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2021 PLAN AND SUMMARY OF BENEFITS AND COVERAGE

For more information about your HMO and HDHP benefit coverage, please refer to the 2021 plan documents. To request a printed copy of the plan documents or ask a question, please contact AvMed's Member Engagement Center dedicated to State of Florida employees, 888-762-8633

Service
Standard HMO Plan
High Deductible Health Plan
Annual Deductible
No Deductible
$1,400 Individual $2,800 Family
Out of Pocket Maximum
Medical: $1,500 Individual, $3,000 Family, Global (Medical & RX): $8,550 Individual, $17,100 Family
Medical & Rx: $3,000 Individual, $6,000 Family
Primary Care Services
$20 Copay Per Visit
20% Coinsurance after deductible
Specialist Services
$40 Copay Per Visit
20% Coinsurance after deductible
Hospital Admission
$250 Copay Per Admission
20% Coinsurance after deductible
Outpatient Services
No Charge
20% Coinsurance after deductible
Emergency Room
$100 Copay Per Visit
20% Coinsurance after deductible
Urgent Care
$25 Copay Per Visit
20% Coinsurance after deductible
Diagnostics Testing
No Charge
20% Coinsurance after deductible
Durable Medical Equipment
No Charge
20% Coinsurance after deductible
Preventive Care
No Charge
No Charge
Prescription Drugs* *Prescription Drug coverage is administered by CVS/Caremark. Please refer to your Summary Plan Description for more details
$7/$30/$50 Copay Retail $14/$60/$100 Copay Mail Order & Participating Retail Pharmacy
30%/30%/50% Coinsurance after deductible (Retail & Mail Order)

Prescription drug coverage is administered by CVS/Caremark. For more information about your coverage or to get a list of participating pharmacies, please visit State of Florida Employees' Prescription Drug Plan Page or call 1-888-766-5490.

2021 Plan and Summary of Benefits and Coverage

For more information about your HMO and HDHP benefit coverage, please refer to the 2021 plan documents. To request a printed copy of the plan documents or ask a question, please contact AvMed's Member Service toll-free at 1-888-762-8633.

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