Promotional brochure for Blue Cross Blue Shield Go Plan 91

7/27/2019 Promotional brochure for Blue Cross Blue Shield Go Plan 91

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FDA Services Inc.800.877.75971113 E. Tennessee St.,Suite 200Tallahassee, FL 32308

Guaranteedacceptance with

GoBlue!Go Blue! Its real coverage for your life how you live and whats important to you.

Discounted rates at in-network

providers* Up to $50 toward doctor visits $5 to $15 toward covered prescriptions Lab visits (services) are free when you go

stay in-network Lower than retail prices from network

pharmacies for covered prescriptions anddiabetic supplies

More than 20,000 doctors and specialists Visit a doctor of your choice, go to an

urgent care or convenient care center

se plans have limitations and exclusions and the premium and amount of benefits provided depend upon the plan selected and your age. For costs and compails, contact your insurance agent. These programs and services are not a part of your benefit plan and are not a substitute for medical advice from your doctor.etworkBlue is one of our Preferred Provider Networks made up of independent hospitals, physicians and ancillary providers. 67810-0910 MX


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For Individuals Under 65

Benefit Summary Plan 91

The Allowed Amount is the maximum amount upon which we will base payment for covered services. The Balance is the difference between our payment and the amount an In-network provider (under the

GoBlue plan) agrees to accept as payment in full for covered services (the Allowed Amount). If youchoose to go Out-of-network, the balance is their charge to you for covered services MINUS ourpayment (it will likely cost you more if you visit Out-of-network providers). You are responsible for payingthe doctor or provider this balance.

Unless otherwise noted, the covered services listed are only covered in the following locations:Physicians Office, Urgent Care Center, Convenient Care Center, e-Visits, Independent ClinicalLaboratory, Retail Pharmacy for Rx, and Dentist Office for dental services.

Benefits for Covered Services Amount you pay

Office Services, Convenient Care Centers

Includes coverage for services such as:Sick visits, routine preventive care for adultsand children, allergy testing and injections,outpatient surgeryIn- or Out-of-Network

We pay $50 or the Allowed Amount (whichever islower) and the member pays the balance

Preventive Care

Mammograms (including IndependentDiagnostic Testing Facility (IDTF) or outpatienthospital)In- or Out-of-Network


Osteoporosis screening, diagnosis and

treatment(including IDTF or outpatient hospital)In- or Out-of-Network

We pay $50 or the Allowed Amount (whichever is

lower) and the member pays the balance

Diabetes Outpatient Self Management(including outpatient hospital)In- or Out-of-Network


Prescription Drug Program

Prescription Drugs (Generic & Brand)In- or Out-of-Network


Urgent Care Centers

In- or Out-of-Network We pay $50 or the Allowed Amount (whichever islower) and the member pays the balance

Independent Clinical Lab

In-NetworkOut-of-Network

We pay 100%, and the member pays $0.We pay $50 or the Allowed Amount (whichever islower) and the member pays the balance

67728B-0209 SU 1


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67728B-0209 SU 2

Dental Coverage

Preventive and Basic Dental Services

Includes coverage for services such as routineoral exams and cleanings 2 times/yr, bitewingx-rays once/yr, and fluoride for children 2times/yr. Plus, complete mouth or panoramicx-ray once in 36 months, repair of brokendentures, fillings, routine tooth extractions,

sealants for children.In- or Out-of-Network


GoBlue is a limited benefit plan that has limitations and exclusions. NetworkBlue is one of our PreferredProvider Networks made up of independent hospitals, physicians and ancillary providers.

This Benefit Summary is only a partial description of the many benefits and services provided orauthorized by Blue Cross and Blue Shield of Florida, Inc., an independent licensee of the Blue Cross andBlue Shield Association. This does not constitute a Contract. For complete details, including a completedescription of benefits and exclusions, please refer to the GoBlue Limited Benefit Plan for IndividualsUnder 65 Non-Group Contract.


