2023 Pinellas County COBRA Premiums

Medical Monthly Premiums

COBRA Monthly Premiums (same for both plans)
Employee only $ 969.69 per month
Employee and Spouse/Domestic Partner $2,026.94 per month
Employee and Child(ren) $1,833.89 per month
Family $2,895.63 per month
Item Choice Fund Open Access Plus HSA Open Access Plus (OAP)
Coverage Employee Only Employee +1 Employee + 2 or More Employee Only Employee + 1 or More
Annual Deductible $1,500 $3,000 (pooled deductible for all family members on the plan) $600 $1,200 (two individual deductibles of $600 each)
Out-of-Pocket Maximum (includes medical and Rx; after you spend this amount, the health plan pays 100%) $3,000 $4,000 $6,000 $2,600 $5,200
In-Network Benefit* Choice Fund Open Access Plus HSA Open Access Plus (OAP), previously called Point of Service
Preventive Medical $0 $0
Primary Care Physician 20% after deductible $25 copay
Behavioral Health 20% after deductible $25 copay
Specialist 20% after deductible $35 copay
Virtual Doctor Visit $40-$70 then 20% after deductible (costs may vary) $15 copay
Convenience Care Clinics/Urgent Care 20% after deductible $25 copay
Emergency Room 20% after deductible $250 copay
Non-Preventive Medical (labs and imaging) 20% after deductible 20% after deductible
Preventive Rx $0
(see preventive medications list)
$15 copay for generic or coinsurance for preferred or non-preferred (see below)
Rx Generic (up to 30 days) 20% after deductible $15 copay
Rx Preferred Brand (up to 30 days) 20% after deductible 20% coinsurance;
min: $30, max: $60
Rx Non-Preferred Brand (up to 30 days) 20% after deductible 40% coinsurance
min: $45, max: $90
Rx Preferred Specialty Brand (up to 30 days) 20% after deductible 20% coinsurance
min: $60, max: $120
Rx Non-Preferred Specialty Brand (up to 30 days) 20% after deductible 40% coinsurance
min: $90, max: $180
Rx (up to 90 days), use Smart90 Program at Walgreens or home delivery, Non-Specialty Brand 20% after deductible 2x cost of 30-day supply
Rx (up to 90 days), use Smart90 Program at Walgreens or home delivery, Specialty Brand 20% after deductible Cost of 30-day supply
Rx (up to 90 days), your cost with another pharmacy 20% after deductible Full retail cost

* Out-of-network benefits are also available. Deductibles, coinsurance and out-of-pocket maximums are higher.

Dental Monthly Premiums

Plan Employee Only Employee + 1 Employee + 2 or more
Dental PPO Basic $42.99 $83.18 $131.47
Dental PPO with Orthodontia $45.21 $87.45 $138.23
Dental HMO $7.31 $10.47 $14.67

12/30/22