Legal Entity Agency Agreement - Florida Blue - BCBSF

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Addendum A: Company ProductsJANUARY 1 – DECEMBER 31, 2014 CALENDAR YEARFlorida Blue Of Florida/Health Options Product Offerings:1) Group Products (4+)a) BlueCare (HMO) (offered by Health Options, Inc.)b) BlueChoice (PPO) (offered by Florida Blue of Florida (“BCBSF”))c) BlueOptions (PPO) (offered by BCBSF)Florida Combined Life Product Offerings:1) Group Productsa) Basic Life with Accelerated Living Benefitsb) Basic Life with Hospital Indemnity Riderc) Short Term Disabilityd) Long Term Disabilitye) Long Term Disability with Spousal Disability, Portability, and Minimum Indemnity (AD&D)Optional Ridersf) Employee Choice (Supplemental Long Term Disability)g) Term Accidental Death and Dismembermenth) Supplemental Term Lifei) Dependent Term Lifej) Pre-Paid Dentalk) Indemnity Dentall) PPO Dentali) Traditional PPOii) In-network fixed Co-payment schedule2) Group Payroll Deduction Programsa) Voluntary Life with Accelerated Living Benefitsb) Voluntary Short Term Disabilityc) Voluntary Long Term Disabilityd) Voluntary Term Accidental Death and Dismembermente) Voluntary Group Long Term Care (integrated product for home, community, and nursing home care)3) Pretax Programsa) Premium Conversion Plansb) Group Long Term Carec) Group Home Health Cared) Flexible Spending Accounts (FSA)e) Health Reimbursement Accounts (HRA)f) Health Savings Accounts (HSA)Florida Blue Agency Agreement 14
Appendix 1 to Addendum ANOTE #1: This Appendix shall only be used pursuant to Section B(1) of the Agreement.Basic HMO Plan Option 1Basic HMO Plan Option 2Basic PPO Plan Option 1Basic PPO Plan Option 2BCBSF Care Manager OptA16-R1BCBSF Care Manager OptA17-R1BCBSF Care Manager OptA18-R1BCBSF Care Manager OptRa16-R1BCBSF Care Manager OptRa17-R1BCBSF Care Manager OptRa18-R1BCBSF Care Manager OptRa1-R1BCBSF Care Manager OptionA/17BCBSF Care Manager OptionA/18BCBSF Care Manager OptionA10BCBSF Care Manager OptionA12BCBSF Care Manager OptionA14BCBSF Care Manager OptionA15BCBSF Care Manager OptionA16BCBSF Care Manager Option A5BCBSF Care Manager OptionRa1BCBSF Care Manager OptionRa10BCBSF Care Manager OptionRa14BCBSF Care Manager OptionRa15BCBSF Care Manager OptionRa17BCBSF Care Manager OptionRa18BCBSF Care Manager OptionRa4BCBSF Care Manager OptionRa7BlueCare Basic SGrp-R2BlueCare FQ Lg Grp Plan 01BlueCare FQ Lg Grp Plan 02BlueCare FQ Lg Grp Plan 04BlueCare FQ Lg Grp Plan 05BlueCare FQ Lg Grp Plan 08BlueCare FQ Lg Grp Plan 09BlueCare FQ Lg Grp Plan 10BlueCare FQ Lg Grp Plan 11BlueCare FQ Lg Grp Plan 12BlueCare FQ Lg Grp Plan 13BlueCare FQ Lg Grp Plan 14BlueCare FQ Lg Grp Plan 15BlueCare NFQ Lg Grp Plan 01BlueCare NFQ Lg Grp Plan 02BlueCare NFQ Lg Grp Plan 03BlueCare NFQ Lg Grp Plan 04BlueCare NFQ Lg Grp Plan 05BlueCare NFQ Lg Grp Plan 06BlueCare NFQ Lg Grp Plan 07BlueCare NFQ Lg Grp Plan 08BlueCare NFQ Lg Grp Plan 09BlueCare NFQ Lg Grp Plan 10BlueCare NFQ Lg Grp Plan 11BlueCare NFQ Lg Grp Plan 112BlueCare NFQ Lg Grp Plan 114BlueCare NFQ Lg Grp Plan 115BlueCare NFQ Lg Grp Plan 12BlueCare NFQ Lg Grp Plan 13BlueCare NFQ Lg Grp Plan 14BlueCare NFQ Lg Grp Plan 15BlueCare NFQ Lg Grp Plan 16BlueCare NFQ Lg Grp Plan 20BlueCare NFQ Lg Grp Plan 21BlueCare NFQ Lg Grp Plan 22BlueCare NFQ Lg Grp Plan 23BlueCare Rx Ded Copay Plan 01BlueCare Rx Ded Copay Plan 02BlueCare Rx Plan 13BlueCare Rx Plan 24BlueCare Rx Plan 25BlueCare Small Group Plan 209BlueCare Small Group Plan 212BlueCare Small Group Plan 215BlueCare Small Group Plan 30BlueCare Small Group Plan 31BlueCare Small Group Plan 32BlueCare Small Group Plan 33BlueCare Small Group R1BlueCare Small Group R10BlueCare Small Group R11BlueCare Small Group R12BlueCare Small Group R13BlueCare Small Group R14BlueCare Small Group R15BlueCare Small Group R16BlueCare Small Group R17BlueCare Small Group R18BlueCare Small Group R19BlueCare Small Group R2BlueCare Small Group R20BlueCare Small Group R21BlueCare Small Group R22BlueCare Small Group R23BlueCare Small Group R24BlueCare Small Group R24-R1BlueCare Small Group R25BlueCare Small Group R25-R1BlueCare Small Group R26BlueCare Small Group R3BlueCare Small Group R4BlueCare Small Group R5BlueCare Small Group R6BlueCare Small Group R7BlueCare Small Group R8BlueCare Small Group R9BlueCare Standard SGrpBlueCare Standard Sgrp-R2BlueChoice Copay Plan 601BlueChoice Copay Plan 601-R1BlueChoice Copay Plan 603BlueChoice Copay Plan 603-R1BlueChoice Copay Plan 606BlueChoice Copay Plan 606-R1BlueChoice Copay Plan 609BlueChoice Copay Plan 609-R1BlueChoice Copay Plan 611BlueChoice Copay Plan 611-R1BlueChoice Copay Plan 612BlueChoice Copay Plan 612-R1BlueChoice Copay Plan 613BlueChoice Copay Plan 613-R1BlueChoice Copay Plan 615BlueChoice Copay Plan 615-R1BlueChoice Copay Plan 702BlueChoice Copay Plan 702-R1BlueChoice Copay Plan 703BlueChoice Copay Plan 703-R1BlueChoice Copay Plan 704BlueChoice Copay Plan 704-R1BlueChoice Copay Plan 706BlueChoice Copay Plan 706-R1BlueChoice Copay Plan 708BlueChoice Copay Plan 708-R1BlueChoice Copay Plan 714Florida Blue Agency Agreement 15
Page 10 and 11: follow-up documentation pursuant to
Page 12 and 13: the compliance date of such finalre
Page 16 and 17: BlueChoice Copay Plan 714-R1BlueCho
Page 18 and 19: Point Of Service Option 25-R3Point
Page 20 and 21: Addendum B: Agency “Good Standing
Page 22 and 23: Location-specific rates are based o
Page 24: Addendum D: Operating & Hardware Re

Legal Entity Agency Agreement - Florida Blue - BCBSF

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