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Rates for GoBlue limited benefit plans

Age Male Female Male Female Age Male Female Male Female

1 $32 $32 $39 $39 34 $27 $27 $35 $35

2 $29 $29 $36 $36 35 $28 $28 $36 $36

3 $27 $27 $34 $34 36 $29 $29 $37 $37

4 $25 $25 $32 $32 37 $29 $29 $37 $37

5 $23 $23 $30 $30 38 $29 $29 $38 $38

6 $22 $22 $29 $29 39 $30 $30 $38 $38

7 $21 $21 $27 $27 40 $30 $30 $39 $39

8 $20 $20 $27 $27 41 $30 $30 $39 $39

9 $19 $19 $26 $26 42 $31 $31 $39 $39

10 $19 $19 $25 $25 43 $31 $31 $40 $4011 $18 $18 $25 $25 44 $31 $31 $40 $40

12 $18 $18 $25 $25 45 $31 $31 $40 $40

13 $18 $18 $25 $25 46 $32 $32 $40 $40

14 $18 $18 $25 $25 47 $32 $32 $41 $41

15 $18 $18 $24 $24 48 $32 $32 $42 $42

16 $18 $18 $24 $24 49 $33 $33 $42 $42

17 $18 $18 $24 $24 50 $33 $33 $43 $43

18 $18 $18 $24 $24 51 $34 $34 $44 $44

19 $18 $18 $24 $24 52 $35 $35 $45 $4520 $18 $18 $24 $24 53 $35 $35 $46 $46

21 $18 $18 $24 $24 54 $36 $36 $46 $46

22 $18 $18 $24 $24 55 $37 $37 $47 $47

23 $18 $18 $25 $25 56 $37 $37 $48 $48

24 $18 $18 $25 $25 57 $38 $38 $49 $49

25 $19 $19 $26 $26 58 $39 $39 $50 $50

26 $20 $20 $26 $26 59 $40 $40 $51 $51

27 $21 $21 $27 $27 60 $41 $41 $53 $53

28 $22 $22 $28 $28 61 $42 $42 $54 $54

29 $23 $23 $29 $29 62 $43 $43 $55 $55

30 $24 $24 $30 $30 63 $44 $44 $56 $56

31 $25 $25 $32 $32 64 $45 $45 $57 $57

32 $26 $26 $33 $33 65 $46 $46 $59 $59

33 $26 $26 $34 $34

66457-1107

Plan 90 Rate Plan 91 Rate Plan 90 Rate Plan 91 Rate


5/522515B-0910 SR

KEY CODE

SECTIONA

SECTIONB

SECTIOND

SECTIONE

SEC.

C

(1) APPLICANT NAME (LAST NAME, FIRST NAME, MIDDLE INITIAL)

(2) APPLICANT ADDRESS (STREET ADDRESS, CITY, COUNTY, STATE, ZIP CODE)

(5) SEXn

Mn

F

(7) This information is optional and is for data collection only. It will not determine eligibility, rating or

claim payment. Language Preference: n English n Spanish n Other: ____________________________

(4) MARITAL STATUSn

SINGLEn

MARRIED

(8) TELEPHONE NUMBER( )

(3) OTHER MAILING ADDRESS IF DIFFERENT THAN IN QUESTION #2 n Billing Only n Correspondence & BillingAddress: City: State: Zip:

(1) Will the coverage being applied for replace your current medical insurance? n Yes n No (If yes, please complete the following information.)Name of Company: _________________________________________________________ Policy Number: __________________________ ________________________________________

Termination Date: ____________________________ Mailing Address of Company: _________________________________________________________________________________

(1) BENEFIT OPTION SELECTED:n Plan 90 n Plan 91

(2) Please select your Automatic Payment Option (APO) billing mode:Pay Every: n Month, n 2 Months, n 3 Months, n 4 Months, n 6 Months, n 12 Months

