Summary of Benefits and Coverage Small Employer Groups

Summary of Benefits and Coverage

Small Employer Groups

The purpose of the SBC is to provide employers and employees with standard information, so they can more easily compare plans and make an informed choice about coverage plan options.

Florida Blue has produced an SBC for all of its actively sold plans which can be found below. It is your responsibility to distribute the appropriate SBC for the benefit plans you offer to your employees, as described below. You are only required to send to dependents if they have a different address than the employee.

1. Upon application. If you distribute written application materials for enrollment, the SBC must be provided as part of those materials. For this purpose, written application materials include any forms or requests for information, in paper form or through a website or email that must be completed for enrollment. If you do not distribute written application materials for enrollment (in either paper or electronic form), the SBC must be provided no later than the first date on which the participant is eligible to enroll in coverage.

2. By first day of coverage (if there are any changes after application). If there is any change in the information required to be in the SBC that was provided upon application and before the first day of coverage, you must update and provide a current SBC no later than the first day of coverage.

3. Special enrollees. The SBC must be provided to special enrollees no later than 90 days from enrollment.

4. Upon renewal. If you require your employees to actively elect to maintain coverage during open enrollment or provide them with the opportunity to change coverage options in open enrollment, you must provide the SBC at the same time you distribute your other open enrollment materials. If renewal is automatic you must provide the SBC no later than 30 days prior to the first day of the new plan or policy year.

5. Upon request. The SBC must be provided upon request for an SBC or summary information about the health coverage within seven business days following receipt of the request.

For most employers, the first time you will need to distribute an SBC will be on the first day of your first open enrollment period after September 23, 2012.

This is only a summary of the requirements. Please contact your own legal counsel or benefit advisor to discuss your specific obligations under this requirement. For more information, or questions on how Florida Blue is handling the requirement, please call 1-800-352-2583.

To be routed directly to your plan, enter the Plan Number in the FIND box located on the toolbar. *Your plan number may be obtained from your Group Administrator.

BLUEOPTIONS

Predictable Cost:

Plan 5461 ($10-$30-$50) Plan 5461 ($10-$60-NC) Plan 5461 ($10-$60-$100) Plan 5461 with MHP ($10-$30-$50) Plan 5461 with MHP ($10-$60-NC) Plan 5461 with MHP ($10-$60-$100)

Plan 5462 ($10-$30-$50) Plan 5462 ($10-$60-NC) Plan 5462 ($10-$60-$100) Plan 5462 with MHP ($10-$30-$50) Plan 5462 with MHP ($10-$60-NC) Plan 5462 with MHP ($10-$60-$100)

Plan 5463 ($10-$30-$50) Plan 5463 ($10-$60-NC) Plan 5463 ($10-$60-$100) Plan 5463 with MHP ($10-$30-$50) Plan 5463 with MHP ($10-$60-NC) Plan 5463 with MHP ($10-$60-$100)

Plan 5464 ($10-$30-$50) Plan 5464 ($10-$60-NC) Plan 5464 ($10-$60-$100) Plan 5464 with MHP ($10-$30-$50) Plan 5464 with MHP ($10-$60-NC) Plan 5464 with MHP ($10-$60-$100)

Plan 5465 ($10-$30-$50) Plan 5465 ($10-$60-NC) Plan 5465 ($10-$60-$100) Plan 5465 with MHP ($10-$30-$50) Plan 5465 with MHP ($10-$60-NC) Plan 5465 with MHP ($10-$60-$100)

Plan 5466 ($10-$30-$50) Plan 5466 ($10-$60-NC) Plan 5466 ($10-$60-$100) Plan 5466 with MHP ($10-$30-$50) Plan 5466 with MHP ($10-$60-NC) Plan 5466 with MHP ($10-$60-$100)

Plan 5467 ($10-$30-$50) Plan 5467 ($10-$60-NC) Plan 5467 ($10-$60-$100) Plan 5467 with MHP ($10-$30-$50) Plan 5467 with MHP ($10-$60-NC) Plan 5467 with MHP ($10-$60-$100)

