Choice POS II

Annual Deductible: Individual $500 / Family $1,000

What you pay for care received in network

• Doctor office visits: 20% after deductible per visit for PCP / 20% after deductible per visit for Specialist
• Hospital Stay: $500 copay/day first 5 days per stay
• Emergency Room: 20% after deductible (waived if admitted)
• Urgent Care: 20% after deductible

What you pay for care received out of network

• Doctor office visits: 40% after deductible per visit by PCP / 40% after deductible per visit for Specialist
• Hospital Stay: 40% after deductible
• Urgent Care: 40% after deductible
• Emergency Room: 20% after deductible (waived if admitted)

Prescription Drugs
Retail 30 day supply / Retail or Mail order 30-90 day supply

• Generic: $15 / $30 (90 day supply)
• Preferred Brand: $60 / $120 (90 day supply)
• Non-Preferred Brand: $90 / $180 (90 day supply) (copay after deductible)
• Specialty: 30% coinsurance / $0 if enrolled in Prudent RX (30 days only)
• Pharmacy deductible: Individual $250 / Family $500 only for Non-Preferred Brand and Specialty

Pinellas has implemented PrudentRX effective 1/1/2022. Specialty drugs are the most expensive, high-technology and self-administered injectable medications not available on other levels. May be eligible for $0 co-pay under PrudentRx program. If not enrolled, 30% coinsurance applies.

Questions?
Visit pcsb.org/pharmacy for a list of covered medications and additional details on the PrudentRx program. Or call PrudentRx, 1-800-578-4403, Monday through Friday, 8 AM to 8 PM ET.

Look up your prescriptions for the Aetna Standard Plan formulary (PDF) »
Learn more about the Maintenance Choice Program here (PDF) »

Annual Medical out-of-pocket max (does not include prescription copays)

• Individual: $5,000
• Family: $10,000

Annual Pharmacy out-of-pocket max (does not include medical copays)

• Individual: $2,000
• Family: $4,000

Preventive care: Covered 100% (for specific services, frequency limitations may apply)

Teladoc Benefits

• General Medical: $25 per visit / treatment for flu, allergies, bronchitis, and more
• Mental Health: Support for stress, anxiety, depression, and more
• Appointments available by video only to members and eligible dependents 18 and older
• Therapist, Psychologist $80 or less / session
• Psychiatrist $160 or less / evaluation
• (Ongoing sessions) $90 or less / session
• Your cost for Mental Health visits is 20% coinsurance after deductible is met