Healthcare Plans

Health Plan Transparency Machine Readable Files https://www.ticmrf.com/59-6000572

This link leads to the machine readable files that are made available in response to the federal Transparency in Coverage Rule and includes negotiated service rates and out-of-network allowed- amounts between health plans and healthcare providers. The machine-readable files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.

Cigna Healthcare Highlights

OAP High

This plan offers a higher level of coverage with a lower out-of-pocket expense when receiving services, while having access to nationwide providers in exchange for a higher premium.

No Primary Care Physician selection required
No referral for Specialists
Nationwide Provider Network
Low Deductible – deductible must be satisfied for services subject to co-insurance
Lower Primary Care Physician co-payment
Lower Urgent Care co-payment
$0 co-payment for Telemedicine
$0 co-payment for Generic Seven Drug Classes (both retail & 90-day supply)

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Plan Design

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Benefits Summary

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Plan Providers

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How It Works For You

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How to Find a Doctor

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Cigna Care Doctor

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Cigna Collaborative Care

OAP Standard

This plan offers individuals needing less access to care a lower premium option, with access to nationwide providers in exchange for a higher out-of-pocket expense when receiving services.

No Primary Care Physician selection required
No referral for Specialists
Co-payments for Primary and Specialist visits
Co-payments for Urgent visits
Nationwide Provider Network
Low Deductible – deductible must be satisfied for services subject to co-insurance
$0 co-payment for Telemedicine
$0 co-payment for Generic Seven Drug Classes (both retail & 90-day supply)

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Plan Design

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Benefits Summary

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Plan Providers

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How It Works For You

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How to Find a Doctor

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Cigna Care Doctor

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Cigna Collaborative Care

SureFit Plan

This plan offers a lower out-of-pocket expense when receiving services, a lower premium, and a narrow strong network of providers. You must reside in the tri-county area (Miami-Dade, Broward and Palm Beach Counties).

Selection of Primary Care Physician required
Referrals needed for Specialists
Narrow network with a minimum disruption in comparison to the OAP Plans
Co-payments for Primary and Specialist visits
Low co-payments for Urgent visits
A significant lower deductible – deductible must be satisfied for services subject to co-insurance
A significant lower Maximum Out of Pocket – The amount that you must pay before the plan covers 100% of all the services subject to co-insurance
$0 co-payment for Telemedicine
$0 co-payment for Generic Seven Drug Classes (both retail & 90-day supply)

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Healthcare Plan Comparison


	OAP High			OAP Standard		SureFit
Coverage	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network Only
Medical Network Basis	OAP Network			OAP Network		SureFit Network TriCounty ¹
PCP Coordination of Medical Care	No			No		Yes
Medical Benefits
Deductible (Individual/Family)	$500/$1,000	$1,000/$2,000	$750/$1,500	$1,500/$3,000	$150/$250
Out of Pocket Max (Ind/Fam)(incl ded. & copay & Rx)	$3,000/$6,000	$6,000/$12,000	$4,000/$8,000	$8,000/$16,000	$1,500/$3,000
Coinsurance	30%	50%	30%	50%	30%
Telemedicine	$0	N/A	$0	N/A	$0
Primary Care Physician OV	$25/ $0 M-DCPS Clinic	50% AD	$30/ $0 M-DCPS Clinic	50% AD	$20/ $0 M-DCPS Clinic
Tier 1 Specialist	$50	50% AD	$50	50% AD	$50
Non-Tier 1 Specialist	$70	50% AD	$75	50% AD	N.A.
Outpatient BH	$0	50% AD	$0	50% AD	$0
Physical Therapy	$35		$55		$35
Speech & Occupational Therapies	$55 ST, OT	50% AD	$60 ST, OT	50% AD	$20 PCP/ $50 SCP
Pulmonary Cardiac Therapy (40 days per year)	$55	50% AD	$70	50% AD	$45
Chiropractic Care (30 days per year)	$60	50% AD	$70	50% AD	$45
Convenience Care Centers	$10	50% AD	$15	50% AD	$10
Urgent Care	$40	$40	$40	$40	$40
Imaging	30% AD, or $100 at non-hospital based	50% AD	30% AD, or $100 at non-hospital based	50% AD	30% AD, or $100 at non-hospital based
Inpatient Hospital	30% AD	50% AD	30% AD	50% AD	30% AD
Outpatient Hospital and Major Diagnostics	30% AD or $150 at affiliated Non-hospital	50% AD	30% AD or $150 at affiliated Non-hospital	50% AD	30% AD or $100 at affiliated Non-hospital
Emergency Room	$350/$200 preferred facilities	$350	$400/$200 preferred facilities	$400	$300/$150 preferred facilities
Other - Hearing Aides	$65 visit/ 30% AD for devices	Not covered	$70 visit/ 30% AD for devices	Not covered	$50 visit/ 30% AD for devices
Other - Bariatric Surgery	30% AD	Not covered	Not covered	Not covered	Not covered
Prescription Drug Benefits (50% Retail only out-of-network benefit)
Prescription Drug Deductible (Ind/Fam)	N/A			N/A		N/A
Formulary	Same as OAP Standard and SureFit		Same as OAP High and SureFit		Same as OAP plans
Other - Insulin Copay Waiver	Yes		Yes		Yes
Retail Drug Network (no coverage for maintenance meds after 3rd fill)
Generic Seven Drug Classes²	$0	50%	$0	50%	$0
Generic	$20 – no coverage for maintenance meds after 3rd fill				$20 – no coverage for maintenance meds after 3rd fill	$15 – no coverage for maintenance meds after 3rd fill
GENERIC ADD & ADHD	$15				$15	$15
Preferred Brand (Including Specialty Drugs)	$55 – no coverage for maintenance meds after 3rd fill				$65 – no coverage for maintenance meds after 3rd fill	$40 – no coverage for maintenance meds after 3rd fill
Non-Preferred Brand (Including Specialty Drugs)	$150 – no coverage for maintenance meds after 3rd fill				$175 – no coverage for maintenance meds after 3rd fill	$125 – no coverage for maintenance meds after 3rd fill
Mail Order Prescription (90 day supply)		N/A		N/A
Generic Seven Drug Classes2	$0				$0	$0
Generic	$40				$40	$30
Generic ADD & ADHD	$30				$30	$30
Preferred Brand (Including Specialty Drugs)	$140				$160	$80
Non-Preferred Brand (Including Specialty Drugs)	$375				$435	$315
1 Broward, Dade and Palm Beach Counties, FL
2 90-Day supply on Seven Drug Classes related to the following conditions: Asthma, Blood Pressure, Blood Thinner, Cholesterol, Diabetes, Osteoporosis, Prenatal Vitamins
AD = after deductible, OV = office visit

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Prescription Coverage

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Preventive Health Services

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Behavioral Health

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Tools & Resources

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Urgent Care and Convenience Care Centers

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FBMC Service Center
Monday - Friday, 7 a.m. – 7 p.m.
1-855-MDC-PS4U (1-855-632-7748)