615 NARCOOSSEE RD 6801 W COLONIAL DR STE D 16825 E COLONIAL DR

ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO

FL FL FL FL FL FL

32812 32809 32806 32810 32804 32837

4078502373 4078565459 4078960552 4072900366 4072451001 8774534566

ORLANDO

FL

32826

9076782068

ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO

FL FL FL FL FL

32839 32821 32832 32818 32820

4075410020 4072381960 4072771446 4072911236 4075681631

5832 N ORANGE BLOSSOM TRL

ORLANDO

FL

32810

4078221121

4402 CURRY FORD RD

ORLANDO

FL

32812

4072828128

754 S GOLDENROD RD

ORLANDO

FL

32822

4073472462

ORLANDO

FL

32837

4078162999

ORLANDO

FL

32814

4078954737

ORLANDO

FL

32809

4072515492

ORLANDO

FL

32822

4073038676

ORLANDO

FL

32809

4078554770

8015 TURKEY LAKE RD STE 300

ORLANDO

FL

32819

4079031544

4809 E COLONIAL DR 92 W MILLER ST STE MP374 10727 NARCOOSSEE RD 10967 LAKE UNDERHILL RD #118 13651 HUNTERS OAK DR 12550 S ORANGE BLOSSOM TRL 1222 S ORANGE AVE

ORLANDO ORLANDO ORLANDO

FL FL FL

32803 32806 32832

4077306800 4072376337 4077306909

ORLANDO

FL

32825

4077307989

ORLANDO

FL

32837

4077305998

ORLANDO

FL

32837

4075411270

ORLANDO

FL

32806

3218434690

12981 S ORANGE BLOSSOM TRL 891 OUTER RD STE A 6149 CHANCELLOR DR STE 2780 7975 LAKE UNDERHILL RD STE 125 717 W LANCASTER ROAD

II. Medical Insurance: CVS / Caremark Pharmacy Benefit

79

ORLANDO PROCARE PHARMACY PROCARE PHARMACY LLOYDS PHARMACY MEDI SHOP PHARMACY, LLC SCRIPTS PLUS PHARMACY PLANNED PARENTHD OF GRTR ORLAN PLANNED PARENTHOOD G. ORLANDO INC MAGRUDER EYE INSTITUTE SCRIPTS INFUSION PHARMACY NEMOURS SCRIPTS PUBLIX PHARMACY A & M PHARMACY ADVANCED INTERV'N PAIN CLINIC US HEALTHLINK PHARMACY WALMART PHARMACY METROMEDS RITECARE PHARMACY OAKRIDGE PHARMACY CENTRAL FL PHARMACY WALMART PHARMACY KIRKMAN DISPENSARY WALMART PHARMACY WALMART PHARMACY PRIORITY HEALTH RX ALM BUDGET PHARMACY WALMART PHARMACY ANGEL'S PHARMACY LAKE BALDWIN VA CBOC PHARMACY PUBLIX PHARMACY #3212 INTERAMERICAN MED CTR GRP PUBLIX PHARMACY #1439 CENTRAL FLORIDA INTERNISTS ORLANDO UNLIMITED MED SERVICES OF FL FELIX R MARICHAL MD PA ROBERT LAW DO PA PUBLIX PHARMACY CVS PHARMACY PUBLIX PHARMACY

2021 S ORANGE AVE 1084 LEE RD STE 4 1810 N ORANGE AVE 715 N FERNCREEK AVE STE C 6210 W COLONIAL DR STE 116

ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO

FL FL FL FL FL

32806 32810 32804 32803 32808

4077303557 4077302770 4074207900 4074404504 4072862996

726 S TAMPA AVE

ORLANDO

FL

32805

4072461788

11500 UNIVERSITY BLVD STE B

ORLANDO

FL

32817

3212355513

1911 N MILLS AVE 92 W MILLER ST MP-374 13535 NEMOURS PKWY 13900 NARCOOSEE RD 6564 OLD WINTER GARDEN RD 1170 S SEMORAN BLVD 1516 HILLCREST ST STE 301 8801 CONROY WINDERMERE RD 409 E MICHIGAN ST 12014 E COLONIAL DR STE 140 1745 W OAK RIDGE RD 1219 E COLONIAL DR 2715 S ORANGE AVE 882 S KIRKMAN RD STE 108A 5734 S ORANGE BLOSSOM TRL 1101 S. GOLDWYN 1215 E LIVINGSTON ST STE A 419 E MICHIGAN ST STE 4 4520 S SEMORAN BLVD 259 E MICHIGAN ST

ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO

FL FL FL FL FL FL FL

32803 32806 32827 32827 32835 32807 32803

4073472159 4072376337 4075674799 4072402107 4072504822 8778633228 4074404945

ORLANDO

FL

32835

4076054006

ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO ORLANDO

FL FL FL FL FL FL FL FL FL FL FL FL

32806 32826 32809 32803 32806 32811 32839 32805 32803 32806 32822 32806

3218882222 4072036895 4072036750 4078980055 4072414402 4072984045 3212474820 4075639147 8556522163 4073786679 4075639170 5513584242

5201 RAYMOND ST

ORLANDO

FL

32803

4076291599

ORLANDO

FL

32809

8772538949

ORLANDO ORLANDO

FL FL

32818 32819

4074348080 4072269884

431 N KIRKMAN RD

ORLANDO

FL

32811

8666254280

5580 E GRANT ST 11602 LAKE UNDERHILL RD 3151 N ALAFAYA TRL STE 101 13450 SUMMERPORT VILLAGE PKWY 2831 MAGUIRE RD 7880 WINTER GARDEN VINELAND RD

ORLANDO ORLANDO ORLANDO

FL FL FL

32822 32825 32826

3212356230 4078024655 4072075000

WINDERMERE

FL

34786

4079050409

WINDERMERE

FL

34786

4076540568

WINDERMERE

FL

34786

4078760417

FL

34787

4076568333

FL

34787

4076546603

FL

34787

4073950112

FL

34787

4076560081

FL

34787

4078774301

FL

34787

4076549697

FL FL FL

32789 32792 32792

4076471862 4076785151 4076700389

7616 SOUTHLAND BLVD STE 112 8010 W COLONIAL DR # 146-162 7524 DR PHILLIPS BLVD

CVS PHARMACY

13697 W COLONIAL DR

PUBLIX PHARMACY

15502 STNYBROOK W PKWY STE 100

TARGET PHARMACY

3343 DANIELS RD

THE MEDICINE SHOPPE

646 S DILLARD ST

WINTER GARDEN FAMILY HEALTH CENTER

1210 E PLANT ST

PUBLIX PHARMACY

13750 W COLONIAL DR

CVS PHARMACY CVS PHARMACY TARGET PHARMACY HOMETOWN OLD COUNTRY PHARMACY TAYLORS PHARMACY FAIRBANKS PUBLIX PHARMACY

839 N ORLANDO AVE 2527 ALOMA AVE 3770 N GOLDENROD RD

WINTER GARDEN WINTER GARDEN WINTER GARDEN WINTER GARDEN WINTER GARDEN WINTER GARDEN WINTER PARK WINTER PARK WINTER PARK

6918 ALOMA AVE

WINTER PARK

FL

32792

4076710003

1021 W FAIRBANKS AVE 440 N ORLANDO AVE 155 E NEW ENGLAND AVE STE B

WINTER PARK WINTER PARK

FL FL

32789 32789

4076441025 4076442830

WINTER PARK

FL

32789

4076472311

COLONIAL DRUGS LLC

II. Medical Insurance: CVS / Caremark Pharmacy Benefit

80

TAYLORS PHARMACY COLONIAL DRUGS OF ORLANDO LLC PUBLIX PHARMACY PUBLIX PHARMACY PUBLIX PHARMACY COSTCO PHARMACY CVS PHARMACY NATIONAL PAIN INSTITUTE

306 S PARK AVE

WINTER PARK

FL

32789

4076441025

155 E NEW ENGLAND AVE

WINTER PARK

FL

32789

4076472311

2295 ALOMA AVE 741 S ORLANDO AVE 4000 NORTH GOLDENROD RD 3333 UNIVERSITY BLVD 7496 UNIVERSITY BLVD 1693 LEE RD

WINTER PARK WINTER PARK WINTER PARK WINTER PARK WINTER PARK WINTER PARK

FL FL FL FL FL FL

32792 32789 32792 32792 32792 32789

4076783273 4076220309 4076813191 4076812110 4076576100 8778633228

TURNER DRUGS CELEBRATION CELEBRATION OBSTETRICS & GYNECOLOGY LEGENDS FAMILY MEDICAL CENTER CVS PHARMACY CVS PHARMACY WALMART PHARMACY

1530 CELEBRATION BLVD # 105 410 CELEBRATION PLACE STE 208

CELEBRATION

FL

34747

4075669060

CELEBRATION

FL

34747

4075662229

FL

33896

8666254280

FL FL FL

33896 34741 34759

3216770531 4078475174 4078702501

KISSIMMEE

FL

34746

4075940030

KISSIMMEE KISSIMMEE KISSIMMEE KISSIMMEE

FL FL FL FL

34746 34743 34744 34741

4073971202 4079323232 4073431230 4073449700

KISSIMMEE

FL

34741

3212844631

KISSIMMEE

FL

34744

4073438358

KISSIMMEE KISSIMMEE KISSIMMEE KISSIMMEE KISSIMMEE KISSIMMEE KISSIMMEE KISSIMMEE KISSIMMEE KISSIMMEE KISSIMMEE KISSIMMEE KISSIMMEE KISSIMMEE KISSIMMEE

FL FL FL FL FL FL FL FL FL FL FL FL FL FL FL

34741 34746 34741 34744 34747 34741 34741 34746 34746 34744 34741 34741 34743 34746 34744

4078461109 4073437878 4079331524 4078467858 3216773972 4072018417 4073971002 4079449030 4079322605 4079335088 4078460100 4079330947 4073443000 4079440072 4073487686

