Quick facts
Annual Medical Deductible (In-Network)
$0 per year for In-Network health care services
Maximum Out-of-Pocket (In-Network)
$2,000
Maximum Out-of-Pocket (In- and Out-of-Network combined)
$5,000
Doctor Visit - Provider of Choice Copay (In-Network)
$10 copay
Doctor Visit - Specialist Copay (In-Network)
$25 copay
Emergency Room Copay (In-Network)
$75 copay
Urgent Care Center Copay
$25 copay
Out-of-Network General Coinsurance
30% of the total cost after you reach your $1,000 out-of-network deductible
More details (23)
Tier 1 - Preferred Generic (31-day retail)
$0 copay
Preventive Dental Care (In-Network)
$0 copay per service
Routine Eye Exam Copay (In-Network)
$0 copay
Annual Maximum Allowance for Lenses, Frames or Contacts
$250 maximum allowance per year
Ambulance Ground (In-Network)
$150 copay
Comprehensive Dental Care (In-Network)
$0 copay per service
Out-of-Pocket Threshold to Catastrophic Coverage Stage
$2,100
Lenses, Frames or Contacts Copay (In-Network)
$0 copay
Hearing Aid Benefit Allowance
$350 per ear
Routine Hearing Exam Copay (In-Network)
$0 copay
Inpatient Hospital Coverage (In-Network)
$200 copay per day, for days 1-7; $0 copay per day, after day 7
Inpatient Hospital Coverage (Out-of-Network)
30% of the total cost after you reach your $1,000 out-of-network deductible
Insulin Monthly Cap
$35 for a one-month supply
Medicare-Covered Non-routine Dental (In-Network)
$25 copay
Monthly Plan Premium
$331.18
Annual Medical Deductible (Out-of-Network)
$1,000 per year for Out-of-Network health care services
Part D Deductible
$100 per year applies to Tier 3, Tier 4, and Tier 5
Tier 2 - Generic (31-day retail)
$0 copay
Tier 3 - Preferred Brand (31-day retail)
$30 copay
Tier 4 - Non-Preferred Drug (31-day retail)
$60 copay
Tier 5 - Specialty Tier
33% of the total cost
Tier 6 - Select Care Drugs
$0 copay
Skilled Nursing Facility (In-Network)
$0 copay per day for days 1-20; $100 copay per day for days 21-100
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.