Plan 5468 ($10-$30-$50) Plan 5468 ($10-$60-NC) Plan 5468 ($10-$60-$100) Plan 5468 with MHP ($10-$30-$50) Plan 5468 with MHP ($10-$60-NC) Plan 5468 with MHP ($10-$60-$100)

Plan 5469 ($10-$30-$50) Plan 5469 ($10-$60-NC) Plan 5469 ($10-$60-$100) Plan 5469 with MHP ($10-$30-$50) Plan 5469 with MHP ($10-$60-NC) Plan 5469 with MHP ($10-$60-$100)

Plan 5470 ($10-$30-$50) Plan 5470 ($10-$60-NC) Plan 5470 ($10-$60-$100) Plan 5470 with MHP ($10-$30-$50) Plan 5470 with MHP ($10-$60-NC) Plan 5470 with MHP ($10-$60-$100)

Plan 5471 ($10-$30-$50) Plan 5471 ($10-$60-NC) Plan 5471 ($10-$60-$100) Plan 5471 with MHP ($10-$30-$50) Plan 5471 with MHP ($10-$60-NC) Plan 5471 with MHP ($10-$60-$100)

Plan 5472 ($10-$30-$50) Plan 5472 ($10-$60-NC) Plan 5472 ($10-$60-$100) Plan 5472 with MHP ($10-$30-$50) Plan 5472 with MHP ($10-$60-NC) Plan 5472 with MHP ($10-$60-$100)

Plan 5473 ($10-$30-$50) Plan 5473 ($10-$60-NC) Plan 5473 ($10-$60-$100) Plan 5473 with MHP ($10-$30-$50) Plan 5473 with MHP ($10-$60-NC) Plan 5473 with MHP ($10-$60-$100)

Lower Cost

Plan 5260 ($300 Pharmacy Deductible $10-$30-$50) Plan 5260 ($300 Pharmacy Deductible $10-$60-NC) Plan 5260 ($300 Pharmacy Deductible $10-$60-$100) Plan 5260 with MHP ($300 Pharmacy Deductible $10-$30-$50) Plan 5260 with MHP ($300 Pharmacy Deductible $10-$60-NC) Plan 5260 with MHP ($300 Pharmacy Deductible $10-$60-$100)

Plan 5261 ($300 Pharmacy Deductible $10-$30-$50) Plan 5261 ($300 Pharmacy Deductible $10-$60-NC) Plan 5261 ($300 Pharmacy Deductible $10-$60-$100) Plan 5261 with MHP ($300 Pharmacy Deductible $10-$30-$50) Plan 5261 with MHP ($300 Pharmacy Deductible $10-$60-NC) Plan 5261 with MHP ($300 Pharmacy Deductible $10-$60-$100)

Plan 5262 ($300 Pharmacy Deductible $10-$30-$50) Plan 5262 ($300 Pharmacy Deductible $10-$60-NC) Plan 5262 ($300 Pharmacy Deductible $10-$60-$100) Plan 5262 with MHP ($300 Pharmacy Deductible $10-$30-$50) Plan 5262 with MHP ($300 Pharmacy Deductible $10-$60-NC) Plan 5262 with MHP ($300 Pharmacy Deductible $10-$60-$100)

Plan 5800 ($10 Generic Only) Plan 5800 ($800 Pharmacy Deductible $10-$60-NC) Plan 5800 ($800 Pharmacy Deductible $10-$60-$100) Plan 5800 with MHP ($10 Generic Only) Plan 5800 with MHP ($800 Pharmacy Deductible $10-$60-NC) Plan 5800 with MHP ($800 Pharmacy Deductible $10-$60-$100)

Plan 5801 ($10 Generic Only) Plan 5801 ($800 Pharmacy Deductible $10-$60-NC) Plan 5801 ($800 Pharmacy Deductible $10-$60-$100) Plan 5801 with MHP ($10 Generic Only) Plan 5801 with MHP ($800 Pharmacy Deductible $10-$60-NC) Plan 5801 with MHP ($800 Pharmacy Deductible $10-$60-$100)

