Large Group POSHealth Benefit Plan T25Amount Member PaysIn-NetworkOut-of-NetworkSchedule of Benefits for Covered ServicesFinancial FeaturesMedical Benefits Deductible (DED1) (PBP2)(DED is the amount the member is responsible for before FHCP pays)Drug Benefits Deductible (DED1) (PBP2)(DED is the amount the member is responsible for before FHCP pays)Coinsurance(Coinsurance is the percentage the member pays for services)Out-of-Pocket Maximum (PBP)(Out-of-Pocket Maximum includes DED, Coinsurance, Copayments and Pharmacy) 0 per person 0 per family 0 per person 0 per family15% of Allowed Amount 500 per person 1,500 per familyNot Covered 5,000 per person 10,000 per family 7,000 per person 14,000 per family30% of Allowed AmountOffice ServicesPhysician Office Services (per visit)Primary Care Office 15 CopayDeductible 30%Specialist 25 CopayDeductible 30%Maternity (Cost Share for initial visit only)Primary Care Physician 15 CopayDeductible 30%Specialist 25 CopayDeductible 30%Allergy Injections (per visit)Primary Care Physician 0Deductible 30%Specialist 0Deductible 30%Medical Pharmacy - Physician-Administered Medications including but not limited to:*Therapeutic Injections15% CoinsuranceDeductible 30%*Infusions15% CoinsuranceDeductible 30%*Chemotherapy15% CoinsuranceDeductible 30%Dialysis Drugs15% CoinsuranceDeductible 30%Physician-Administered Medications – These medications require the administration to be performed by a health care provider. The medications are orderedby a provider and administered in an office or outpatient setting. Physician-Administered medications are covered under the medical benefit.*Prior Authorization is required.Preventive CareRoutine Adult & Child Preventive Services, Wellness Services, Blood Work and 0Deductible 30%ImmunizationsMammogram Screening 0Deductible 30%Bone Density Screening 0Deductible 30%Colonoscopy (Routine for age 50 then frequency schedule applies) 0Deductible 30%Emergency Medical CareUrgent Care Centers (per visit) 40 Copay 40 CopayHospital Emergency Room or Stand-Alone Emergency Facility Services (per visit)(waived if admitted) 75 Copay 75 CopayAmbulance Services 75 Copay 75 CopayDED DeductiblePBP Per Benefit PeriodNote: Out-of-Network services may be subject to balance billing.12Florida Health Care Plans is an Independent Licensee of the Blue Cross and Blue Shield Association.T25 – 1/181 of 4

Large Group POSHealth Benefit Plan T25Amount Member PaysIn-NetworkOut-of-NetworkSchedule of Benefits for Covered ServicesOutpatient Diagnostic Services - services with an asterisk * require prior authorizationIndependent Diagnostic Testing Facility/Provider’s OfficeAllergy TestingX-rays and UltrasoundsDiagnostic Services (except AIS)*Advanced Imaging Services (AIS) (MRI, MRA, PET, CT, Nuclear Med.)Independent Clinical Lab (diagnostic testing of blood and specimens)Outpatient Hospital Facility Services (per visit)X-rays and UltrasoundsDiagnostic Services (except AIS)*Advanced Imaging Services (AIS) (MRI, MRA, PET, CT, Nuclear Med.) 0 0 0 50 Copay 0Deductible 30%Deductible 30%Deductible 30%Deductible 30%Deductible 30%15% Coinsurance15% Coinsurance15% CoinsuranceDeductible 30%Deductible 30%Deductible 30%Important: Diagnostic or therapeutic services rendered in physician offices, testing centers or other outpatient locations that are owned and operated by a hospital system are considered by thehospital system to be departments of the hospital. As a result, FHCP will be billed by the hospital for such services, and the member’s outpatient hospital benefit will be applied to these claims.FHCP’s Provider Directories and online Provider Search application provides information regarding which provider offices are actually hospital outpatient departments. Members should contactFHCP’s cost estimation center to determine if having the diagnostic test or service performed in a hospital or hospital owned facility will result in higher cost sharing.Hospital / Surgical - * all services require prior authorization*Ambulatory Surgical Center Facility (ASC) 200 CopayDeductible 30%*Outpatient Hospital Facility Services (surgical) (per visit) 200 CopayDeductible 30%*Inpatient Hospital Facility (per admit) 200 CopayDeductible 30%Mental Health / Substance Dependency - services with an asterisk * require prior authorization*Inpatient Hospitalization Facility Services (per admit) 200 CopayDeductible 30%Outpatient Facility Service (per visit) 25 CopayDeductible 30%*Partial Hospitalization (per admit) 100 CopayDeductible 30%*Residential/Rehabilitation Facility (per day) 15 CopayDeductible 30%Hospital Emergency Room or Stand-Alone Emergency Facility Services (per visit)(waived if admitted) 75 Copay 75 CopayProvider Services at Hospital/Crisis UnitPrimary Care Physician / Specialist 0Deductible 30%Provider Services at Locations other than Office, Hospital and ERPrimary Care Physician / Specialist 0Deductible 30%Outpatient Office VisitPrimary Care PhysicianSpecialist 15 Copay 25 CopayDeductible 30%Deductible 30%Other Provider ServicesProvider Services at ER 0 0Provider Services at HospitalInpatient/ Outpatient 0Deductible 30%Provider Services at an Ambulatory Surgical Center (ASC) 0Deductible 30%T25 – 1/182 of 4