400 CELEBRATION PL

KISSIMMEE

FL

34747

4073034005

1910 N JOHN YOUNG PKWY 5308 W IRLO BRONSON MEMORIAL H 1471 E OSCEOLA PKWY 4763 W IRLO BRONSON MEMORIAL H

KISSIMMEE

FL

34741

4078702446

KISSIMMEE

FL

34746

4073909431

KISSIMMEE

FL

34744

4078702235

KISSIMMEE

FL

34746

4073979993

728 N JOHN YOUNG PKWY

KISSIMMEE

FL

34741

4073445588

1100 N JOHN YOUNG PKWY

KISSIMMEE

FL

34741

4073430099

720 W OAK ST STE 114

KISSIMMEE

FL

34741

4073742550

805 E OAK ST STE 2 6085 W IRLO BRONSON MEMORIAL H 22 BROADWAY 2608 BOGGY CREEK RD 410 CELEBRATION PL STE 206 4543 PLEASANT HILL RD #D & E 1026 MANN ST

KISSIMMEE

FL

34744

4073505925

KISSIMMEE

FL

34747

3216770349

KISSIMMEE KISSIMMEE KISSIMMEE KISSIMMEE KISSIMMEE

FL FL FL FL FL

34741 34744 34747 34759 34741

4074835880 4073444555 4075669700 4073434434 4072795160

TARGET PHARMACY WALMART PHARMACY PUBLIX PHARMACY SUPER SAVER PHARMACY GENOA HEALTHCARE OF FL LLC SUPER SAVER PHARMACY CVS PHARMACY KMART PHARMACY PUBLIX PHARMACY PUBLIX PHARMACY CVS PHARMACY TARGET PHARMACY JOSEYKAY PHARMACY WALMART PHARMACY CVS PHARMACY PUBLIX PHARMACY WINN-DIXIE PHARMACY TARGET PHARMACY CVS PHARMACY CVS PHARMACY CVS PHARMACY PUBLIX PHARMACY FLORIDA HOSPITAL PHARMACARE CT PUBLIX PHARMACY CVS PHARMACY WALMART PHARMACY SAM'S CLUB PHARMACY COLONIAL DRUGS OF KISSIMMEE LLC MD FAMILY PHARMACY MEDOZ PHARMACY OF OSCEOLA INC OAKS PHARMACY CVS PHARMACY PHARMACY EXPRESS WEST LAKE PHARMACY CELEBRATION PEDIATRICS SUNRISE DISCOUNT PHARMACY PHARMACY 4U

OSCEOLA COUNTY

1485 LEGENDS BLVD 7575 OSCEOLA POLK LINE RD 1205 W VINE ST 904 CYPRESS PKWY 4795 W IRLO BRONSON MEMORIAL H 3250 VINELAND RD 1980 E OSCEOLA PKWY 1207 E VINE ST STE B 208 PARK PLACE BLVD 1901 S JOHN YOUNG PKWY STE 101 2454 E IRLO BRONSON MEMORIAL H 2211 W VINE ST 3839 PLEASANT HILL RD 3040 DYER BLVD 1300 E VINE ST 3200 ROLLING OAKS BLVD 407 W VINE ST 4081 W IRLO HWY # 4500 PLEASANT HILL RD 3343 S ORANGE BLOSSOM TRL 1347 E VINE ST 3003 W VINE ST 3250 N JOHN YOUNG PKWY 1999 E OSCEOLA PKWY 3300 S ORANGE BLOSSOM TRL 2340 FORTUNE RD

II. Medical Insurance: CVS / Caremark Pharmacy Benefit

CHAMPIONS GATE DAVENPORT KISSIMMEE KISSIMMEE

81

WALMART PHARMACY PUBLIX PHARMACY THE LUNG CLINIC, P.A. THE HUNTER'S CREEK PHARMACY PUBLIX PHARMACY MUMTAZ MEDICAL ASSOCIATESPOINCIANA CENTRAL FL INTERNISTS KISSIMMEE MUMTAZ MEDICAL ASSOCIATES WEST VINE ALL-SCRIPTS PHARMACY ACUTE PATIENT CARE KISSIMMEE RITEMED PHARMACY BVL FAMILY MEDICAL CENTERS POINCIANA FAMILY MEDICAL CENTER ORLANDO FAMILY MEDICAL INC PUBLIX PHARMACY PUBLIX PHARMACY CVS PHARMACY PUBLIX PHARMACY PRESCRIPTIONS UNLIMITED WALMART PHARMACY PRESCRIPTIONS UNLIMITED VC CVS PHARMACY WINN-DIXIE PHARMACY SUPER SAVER PHARMACY LLC ST CLOUD PHCY & WELLNESS CTR PUBLIX PHARMACY WINN-DIXIE PHARMACY PUBLIX PHARMACY WALMART PHARMACY CVS PHARMACY WINN-DIXIE PHARMACY RX CARE PHARMACY CVS PHARMACY WALMART PHARMACY BARTOW PHARMACY & MED SUPPLY PUBLIX PHARMACY PUBLIX PHARMACY TARGET PHARMACY PUBLIX PHARMACY CVS PHARMACY PUBLIX PHARMACY WEBB'S SQUARE PHARMACY CVS PHARMACY WINN-DIXIE PHARMACY EAGLE LAKE PHARMACY FAST AND FRIENDLY PHARMACY WATSONS PHARMACY PUBLIX PHARMACY CVS PHARMACY WALMART PHARMACY WINN-DIXIE PHARMACY FIRST CHOICE PHARMACY CENTRAL PHARMACY FIRST CHOICE PHARMACY, ZOCALO PLAZA PUBLIX PHARMACY

3135 W VINE ST 2338 E IRLO BRONSON MEM HWY 1115 N CENTRAL AVE

KISSIMMEE

FL

34741

4078474083

KISSIMMEE

FL

34744

4078466825

KISSIMMEE

FL

34741

3109434180

1196 CYPRESS GLEN CIR.

KISSIMMEE

FL

34741

4074838901

29 BLAKE BLVD

KISSIMMEE

FL

34747

3219393106

1000 CYPRESS PKWY

KISSIMMEE

FL

34759

8666254280

802 W OAK ST

KISSIMMEE

FL

34741

8666254280

724 W VINE ST

KISSIMMEE

FL

34741

8666254280

1530B W VINE ST 1032 MANN ST 2130 MICHIGAN AVE 2551 BOGGY CREEK RD

KISSIMMEE KISSIMMEE KISSIMMEE KISSIMMEE

FL FL FL FL

34741 34741 34744 34744

4075304745 8666254280 4072876735 8666254280

4551 PLEASANT HILL RD

KISSIMMEE

FL

34744

8666254280

931 W OAK STE 103 841 CYPRESS PKWY 4401 13TH ST 3555 13TH ST 3372 CANOE CREEK RD 2521 13TH ST STE A 4257 13TH ST 2521 13TH ST STE A1 2105 13TH ST 3314 CANOE CREEK RD 520 13TH ST

KISSIMMEE POINCIANA SAINT CLOUD SAINT CLOUD SAINT CLOUD SAINT CLOUD SAINT CLOUD SAINT CLOUD SAINT CLOUD SAINT CLOUD SAINT CLOUD

FL FL FL FL FL FL FL FL FL FL FL

34741 34759 34769 34769 34772 34769 34769 34769 34769 34772 34769

4079310444 3216970009 4074983133 4078927161 4079578060 4078927166 4079574333 4078921060 4078923213 4078927103 4075932844

4073 13TH STREET

SAINT CLOUD

FL

34769

4075932959

1951 S NARCOOSSEE RD 4855 E IRLO BRONSON HWY

ST CLOUD ST CLOUD

FL FL

34771 34771

4078922060 4078925232

606 HAVENDALE BLVD 2120 US HIGHWAY 92 W 99 MAGNOLIA AVE 319A HAVENDALE BLVD 301 HAVENDALE BLVD 120 W VAN FLEET DR 1050 STATE ROAD 60 E

AUBURNDALE AUBURNDALE AUBURNDALE AUBURNDALE AUBURNDALE BARTOW BARTOW

FL FL FL FL FL FL FL

33823 33823 33823 33823 33823 33830 33830

8635519798 8635513536 8639674451 9419677803 8638755700 8635334153 8635332131

220 E VAN FLEET DR

BARTOW

FL

33830

8635376694

255 E VAN FLEET DR 39883 HIGHWAY 27 5000 GRANDVIEW PKWY 7800 LAKE WILSON RD 39902 HIGHWAY 27 2424 SAND MINE RD 141 WEBB DR STE 100 49581 US HIGHWAY 27 243 US HIGHWAY 27 S UNIT 16 169 US HWY 17 N 13 W BROADWAY ST 16 W WALL ST 617 US HIGHWAY 17 92 W 35799 HWY 27 1401 US HIGHWAY 27 N 1151 HWY 27 N 401 E HINSON AVE 1671 E HINSON AVE

BARTOW DAVENPORT DAVENPORT DAVENPORT DAVENPORT DAVENPORT DAVENPORT DAVENPORT DUNDEE EAGLE LAKE FORT MEADE FROSTPROOF HAINES CITY HAINES CITY HAINES CITY HAINES CITY HAINES CITY HAINES CITY

FL FL FL FL FL FL FL FL FL FL FL FL FL FL FL FL FL FL

33830 33837 33837 33896 33837 33897 33837 33897 33838 33839 33841 33843 33844 33844 33844 33844 33844 33844

8635341824 8634219245 8632561052 8634203727 8634192721 8634249973 8634219200 8634207563 8634393511 8638757977 8636222087 8636354568 8634191231 8634224969 8634227582 9414210639 8634382799 8634197777

