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)
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)
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)
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 |
Prescription Coverage
Preventive Health Services
Behavioral Health
Tools & Resources
Urgent Care and Convenience Care Centers
Cigna Healthcare
24 hours / Seven days a week
1-800-806-3052
Office of Risk and Benefits Management
1501 N.E. 2nd Avenue, Suite 335
Miami, Florida 33132
Mon - Fri, 8 a.m. to 4:30 p.m. ET
www.dadeschools.net
305-995-7129
FBMC Service Center
Monday - Friday, 7 a.m. – 7 p.m.
1-855-MDC-PS4U (1-855-632-7748)