Large Group POSHealth Benefit Plan T25Amount Member PaysIn-NetworkOut-of-NetworkSchedule of Benefits for Covered ServicesOther Special Services - services with an asterisk * require prior authorizationCombined Limit for Outpatient Occupational, Physical and Speech Therapy (per visit)Combined Limit for Outpatient Cardiac and Pulmonary Rehabilitation Therapy (per visit)Chiropractic Care (per visit)*Durable Medical Equipment*Prosthetics and Medical Brace Device*Home Health Care (per visit)*Skilled Nursing Facility (per day)HospiceHearing Exam (Audiologist/Specialist)*Radiation (per visit)Telehealth Services (PCP/Specialist)Diabetes Care Management 15 Copay 15 Copay 10 Copay15% Coinsurance 0 0 15 Copay 0 25 Copay 25 Copay 10/ 30 CopayDeductible 30%Deductible 30%Deductible 30%Deductible 30%Deductible 30%Deductible 30%Deductible 30%Deductible 30%Deductible 30%Deductible 30%Not CoveredDiabetes Outpatient Self-Management EducationGlucometerAnnual Complete Diabetic Eye Exam (Optometrist/Ophthalmologist)50 Test Strips /Sensors (per box)Lancets (per box) 0 0 15 / 25 Copay 10 Copay 10 CopayNot CoveredDeductible 30%Deductible 30%Deductible 30%Deductible 30%*Prior Authorization is Required: There are certain medical services for which members are required to obtain Prior Authorizationbefore receiving that service. If you don’t obtain prior authorization from FHCP, you will have to pay the entire cost of the service. Beforea specialty or testing appointment you should visit or call toll-free 1-877-615-4022 to see if prior authorization is required.Any one individual in a covered family can satisfy the individual out-of-pocket maximum for your plan. The entire family amount can besatisfied by any or all of the other covered dependents.Schedule of Benefits for Covered ServicesAmount Member PaysPrescription Drug ProgramNetwork Provider Services: A Network Provider pharmacy must be used when a member needs to have a prescription filled or the member will have topay the full cost of the drug (except in certain situations such as emergencies). Members should log into their member account at and clickFind a Provider/Facility to locate a Network Provider pharmacy. Mail Order is only available through FHCP Pharmacy.Network PharmacyMail Order(1 month supply)(3 month supply)FHCPWalgreensFHCP Only 0 3 Copay 10 Copay 30 CopayNot Covered 15 Copay 15 Copay 35 Copay 0 6 Copay 27 Copay 87 Copay 55 Copay 60 Copay 162 CopayPreferred Specialty15% CoinsuranceNot CoveredNot CoveredNon Preferred Specialty25% CoinsuranceNot CoveredNot CoveredGeneric DrugsPreventive (e.g., oral contraceptives)Preferred GenericNon Preferred GenericPreferred Brand DrugsNon-Preferred Brand DrugsSpecialty Drugs (Prior authorization is required)If a Brand Name Prescription Drug is requested when there is a Generic Prescription Drug available, the member will be responsible for paying the Average Wholesale Price (AWP)for that prescription.FHCP Pharmacy benefit provides coverage for Generic contraceptive medications or devices (e.g., oral contraceptives, emergency contraceptive, and diaphragms) at no costwhen obtained from a pharmacy owned and operated by FHCP. FHCP’s Pharmacy Benefit also covers certain preventive medications at no cost in accordance with theUnited States Preventative Task Force (USPSTF) Affordable Care Act A and B recommendations as long as all criteria are met and the medication is obtained from a FHCPowned and operated pharmacy.T25 – 1/183 of 4

