| Benefit Description |
Member Pays PY 2012 |
| Plan year out-of-pocket (per person) |
$3,400 |
| |
|
| Physicians and Lab Services |
|
| Physician office visit |
$0 copayment |
| Specialist office visit |
$0 copayment |
| Routine physical exams |
$0 copayment |
| Diagnostic x-rays, mammography, and lab tests |
$0 copayment |
| High Tech Radiology |
$0 copayment |
| Immunizations |
$0 copayment |
| Well woman exam |
$0 copayment |
| Vision and Hearing screenings |
$0 copayment |
| Hearing Testing |
$0 copayment |
| Rehabilitative Therapy |
$0 copayment |
| Allergy Testing |
$0 copayment |
| Allergy serum |
$0 copayment |
| Allergy serum administration |
$0 copayment |
| Routine eye exam |
$0 copayment |
| Office surgery |
$0 copayment |
| |
|
| Hospital Services |
|
| Inpatient Hospital Care |
$0 copayment |
| Outpatient/Services surgery |
$0 copayment |
| Emergency Care |
$0 copayment |
| Urgent Care |
$0 copayment |
| |
|
| Extended Care Services |
|
| Skilled nursing facility |
Days 1-100 $0 copay per day |
| Home Health |
$0 copayment |
| |
|
| Other Medical Services |
|
| Durable Medical Equipment |
covered 100% |
| Prosthesis |
covered 100% |
| Ambulance |
$0 copayment |
| |
|
| Behavioral Health |
|
| Inpatient mental health |
$0 copayment |
| Outpatient mental health |
$0 copayment for individual
$0 copayment for group |
| Outpatient substance abuse care |
$0 copayment for individual
$0 copayment for group |
| Important Update about your Prescription Drug Deductible |
|
| |
|
| Participating Retail Pharmacy - Tier 1 - 5 |
|
| Up to 30-day supply per prescription or refill of Non-Maintenance medication |
| Tier 1 & 2 |
$15 |
| Tier 3 |
$35 |
| Tier 4 & 5 |
$60 |
|
| Up to 30-day supply per prescription or refill of Maintenance medication |
| Tier 1 & 2 |
$20 |
| Tier 3 |
$45 |
| Tier 4 & 5 |
$75 |
|
| Up to a 30-day supply of insulin for one copayment |
| Tier 1 & 2 |
$15 |
| Tier 3 |
$35 |
| Tier 4 & 5 |
$60 |
|
| Up to a 30-day supply of each diabetic oral agent for one copayment |
| Tier 1 & 2 |
$15 |
| Tier 3 |
$35 |
| Tier 4 & 5 |
$60 |
|
| The supply of necessary disposable syringes for the 30-day supply of insulin for one copayment |
$35 |
| 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. |
20% |
| |
|
| Mail Order Pharmacy |
|
| Up to a 90-day supply per prescription or refill for one mail order copayment |
| Tier 1 & 2 |
$45 |
| Tier 3 |
$105 |
| Tier 4 & 5 |
$180 |
|
| Up to a 90-day supply of insulin for one mail order copayment |
| Tier 1 & 2 |
$45 |
| Tier 3 |
$105 |
| Tier 4 & 5 |
$180 |
|
| Up to a 90-day supply of each diabetic oral agent for one mail order copayment |
| Tier 1 & 2 |
$45 |
| Tier 3 |
$105 |
| Tier 4 & 5 |
$180 |
|
| The supply of necessary disposable syringes for up to a 90-day supply of insulin for one mail order copayment |
$105 |
| 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. |
20% |