Employee Benefits Package
Group Insurance Plans (Optional): Premiums
1. FirstCare / $0 / $191.37 / $134.74 / $346.12
2. HealthSelect / $0 / $162.87 / $112.87 / $275.22
Health Coverage subject to a 90 day waiting period.
Part-time benefits eligible employees pay 50% of employee premium and 100% of dependent premium for health coverage.
Health Insurance
HealthSelect Individual Plan
(the client’s current plan)
Set amount you must pay out-of-pocket before the health/dental plan begins to pay their share of expenses. This applies to services under:
· HealthSelect non-network benefits
· HealthSelect out-of-area benefits,
· Prescription Drug Program, and
· State of Texas Dental Choice Plan
Deductibles do not include:
· copayments,
· coinsurance, or
· charges not covered by the carrier.
Authorization to see a specialty doctor from:
· your primary care physician (PCP), or
· INROADS Behavioral Health Services (HealthSelect)
You are required to obtain a referral to see a specialist if you are a HMO participant, or HealthSelect participant accessing network benefits
Year from January 1 to December 31 of the same year.
Percentage of the allowable cost that you pay for covered medical and dental services and supplies. Coinsurance does not include:
· deductibles,
· copayments, or
· non-covered charges.
Coinsurance differs from a copayment in that you pay a percentage of the cost rather than the set dollar amount of a copayment.
Set dollar amount you pay out-of-pocket for medical services at the time services are provided.
Benefits / Participant pays for Network Benefits / Participant pays for Non-Network Benefits
Calendar year deductible(January 1-December 31) / None / $500 individual
$1,500 family
Benefits are not paid until the deductible is satisfied.
Calendar year out-of-pocket coinsurance maximum / $1,000 per person
Does not include copayments / $3,000 per person
Does not include copayments
Benefits are paid on allowable amounts. You may also be responsible for charges above the BCBSTX allowable amount.
Lifetime maximum / None / $1,000,000
Primary care physician (PCP) required? / Yes
You must use your PCP or have a referral from your PCP for all services except where noted. / No
May use any physician or specialist.
Benefits are paid on allowable amounts. You may be responsible for charges above the BCBSTX allowable amount.
PCP office visit / $20 / 40%
Physicals / $20 / 40%
Specialty physician office visit / $30 / 40%
Eye exam, one per year / $30
One visit per calendar year with a network optometrist or ophthalmologist.
Does not require a referral from your PCP. / 40%
One visit per calendar year.
Family planning services / $30 / 40%
Well woman exam / With your PCP: $20
With network OB/GYN: $30
One visit per calendar year with a network OB/GYN.
Does not require a referral from your PCP. / 40%
One visit per calendar year.
Speech and hearing testing/therapy / 20% if no office visit
$30 copayment
+20% with an office visit / 40%
Allergy antigens/serum / 20% / 40%
Allergy injections / 20%
except when performed during an office visit / 40%
Allergy testing / 20% / 40%
Diagnostic x-rays, lab tests, mammography / 20% / 40%
Office surgery,Diagnostic procedures / 20% / 40%
Rehabilitative therapy / 20% if no office visit, or
$30 copayment
+20% with an office visit / 40%
Immunizations ages 0-6 / No charge without an office visit, or $20 with an office visit / No charge without an office visit, or 40% with an office visit
Immunizations ages 7 and up / 20% without an office visit, or $20 with an office visit / 40%
Maternity care: physician charges only inpatient hospital copayments will apply / $30
For the first office visit. / 40%
Inpatient hospital (semi-private room, or intensive care unit) / $100 per day copayment + 20% coinsurance per person / $100 per day copayment + 40% coinsurance per person
Inpatient hospital copayment maximum (semi-private room, or intensive care unit) / $500
Up to five days per hospital stay, $1,500 per year cap and preauthorization required / $500
Up to five days per hospital stay, $1,500 per year cap and preauthorization required
Emergency care / $100 copayment
+ 20% coinsurance
If admitted will apply to hospital copayment / 40%
Outpatient surgery other than in a physician’s office / $100 copayment
+ 20% coinsurance / $100 copayment
+ 40% coinsurance
Skilled nursing facility / 20%
Preauthorization required / 40%
Preauthorization required
Skilled nursing facility maximum / 60 days
per calendar year / 60 days/$4,200
per calendar year
Hospice / 20%
Preauthorization required / 40%
Preauthorization required
Hospice lifetime maximum / $18,000 / $18,000
Home health care / 20%
Preauthorization required / 40%
Preauthorization required
Home health care maximum / None / 100 visits/$3,500
per calendar year
Hearing aids / Up to $500 per ear
every three years / Up to $500 per ear
every three years
Durable medical equipment / 20% / 40%
Ambulance services / 20% of allowable amount / 20% of allowable amount
Prescription Drug
Set amount you must pay out-of-pocket before the health/dental plan begins to pay their share of expenses. This applies to services under:
· HealthSelect non-network benefits
· HealthSelect out-of-area benefits,
· Prescription Drug Program, and
· State of Texas Dental Choice Plan
Deductibles do not include:
· copayments,
· coinsurance, or
· charges not covered by the carrier.