Large Group POSHealth Benefit Plan T25Schedule of Benefits for Covered ServicesAmount Member Pays - Network ProviderPediatric VisionNetwork Provider Services: The services listed below must be received from a Network Provider or the member will have to pay the full costof the service (except in certain situations such as emergencies). Members should log onto and click Find a Provider/Facility tolocate a Network Provider near them.ExamNot CoveredEyeglass LensesNot CoveredFramesPediatric Selection: Not CoveredNon-Selection: Not CoveredContact Lenses (Instead of eyeglasses)Pediatric Selection: Not CoveredIncludes contact lenses, evaluation, fitting and follow up care.Non-Selection: Not CoveredNote: Anything over the allowance will not count toward your out-of-pocket maximum limitation.Pediatric DentalPreventive, basic and majorNot CoveredBenefit Maximums - Combined Limit In-Network and Out-of-NetworkHome Health Care60 Visits PBPOT, PT, ST Outpatient Rehabilitation Therapy20 Visits PBPCardiac and Pulmonary Therapy20 Visits PBPChiropractic Care20 Visits PBPSkilled Nursing/Rehabilitation Facility20 Days PBPBehavioral Health Residential Facility20 Days PBPAdditional Benefits and Features To find out more about their benefits and/or treatment options, members are encouraged to call the Member Services Department at1-877-615-4022. This can help them save time and money. Members have online access to view their health benefit plan information as well as self-service tools through the Member Portal is not an insurance contract or Benefit Booklet. This Benefit Schedule is only a partial description of the many benefits and servicesprovided or authorized by Florida Health Care Plans. This does not constitute a contract. For a complete description of benefits and exclusions,please see the Florida Health Care Plans Certificate of Coverage; its terms prevail.T25 – 1/184 of 4

If you or someone you’re helping has questions about Florida Health Care Plans, you have the right to get help andinformation in your language at no cost. To talk to an interpreter, call 1-877-615-4022. (TTY: TRS Relay 711)Si usted o alguien a quien ayuda tienen preguntas sobre Florida Health Care Plans, tienen derecho a obtener ayuda einformación en su idioma de manera gratuita. Para hablar con un intérprete, llame al 1-877-615-4022. (TTY: TRS Relay 711)Si ou menm, oswa yon moun w ap ede, gen kesyon sou Florida Health Care Plans ,ou gen dwa pou jwenn enfòmasyon nanlang ou gratis. Pou ale ak yon entèprèt, rele 1-877-615-4022. (TTY: TRS Relay 711)Nếu quý vị, hoặc người nào đó mà quý vị đang giúp đỡ, có các thắc mắc về Florida Health Care Plans, quý vị có quyền đượcnhận trợ giúp và thông tin bằng ngôn ngữ của quý vị miễn phí. Để trao đổi với phiên dịch, hãy gọi theo số 1-877-615-4022.(TTY: TRS Relay 711)Se você, ou alguém que estiver a ajudar, tiver dúvidas sobre Florida Health Care Plans, tem o direito de obter ajuda einformações na sua língua, sem nenhumas custas. Para falar com um intérprete, ligue para 1-877-615-4022. (TTY: TRS da Health Care 請致電1-877-615-4022. (TTY: TRS Relay711)Si vous ou une personne que vous aidez avez des questions au sujet de Florida Health Care Plans, vous avez le droitd'obtenir gratuitement de l'aide et des informations dans votre langue. Pour parler à un interprète, veuillez appeler le 1877-615-4022. (TTY: TRS Relay 711)Kung ikaw, o ang isang taong tinutulungan mo, ay may mga tanong tungkol sa Florida Health Care Plans, mayroon kangkarapatang humingi ng tulong at impormasyon sa iyong wika nang walang bayad. Upang makipag-usap sa isang interpreter,tumawag sa 1-877-615-4022. (TTY: TRS Relay 711)Если у Вас или у кого-то, кому Вы помогаете, есть вопросы о программе Florida Health Care Plans, Вы имеет правобесплатно получить ответы в переводе на Ваш язык. Для того чтобы воспользоваться помощью устного переводчика,позвоните по телефону 1-877-615-4022. (TTY: TRS Relay 711) ﺗﺤﺪث إﻟﻰ ﻣﺘﺮﺟﻢ .ً ﯾﺤﻖ ﻟﻚ ﺗﻠﻘﻲ اﻟﻤﺴﺎﻋﺪة واﻟﻤﻌﻠﻮﻣﺎت ﺑﻠﻐﺘﻚ ﻣﺠﺎﻧﺎ , Florida Health Care Plans] ذا ﻛﺎن ﻟﺪﯾﻚ أو اﻟﺸﺨﺺ اﻟﺬي ﺗﺴﺎﻋﺪه اﺳﺘﻔﺴﺎرات ﺣﻮل .1-877-615-4022. (TTY: TRS Relay 711)] اﺗﺼﻞ ﻋﻠﻰ اﻟﺮﻗﻢ ، ﻓﻮري se voi, o una persona che state aiutando, avete domande relative al Florida Health Care Plans, avete diritto a ottenereassistenza e informazioni gratuitamente nella vostra lingua. Per parlare con un interprete, chiamare il numero 1-877-6154022. (TTY: TRS Relay 711)Falls Sie oder jemand, dem Sie helfen, irgendwelche Fragen über Florida Health Care Plans haben, so haben Sie Anspruchauf kostenlose Unterstützung und Informationen in Ihrer eigenen Sprache. Bitte rufen Sie uns unter der Nummer 1-877615-4022. (TTY: TRS Relay 711) an, um mit einem Dolmetscher/einer Dolmetscherin zu sprechen.귀하 또는 귀하가 도와드리고 있는 분이Florida Health Care Plans에 관한 질문이 있을 경우, 귀하에게는 무료로 본인이구사하는 언어로 도움과 정보를 받을 권리가 있습니다. 통역으로 전화 연결되려면1-877-615-4022. (TTY: TRS Relay711) 번으로 전화해 주십시오.Jeśli Ty lub ktoś, komu pomagasz macie pytania dotyczące Florida Health Care Plans, macie prawo uzyskać pomoc iinformacje w swoim języku, bez żadnych kosztów. Porozmawiaj z tłumaczem, zadzwoń pod nume