460 US HWY 17-92 N

HAINES CITY

FL

33844

8634224222

23965 US HIGHWAY 27

LAKE WALES

FL

33859

8636761399

POLK COUNTY

II. Medical Insurance: CVS / Caremark Pharmacy Benefit

82

CVS PHARMACY WALMART PHARMACY WINN-DIXIE PHARMACY THE APOTHECARY SHOP LAKE WALES PHARMACY TARGET PHARMACY CVS PHARMACY CVS PHARMACY WINN-DIXIE PHARMACY CLEVELAND HEIGHTS PHARMACY PUBLIX PHARMACY PEOPLES PHARMACY LIDDYS PHARMACY CLINIC PRESCRIPTION SHOP TRI COUNTY PHARMACY CAREPLUS PHARMACY SAM'S CLUB PHARMACY LAKELAND PHARMACY CLARK N DAUGHTREY MEDICAL GROUP PA PUBLIX PHARMACY CVS PHARMACY CVS PHARMACY CENTRAL FL HLTH CARE PHCY LAKELAND FAST AND FRIENDLY PHARMACY LAKELAND RGNL MDCL CNTR OTPTNT PHCY COVANCE SPECIALTY PHARMACY EDGE PHARMACY WALMART PHARMACY LAKELAND CITY PHARMACY PUBLIX PHARMACY PUBLIX PHARMACY WALMART PHARMACY CVS PHARMACY WINN-DIXIE PHARMACY PUBLIX PHARMACY CVS PHARMACY WINN-DIXIE PHARMACY SAM'S CLUB PHARMACY CVS PHARMACY WINN-DIXIE PHARMACY PUBLIX PHARMACY PUBLIX PHARMACY WINN-DIXIE PHARMACY TARGET PHARMACY PUBLIX PHARMACY SENIOR CARE PHARMACY DOCTOR TODAY TLC LLC RX CARE CLUB SUPREME RX PUBLIX PHARMACY #3211 WALMART PHARMACY MULBERRY PHARMACY INC MULBERRY LONG TERM CARE PHCY PUBLIX PHARMACY SUNSHINE PHARMACY

500 S 11TH ST 2000 STATE ROAD 60 E 1860 STATE ROAD 60 E 437 S 11TH ST 1322 STATE ROAD 60 E 4005 HIGHWAY 98 N 1635 BARTOW RD 101 N WABASH AVE 6902 S FLORIDA AVE 3405 CLEVELAND HEIGHTS BLVD 4730 S FLORIDA AVE 4977 HWY 98 N 4204 S FLORIDA AVE STE E 1600 LAKELAND HILLS BLVD 1807 CRYSTAL LAKE DR 3020 S COMBEE RD 3530 LAKELAND HIGHLANDS RD 950-952 SOUTH FLORIDA AVE

LAKE WALES LAKE WALES LAKE WALES LAKE WALES LAKE WALES LAKELAND LAKELAND LAKELAND LAKELAND

FL FL FL FL FL FL FL FL FL

33853 33898 33853 33853 33853 33809 33801 33815 33813

8636762564 8636769468 9416762266 8636761974 8636760400 8638159408 8636865161 8636863131 8636463617

LAKELAND

FL

33803

8636465041

LAKELAND LAKELAND LAKELAND LAKELAND LAKELAND LAKELAND

FL FL FL FL FL FL

33813 33809 33813 33805 33801 33803

8636465471 8638584444 8636479899 8636807235 8639370480 8636688490

LAKELAND

FL

33803

8636449513

LAKELAND

FL

33803

8636883444

1730 LAKELAND HILLS BLVD

LAKELAND

FL

33805

8632845040

5185 US HIGHWAY 98 S 5010 S FLORIDA AVE 6105 US HIGHWAY 98 N

LAKELAND LAKELAND LAKELAND

FL FL FL

33812 33813 33809

8636447969 8636442411 8638584441

936 E PARKER ST

LAKELAND

FL

33801

8634138668

5100 US HWY 98TH N STE 3

LAKELAND

FL

33809

8639379045

1324 LAKELAND HILLS BLVD

LAKELAND

FL

33805

8632841834

500 EAGLE LANDING DR STE A 2039 E EDGEWOOD DR 3501 S FLORIDA AVE 2614 LAKELAND HILLS BLVD STE 4 3636 HARDEN BLVD 2515 S FLORIDA AVE 5800 US HIGHWAY 98 N 5391 N SOCRUM LOOP RD 1305 ARIANA ST 5375 N SOCRUM LOOP RD 2536 US HIGHWAY 92 E 2900 HIGHLAND RD 4600 US HIGHWAY 98 N 6170 LAKELAND HIGHLANDS RD 6600 N SOCRUM LOOP RD 2125 E COUNTY ROAD 540A 2300 GRIFFIN RD 2630 US HIGHWAY 92 E 3570 HARDEN BLVD 6767 US HIGHWAY 98 N 4175 S PIPKIN RD #208 1429 LAKELAND HILLS BLVD 500 EAGLES LANDING DR STE B 1611 N FLORIDA AVE 1324 LAKELAND HILLS BLVD #203 6745 N CHURCH AVE 1009 N CHURCH AVE

LAKELAND LAKELAND LAKELAND

FL FL FL

33810 33803 33803

8668422147 8639371050 8636440671

LAKELAND

FL

33805

8636879700

LAKELAND LAKELAND LAKELAND LAKELAND LAKELAND LAKELAND LAKELAND LAKELAND LAKELAND

FL FL FL FL FL FL FL FL FL

33803 33803 33809 33809 33803 33809 33801 33803 33809

8636473781 8636864241 8638593772 8638586001 9416883117 8638596353 8636653171 9416672711 8638533701

LAKELAND

FL

33813

8636196409

LAKELAND LAKELAND LAKELAND LAKELAND LAKELAND LAKELAND LAKELAND LAKELAND

FL FL FL FL FL FL FL FL

33809 33813 33810 33801 33803 33809 33811 33805

9418593611 8636198332 8638585779 9416655553 8636480512 8638595838 8635771440 8636870200

LAKELAND

FL

33810

8663364103

LAKELAND

FL

33805

2672591254

LAKELAND

FL

33805

8632841834

MULBERRY MULBERRY

FL FL

33860 33860

8637018049 8634251101

1011 N CHURCH AVE

MULBERRY

FL

33860

8634251101

2040 SHEPHERD RD 120 CARTER BLVD STE 6

MULBERRY POLK CITY

FL FL

33860 33868

8636445929 3219475847

II. Medical Insurance: CVS / Caremark Pharmacy Benefit

83

PHARMACY ONE PRO SPECIALTY CARE PH CVS PHARMACY CVS PHARMACY CVS PHARMACY WALMART PHARMACY GENOA HEALTHCARE OF FLORIDA, LLC PUBLIX PHARMACY CVS PHARMACY BOND CLINIC WALMART PHARMACY KAY PHARMACY #003 PUBLIX PHARMACY KMART PHARMACY WINN-DIXIE PHARMACY PUBLIX PHARMACY WINTER HAVEN PHARMACY DUNDEE COMMUNITY PHARMACY GOOD HEALTH PHARMACY

65 3RD ST NW STE 59

WINTER HAVEN

FL

33881

8634019300

3005 SR 540 WEST 970 CYPRESS GARDENS BLVD 400 6TH ST NW 7450 CYPRESS GARDENS BLVD

WINTER HAVEN WINTER HAVEN WINTER HAVEN

FL FL FL

32561 33880 33881

8632930193 8632943138 8632944493

WINTER HAVEN

FL

33884

8633180252

1201 1ST ST S

WINTER HAVEN

FL

33880

8632914707

884 CYPRESS GARDENS BLVD 7009 CYPRESS GARDENS BLVD 500 E CENTRAL AVE 355 CYPRESS GARDENS BLVD 637 1ST ST S 1090 SPIRIT LAKE RD 6015 CYPRESS GARDENS BLVD 2700 RECKER HWY 1395 6TH ST NW 1620 6TH ST SE 5999 DUNDEE RD STE 200 1501 1ST ST S

WINTER HAVEN

FL

33880

8632932382

WINTER HAVEN

FL

33884

8633245873

WINTER HAVEN WINTER HAVEN WINTER HAVEN WINTER HAVEN

FL FL FL FL

33880 33880 33880 33880

8632931191 8632995131 8632688218 8632935007

WINTER HAVEN

FL

33884

8633261612

WINTER HAVEN WINTER HAVEN WINTER HAVEN WINTER HAVEN WINTER HAVEN

FL FL FL FL FL

33880 33881 33880 33884 33880

8632913522 8632948282 8632910400 8633244100 8632295974

FL

32701

4078313454

FL

32714

4073896025

FL

32714

4078623013

FL

32701

4078309554

FL

32714

4078696463

FL

32701

4077904863

FL

32714

4076825555

FL

32714

4077746255

FL

32701

4076474895

FL

32701

4078308820

FL

32714

4077867818

FL

32701

4072607002

FL

32701

4072609985

FL

32714

4077888718

FL

32714

4077887377

FL

32714

4072914198

FL

32714

4075221105

FL

32701

4073326366

FL

32701

4078698747

FL

32714

4076827272

SEMINOLE COUNTY ALBERTSON'S PHARMACY

503 E ALTAMONTE DR

CVS PHARMACY

277 W STATE ROAD 436

CVS PHARMACY

221 S STATE ROAD 434

CVS PHARMACY

484 E ALTAMONTE DR STE 1008

CVS PHARMACY

1098 MONTGOMERY RD

HIS GRACE PHARMACY

600 E ALTAMONTE DR STE 1400

PUBLIX PHARMACY

951 N STATE ROAD 434

WALMART PHARMACY

200 S STATE ROAD 434

INNOVATIVE NURSING MANAGEMENT

499 E CENTRAL PKWY STE 100

BIO-PLUS SPECIALTY PHARMACY

376 S NORTHLAKE BLVD STE 1008

COSTCO PHARMACY

741 ORANGE AVE

PHARMACY SPECIALISTS

393 MAITLAND AVE

PUBLIX PHARMACY

482 E ALTAMONTE DR

WINN-DIXIE PHARMACY

340 S STATE ROAD 434 STE 1034

TARGET PHARMACY

886 W STATE ROAD 436

CVS PHARMACY

1401 DUTCH ELM DR

PUBLIX PHARMACY

851 S STATE ROAD 434

ALTAMONTE FAMILY PRACTICE

249 MAITLAND AVE STE 1000

ALTAMONTE MEDICAL

460 E ALTAMONTE DR STE 2200

LUIS E. MORALES FAMILY PRACTICE

809 DOUGLAS AVE

II. Medical Insurance: CVS / Caremark Pharmacy Benefit

ALTAMONTE SPRINGS ALTAMONTE SPRINGS ALTAMONTE SPRINGS ALTAMONTE SPRINGS ALTAMONTE SPRINGS ALTAMONTE SPRINGS ALTAMONTE SPRINGS ALTAMONTE SPRINGS ALTAMONTE SPRINGS ALTAMONTE SPRINGS ALTAMONTE SPRINGS ALTAMONTE SPRINGS ALTAMONTE SPRINGS ALTAMONTE SPRINGS ALTAMONTE SPRINGS ALTAMONTE SPRINGS ALTAMONTE SPRINGS ALTAMONTE SPRINGS ALTAMONTE SPRINGS ALTAMONTE SPRINGS

