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
WordPress Data Table

Cigna Healthcare
24 hours / Seven days a week
1-800-806-3052

M-DCPS Logo in white

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)