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
Service
|
Standard HMO Plan
|
High Deductible Health Plan
|
---|---|---|
Annual Deductible
|
No Deductible
|
$1,500 Individual $3,000 Family
|
Out of Pocket Maximum
|
Medical: $1,500 Individual, $3,000 Family, Global (Medical & RX): $9,100 Individual, $18,200 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.