List of drugs under a health plan’s Prescription Drug Program that includes drugs’:
· Tier classification,
· preferred or non-preferred brand-name drug status, and
· maintenance drug designation (if any).
Local pharmacy that does not participate in a health plan’s Prescription Drug Program. At a non-participating retail pharmacy, HMO participants cannot access benefits. HealthSelect participants may fill a prescriptionat a non-participatingpharmacy,but they will pay a higher price than if they used a retail pharmacy that is part of the HealthSelect network.
Prescription Drug Program classifies prescription drugs into one of three Tiers, which determines a drug’s copayment.
Drugs with their corresponding Tier are listed in the health plan’s formulary.
Pharmacy that provides home delivery services for a health plan’s prescription mail order program, such as Medco, who provides mail order services for HealthSelect.
Set dollar amount you pay out-of-pocket for medical services at the time services are provided.
Annual Deductible
The $50 deductible per person per plan yearmust be paid before benefits begin. Each covered individual in your family has a separate $50 deductible each plan year, September 1 - August 31. The deductible must be paid before the plan covers your costs and you begin paying copayments for your prescriptions.If you change carriers during the plan year, you will have a new $50 deductible, regardless of when you make the change.
Drug Tiers
Drugs are classified into three tiers and listed in the provider's formulary.
· Tier 1 - These drugs are mostly generic drugs and have the lowest copayment.
· Tier 2 - These drugs are usually listed as the health plan’s preferred brand-name drugs and have a higher copayment than Tier 1 drugs.
· Tier 3 - These drugs are usually non-preferred brand-name drugs and have the highest copayment.
Maintenance drugs
A drug taken on a long-term basis may be designated as a maintenance drug. Maintenance drugs have a higher copayment if you buy them at a retail pharmacy. Only the drugs listed as maintenance drugs inCaremark's formulary have this extra cost, regardless of how long you take a drug. You can avoid the extra cost by buying maintenance drugs through a mail order pharmacy instead of a retail pharmacy.
Non-maintenance drug bought at a participating retail pharmacy / Non-maintenance drug bought through a mail order pharmacy / Maintenance drug bought at a participating retail pharmacy / Maintenance drug bought through a mail order pharmacy
Tier 1 / $10 for a 30-day supply / $30 for a 90-day supply / $15 for a 30-day supply / $30 for a 90-day supply
Tier 2 / $25 for a 30-day supply / $75 for a 90-day supply / $35 for a 30-day supply / $75 for a 90-day supply
Tier 3 / $40 for a 30-day supply / $120 for a 90-day supply / $55 for a 30-day supply / $120 for a 90-day supply
Participating Pharmacies
Not all retail pharmacies are part of the HealthSelect network. You can search for a participating retail pharmacyon theCaremark website. Prescriptions filled at a non-participating retail pharmacy have a greater cost. You will pay the full price of the prescription at the time of purchase, then file a claim to receive benefits.
If you use a non-participating pharmacy, you will be reimbursed 60% of the lesser amount of:
· the cost of the prescription minus your copayment, or
· the average wholesale price of the drug, plus the dispensing fee, minus your copayment.
FirstCare Individual Plan
FirstCare – Health Plans that Work
SUMMARY OF BENEFITS
TEXAS EMPLOYEES GROUP BENEFITS PROGRAM
The following is a summary of the Copayment amounts You and any Dependents must pay when receiving the services listed below. These services must be performed, prescribed, or directed by Your Primary Care Physician or designated OB/GYN Physician. Please refer to Your Evidence of Coverage for a detailed explanation of covered and non-covered services.
Benefit Description / Member’s CopaymentPhysicians and Lab Services
Physician Office Visit Primary Care Physician / $30
Specialist Office Visit / $40
Routine physicals-One per plan year for adults; periodic for children, or as
directed by the primary care physician / $30 or $40
Diagnostic x-rays, mammography, and lab tests / No copayment
Immunizations - For Children 0 to 6 years of age / No copayment
Immunizations - For Children 7 years and older, and adults / $30
Well woman exam - One per plan year / $30 or $40
Vision, speech, and hearing screenings -For all enrolled participants / $40
Speech & hearing testing (covered for all participants) / $40
Speech therapy and rehabilitative therapy, including physical and occupational therapy-Covered as any other illness and not subject to any maximum / $40
Allergy testing / $40
Allergy serum / 50%
Allergy serum administration-When allergy shot is administered without an office visit / No copayment
Routine eye exam-one per plan year / $40
Office surgery & procedures (all office surgeries, excluding vasectomies and tubal ligations) / $30 or $40
Maternity care-Physician services, including diagnosis of pregnancy, pre- & postnatal
care, and delivery (including delivery by C-section)
– see “Hospital Services” for Inpatient charges / No copayment
Family planning / $40
Vasectomy & tubal ligation / No copayment
Infertility benefits / 50%
Hospital Services
Inpatient hospital-Semi-private room & board or intensive care units / $100 per day copayment per admission, 5 day max. $1500 max. per person per year
Outpatient day surgery / $100
Other inpatient charges, including medically necessary surgical procedures.