84

TOTAL OPTIMAL HEALTH PHCY CHUCK DAHAN, M.D., P.A. MEDICINE SHOPPE PUBLIX PHARMACY WALMART PHARMACY PUBLIX PHARMACY PUBLIX PHARMACY TARGET PHARMACY WINN-DIXIE PHARMACY CASSELBERRY DISCOUNT PHARMACY MEDS TO HOME XUBEX COMMUNITY PHARMACY WINN-DIXIE PHARMACY SAM'S CLUB PHARMACY SKYEMED ORLANDO INC ADVANCED PHARMACY PUBLIX PHARMACY CVS PHARMACY PUBLIX PHARMACY CVS PHARMACY TARGET PHARMACY PUBLIX PHARMACY AXIUM HEALTHCARE PHARMACY, INC PUBLIX PHARMACY MEDPLEX PHARMACY NH PHARMA AVELLA OF ORLANDO, INC PAIN CENTER OF ORLANDO CVS PHARMACY CVS PHARMACY PHARMERICA LONGWOOD PHARMACY FL HOSPITAL HOME INFUSION LLC PHARM-EZ MEDICAL, LLC ADVANCED INTERV'N PAIN CLINIC PUBLIX PHARMACY #1428 OVIEDO HEALTHMART PHARMACY PUBLIX PHARMACY PUBLIX PHARMACY PUBLIX PHARMACY TARGET PHARMACY PUBLIX PHARMACY WINN-DIXIE PHARMACY CVS PHARMACY CVS PHARMACY PUBLIX PHARMACY WALMART PHARMACY WALMART PHARMACY OMNICARE PHARMACY OF FLORIDA WALMART PHARMACY CVS PHARMACY TARGET PHARMACY RX PLUS PHARMACY

990 N SR 434 STE 1128

ALTAMONTE SPRINGS ALTAMONTE SPRINGS

FL

32714

4078657977

FL

32701

3109434180

APOPKA

FL

32703

4077741957

APOPKA CASSELBERRY CASSELBERRY CASSELBERRY CASSELBERRY CASSELBERRY

FL FL FL FL FL FL

32703 32707 32707 32707 32707 32707

4078625823 4076790373 4076730788 4078312323 4078306363 4076962885

1015 STATE ROAD 436 STE 117

CASSELBERRY

FL

32707

3219728947

1015 STATE ROAD 436 STE 237 500 STATE ROAD 436 STE 1010 7800 S US HIGHWAY 17/92 STE 16 355 STATE ROAD 436 560 RINEHART RD STE 110 45 SKYLINE DR STE 1011 870 VILLAGE OAK LN 924 RINEHART RD 4195 W LAKE MARY BLVD 100 INTERNATIONAL PKWY STE 130 3810 GREENWOOD BLVD 601 WELDON BLVD

CASSELBERRY CASSELBERRY

FL FL

32707 32707

4073310545 4076245088

FERN PARK

FL

32730

4073395661

FERN PARK LAKE MARY LAKE MARY LAKE MARY LAKE MARY LAKE MARY

FL FL FL FL FL FL

32730 32746 32746 32746 32746 32746

4073399223 8663982148 4078058300 4078041963 4078059702 4073220767

LAKE MARY

FL

32746

4073333102

LAKE MARY LAKE MARY

FL FL

32746 32746

4073309190 4076880575

550 TECHNOLOGY PARK

LAKE MARY

FL

32746

4078657795

825 RINEHART RD 4106 W LAKE MARY BLVD STE 130 405 WAYMONT CT STE 101 100 TECHNOLOGY PARK, STE 155 225 W STATE ROAD 434 STE 205 130 E STATE ROAD 434 3905 WEKIVA SPRINGS RD 735 W HIGHWAY 434 STE B 252 W STATE ROAD 434 556 FLORIDA CNTRL PKWY #1044 181 SABAL PALM DR STE 101 451 S MILWEE ST STE 1010 2381 WEST SR 434 85 GENEVA DR 2871 CLAYTON CROSSING WY #1001 81 ALAFAYA WOODS BLVD 4250 ALAFAYA TRL 820 OVIEDO TER 2100 WINTER SPRINGS BLVD 1021 LOCKWOOD BLVD 1030 LOCKWOOD BLVD 8315 RED BUG LAKE RD 1801 E BROADWAY ST 4255 ALAFAYA TRL 5511 DEEP LAKE RD 4150 CHURCH ST CNTRL PKWY 1030 1601 RINEHART RD 3798 S ORLANDO DR 1201 WP BALL BLVD 582 MONROE RD STE 1412

LAKE MARY

FL

32746

4073249822

LAKE MARY

FL

32746

4078787615

LAKE MARY

FL

32746

4073222440

LAKE MARY

FL

32746

4079420080

LONGWOOD

FL

32750

4076793337

LONGWOOD LONGWOOD LONGWOOD LONGWOOD

FL FL FL FL

32750 32779 32750 32750

4073328384 4078628086 4077679010 4073329753

LONGWOOD

FL

32750

4078655489

LONGWOOD LONGWOOD LONGWOOD OVIEDO

FL FL FL FL

32779 32750 32778 32765

4079653980 8778633228 4078659924 4073662677

OVIEDO

FL

32765

4076732317

OVIEDO OVIEDO OVIEDO OVIEDO OVIEDO OVIEDO OVIEDO OVIEDO OVIEDO OVIEDO

FL FL FL FL FL FL FL FL FL FL

32765 32765 32765 32765 32765 32765 32765 32765 32765 32765

4073668319 4073669720 4073665907 4073669810 4079779020 4073661717 4079775613 4079710395 4073596989 4076182622

SANDFORD

FL

32771

4072615800

SANFORD SANFORD SANFORD SANFORD

FL FL FL FL

32771 32773 32771 32771

4073211717 4073229440 4075470008 8669434535

616 E ALTAMONTE DR SUITE 201 3030 E SEMORAN BLVD STE 164 540 S HUNT CLUB BLVD 1241 STATE ROAD 436 STE 101 1455 STATE ROAD 436 STE 221 3385 S US 1792 4410 S US HWY 17-92 1750 SUNSHADOW DR STE 100

II. Medical Insurance: CVS / Caremark Pharmacy Benefit

85

RX PLUS PHARMACY TRU-VALU DRUGS WALMART PHARMACY WINN-DIXIE PHARMACY CENTRAL FL COMM CLINIC PHCY RX PLUS PHARMACY PUBLIX PHARMACY CVS PHARMACY SAM'S CLUB PHARMACY DISCOUNT RX MID FL HEMATOLOGY & ONCLGY CTRS WINN-DIXIE PHARMACY CVS PHARMACY THE MEDICINE SHOPPE GOODINGS

582 MONROE RD STE 1412 503 E 1ST ST 3653 S ORLANDO DR 1514 S FRENCH AVE 2400 SR 415 582 MONROE RD STE 1412 5240 W STATE ROAD 46 4639 W STATE ROAD 46 1101 RINEHART RD 1402 W 1ST ST

SANFORD SANFORD SANFORD SANFORD SANFORD SANFORD SANFORD SANFORD SANFORD SANFORD

FL FL FL FL FL FL FL FL FL FL

32771 32771 32773 32771 32771 32771 32771 32771 32771 32771

8669434535 4073236413 4073217610 4073216626 4073222095 8669434535 4076882971 4076880828 4073021979 4073222244

2100 W 1ST ST

SANFORD

FL

32771

4073232250

951 STATE ROAD 434 1510 STATE ROAD 436 3796 HOWELL BRANCH RD 750 UNIVERSITY BLVD

FL FL FL FL

32750 32792 32792 32792

4073317340 4076577960 4076718070 4076774515

FERTILITY PHARMACY

120 W STATE ROAD 434 STE B

FL

32708

4075572029

CVS PHARMACY

5650 RED BUG LAKE RD

FL

32708

4076990781

KMART PHARMACY

1425 TUSKAWILLA RD STE 225

FL

32708

4076991388

PUBLIX PHARMACY

5655 RED BUG LAKE RD

FL

32708

4076955814

PUBLIX PHARMACY

1160 E STATE ROAD 434

FL

32708

4073279731

WALMART PHARMACY

5216 RED BUG LAKE RD

SEMINOLE WINTER PARK WINTER PARK WINTER PARK WINTER SPRINGS WINTER SPRINGS WINTER SPRINGS WINTER SPRINGS WINTER SPRINGS WINTER SPRINGS

