South Dade – Medical Plan Highlights

BENEFITS

     
HMO OA 5912

HMO OA 6071

HMO OA 6333

Annual Deductible

          Individual

Family

$5,000

               
$10,000

$5,000

               
$11,000

$3,500

$7,000

Annual Out-Of-Pocket Maximum Individual

Family

   $6,350

$12,700

 $6,350

           $12,700

  $6,850

$13,700

Primary
Care Physician

$60
copay

$35
copay

$35
copay

Specialist Office Visit

$70
copay

$50
copay

$70
copay

Inpatient Facility Charges

30% after
deductible

30% after deductible

$1000
per day x3 days

Outpatient
Facility Charges

30%
after deductible

30% after deductible

$1000
co pay

Physician Services at Hospital / ER

$30% after deductible

30% after deductible

100%
after deductible

MRI,
CT Scans, PET Scans

$30% after deductible

30% after deductible

$50
copay

Emergency Room Copay (waived if admitted)

30%
after deductible

30%
after deductible

$600
copay

Urgent Care Copay

$120
copay

$100
copay/per visit

$100
copay

Prescriptions:

Tier 1 / Tier 2 / Tier
3 / Tier 4

$25/$50/$75/35%

after deductible

$20/$50/$70/50%

$25/$50/$75/20%

Employee

$74.72

               $115.52

$133.88

Employee + Spouse

         
$238.44

              
$320.04

  $356.76

Employee + Child(ren)

$222.07

              
$299.52

  $334.48

Employee + Family

$434.90

              
$560.47

  $623.92