Includes orthognathic surgery. Guest trays, cots, telephone, maternity kits,
paternity kits, and other personal items not covered / No copayment
Blood and blood products-Inpatient & outpatient / No copayment
Private Duty Nursing, based on medical necessity / No copayment
Outpatient facilities, including pre-admission testing and/or treatment room / No copayment
Emergency care - In-area and out-of-area covered at listed copayment. If hospitalized, copayment is waived / $100
Urgent care - Includes physician's after-hours care or at an urgent care facility / $50
Extended Care Services (Based on medical necessity)
Skilled Nursing facility - covered up to 60 days per plan year / No copayment
Hospice Care-inpatient and outpatient / No copayment
Home health / No copayment
Private duty nursing / No copayment
Other Medical Services
Hearing aids - $500.00 per ear every 3 years (Repairs not covered) / Plan pays $500 per ear every 3 years
Hearing aid batteries - Not subject to any maximum amounts / No copayment
Dental - Restoration & correction of damage caused by external violent accidental injury to healthy, natural teeth, occurring while covered under the plan for services provided within 24 months of the date of the accident. Certain oral surgeries are covered / $40
Durable Medical Equipment - Includes medically necessary purchase and/or rental.
Benefits for rental are limited to, and will not exceed, the purchase price of the equipment. (Repairs are covered if not due to neglect or abuse.) This benefit also includes diabetic supplies other than insulin, diabetic oral agent(s), and syringes as specified in Section 1358.051(2), Tex. Ins. Code / 20%
Prostheses - Artificial devices, surgical or non-surgical, which replace body parts, including arms, legs, eyes and cochlear implants are covered. Replacements and repairs are covered as required by medical necessity. / 20%
Organ Transplants - Covered as any other illness for kidney, cornea, liver, heart, heart-lung, lung, pancreatic-kidney, bone marrow, and other organ transplants that the HMO determines to be not experimental and/or not investigational according to current medical plan guidelines. Donor expenses are covered. Artificial organs (e.g. heart) not covered / No copayment (Hospital copayments will apply)
Ambulance - professional local ground or air ambulance transportation services to the nearest hospital, appropriately equipped and staffed for the treatment of the participant's condition / No copayment
Behavioral Health
Inpatient mental health-Covered in full up to 30 days per plan year / $100 per day copayment per admission, 5 day max. $1500 max. per person per year
Inpatient serious mental illness-Covered as any other illness / $100 per day copayment per admission, 5 day max. $1500 max. per person per year
Inpatient chemical dependency-Covered as any other illness, based on medical necessity / $100 per day copayment per admission, 5 day max. $1500 max. per person per year
Outpatient mental health-25 visits per plan year / $40
Outpatient serious mental illness-Covered as any other illness / $40
Outpatient chemical dependency-Same as any other illness and not subject to any maximums / $40
Prescription Drugs
Plan Year Deductible
If a Brand Name medication is dispensed when a Generic is available, member shall be responsible for the Generic Copayment plus the cost difference between the Generic and the Brand Name medication / $50
Participating Retail Pharmacy-Tier 1, Tier 2 & Tier 3
Up to a 30-day supply per prescription or refill of Non-Maintenance medication / $10/$25/$40
Up to a 30-day supply per prescription or refill of Maintenance medication / $15/$35/$55
Infertility drugs are paid at 50% copayment / 50%
Up to a 30-day supply of insulin for one copayment / $10/$25/$40
Up to a 30-day supply of each diabetic oral agent for one copayment / $10/$25/$40
The supply of necessary disposable syringes for the insulin supply for one copayment / $25
This benefit also includes diabetic supplies other than insulin, diabetic oral agent(s), and syringes as specified in Section 1358.051(2), Tex. Ins. Code. Up to a 30-day supply for a 20% copayment / 20%
Mail Order Pharmacy-Tier 1, Tier 2 & Tier 3
Up to a 90-day supply per prescription or refill for one mail order copayment / $30/$75/$120
Oral contraceptives up to a 90-day supply for one mail order copayment / $30/$75/$120
Infertility drugs are paid at 50% copayment / 50%
Up to a 90-day supply of insulin for one mail order copayment / $30/$75/$120
Up to a 90-day supply of each diabetic oral agent for one mail order copayment / $30/$75/$120
The supply of necessary disposable syringes for the insulin supply for one mail order copayment / $75
This benefit also includes diabetic supplies other than insulin, diabetic oral agent(s), and syringes as specified in Section 1358.051(2), Tex. Ins. Code. Up to a 90-day supply for a 20% copayment / 20%
VALUE-ADDED SERVICES