FL

32708

4076997055

FL

32114

3862555396

FL

32114

3862529659

FL

32117

3862550907

FL

32117

3866728955

FL

32117

3862741490

FL

32114

3862363188

FL

32118

3867560481

FL

32114

3863237500

FL

32119

3867604443

FL

32114

9042583992

FL

32114

3863230765

FL

32119

3867603078

FL

32114

3862554226

FL

32114

3863107900

FL

32118

3866771073

FL

32117

8666254280

FL

32117

3866760307

FL

32114

8666254280

VOLUSIA COUNTY CVS PHARMACY

101 S RIDGEWOOD AVE

KMART PHARMACY

1300 W INTERNATIONAL SPEEDWAY

STEVES PHARMACY INC

636 MASON AVE

WALMART PHARMACY

1905 N NOVA RD

CVS PHARMACY

1891 LPGA BLVD

SMA BEHAVIORAL HEALTHCARE PHCY

1220 WILLIS AVE BLDG 2

CVS PHARMACY

3038 S ATLANTIC AVE

DAYTONA BEACH VA CBOC PHARMACY

551 NATIONAL HEALTH CARE DR

WALMART PHARMACY

1101 BEVILLE RD

TARGET PHARMACY

2380 W INTERNATIONAL SPEEDWAY

CVS PHARMACY

1350 BEVILLE RD

SAM'S CLUB PHARMACY

1175 BEVILLE RD

PUBLIX PHARMACY

1500 BEVILLE RD STE 300

THE MEDICINE SHOPPE

948 ORANGE AVE

PUBLIX PHARMACY #0814

2595 N ATLANTIC AVE

PRIMECARE URG CARE CNTR TWIN LAKES ARTHRITIS AUTOIMMUNE & ALLERGY VOLUSIA MEDICAL CENTER DAYTONA

1890 LPGA BLVD STE 130 1893 N CLYDE MORRIS BLVD #110 575 N CLYDE MORRIS BLVD

II. Medical Insurance: CVS / Caremark Pharmacy Benefit

DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH

86

SHORES MEDICAL CENTER DAYTONA WINN-DIXIE PHARMACY WINN-DIXIE PHARMACY CVS PHARMACY RITTER'S TOWNE PHARMACY PETER'S PHARMACY PUBLIX PHARMACY PIERSON COMMUNITY PHARMACY WEST VELUSIA MEDICAL ASSOCIATES WINN-DIXIE PHARMACY WALMART PHARMACY CVS PHARMACY THE MEDICINE SHOPPE PUBLIX PHARMACY MOHAN SHARMA, M.D. FAMILY PRACTICE OF W VOLUSIA DELAND ANDREW C FELDMAN MID FL HEMATOLOGY & ONC CENTERS DELAND QUICK CARE DELTONA PHARMACY OF FLORIDA LLC CVS PHARMACY PUBLIX PHARMACY WALMART PHARMACY PUBLIX PHARMACY CVS PHARMACY PUBLIX PHARMACY WINN-DIXIE PHARMACY PUBLIX PHARMACY LLOYDS PHARMACY PUBLIX PHARMACY CVS PHARMACY WINN-DIXIE PHARMACY HOLLY HILL PHARMACY WINN-DIXIE PHARMACY PUBLIX PHARMACY

DAYTONA BEACH SHORES

FL

32118

8666254280

DEBARY

FL

32713

4076688845

DELAND DELAND DELAND

FL FL FL

32720 32720 32724

9049439940 3867345822 3867346666

DELAND

FL

32724

3867348477

DELAND DELAND

FL FL

32720 32720

3867345369 3867386268

1070 N STONE ST

DELAND

FL

32720

8006540889

1050 W NEW YORK AVE 1699 N WOODLAND BLVD 2497 S WOODLAND BLVD 319 S WOODLAND BLVD 299 E INTL SPWD BLVD 229 E RICH AVE

DELAND DELAND DELAND DELAND DELAND DELAND

FL FL FL FL FL FL

32720 32720 32720 32720 32724 32724

9047385429 3867341311 3867369001 3867343383 3867383619 8666254280

862 PEACHWOOD DR

DELAND

FL

32720

8666254280

800 N STONE ST

DELAND

FL

32720

8666254280

1070 N STONE ST STE C

DELAND

FL

32720

3867341013

650 W PLYMOUTH AVE

DELAND

FL

32720

8666254280

776 DELTONA BLVD

DELTONA

FL

32725

3865747600

2187 HOWLAND BLVD 605 COURTLAND BLVD 101 HOWLAND BLVD 2100 SAXON BLVD 1250 PROVIDENCE BLVD 2783 ELKCAM BLVD 2880 HOWLAND BLVD 915 DOYLE RD 1240 PROVIDENCE BLVD STE 7 2970 S RIDGEWOOD AVE 1806 S RIDGEWOOD AVE 1838 S RIDGEWOOD AVE 1702 RIDGEWOOD AVE STE C 1541 N NOVA RD 1850 RIDGEWOOD AVE

DELTONA DELTONA DELTONA DELTONA DELTONA DELTONA DELTONA DELTONA DELTONA EDGEWATER EDGEWATER EDGEWATER HOLLY HILL HOLLY HILL HOLLY HILL NEW SMYRNA BEACH NEW SMYRNA BEACH NEW SMYRNA BEACH NEW SMYRNA BEACH NEW SMYRNA BEACH NEW SMYRNA BEACH NEW SMYRNA BEACH NEW SMYRNA BEACH ORANGE CITY ORANGE CITY

FL FL FL FL FL FL FL FL FL FL FL FL FL FL FL

32738 32738 32738 32725 32725 32738 32725 32725 32725 32141 32132 32141 32117 32117 32117

3867890813 4073215421 4073289414 3865326388 3865745291 3867893786 9045327178 3865750511 3862595124 3864781334 3864234674 3864281844 3866777377 9042529883 3866779495

FL

32168

3864289041

FL

32168

3864273459

FL

32169

3864275244

FL

32168

3864231173

FL

32168

3864276030

FL

32168

9044240440

FL

32169

3864279161

FL

32169

8666254280

FL FL

32763 32763

3867747933 3867757770

ORANGE CITY

FL

32763

3867754844

ORANGE CITY ORANGE CITY ORANGE CITY ORANGE CITY ORANGE CITY

FL FL FL FL FL

32763 32763 32763 32763 32763

3867747446 9047746477 3867745800 3862184993 3867741223

3512 S ATLANTIC AVE 2 N CHARLES RICHARD BEALL BLVD 2701 WOODLAND BLVD 901 N WOODLAND BLVD 120 E NEW YORK AVE 1431 ORANGE CAMP RD STE 102 2400 S WOODLAND BLVD 650 W PLYMOUTH AVE

LITTLE DRUG COMPANY

412 CANAL ST

THE MEDICINE SHOPPE

1141 N DIXIE FWY

CVS PHARMACY

615 E 3RD AVE

PUBLIX PHARMACY

1930 STATE ROAD 44

WALMART PHARMACY

1998 STATE ROAD 44

WINN-DIXIE PHARMACY

1835 STATE ROAD 44

PUBLIX PHARMACY

709 E 3RD AVE

VOLUSIA MEDICAL CENTER NEW SMYRNA TOWN CENTER PHARMACY CVS PHARMACY WALMART PHARMACY PUBLIX PHARMACY TARGET PHARMACY ACCARDI CLINICAL PHARMACY LEGACY PHARMACY OC MID-FLORIDA H&O CENTERS, PA

161 N CAUSEWAY STE A 921 TOWN CENTER DR STE 100 2400 ENTERPRISE RD 2400 VETERANS MEMORIAL PKWY 2556 ENTERPRISE RD 2575 ENTERPRISE RD 2583 S VOLUSIA AVE STE 100 2413 ENTERPRISE RD 2776 ENTERPRISE RD, STE 100

II. Medical Insurance: CVS / Caremark Pharmacy Benefit

87

GENESIS FAMILY PRACTICE LLC DELTONA MEDICAL CENTER LLC FAMILY PRACTICE OF WEST VOLUSIA CVS PHARMACY CAREPOINT PHARMACY GUARDIAN PHARMACY OF DAYTONA CVS PHARMACY WALMART PHARMACY PUBLIX PHARMACY WINN-DIXIE PHARMACY PUBLIX PHARMACY PUBLIX PHARMACY ORMOND PHARMACY BLACKSHEEP MEDICAL LLC PIERSON COMMUNITY PHARMACY CVS PHARMACY CVS PHARMACY PUBLIX PHARMACY WALMART PHARMACY THE MEDICINE SHOPPE TARGET PHARMACY CVS PHARMACY PUBLIX PHARMACY #1450 PORT ORANGE INTERNIST PRIMECARE URGENT CARE CENTERS

1133 SAXON BLVD 747 FAWN RIDGE DR STE 200

ORANGE CITY ORANGE CITY

FL FL

32763 32763

8666254280 8666254280

2582 S VOLUSIA AVE

ORANGE CITY

FL

32763

8666254280

250 E GRANADA BLVD 1400 HAND AVE STE O

ORMOND BEACH ORMOND BEACH

FL FL

32176 32174

3866722041 3866719476

10 AVIATOR WAY

ORMOND BEACH

FL

32174

3866151925

218 N NOVA RD 1521 W GRANADA BLVD 1478 W GRANADA BLVD 353 W GRANADA BLVD 3750 ROSCOMMON DR 1258 OCEAN SHORE BLVD 500 W GRANADA BLVD STE 4 1425 HAND AVE STE L 112 E 1ST AVE 3771 S CLYDE MORRIS BLVD 1001 DUNLAWTON AVE 3821 S NOVA RD 1590 DUNLAWTON AVE 4036-D SOUTH NOVA RD 1771 DUNLAWTON AVE 1816 DUNLAWTON AVE 1660 TAYLOR RD 3890 TURTLE CREEK DR

