2024 Pinellas County Non-Medicare Retiree Medical Plan Comparison Chart

Item Choice Fund Open Access Plus HSA Open Access Plus (OAP)
Coverage Retiree Only Retiree +1 Retiree + 2 or More Retiree Only Retiree + 1 or More
In-Network Annual Deductible $1,600 $3,200 (pooled deductible for all family members on the plan) $600 $1,200 (two individual deductibles of $600 each)
Out-of-Network Annual Deductible $3,000 $6,000 (pooled deductible for all family members on the plan) $1,200 $2,400
County HSA Contribution (must have HSA Bank account) $500 $1,200 $1,200 N/A N/A
In-Network 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
Out-of-Network Out-of-Pocket Maximum (includes medical and Rx; after you spend this amount, the health plan pays 100%) $4,200 $6,000 $8,400 $5,200 $10,400
In-Network Benefit* Choice Fund Open Access Plus HSA Open Access Plus (OAP)
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 (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
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
*For out-of-network copay and coinsurance amounts, see the Summary of Benefits and Coverage for the HSA and OAP plans.
Coverage Biweekly Premiums (same for both plans)
Employee only $ 13.09
Employee and Spouse/Domestic Partner $151.16
Employee and Child(ren) $120.60
Family $247.67

* For out-of-network copay and coinsurance amounts, see the Summary of Benefits and Coverage for the HSA and OAP plans.

See Medical Plan Rates for Non-Medicare Eligible Retirees 
(The rates are the same for both plans.)

7/5/24