Quick facts
Annual Deductible (In-Network)
$0 per year for In-Network health care services
Maximum Out-of-Pocket (In-Network)
$2,000
Provider of Choice (PCP) Copay
$10 copay
Specialist Copay
$25 copay
Emergency Care Copay
$75 copay
Urgent Care Copay
$25 copay
Tier 1 - Preferred Generic (Standard Retail 31-day)
$0 copay
Preventive Care (Medicare-covered Services)
$0 copay
More details (21)
Routine Eye Exam Copay
$0 copay
Maximum Allowance for Lenses, Frames or Contacts
$250 maximum allowance per year
Monthly Plan Premium
$331.18
Annual Deductible (Out-of-Network)
$1,000 per year for Out-of-Network health care services
Part D Prescription Drug Deductible
$100 per year applies to Tier 3, Tier 4, and Tier 5
Maximum Out-of-Pocket (In- and Out-of-Network combined)
$5,000
Inpatient Hospital Coverage (In-Network)
$200 copay per day, for days 1-7; $0 copay per day, after day 7
Ambulance (Ground)
$150 copay
Skilled Nursing Facility Copay
$0 copay per day for days 1-20; $100 copay per day for days 21-100
Tier 2 - Generic (Standard Retail 31-day)
$0 copay
Tier 3 - Preferred Brand (Standard Retail 31-day)
$30 copay
Tier 4 - Non-Preferred Drug (Standard Retail 31-day)
$60 copay
Tier 5 - Specialty Tier
33% of the total cost
Tier 6 - Select Care Drugs
$0 copay
Insulin Monthly Copay Cap
$35 for a one-month supply
Catastrophic Coverage Stage Threshold
$2,100 out-of-pocket costs
Comprehensive Dental Care
$0 copay per service (denture adjustment and extraction per calendar year)
Non-routine Dental Care (Medicare-Covered)
$25 copay
Lenses, Frames or Contacts Copay
$0 copay
Hearing Aid Benefit Allowance
$350 per ear; $0 copay for up to 2 hearing aids every year with a maximum benefit allowance of $350 per ear
Routine Hearing Exam Copay
$0 copay
Carrier contact
1-800-926-6565 — member services
Group number: City of Tallahassee #45380
Your member ID card: check the carrier website or app, or ask HR for a copy.
Plan documents
Confirm details with your carrier for current plan information.