Jackson County

Employee Benefits

FLORIDA RETIRMENT SYSTEM (FRS)

Florida Combined Life Dental Plan 16

Outline of Plan Benefits 16

FL Combined Life Dental Rates 16

Blue Cross Blue Shield of Florida 16

ADULT ROUTINE WELL EXAM

SUPPLEMENTAL BENEFITS

CAFETERIA PLAN

Outline of Plan Benefits

BlueDental Choice

Preventive Services	Basic Services	Major Services
Oral Evaluations Exams Prophylaxes (Cleanings) – Adult/Child Fluoride Treatment – Child Bitewing X-rays x-rays – Intraoral/Complete Series/Panoramic Sealants BlueDental Choice Pays 100% In-Network 100% Out-of-Network	Space Maintainers Amalgam Restorations (Silver Fillings) Resin-Based Restorations – Anterior and Posterior Extractions – Routine and Surgical Root Canal Therapy Periodontal Treatment BlueDental Choice Pays 100% In-Network 80% Out-of-Network	Crowns – Single Restorations Osseous Surgery Complete Dentures Partial Dentures Fixed Partial Dentures (Bridges) BlueDental Choice Pays 60% In-Network 50% Out-of-Network

Deductible for Basic and Major Services Only:

Participating Dentist Non-Participating Dentist

$50 per person $75 per person

$150 max calendar yr $225 max calendar year

Waiting period: (Major Services) 12 Months

Plan Year Maximum Benefit Per Person: $1,000

Rollover Benefits Included: Yes

Toll-Free Customer Service for BlueDental Choice

Members --- Call our trained dental professionals at

1-877-203-9921

FINDING A BLUEDENTAL PROVIDER

The current directory of providers can be found on the

Blue Cross and Blue Shield of Florida website at

www.bcbsfl.com. Select the BlueDental Choice Plus plan.

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Blue Dental Choice Plus Rates

Rates as of 10-01-2010

Monthly Rate Annual Cost

Employee Only	$24.53	$294.36
Employee + Family	$69.05	$828.60
Employee + Spouse	$48.73	$584.76
Employee + Children	$44.87	$538.44

These are monthly rates. The Finance Office will prorate your deduction for 24 pay periods.

· Employees may not elect dependent coverage alone.

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Blue Cross Blue Shield of Florida

Blue Cross Blue Shield

MyBlueService

BCBSF Member Self-Service

Via the Internet

MyBlueService is Blue Cross Blue Shield of Florida’s self-service website for our members. It gives members the ability to:

Check Claim status

Request ID cards and benefit booklets

Search provider directories

Submit general inquiries

Download forms

Search Frequently Asked Questions

Tips for Registration:

To access, go to www.bcbsfl.com and click on Member, then on MyBlueService. If a member has not registered, click on DEMO, then click on REGISTER. When registering, the member will be asked to enter their full contract number (including prefix on ID card), social security number, month and full year of birth (e.g. 1954). You can access the DEMO home page directly by clicking on this link: www.bcbsfl.com/ffn_member/MyBlueservice.cfm

BlueComplements Discount Program: The products, services and information provided through the BlueComplements Program are made available as a courtesy to BCBS members and are not a part of insurance coverage, nor a substitute for medical advice.

BlueComplements offers discounts for chiropractors, eye exams, contact lenses, LASIK vision correction and hearing aids. Obtain more information by login on the Blue Cross Blue Shield of FL web site at www.bcbsfl.com

Note: The Primary Plus Vision Discount program is no longer available effective 1/1/02. Vision One Discount Program administered by Cole Managed Vision, Inc. has replaced it.

Prior authorization or override bulletin from BCBS of FL

The purpose of this bulletin is to provide an appropriate process for submission of a prior authorization request for Pharmacy Utilization Management (UM) programs including Responsible Step and Responsible

Quantity.

Pharmacy Programs has a process established for members to receive a prior authorization or override in order to receive coverage for a medication included in the Responsible Step or Quantity programs, based on medical necessity. The member's physician must complete the appropriate Prior Authorization form and fax it to 877-480-8130 for the review to be completed.

Once the required information is received by the Clinical Review Department at Prime Therapeutics, the review will be completed and the member will be notified by letter regarding the outcome. The physician will also be notified by fax regarding the outcome.

If the physician has indicated the request is urgent, then the review shall be completed within 72 hours from the date received from the practitioner. Non-urgent initial UM decisions shall be completed within 10 calendar days from the date received from the practitioner, if the practitioner has provided all required information on the initial request fax form. If the practitioner has not provided all the required information on the fax form, the request may take up to 15 working days.

These time frames are consistent with NCQA UM standards.

Pharmacy Programs routinely tracks the average turn around time required for Prime Therapeutics to perform these reviews. The average turn around times for third quarter 2008, were:

* 15.8 hours for urgent requests

* Less than 2 days for non-urgent

The Prior Authorization form for drugs included in the Responsible Quantity program is located at www.bcbsfl.com <http://www.bcbsfl.com/> , under Physicians & Providers, Pharmacy, Quantity Limit Authorization.

The form is titled Quantity Limit Prior Authorization Form. This form should be utilized for all Quantity Limit prior authorization requests.

Prior Authorization forms for drugs included in the Responsible Step program are also located at www.bcbsfl.com <http://www.bcbsfl.com/> , under Physicians & Providers, Pharmacy, Responsible Step Program Information and Authorization Forms. Please note there are separate forms for different therapeutic classes or drugs in the Responsible Step program that should be utilized by the Physician.

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Board of County Commissioners

Of Jackson County Group #45547

2010-11 Renewal

Plans/Rates

Blue Options Plan #1150 Rx 7/20/35

Employee: No Cost to Employee

Family: $134.91 Bi-weekly from employee (24 pay periods)

Blue Options Plan #1351 Rx 15/30/50

Employee: No Cost to Employee

Family: $127.50 Bi-weekly from employee (24 pay periods)

H.S.A. #1167 Rx CYD, 100%

Employee: No Cost to Employee

Family: $83.57 Bi-weekly from employee (24 pay periods)

H.S.A. #1166 Rx CYD, 100%

Employee Only – No Cost

NOTE: 4^th Quarter Deductible Carryover no longer applies.

LABORATORY TESTS AND SERVICES:

QUEST LABS IS THE ONLY BLUE CROSS BLUE SHIELD PROVIDER IN OUR AREA.

You must request that your physician/hospital use this lab to stay in network. Our cost for using this facility is $0. The use of any other lab facility will result in Calendar Year Deductible plus co-insurance fees.

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Updated on Tuesday, August 03, 2010