2023 PLAN AND SUMMARY OF BENEFITS AND COVERAGE
For more information about your HMO and HDHP benefit coverage, please refer to the 2023 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 at 1-888-762-8633
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Service
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Standard HMO Plan
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High Deductible Health Plan
|
|---|---|---|
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Annual Deductible
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No Deductible
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$1,500 Individual $3,000 Family
|
|
Out of Pocket Maximum
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Medical: $1,500 Individual, $3,000 Family, Global (Medical & RX): $9,100 Individual, $18,200 Family
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Medical & Rx: $3,000 Individual, $6,000 Family
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|
Primary Care Services
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$20 Copay Per Visit
|
20% Coinsurance after deductible
|
|
Specialist Services
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$40 Copay Per Visit
|
20% Coinsurance after deductible
|
|
Hospital Admission
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$250 Copay Per Admission
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20% Coinsurance after deductible
|
|
Outpatient Services
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No Charge
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20% Coinsurance after deductible
|
|
Emergency Room
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$100 Copay Per Visit
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20% Coinsurance after deductible
|
|
Urgent Care
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$25 Copay Per Visit
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20% Coinsurance after deductible
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Diagnostics Testing
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No Charge
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20% Coinsurance after deductible
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Durable Medical Equipment
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No Charge
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20% Coinsurance after deductible
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Preventive Care
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No Charge
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No Charge
|
|
Prescription Drugs* *Prescription Drug coverage is administered by CVS/Caremark. Please refer to your Summary Plan Description for more details
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$7/$30/$50 Copay Retail $14/$60/$100 Copay Mail Order & Participating Retail Pharmacy
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30%/30%/50% Coinsurance after deductible (Retail & Mail Order)
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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.
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