Plan 5802 ($10 Generic Only) Plan 5802 ($800 Pharmacy Deductible $10-$60-NC) Plan 5802 ($800 Pharmacy Deductible $10-$60-$100) Plan 5802 with MHP ($10 Generic Only) Plan 5802 with MHP ($800 Pharmacy Deductible $10-$60-NC) Plan 5802 with MHP ($800 Pharmacy Deductible $10-$60-$100)

Plan 5803 ($10 Generic Only) Plan 5803 ($800 Pharmacy Deductible $10-$60-NC) Plan 5803 ($800 Pharmacy Deductible $10-$60-$100) Plan 5803 with MHP ($10 Generic Only) Plan 5803 with MHP ($800 Pharmacy Deductible $10-$60-NC) Plan 5803 with MHP ($800 Pharmacy Deductible $10-$60-$100)

Plan 6000 ($800 Pharmacy Deductible $10-$60-NC) Plan 6000 with MHP ($800 Pharmacy Deductible $10-$60-NC) Plan 6000 with MHP and Pharmacy Discount Plan 6000 with Pharmacy Discount

Plan 6001 ($800 Pharmacy Deductible $10-$60-NC) Plan 6001 with MHP ($800 Pharmacy Deductible $10-$60-NC) Plan 6001 with MHP and Pharmacy Discount Plan 6001 with Pharmacy Discount

HSA:

Single Plan 5020 with Pharmacy ($10-$50-NC) Single Plan 5020 with Pharmacy ($10-$50-$80) Single Plan 5020 with Pharmacy and MHP ($10-$50-NC) Single Plan 5020 with Pharmacy and MHP ($10-$50-$80) Single Plan 5020 with Pharmacy Discount Single Plan 5020 with Pharmacy Discount and MHP

Family Plan 5021 with Pharmacy ($10-$50-NC) Family Plan 5021 with Pharmacy ($10-$50-$80) Family Plan 5021 with Pharmacy and MHP ($10-$50-NC) Family Plan 5021 with Pharmacy and MHP ($10-$50-$80) Family Plan 5021 with Pharmacy Discount Family Plan 5021 with Pharmacy Discount and MHP

Single Plan 5022 with Pharmacy ($10-$50-NC) Single Plan 5022 with Pharmacy ($10-$50-$80) Single Plan 5022 with Pharmacy and MHP ($10-$50-NC) Single Plan 5022 with Pharmacy and MHP ($10-$50-$80) Single Plan 5022 with Pharmacy Discount Single Plan 5022 with Pharmacy Discount and MHP

Family Plan 5023 with Pharmacy ($10-$50-NC) Family Plan 5023 with Pharmacy ($10-$50-$80) Family Plan 5023 with Pharmacy and MHP ($10-$50-NC) Family Plan 5023 with Pharmacy and MHP ($10-$50-$80) Family Plan 5023 with Pharmacy Discount Family Plan 5023 with Pharmacy Discount and MHP

Single Plan 5040 with Pharmacy ($10-$50-NC) Single Plan 5040 with Pharmacy ($10-$50-$80) Single Plan 5040 with Pharmacy and MHP ($10-$50-NC) Single Plan 5040 with Pharmacy and MHP ($10-$50-$80) Single Plan 5040 with Pharmacy Discount Single Plan 5040 with Pharmacy Discount and MHP

Family Plan 5041 with Pharmacy ($10-$50-NC) Family Plan 5041 with Pharmacy ($10-$50-$80) Family Plan 5041 with Pharmacy and MHP ($10-$50-NC) Family Plan 5041 with Pharmacy and MHP ($10-$50-$80) Family Plan 5041 with Pharmacy Discount Family Plan 5041 with Pharmacy Discount and MHP

Single Plan 5042 with Pharmacy ($10-$50-NC) Single Plan 5042 with Pharmacy ($10-$50-$80) Single Plan 5042 with Pharmacy and MHP ($10-$50-NC) Single Plan 5042 with Pharmacy and MHP ($10-$50-$80) Single Plan 5042 with Pharmacy Discount Single Plan 5042 with Pharmacy Discount and MHP

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