| Cover Florida |
Plan I
Limited Benefit Plan |
Plan II
Limited Benefit Plan with Hospital and Surgical Services |
| Cost Sharing Benefits (In-Network) |
| Calendar Year Deductible (CYD) |
$0 |
$3,000 |
| Coinsurance (amount you pay) |
0% |
20% |
| Other Benefits (In-Network) |
| Physician or Specialist Office Services |
We pay $50 or the allowed amount, whichever is lower, and you pay the difference between the allowed amount and our maximum payment amount. |
We pay $50 or the allowed amount, whichever is lower, and you pay the difference between the allowed amount and our maximum payment amount. |
| Adult Wellness (includes well woman, routine adult physicals, immunizations and non-invasive colorectal or prostate screenings) |
We pay $50 or the allowed amount, whichever is lower, and you pay the difference between the allowed amount and our maximum payment amount. |
We pay $50 or the allowed amount, whichever is lower, and you pay the difference between the allowed amount and our maximum payment amount. |
| Mammograms |
100% Covered if you stay in-network |
100% Covered if you stay in-network |
| Colonoscopy (routine for age 50+ then frequency schedule applies) |
We pay $50 or the allowed amount, whichever is lower, and you pay the difference between the allowed amount and our maximum payment amount. |
We pay $50 or the allowed amount, whichever is lower, and you pay the difference between the allowed amount and our maximum payment amount. |
| Inpatient Hospital Facility Services (per admission) |
Not Covered |
CYD plus coinsurance |
| Outpatient Hospital Facility Services (services related to surgery only) |
Not Covered |
CYD plus coinsurance |
| Hospital & ER Physician Services |
Not Covered |
CYD plus coinsurance |
| Urgent Care Centers |
We pay $50 or the allowed amount, whichever is lower, and you pay the difference between the allowed amount and our maximum payment amount. |
For non-surgical services, we pay $50 or the allowed amount, whichever is lower, and you pay the difference between the allowed amount and our maximum payment amount.
For surgical services, CYD plus coinsurance. |
| Emergency Room Facility Services (per visit) |
Not Covered |
CYD plus coinsurance |
| Independent Clinical Lab |
100% Covered if you use Quest Diagnostics. |
100% Covered if you use Quest Diagnostics. |
| Rx Benefits |
We pay $15 or the allowed amount, whichever is lower, and you pay the difference between the allowed amount and our maximum pharmacy payment amount. |
We pay $15 or the allowed amount, whichever is lower, and you pay the difference between the allowed amount and our maximum pharmacy payment amount. |
| Dental Benefits (Preventive and Basic Dental Services) |
We pay $50 or the allowed amount, whichever is lower, and you pay the difference between the allowed amount and our maximum payment amount. |
We pay $50 or the allowed amount, whichever is lower, and you pay the difference between the allowed amount and our maximum payment amount. |
| Benefit Maximums (In-Network) |
| Lifetime Maximum (per Individual) |
No Maximum |
$50,000 |
| Annual Maximum (per Individual) |
No Maximum |
$25,000 |
|
View Benefit Summary »
(PDF) |
View Benefit Summary »
(PDF) |