ORMOND BEACH ORMOND BEACH ORMOND BEACH ORMOND BEACH ORMOND BEACH ORMOND BEACH ORMOND BEACH ORMOND BEACH PIERSON PORT ORANGE PORT ORANGE PORT ORANGE PORT ORANGE PORT ORANGE PORT ORANGE PORT ORANGE PORT ORANGE PORT ORANGE

FL FL FL FL FL FL FL FL FL FL FL FL FL FL FL FL FL FL

32174 32174 32174 32174 32174 32176 32174 32174 32180 32129 32127 32127 32127 32127 32127 32127 32128 32129

3866727227 3866722030 3866774215 9046770602 3866156858 3864413730 3866720600 8666254280 3867499557 3867634850 3867881500 3867564170 3867610191 3863048222 3867676082 3863223919 3867607334 8666254280

740 DUNLAWTON AVE STE 100

PORT ORANGE

FL

32127

8666254280

PORT ORANGE URGENT CARE

1690 DUNLAWTON AVE STE 120

PORT ORANGE

FL

32127

8666254280

CVS PHARMACY

2300 S RIDGEWOOD AVE

FL

32119

3867673084

DAYTONA DISCOUNT PHARMACY

815 BEVILLE RD STE D

FL

32119

3863225969

PUBLIX PHARMACY

2400 S RIDGEWOOD AVE

FL

32119

3867560477

CVS PHARMACY

101 S RIDGEWOOD AVE

FL

32114

3862555396

KMART PHARMACY

1300 W INTERNATIONAL SPEEDWAY

FL

32114

3862529659

STEVES PHARMACY INC

636 MASON AVE

FL

32117

3862550907

WALMART PHARMACY

1905 N NOVA RD

FL

32117

3866728955

CVS PHARMACY

1891 LPGA BLVD

FL

32117

3862741490

SMA BEHAVIORAL HEALTHCARE PHCY

1220 WILLIS AVE BLDG 2

FL

32114

3862363188

CVS PHARMACY

3038 S ATLANTIC AVE

FL

32118

3867560481

DAYTONA BEACH VA CBOC PHARMACY

551 NATIONAL HEALTH CARE DR

FL

32114

3863237500

WALMART PHARMACY

1101 BEVILLE RD

FL

32119

3867604443

TARGET PHARMACY

2380 W INTERNATIONAL SPEEDWAY

FL

32114

9042583992

CVS PHARMACY

1350 BEVILLE RD

FL

32114

3863230765

SAM'S CLUB PHARMACY

1175 BEVILLE RD

FL

32119

3867603078

PUBLIX PHARMACY

1500 BEVILLE RD STE 300

FL

32114

3862554226

THE MEDICINE SHOPPE

948 ORANGE AVE

FL

32114

3863107900

PUBLIX PHARMACY #0814

2595 N ATLANTIC AVE

FL

32118

3866771073

II. Medical Insurance: CVS / Caremark Pharmacy Benefit

SOUTH DAYTONA SOUTH DAYTONA SOUTH DAYTONA DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH DAYTONA BEACH

88

PRESCRIPTION DRUG PROGRAM EXCLUSIONS/LIMITATIONS 1. Any drug used primarily for cosmetic purposes such as Rogaine (minoxidil) for hair restoration, Renova for skin wrinkles, or any other drug for cosmetic purposes. 2. All medicinal substances (over the counter) which may be dispensed without a prescription including, but not limited to all strengths and all forms of Allegra, Claritin, Zyrtec, Prilosec, Zantac, Axid AR, Pepcid, and Tagamet. Insulin is an exception and is covered. Aspirin (to prevent cardiovascular disease) is an exception and is covered for all plan members ages 45 to 79. 3. All Non-Sedating Antihistamines (NSAs). 4. Prescription drugs with equivalent products also available over the counter. These products are identical in active chemical ingredient, dosage form, strength, and route of administration. 5. Therapeutic devices or appliances, including but not limited to support garments, ostomy supplies and other non-medical substances. 6. All brand-name prescription drugs not on the formulary. 7. All drugs bearing a label: “Caution – limited by federal law to investigational use,” or experimental drugs. 8. The refilling of a prescription in the amount greater than that authorized by the prescriber. 9. The refilling of a prescription at a point in time after one year from the date of issuance. 10. The filling or refilling of prescriptions not in compliance with applicable state and federal laws, rules and regulations. 11. Quantities in excess of a 90-day supply (100 pills may be dispensed if packaged in lots of 100). 12. Prescription drugs which may be properly received without change under local, state, or federal programs including workers’ compensation. 13. Prescription drugs for medical plan coverage exclusions such as sexual dysfunction or inadequacies, or infertility. 14. Diet medications or medications prescribed for weight control. 15. Abortive contraceptives (e.g., Mifeprex). 16. Impotency medications (e.g., Muse, Edex, Caverject, Viagra, Levitra, Cialis). 17. Fertility drugs, oral and injectable. 18. Oral Fluoride Preps, except for children older than 6 months of age through 5 years old. 19. Non-prenatal vitamins, with the exception of folic acid for women of child-bearing age (e.g. 18 to 45), iron supplements for children ages 6 to 12 months who are at risk for iron deficiency anemia and Vitamin D for all members over the age of 65. 20. Nutritional/Dietary Supplements. II. Medical Insurance: CVS / Caremark Pharmacy Benefit

89

21. Medical foods. 22. Homeopathic drugs, all dosage forms including injectables. 23. Diagnostic, testing & imaging supplies (e.g. Tubersol for TB skin test, Radiopaque dye). 24. Prescriptions for Smoking Cessation medications are covered with a day’s supply maximum of 90 days per 365 day rolling period. 25. Certain medications may be a part of the CVS/Caremark Valued Formulary. This program is designed to limit medications for both quantity and day’s supply based on safe prescribing guidelines from the FDA. Prior Authorizations may be allowed for some of these medications where applicable. 26. Prior Authorizations are required for certain classes of medications before they can be dispensed: For a listing of these medications, please visit www.caremark.com 27. Certain medications under Specialty Pharmacy will require prior authorization prior to filling the medication and can include Step Therapy as well. For a listing of Specialty medications requiring Prior Authorization, please visit www.CVSCaremarkSpecialtyRx.com 28. Certain categories will require Step Therapy. These medications will require that a first line agent is utilized prior to a second line brand agent. For a listing of medications requiring Step Therapy, please visit www.caremark.com 29. Introduction of new medications-- Effective Jan. 1, 2010, new medications coming to the market will be in a “pended” status (that is, not covered under the OCPS plan) until reviewed and approved by the CVS/Caremark Network Pharmacy for safety and effectiveness. The CVS/Caremark Network Pharmacy is a group of physicians and pharmacists from different specialties who advise a Pharmacy Benefit Management (PBM) company regarding safe and effective use of medications. Additionally, prior to approval, CVS/Caremark Network Pharmacy will recommend appropriate Clinical Prior Authorizations, including Step Therapies, for implementation. The Medical Director of the medical and/or behavioral health plan will “sign off” on this recommendation as the final step. CVS/Caremark Network Pharmacy still determines formulary/non-formulary status and the medication shall be so placed if/when approved for coverage. Please note that coverage will not be retroactive; that is, medications in this “pended” category will not be covered or reimbursed until approved. Since the CVS/Caremark Network Pharmacy meets quarterly, OCPS would not expect this process to take longer than three to four months. Members with questions about the coverage of specific drugs should contact CVS/Caremark Customer Service to check on the status of the drug in question. 30. All branded diabetes glucose monitors and test strips with the exception of OneTouch™ monitors (obtained from manufacturer) and OneTouch™ test strips. To obtain a glucose monitor, you must either obtain a coupon from OCPS Benefits or call CVS/Caremark Customer Care at (800)378-9264. If your doctor feels the first-line Step Therapy product (OneTouch™) isn’t right for you, your doctor will need to complete a Prior Authorization review for the second-line product by calling CVS/Caremark Customer Care at (800)3789264. If the Prior Authorization is approved based on the clinical information provided, the second-line non-preferred test strips will be covered. If approved, members in Plan A: Cigna Local Plus OAP In-Network Plan will pay a 50% coinsurance (minimum $120 copay) for a 90-day supply through mail service and members in Plan B: Cigna Health Reimbursement Account Plan or Plan C: Cigna OAP In-Network Plan will pay a $120 copay for a 90-day supply through mail service. II. Medical Insurance: CVS / Caremark Pharmacy Benefit

90

II. MEDICAL INSURANCE

E. ORLANDO BEHAVIORAL HEALTHCARE EAP AND BEHAVIORAL HEALTH SERVICES (Your Mental Health/Chemical Dependency Benefit for All Medical Plans)

BENEFITS FOR BEHAVIORAL HEALTH SERVICES All Behavioral Health Services for eligible OCPS members are provided by Orlando Behavioral Healthcare. These services include Employee Assistance (EAP) and Behavioral Health. Both EAP and Behavioral Healthcare services may be accessed through the Orange County Public Schools’ Employee Assistance Program or through Orlando Behavioral Healthcare at 407.637.8080. OCPS members must call Orlando Behavioral Healthcare for pre-authorization of all Mental Health/Chemical Dependency Inpatient and Outpatient services. Orlando Behavioral Healthcare will provide each member necessary care and treatment of mental and nervous disorders including autism, generally defined, but not limited to ICD-9-CM Mental Disorders Conditions (290-319), DSM-5 or ICD-10-CM when pre-authorized by Orlando Behavioral Healthcare. Subject to the Behavioral Health Services Exclusions listed on page 93 of this section. Medically necessary treatment requiring inpatient psychiatric care, including related hospital inpatient services, physicians, and mental health professionals is provided for up to 30 days per plan year. Preauthorization by Orlando Behavioral Healthcare is required. Outpatient services provided by licensed psychiatrists, psychologists, or licensed mental health professionals up to 20 visits per plan year for mental health services (autism visits include services provided by Certified Behavioral Analysts. NOTE: Certified Behavioral Analysts do not need to hold a licensure but must be certified in Behavioral Analysis) and 44 visits per plan year for substance abuse are covered when services are deemed reasonable and necessary for crisis intervention, diagnostic evaluation, and treatment. Plan year is October 1st through September 30th. Long-term intensive care services must be pre-authorized by Orlando Behavioral Healthcare and provided in a state-licensed and/or Joint Commission approved facility.

