Medical (Master) - Miami-Dade County Public Schools Employee Benefits

All Employee groups are eligible for these plans.

OAP High

This plan offers a higher level of coverage with a lower out-of-pocket expense when receiving services, while having access to nationwide providers in exchange for a higher premium.

No Primary Care Physician selection required
No referral for Specialists
Nationwide Provider Network
Low Deductible – deductible must be satisfied for services subject to co-insurance
Lower Primary Care Physician co-payment
Lower Urgent Care co-payment
$0 co-payment for Telemedicine
$0 co-payment for Generic Seven Drug Classes (both retail & 90-day supply)

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OAP Standard

This plan offers individuals needing less access to care a lower premium option, with access to nationwide providers in exchange for a higher out-of-pocket expense when receiving services.

No Primary Care Physician selection required
No referral for Specialists
Co-payments for Primary and Specialist visits
Co-payments for Urgent visits
Nationwide Provider Network
Low Deductible – deductible must be satisfied for services subject to co-insurance
$0 co-payment for Telemedicine
$0 co-payment for Generic Seven Drug Classes (both retail & 90-day supply)

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SureFit Plan

This plan offers a lower out-of-pocket expense when receiving services, a lower premium, and a narrow strong network of providers. You must reside in the tri-county area (Miami-Dade, Broward and Palm Beach Counties).

Selection of Primary Care Physician required
Referrals needed for Specialists
Narrow network with a minimum disruption in comparison to the OAP Plans
Co-payments for Primary and Specialist visits
Low co-payments for Urgent visits
A significant lower deductible – deductible must be satisfied for services subject to co-insurance
A significant lower Maximum Out of Pocket – The amount that you must pay before the plan covers 100% of all the services subject to co-insurance
$0 co-payment for Telemedicine
$0 co-payment for Generic Seven Drug Classes (both retail & 90-day supply)

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Healthcare Plan Comparison


	OAP High		OAP Standard		SureFit
Coverage	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network Only
Medical Network Basis	OAP Network		OAP Network		SureFit Network TriCounty ¹
PCP Coordination of Medical Care	No		No		Yes
Medical Benefits
Deductible (Individual/Family)	$550/$1,100	$1,100/$2,200	$800/$1,600	$1,600/$3,200	$150/$250
Out of Pocket Max (Ind/Fam)(incl ded. & copay & Rx)	$3,100/$6,200	$6,200/$12,400	$4,100/$8,200	$8,200/$16,400	$1,500/$3,000
Coinsurance	30%	50%	30%	50%	30%
Telemedicine	$0	N/A	$0	N/A	$0
Primary Care Physician OV	$25/ $0 M-DCPS Clinic	50% AD	$30/ $0 M-DCPS Clinic	50% AD	$20/ $0 M-DCPS Clinic
Tier 1 Specialist	$50	50% AD	$50	50% AD	$50
Non-Tier 1 Specialist	$70	50% AD	$75	50% AD	N.A.
Outpatient BH	$0	50% AD	$0	50% AD	$0
Physical Therapy	$35		$55		$35
Speech & Occupational Therapies	$55 ST, OT	50% AD	$60 ST, OT	50% AD	$20 PCP/ $50 SCP
Pulmonary Cardiac Therapy (40 days per year)	$55	50% AD	$70	50% AD	$45
Chiropractic Care (30 days per year)	$60	50% AD	$70	50% AD	$45
Convenience Care Centers	$10	50% AD	$15	50% AD	$10
Urgent Care	$45	$45	$45	$45	$40
Imaging	30% AD, or $100 at non-hospital based	50% AD	30% AD, or $100 at non-hospital based	50% AD	30% AD, or $100 at non-hospital based
Inpatient Hospital	30% AD	50% AD	30% AD	50% AD	30% AD
Outpatient Hospital and Major Diagnostics	30% AD or $150 at affiliated Non-hospital	50% AD	30% AD or $150 at affiliated Non-hospital	50% AD	30% AD or $100 at affiliated Non-hospital
Emergency Room	$375/$225 preferred facilities	$375/$225 preferred facilities	$425/$225 preferred facilities	$425/$225 preferred facilities	$300/$150 preferred facilities
Other - Hearing Aides	$65 visit/ 30% AD for devices	Not covered	$70 visit/ 30% AD for devices	Not covered	$50 visit/ 30% AD for devices
Other - Bariatric Surgery	30% AD	Not covered	Not covered	Not covered	Not covered
Prescription Drug Benefits (50% Retail only out-of-network benefit)
Prescription Drug Deductible (Ind/Fam)	N/A		N/A		N/A
Formulary	Same as OAP Standard and SureFit		Same as OAP High and SureFit		Same as OAP plans
Other - Insulin Copay Waiver	Yes		Yes		Yes
Retail Drug Network (no coverage for maintenance meds after 3rd fill)
Generic Seven Drug Classes²	$0	50%	$0	50%	$0
Generic	$20 – no coverage for maintenance meds after 3rd fill		$20 – no coverage for maintenance meds after 3rd fill		$15 – no coverage for maintenance meds after 3rd fill
GENERIC ADD & ADHD	$15		$15		$15
Preferred Brand (Including Specialty Drugs)	$55 – no coverage for maintenance meds after 3rd fill		$65 – no coverage for maintenance meds after 3rd fill		$40 – no coverage for maintenance meds after 3rd fill
Non-Preferred Brand (Including Specialty Drugs)	$150 – no coverage for maintenance meds after 3rd fill		$175 – no coverage for maintenance meds after 3rd fill		$125 – no coverage for maintenance meds after 3rd fill
Mail Order Prescription (90 day supply)		N/A		N/A
Generic Seven Drug Classes2	$0		$0		$0
Generic	$40		$40		$30
Generic ADD & ADHD	$30		$30		$30
Preferred Brand (Including Specialty Drugs)	$140		$160		$80
Non-Preferred Brand (Including Specialty Drugs)	$375		$435		$315
1 Broward, Dade and Palm Beach Counties, FL
2 90-Day supply on Seven Drug Classes related to the following conditions: Asthma, Blood Pressure, Blood Thinner, Cholesterol, Diabetes, Osteoporosis, Prenatal Vitamins
AD = after deductible, OV = office visit

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Prescription Coverage

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Preventive Health Services

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Behavioral Health

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Tools & Resources

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Urgent Care and Convenience Care Centers

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