Quick facts
Annual Deductible (In-Network medical)
$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 (In-Network)
$25 copay
Emergency Room Copay
$75 copay
Urgent Care Copay
$25 copay
Out-of-Network Coinsurance (general)
30% of the total cost after you reach your $1,000 out-of-network deductible
Tier 1 - Preferred Generic (31-day Retail)
$0 copay
More details (23)
Preventive Dental Care (In-Network)
$0 copay per service. Includes routine exams, cleanings, and X-rays per calendar year.
Routine Eye Exam Copay (In-Network)
$0 copay
Annual Maximum Allowance for Lenses, Frames or Contacts
$250 maximum allowance per year
Ambulance Ground Copay
$150 copay
Comprehensive Dental Care (In-Network)
$0 copay per service. Includes a denture adjustment and an extraction per calendar year.
Catastrophic Coverage Stage Threshold
$2,100
Lenses, frames or contacts copay (In-Network)
$0 copay
Annual Deductible (Out-of-Network medical)
$1,000 per year for Out-of-Network health care services
HealthyBlue Rewards Program
Reward dollars loaded to Blue Dollars Benefits MasterCard Prepaid Card for completing/reporting preventive care and screenings
Hearing Aid Benefit Allowance (In-Network)
$350 per ear. $0 copay for up to 2 hearing aids every year with a maximum benefit allowance of $350 per ear.
Inpatient Hospital Copay (In-Network)
$200 copay per day, for days 1-7; $0 copay per day, after day 7
Insulin Monthly Copay Cap
$35 for a one-month supply
Monthly Plan Premium
$331.18
Non-routine Dental Care (Medicare-Covered, In-Network)
$25 copay
Maximum Out-of-Pocket (In+Out-of-Network combined)
$5,000
Part D Deductible (Tiers 3-5)
$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 (31-day Retail)
33% of the total cost
Tier 6 - Select Care Drugs (31-day Retail)
$0 copay
SilverSneakers Fitness Program
Basic membership to any SilverSneakers participating fitness facility
Skilled Nursing Facility Copay (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.