II. Medical Insurance: Orlando Behavioral Healthcare

91

SCHEDULE OF BENEFITS

BENEFIT FEATURE

IN-NETWORK

MENTAL HEALTH (M.H.)

OUT-OF-NETWORK

Maximum***

Inpatient Psychiatric

90% coverage

30 days/yr

Not covered

Long Term Intensive Care (LIC)*

90% coverage

90 days/yr

Not covered

Outpatient (1 – 5 visits)

100% coverage

N/A

Max reimbursement to member $30**

Outpatient (6 – 10 visits)

$10/visit (copay)

N/A

Max reimbursement to member $30**

Outpatient (11 - 20 visits)

$20/visit (copay)

20 M.H./yr

Max reimbursement to member $30** 20 M.H./yr

Emergency Intervention

100% coverage N/A

Max reimbursement to member $30**

Outpatient (1 – 5 visits)

100% coverage

Max reimbursement to member $30**

Outpatient (6 – 10 visits)

$10/visit (copay)

Max reimbursement to member $30**

Outpatient (beyond 11 visits)

$20/visit (copay) Maximum plan pays $36,000 per year; $200,000 Lifetime

Max reimbursement to member $30**

AUTISM SERVICES

ALCOHOLISM AND CHEMICAL DEPENDENCY (C.D.)

Maximum***

Inpatient Psychiatric

90% coverage

30 days/yr

Not covered

Long Term Intensive Care (LIC)*

90% coverage

90 days/yr

Not Covered

Outpatient (1 – 5 visits) Outpatient (6 – 10 visits) Outpatient (11 - 44 visits)

100% coverage $10/visit (copay) $20/visit (copay)

N/A N/A 44 C.D./yr

Emergency Intervention

100% coverage

Max reimbursement to member $30** Max reimbursement to member $30** Max reimbursement to member $30** 44 C.D./yr Max reimbursement to member $30**

N/A

* Long Term Intensive Care services must be pre-authorized by Orlando Behavioral Healthcare and provided in a state-licensed and/or Joint Commission approved facility and by licensed, in-network practitioners. Specially designed Intensive Outpatient Programs using individual sessions in lieu of Intensive Outpatient group sessions will count against the Long Term Intensive Care benefit as a ½ day. ** This amount is the maximum allowable benefit. Any charges in excess will be the member responsibility. *** Benefits up to the maximum allowed are subject to medical necessity. NOTE: This Schedule of Benefits does not contain all provisions of your benefit plan. A full description of benefits is contained in the Plan Document.

II. Medical Insurance: Orlando Behavioral Healthcare

92

BEHAVIORAL HEALTH SERVICES EXCLUSIONS 1.

Inpatient care for mental or nervous conditions exceeding 30 days per plan year.

2.

Inpatient care for drug or alcohol abuse exceeding 30 days per plan year.

3.

Residential Treatment Center (RTC) care for either mental or nervous conditions and for drug and/or alcohol abuse or addiction.

4.

Services provided to satisfy court orders and/or avoid incarceration.

5.

Outpatient mental health services exceeding a maximum of 20 visits per plan year.

6.

Outpatient services for the treatment of alcoholism, and drug addiction exceeding 44 outpatient visits per plan year.

7.

Experimental procedures or procedures which have not been accepted as established standard medical practice.

8.

Diagnostically unrelated medical conditions defined as medical consultations, and services not directly related to the treatment of a covered person’s mental disorder. These medical conditions may be covered under other medical plan benefits.

9.

CT scans, EEG, (inpatient and outpatient) lab and x-ray are excluded unless ordered by Orlando Behavioral Healthcare as part of a covered person’s mental health or chemical dependency treatment.

10.

Emergency outpatient psychiatric and substance abuse services not certified or provided by Orlando Behavioral Healthcare.

11.

Any service or treatment, covered through the mental health/chemical dependency benefit that was not certified nor pre-authorized by Orlando Behavioral Healthcare.

12.

Medical evaluation resulting in a psychiatric diagnosis. The medical evaluation may be covered under other medical plan benefits.

13.

Any service or treatment covered through the mental health/chemical dependency benefit considered not medically necessary and/or not pre-authorized by Orlando Behavioral Healthcare.

14.

Any mental health or chemical dependency service or treatment provided out-of-network that was not certified and/or pre-authorized by Orlando Behavioral Healthcare.

15.

Treatment of a Covered Person when the Covered Person or Dependent has caused, or threatened to cause personal injury or physical damage to Orlando Behavioral Healthcare property or personnel.

16.

Psychiatric and Substance Abuse treatment services provided outside of Brevard, Lake, Orange, Osceola, Seminole and Volusia Counties, Florida unless in the event of an emergency, or pre-authorized by Orlando Behavioral Healthcare.

17.

Treatment for autism that is not pre-authorized by Orlando Behavioral Healthcare.

18.

Treatment for autism exceeding $36,000 per plan year.

19.

Treatment for Intellectual Disability except for the acute secondary psychiatric symptoms.

20.

Treatment for obesity or weight loss.

II. Medical Insurance: Orlando Behavioral Healthcare

93

21. 22.

Treatment of a Covered Person when the Covered Person or Dependent has demonstrated noncompliance with or non-adherence to recommended treatment by Orlando Behavioral Healthcare. For experimental, investigational or unproven services which are medical, surgical, psychiatric, substance abuse or other healthcare technologies, supplies, treatments, procedures, drug therapies, or devices that are determined to be: a. Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not recognized for the treatment of the particular indication in one of the standard reference compendia (The United States Pharmacopeia Drug Information, the American Medical Association Drug Evaluations, or the American Hospital Formulary Service Drug Information) or in medical literature. Medical literature means scientific studies published in a peer-reviewed national professional journal; or b. The subject of review or approval by an Institutional Review Board for the proposed use; or c. The subject of an ongoing clinical trial that meets the definition of a phase I, II, or III Clinical Trial as set forth in the FDA regulations, regardless of whether the trial is subject to FDA oversight; or d. Not demonstrated, through existing peer-reviewed literature, to be safe and effective for treating or diagnosing the condition or illness for which its use is proposed.

23.

Illness for which the covered person is entitled to benefits under any worker’s compensation law or act, or accidental bodily injury arising out of or in the course of the covered person’s employment or services rendered by any governmental program (i.e., V.A. hospital) unless there is a legal obligation to pay for coverage.

24.

Education, training, and bed and board while confined to an institution which is primarily a school or other institution for training; a place of rest, a place for the aged, or for custodial care.

25.

Health Services and associated expenses for bariatric procedures/surgeries intended primarily for the treatment of morbid obesity or weight loss, including but not limited to gastric bypasses, gastric balloons, stomach stapling, jejunal bypasses, wiring of the jaw and health services of a similar nature.

26.

Assistance in the activities of daily living, including but not limited to eating, bathing, dressing or other Custodial Services or self-care activities, homemaker services and services primarily for rest, domiciliary or convalescent care.

II. Medical Insurance: Orlando Behavioral Healthcare

94

III. MEDICARE SURROUND PLANS

OVERVIEW Once you or your spouse/domestic partner become(s) eligible for Medicare Parts A and B, whether it be because you are 65 years of age or because of a disability, you are eligible for benefits through the Florida School Retiree Benefits Consortium (FSRBC). You must enroll in Medicare Parts A (Hospital) and B (Physician) and one of the FSRBC plans. If any other family members are currently covered under your medical plan, they can select from the three previously described medical plans. All family members must enroll in the same plan. If the OCPS Retiree is Medicare eligible and the other family members are not, ancillary benefits (i.e. dental and vision) will be offered through the FSRBC for the retiree and all dependents. If the spouse/domestic partner or dependent is Medicare eligible and the OCPS Retiree is NOT, ancillary benefits (i.e. dental and vision) for the retiree and all dependents will be offered through TASC and are outlined in this handbook. FSRBC information is distributed in the fall.

III. Medicare Surround Plan

95

IV. TERM LIFE INSURANCE

OCPS-PAID TERM LIFE INSURANCE (Including Accidental Death and Dismemberment) The term life insurance offered by OCPS gives you the opportunity to purchase life insurance while you are a retiree. LEVEL PREMIUM TERM INSURANCE You may purchase a $1,000, $5,000, or $10,000 term life insurance policy for yourself. At the time of your retirement, no health questions are required to be eligible for the $1,000 coverage. Otherwise, health questions are required at all times when electing any of the three term life benefits. ADDITIONAL FORMS TO COMPLETE Lincoln Financial Application for Life Insurance

IV. Term Life Insurance

96

V. GROUP UNIVERSAL LIFE INSURANCE V. GROUP UNIVERSAL LIFE INSURANCE (Underwritten by Minnesota Life Insurance Company) Portability Participating employees, spouses/domestic partners and dependent children may continue their coverage on a direct-bill basis if the employee terminates employment or retires after the plan effective date or if a spouse/domestic partners or child no longer meets the eligibility requirement. Minimum rates (cost of insurance) may increase in the future. For more information regarding portability, please contact Securian/Minnesota Life at 1.866.293.6047.

V. Group Universal Life Insurance

97

VI. DENTAL INSURANCE

A.

DELTACARE® USA BASIC MANAGED CARE DENTAL PLAN (PLAN FLM12)

B.

DELTACARE® USA COMPREHENSIVE MANAGED CARE DENTAL PLAN (PLAN FLM97)

C.

