2024 Pinellas County COBRA Premiums
Medical Monthly Premiums
| COBRA Monthly Premiums (same for both plans) | |
|---|---|
| Employee only | $1,174.61 per month |
| Employee and Spouse/Domestic Partner | $2,455.28 per month |
| Employee and Child(ren) | $2,221.44 per month |
| Family | $3,507.55 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 | $44.28 | $85.68 | $135.42 |
| Dental PPO with Orthodontia | $46.56 | $90.08 | $142.38 |
| Dental HMO | $7.54 | $10.78 | $15.11 |
12/27/23