I hereby apply for the coverage selected on this application form. I understand that the coverage shall not become effective until this application is accepted, the initial premium paid, and an effective dateis assigned to my coverage by BCBSF. The coverage effective date will be the first available BCBSF billing date (1st, 8th, 15th or 23rd) after approval of this application unless an advance effective date isspecified below. I have read this application carefully and I represent that the information I have provided in this application is true and complete. I understand that this information is the basis for determiningthe issuance or denial of coverage and any misstatement or omission may result in the denial of benefits and/or the termination of coverage. I understand that if I am accepted for coverage under this policyand it subsequently terminates for any reason, neither I nor my covered dependents (if applicable) will be eligible to re-enroll in this product for a period of seven months from the termination date of thiscoverage as reflected in BCBSFs records. I understand that from time to time a rate adjustment may be necessary for any given product and that the premium rate for my coverage may change on theanniversary date due to an increase in the age of the covered members. I understand that if I have selected an advance effective date that occurs after the product anniversary date of July 1, my premiumrate may change. I understand that if any additional premium is required, I will receive a bill for it. I understand that any person who knowingly and with intent to injure, defraud or deceive any insurer filesa statement of claim or application containing any false, incomplete or misleading information is guilty of a felony of the third degree. I further understand that there will be no continuation of benefit(continuous coverage) if I purchase another BCBSF policy and any condition that may have occurred under this policy may be treated as a pre-existing condition under the subsequent policy.I understandthat this product provides limited benefits and is not considered major medical coverage. I understand this policy does not meet the definition of qualifying previous coverage orqualifying coverage as defined in F.S. 627.6561. As a result, I may have to meet a pre-existing condition requirement when renewing or purchasing other coverage.I authorize any physician, medical practitioner, hospital, clinic or other medical or medically-related provider, insurance company, employer or other organization, institution or person that has medical recordsor any other knowledge of me, or my eligible dependents, to release such information to BCBSF. This release specifically includes, but is not limited to, authorization to release any and all medical recordsand information associated with (or with reference to) the following conditions: exposure to HIV infection, ARC, AIDS, alcohol or drug dependency, and mental and nervous disorders.

I understand that BCBSF may cancel this coverage for all individuals covered by it after giving 90 days notice, and that any unearned premiums will be returned to me. I also understand that such action wilnot be taken solely because of the amount of claims paid under this contract.

Advance Effective Date __________________________________________________________________ Only fill this in if a future effective date is requested.

Applicants Signature ____________________________________________________________________ Licensed Agent ______________________________________________________________________________

Spouse/Domestic Partners Signature ____________________________________________________ License Number _____________________ Agent Code ___________________ Date _______________

Initial PaymentPlease include a check made payable to Blue Cross and Blue Shield of Florida for the total premium for all applicants included on this application forconsideration of insurance. The initial payment should match the TOTAL in Box # 9G above. The application and check should be mailed to Blue Cross andBlue Shield of Florida in the business reply envelope that has been provided to you.

Initial Payment $ _______________________________ (Amount Enclosed)This initial payment is subject to all terms, conditions and representations contained in the application and the coverage applied for. If my application is

denied, I understand that I will not receive a contract and my initial payment will be refunded to me.

(6) EMAIL ADDRESS

(9) APPLICANT, SPOUSE/DOMESTIC PARTNER AND DEPENDENT INFORMATION

(9A) APPLICANT

(9B) SPOUSE/DOMESTIC PARTNER

(9C)

(9D)(9E)

(9F)

$

$

$

$

$

$

$

Full NameSocial Security Number

(or Tax ID if no SSN issued)Relationship to

Applicant Zip Code Premium

(9G) TOTAL (ADD LINES 9A 9F)

SEX - M/FDate of Birth

(MM/DD/YYYY)

(PRINTED AND SIGNATURE)

Print FormSubmit by Email

Print FormSubmit by Email

Documents

Promotional brochure for Blue Cross Blue Shield Go Plan 91