DELTA DENTAL PPO DENTAL PLAN (PREFERRED PROVIDER ORGANIZATION)

D.

ORTHODONTICS DISCOUNT PROGRAM FOR RETIREES

E.

VISION DISCOUNT PROGRAM FOR RETIREES

VI. DENTAL INSURANCE Overview Under your dental coverage you may select one of three different options: A. DELTACARE® USA BASIC MANAGED CARE DENTAL PLAN This is a plan designed for people who currently have healthy teeth and gums. This plan focuses on preventive dental maintenance, however, it also provides for other more complex dental work as well. You must use a participating general dentist to receive benefits. B. DELTACARE® USA COMPREHENSIVE MANAGED CARE PLAN This plan offers a broader range of benefits including some restorative dental procedures (fillings) at no charge after a $5 office visit copayment. It offers a wide range of benefits for specialty referrals when you are referred by your participating general dentist. Please Note: With either the basic or comprehensive managed care dental plans you receive the following benefits:  No Deductibles  No Claim Forms  No Annual Maximum Benefit  No Waiting Periods  No Pre-Existing Condition Limitations C. DELTA DENTAL PPO (PREFERRED PROVIDER ORGANIZATION) With this plan, you have the freedom to select any dentist you wish. If you choose to see a participating PPO dentist you will receive a higher level of payment for your dental work. You may decide at the time you receive services whether or not to use a participating provider. D. ORTHODONTICS DISCOUNT PROGRAM FOR RETIREES E. VISION DISCOUNT PROGRAM FOR RETIREES

VI. Dental Insurance

98

Delta Dental Insurance Company ORANGE COUNTY PUBLIC SCHOOLS DENTAL PLAN OPTIONS DeltaCare® USA Basic Plan FLM12*

DeltaCare® USA Comprehensive Plan FLM97*

Delta Dental In-PPO Network**

Delta Dental Out-Of-PPO Network**

Retiree Copayment

Retiree Copayment

Delta Dental Pays

Delta Dental Pays

$5 per visit (1)

$5 per visit (1)

N/A

N/A

DIAGNOSTIC - oral examinations, x-rays

No Cost to $5

No Cost to $5

100%

80%

PREVENTIVE - routine cleanings (2 per 12-month period), fluoride treatment, sealants and space maintainers

No Cost to $90

No Cost to $85

100%

80%

BASIC BENEFITS - fillings, basic endodontics (root canal), basic periodontics, basic restoratives, denture repairs, oral surgery (incisions, excisions, surgical removal of tooth)

No Cost to $240

No Cost to $300

80%

60%

50%

40%

N/A

Benefit Description

Office Visit Copayment

MAJOR BENEFITS - Crowns, inlays, onlays, cast restorations, bridges, dentures, major endodontics, major periodontics (gum treatment), major restoratives and major denture repairs

$15 to $355

ORTHODONTIC BENEFITS dependent children only

75 percent of “filed fees”

$120 to $1,850

N/A

DEDUCTIBLE

$0

$0

$25 per person $75 per family per calendar year

$50 per person $150 per family per calendar year

PLAN YEAR MAXIMUM

N/A

N/A

$1,300 per person per calendar year

$1,300 per person per calendar year

LIFETIME MAXIMUM FOR ORTHODONTIC

N/A

N/A

N/A

VI. Dental Insurance

(2)

$12 to $375

N/A

99

*If you choose a DeltaCare® USA plan, you must use a DeltaCare® USA dentist for treatment. NOTE: If you choose the DeltaCare USA Basic Plan FLM12, when referable services are provided by a Contract Specialist, the Enrollee pays 75 percent of that Dentist’s “filed fees.” **Delta Dental PPO® products offer freedom of choice of any dentist and you can maximize savings by utilizing PPO (in-network) dentists. Visiting a Delta Dental PPO provider usually saves patients almost 30% on average out-of- pocket costs. **Delta Dental PPO plans includes the D&P Maximum Waiver benefit allowing you to obtain diagnostic and preventive dental services without those costs applying to the plan year maximum. This is only a brief summary of the plans and reflects copayment ranges for the highly utilized procedures. The above procedures under DeltaCare® USA are subject to limitations and

exclusions of the plan. The dental health plan contract must be consulted to determine the exact terms and conditions of coverage. A Certificate of Coverage will be sent to you upon enrollment.

(1) Includes office visit, per visit cost (in addition to other services).

--Under FLM97, there are no additional upgrade charges; the copayment reflects the Enrollee’s total cost, including placement of porcelain/ceramic and other tooth colored material on molars, and lab costs.

VI. Dental Insurance

100

Your Choice — Prepaid or PPO Features

Dentist network

DeltaCare® USA plan (Prepaid)

 

Selecting a dentist



Delta Dental PPO plan

® Visit your assigned DeltaCare USA network dentist to receive benefits. Easy referrals to a large specialty care network (referred by selected primary care dentist).



Ability to change selected network dentist monthly with a phone call or email to Customer Service







Freedom to choose any licensed dentist, anywhere in the world, each time you or a family member requires treatment No referral required for specialty care

No need to preregister with a dental office. Ability to change dentists anytime without contacting Delta Dental

Access



16,000 facilities



166,000 dentist locations

Deductible/Maximum



No annual deductible and no annual dollar maximum



Annual deductible for all services except diagnostic and preventive An annual maximum

All covered procedures have predetermined copayments. No or minimal copayments for most diagnostic and preventive services. Minimal or no copayments for many restorative services.



Covered services paid at applicable percentage of contract allowance (for example, 80%)

Copayments/ Coinsurance   



Out-of-area coverage



Out-of-area (35 or more miles from selected network dentist) emergency care allowance, up to $100 per incident.



Can visit any licensed dentist

Covered Benefits



Wide range of covered services, including orthodontia Orthodontic takeover provision for new enrollees who have orthodontic treatment in progress (see plan booklet for full details)



Wide range of covered services, including orthodontia



Administration



No claim forms



Claim forms filed by Delta Dental dentists

Cost savings



® Visit your selected DeltaCare USA dentist to receive benefits. Pay only the copayment at the time of treatment.



You usually have the lowest out- ofpocket expenses when visiting a Delta Dental PPO dentist. If you don’t see a PPO dentist, a Delta Dental Premier dentist is usually your next best option.



VI. Dental Insurance



101

Delta Dental Eligibility for Enrollment All of the Contract holder’s retired employees will be eligible on the Effective Date. If your dependents are covered, they will be eligible when you are or as soon as they become dependents. Dependents are your:  Lawful spouse;  Same-sex domestic partner as defined by OCPS;  Children from birth to the end of the calendar year in which occurs their 26th birthday if: (1) the child is dependent on the Eligible Person/Primary Enrollee for support; and (2) the child lives in the Enrollee’s household; or (3) the child is a full-time or part-time student. Children includes natural children, step-children, children of a domestic partner, adopted children, foster children, custodial children and newborn children including a newborn child of a covered dependent child. Newborn children, including a newborn child of a covered dependent child or a newborn child where a written agreement to adopt has been entered into prior to birth, are eligible from the moment of birth. Adopted children, foster children and custodial children are eligible from the moment of placement in the Enrollee’s residence. Notice of birth, adoption placement, foster home placement or other custodial placement of a child with Enrollee must be received within 31 days of the birth or placement. If notice of birth or adoption is received within the 31 day notice period, no additional premiums are due during the notice period. If notice is received within 60 days of the birth or adoption placement instead of 31 days, coverage will be effective from the date of birth or placement, but the Enrollee must pay any additional Premium from the date of birth or placement. Eligibility for a newborn child of covered dependent child terminates 18 months after the birth of the newborn. 

A child 26 years or older may continue to be eligible as a dependent if the child is not selfsupporting because of physical handicap or mental incapacity that began before age 26 and the child is mostly dependent on the Eligible Employee for support and maintenance. Proof of incapacity will not be required until a claim has been denied due to a child having reached age 26. Proof of these facts must be given to Del ta Dental or to the Contract holder within 31 days if it is requested. Proof will not be required more than once a year after the child is 27.

VI. Dental Insurance

102

VI. DENTAL INSURANCE

A.

DELTACARE® USA BASIC MANAGED CARE DENTAL PLAN (PLAN FLM12)

VI. Dental Insurance

103

®

DeltaCare USA – provided by Delta Dental Insurance Company We’ll do whatever it takes and then some.

Welcome to DeltaCare USA — quality, convenience, predictable costs DeltaCare USA is a dental program that provides you and your family with quality dental benefits at an affordable cost. Offered through Delta Dental Insurance Company, the DeltaCare USA program is designed to encourage you and your family to visit the dentist regularly to maintain your dental health. When you enroll, you select a contract dentist to provide services. The DeltaCare USA network consists of private practice dental facilities that have been carefully screened for quality. Delta Dental Insurance Company provides benefits as a Prepaid Limited Health Services Organization as described in Chapter 636 of the Florida Statutes. Enroll in DeltaCare USA and you’ll enjoy these features: Quality

Convenience

Predictable costs

• Extensive benefits for you and your family

• No claim forms to complete

• No deductibles

• Easy access to specialty care

• Out-of-pocket costs are clearly defined

• No restrictions on pre-existing conditions, except for work in progress • Large, stable network of dentists, so you can enjoy a long-term relationship with your dentist

• Expanded business hours for toll-free customer service, from 8 a.m. to 9 p.m., Eastern time

• Out-of-area dental emergency coverage up to $100 per emergency • No annual or lifetime dollar maximums

Find a DeltaCare USA dentist Select from among the many conveniently located DeltaCare USA contracted general dentists. To find the most current listing of DeltaCare USA dental offices you can: Visit our website at deltadentalins.com/enrollees. Under Find a dentist, select DeltaCare USA as your network. Or call Customer Service at 800-422-4234 for help in finding a DeltaCare USA dentist.

VI. Dental Insurance

104

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VI. Dental Insurance

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129

               

               



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